Caesarean Wound Dehiscence

Caesarean wound dehiscence is separation of the edges of the caesarean incision, either superficial (skin and subcutaneous tissue) or deep (fascial dehiscence, with a risk of evisceration of bowel). It results from infection, haematoma, tension, poor technique, obesity, diabetes, malnutrition and repeated coughing. It matters because fascial dehiscence is a surgical emergency, and superficial dehiscence delays healing.

• Risk factors: obesity, wound infection, diabetes, anaemia, malnutrition, smoking, emergency surgery, vertical incision, steroid use, HIV, chronic cough.
• Typically appears on days 5 to 10.
• Pink serous discharge from the wound is a warning sign of fascial dehiscence.

Women have wound discharge, a visible gap in the incision, pain and, with fascial dehiscence, a sudden gush of pink fluid after straining and a palpable defect in the fascia, sometimes with bowel visible.

• Wound edges open, with slough or granulation tissue in the gap.
• Serosanguinous discharge on days 5 to 10.
• Differential diagnosis: wound infection, haematoma, seroma, wound separation from stitch removal, incisional hernia, endometritis.
• Complications: evisceration, infection, abscess, necrotising fasciitis, incisional hernia, prolonged healing, scarring, readmission, sepsis.

The diagnosis is made by examination, assessing the depth of the gap.

• Inspect the wound for the depth of separation; probe gently with a sterile gloved finger to feel for an intact fascia.
• Temperature, pulse, blood pressure; culture of any discharge; full blood count, C-reactive protein, glucose.
• Ultrasound or CT if a deep collection or hernia is suspected.
• Document the size and appearance with photographs.

The principle is to clean and heal superficial dehiscence by secondary intention or delayed closure, and to take the woman to theatre for fascial dehiscence.

• Supportive: cover evisceration with sodium chloride 0.9 percent soaked sterile gauze and keep the woman supine with knees flexed; nil by mouth; two cannulae; analgesia; abdominal binder after repair; wound packing with moist gauze once or twice daily; nutrition with protein; stop smoking; glucose control.
• Pharmacological: ceftriaxone 2 g IV once daily plus metronidazole 500 mg IV 8-hourly for infected dehiscence, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 days; flucloxacillin 500 mg oral 6-hourly for 7 days for superficial infection; cefazolin 2 g IV before re-operation; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); morphine 2.5 to 5 mg IV every 4 hours as needed for severe pain; iron: ferrous sulphate 200 mg oral 8-hourly for 3 months for anaemia; insulin to keep glucose below 10 mmol/L.
• Procedures: debridement of dead tissue; secondary healing with packing or negative pressure dressing (continuous pressure of 125 mmHg), or delayed primary closure after 5 to 7 days when granulating; re-suture of the fascia with size 1 polydioxanone or nylon mass closure in theatre for fascial dehiscence, after washing out the abdomen, with retention sutures if needed; mesh for large defects.
• Red flags: bowel visible in the wound, pink watery discharge, fever above 38 degrees Celsius, spreading redness, foul smell, sudden severe pain on straining.
• Follow-up: wound review every 2 to 3 days until healed (often 4 to 8 weeks); review at 1 week and 6 weeks; advise to avoid heavy lifting for 6 weeks; plan the next birth.