Infected Episiotomy

Infected episiotomy is infection of the surgical cut made in the perineum at birth, with redness, swelling, pain, pus and fever. It occurs in about 1 to 3 percent of episiotomies and is more common in prolonged labour, instrumental delivery, haematoma and poor hygiene. It matters because infection breaks down the repair, delays healing and can involve the anal sphincter or spread deeply.

• Risk factors: instrumental delivery, prolonged labour, diabetes, obesity, anaemia, haematoma, rupture of membranes for 18 hours or more, poor perineal hygiene, tight or contaminated sutures.
• Usually appears 2 to 5 days after birth.
• Most respond to opening the wound and antibiotics.

Women have increasing perineal pain, difficulty sitting, swelling, redness, foul discharge, and fever. The episiotomy wound is hot, tender and may be gaping with pus.

• Throbbing pain with oedema.
• Discharge from the wound.
• Differential diagnosis: perineal haematoma, normal wound pain, retained swab, perineal abscess, necrotising fasciitis, urinary tract infection, endometritis, ischiorectal abscess.
• Complications: wound breakdown, abscess, necrotising fasciitis, rectovaginal fistula, sphincter injury, sepsis, dyspareunia, chronic pain.

The approach is examination of the wound with a rectal examination.

• Inspect the wound with good light; note extent of redness, pus, necrotic tissue and gaping; probe gently; digital rectal examination for sphincter integrity.
• Temperature, pulse and blood pressure; swab for Gram stain and culture; full blood count, C-reactive protein, glucose.
• Ultrasound for collection; CT for suspected deep or necrotising infection.
• Urine dipstick and culture.

The principle is to open and drain the wound, clean it, give antibiotics and defer re-suturing until the wound is clean.

• Supportive: remove infected sutures and open the wound; irrigate with sodium chloride 0.9 percent twice daily; sitz baths with warm water 3 times daily; keep dry; ice in the first 24 hours; a cushion for sitting; lactulose; breastfeeding continues.
• Pharmacological: amoxicillin-clavulanate 625 mg oral 8-hourly for 5 to 7 days; severe infection: ceftriaxone 2 g IV once daily plus metronidazole 500 mg IV 8-hourly until afebrile for 48 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to complete 7 days; necrotising infection: meropenem 1 g IV 8-hourly plus clindamycin 900 mg IV 8-hourly plus vancomycin 15 mg/kg IV 12-hourly; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); diclofenac 50 mg oral 8-hourly for 3 days with food if no contraindication; lactulose 15 mL oral 12-hourly.
• Procedures: drainage of abscess; surgical debridement; urgent wide debridement for necrotising infection; secondary repair after 6 to 14 days when the wound is clean and granulating, or at 3 months for a large defect.
• Red flags: dusky or blistering skin, crepitus, fever above 39 degrees Celsius, severe pain, leaking stool or flatus from the vagina, hypotension.
• Follow-up: wound review every 2 to 3 days until healed; review at 1 week and 6 weeks; advise on hygiene; counselling about the next birth and the need for episiotomy only when indicated.