What is the recommended treatment and wound care for a postpartum woman with a recent uncomplicated Caesarean section incision to promote healing, manage pain, and prevent infection and scarring?

Caesarean Section Wound Care and Healing

For optimal healing of an uncomplicated caesarean incision, implement multimodal pain management with scheduled paracetamol and NSAIDs (avoiding opioids except for breakthrough pain), keep the wound dressing in place for 48 hours, use subcuticular sutures rather than staples for skin closure, and monitor for infection without routine antibiotics. 1, 2, 3

Pain Management for Optimal Healing

The foundation of post-caesarean pain control should be scheduled non-opioid analgesia, as adequate pain relief directly impacts recovery, breastfeeding, and mother-child bonding. 1

Core Pain Regimen

• Prescribe scheduled paracetamol (650 mg every 6 hours) and NSAIDs (ibuprofen 600 mg every 6 hours or ketorolac 30 mg IV every 6 hours for 4 doses) starting immediately after delivery and continuing regularly postoperatively. 1, 4
• Reserve short-acting opioids for breakthrough pain only, with individualized prescribing based on inpatient requirements to minimize unnecessary opioid consumption. 1, 4
• Consider transcutaneous electrical nerve stimulation (TENS) as an analgesic adjunct. 1

Intraoperative Considerations That Impact Healing

• If intrathecal morphine was not administered during spinal anaesthesia, consider local anaesthetic wound infiltration or continuous wound infusion to improve early pain control. 1
• A single dose of IV dexamethasone after delivery reduces pain and inflammation (in absence of contraindications). 1

Wound Dressing Management

Leave the wound dressing in place for 48 hours after caesarean delivery for optimal wound healing outcomes. 3

• Dressing removal at 48 hours results in significantly better wound healing scores at 6 weeks compared to 24-hour removal (3.9% vs 9% wound complications, p=0.002). 3
• While early removal at 6 hours does not increase wound complications and improves patient satisfaction with hygiene, the 48-hour timeframe provides superior long-term healing in low-risk scheduled caesareans. 5, 3
• For patients requiring early discharge (24-28 hours postoperatively), dressing removal timing should balance infection prevention with practical discharge needs. 4

Infection Prevention

Antibiotics are NOT routinely indicated after uncomplicated caesarean delivery beyond the prophylactic dose. 6, 4

When to Add Antibiotics

• Administer additional antibiotic doses only for specific high-risk scenarios: obesity without preoperative azithromycin, surgery lasting ≥4 hours since prophylactic dose, blood loss >1500 mL, or intra-amniotic infection. 4
• For wound complications, add antibiotics only if signs of infection with systemic involvement are present: temperature >38.5°C, heart rate >110 bpm, erythema extending >5 cm from wound edge, or purulent drainage. 6

Surgical Technique Impact on Infection Risk

• Subcuticular suture closure significantly reduces wound complications compared to staples and should be the preferred closure method. 6, 2, 7
• When subcutaneous tissue depth is ≥2 cm, reapproximation reduces wound complications. 2, 7
• Chlorhexidine skin preparation is superior to iodine for infection prevention. 7

Management of Wound Complications

Seroma Treatment

If a seroma develops (fluctuant swelling without erythema or systemic signs), the primary treatment is prompt drainage followed by wound care allowing healing by secondary intention. 6

• For recurrent or large seromas, consider opening part of the incision to allow complete drainage with continued dressing changes until healing by secondary intention. 6
• Negative pressure wound therapy (NPWT) may benefit chronic seromas by promoting granulation tissue and obliterating dead space, with significant reduction in surgical site infections (pooled OR 0.25,95% CI 0.12-0.52). 6
• Do not routinely prescribe antibiotics for uncomplicated seromas without infection signs. 6

Distinguishing Seroma from Infection

• Seromas present as fluctuant swelling without significant erythema or systemic signs. 6
• Surgical site infections present with purulent drainage, pain, tenderness, redness, and induration. 6

Scar Prevention and Optimization

Proper surgical technique during closure is the primary determinant of scar quality. 2

• Use subcuticular sutures rather than staples to minimize scarring and wound complications. 2
• Consider triclosan-coated Vicryl (Vicryl Plus) when available, as it reduces surgical site infections (OR 0.62,95% CI 0.44-0.88). 2
• Avoid overly tight sutures that can strangulate tissue and impair healing. 2

Early Mobilization and Recovery

Early ambulation starting 4 hours postoperatively should be encouraged and incentivized. 4

• Chewing gum aids return of bowel function and should be initiated immediately after caesarean. 4
• Early oral intake of solid food can occur within 2 hours postoperatively. 4
• Remove indwelling bladder catheter immediately postoperatively for scheduled caesareans. 4

Common Pitfalls to Avoid

• Do not prescribe prophylactic multi-dose antibiotics to all patients—this is not evidence-based and contributes to antibiotic resistance. 4
• Do not remove dressings at 24 hours in low-risk patients—48 hours provides better healing outcomes. 3
• Do not use staples for skin closure—subcuticular sutures have superior outcomes for wound healing and patient satisfaction. 2, 7
• Do not prescribe excessive opioids at discharge—base prescribing on actual inpatient requirements and emphasize scheduled non-opioid analgesia. 1, 4