Episiotomy Wound Breakdown

Episiotomy wound breakdown is partial or complete separation of the episiotomy repair, so that the edges gape and the underlying muscle or skin is exposed. It results from infection, haematoma, tension, poor suture technique, diabetes, malnutrition and poor hygiene. It matters because it causes pain, delayed healing, scarring and, in deep breakdown, damage to the anal sphincter.

• Risk factors: wound infection, haematoma, diabetes, obesity, anaemia, malnutrition, smoking, extension to a third or fourth degree tear, constipation and straining, instrumental delivery.
• Usually appears on days 4 to 10.
• Many wounds heal well by secondary intention.

Women have perineal pain, gaping of the wound edges, serous or purulent discharge and sometimes fever. The wound shows slough or granulation tissue.

• Open wound edges with exposed tissue.
• Tender wound with foul discharge in infection.
• Differential diagnosis: infection, haematoma, retained swab, rectovaginal fistula, sphincter breakdown, necrotising fasciitis, wound dehiscence without infection.
• Complications: infection, abscess, delayed healing, scarring, dyspareunia, rectovaginal fistula, anal incontinence, chronic perineal pain.

The approach is examination of the depth and cause of breakdown.

• Inspect with good light; measure the length and depth of the gap; probe gently for extent; digital rectal examination for sphincter and rectal mucosa.
• Temperature, pulse; wound swab for culture if discharge; full blood count, C-reactive protein, glucose.
• Ultrasound for collection; endo-anal ultrasound where available if the sphincter is suspected.
• Check haemoglobin and nutrition.

The principle is to treat infection, clean and encourage healing, and repair later if the gap is large.

• Supportive: irrigate with sodium chloride 0.9 percent twice daily; sitz baths with warm water 3 times daily; keep dry and expose to air; remove loose sutures; high fibre diet and fluids; protein rich diet; glucose control; stop smoking; breastfeeding continues.
• Pharmacological: amoxicillin-clavulanate 625 mg oral 8-hourly for 7 days when infected; ceftriaxone 2 g IV once daily plus metronidazole 500 mg IV 8-hourly for severe infection until afebrile for 48 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 days; lactulose 15 mL oral 12-hourly; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); ferrous sulphate 200 mg oral 8-hourly for 3 months if anaemic; lignocaine 2 percent gel to the area before cleaning.
• Procedures: secondary repair under anaesthesia after 6 to 14 days when the wound is clean, free of infection and granulating; debridement of dead tissue; delayed repair at 3 months for a large defect or sphincter involvement; healing by secondary intention for small gaps.
• Special groups: diabetic women need insulin to keep glucose below 10 mmol/L; women with sphincter breakdown or fistula need repair by a trained surgeon.
• Red flags: spreading redness, fever above 38 degrees Celsius, foul pus, dusky skin, leaking stool or flatus from the vagina, severe pain.
• Follow-up: wound review every 3 to 4 days until healed; review at 1 week, 2 weeks and 6 weeks; pelvic floor and anal function review at 6 weeks.