Rebecca B. Singson, M.D, FPOGS, FPCPC

After delivery, having a new baby to care for often precedes taking care of ourselves. Sometimes, the medical staff fail to give you the instructions for proper wound care that you neglect to care for your incision whether after a normal deliver or a C-section. The following describes the proper care for your wound post-episiotomy (the incision made on the perineum after a normal delivery) and post Cesarean section.

TYPES OF CLOSURE MATERIALS AND DRESSINGS

There are several ways your doctor will close the wound following a Cesarean section. It may be closed sutures with staples, Steri-strips (small strips of bandages running across the incision line to tape the edges together), and the latest is Super Glue. Staples and Steri-Strips are the least reactive since it only keeps the wound edges together without causing much surrounding tissue reaction. Episiotomies in the perineum are usually closed with sutures, never staples nor Steri-Strips since these are not ideal as the patient continues with her toilet function. There have been reports on the use of cyanoacrylate or Super Glue for wound closure. It works to make wound edges stick by a chemical reaction called polymerization, which produces heat. However, since it uses methyl alcohol, it has a pronounced heating action when it contacts tissue and may even produce burns if the glue contacts a large enough area of tissue. The glue is applied to bridge over the closed edges; it should not be used within the wound (on raw surfaces). The only currently FDA approved adhesives suitable for use as suture alternatives are: (intended for topical skin closure when deep sutures have been placed) Histoacryl Blue (butyl based) (Davis & Geck) and Tissu-Glu (isobutyl based) (Medi-West Pharmaceuticals) are sold for human use.

Immediately after the surgery a form of dressing will be applied over your wound which may be a pressure dressing with thick gauze and some bandage or just a sterile gauze and bandage or a waterproof dressing (brand name Tegaderm or Opsite) that can allow the wound to “breathe” at the same time. In the first 72-96 hours, it is essential to keep the wound dry and clean. Your wound will be inspected to determine if there is any evidence of dehiscence or infection. No dressings are ever applied on perineal wounds.

HOW SHOULD I TAKE CARE OF MY WOUND?

The amount of care your surgical wound will require will be very minimal compared to the amount of care you will be giving your newborn. You may be asked either to keep the wound open or unbandaged. It is best to clean the wound daily with a cotton swab and hydrogen peroxide followed by povidone iodine antiseptic. Make sure you wash your hands thoroughly with soap and water prior to handling your post-op wound. If the wound has some bruising (like a black and blue) around it with minimal swelling, this may be normal from blood that collected during closure. But if there is significant swelling, redness, pain, wound discharge, fever or the wound edges are opening, contact your doctor immediately. That may be a sign of infection and or wound dehiscence.

For an episiotomy wound, one may use a povidone iodine wash (like Betadine vaginal wash) for at least a week post partum then switch to a regular vaginal wash after your doctor has inspected that the wound is on its way to healing.

There have been instances where a blood vessel was not ligated or the ligature loosened up causing an accumulation of blood forming a hematoma in the perineum. If you have any significant pain and swelling especially on one side of the perineum, call the attention of your doctor so your wound may be re-examined.

IS IT NORMAL FOR THE WOUND TO ITCH?
Most of the time, itchiness comes from the dressing applied over the wound to the point where a rash may even occur if the patient has sensitive skin and developed an allergy to her bandage. A mild steroid cream like momethasone can take care of this. Itchiness may also come from the Steri-Strips although I have yet to see anyone develop any allergy to this. Itchiness may also come when the wound starts to heal. The important thing to remember is not to scratch it since you may introduce infection with your nails.

If the episiotomy wound itches, consider a fungal infection in the perineum. This may be common due to the immunocompromised state of the mother, antibiotics given during or after delivery to cure UTI or prophylaxis against infection especially if there had been fecal contamination in the process of delivery.

WHEN CAN I BATHE?
It is a fallacy that postpartum women should not bathe. Some Chinese or Indian elders prohibit their daughters from bathing for a specified number of days to prevent post partum complications. There is no scientific evidence to support this practice. If at all, it may cause more harm than good since the bacteria have a chance to build up.

Different surgeons and obstetricians have different opinions about when to bathe the wound. It is safest to keep the wound covered with a waterproof dressing to prevent it from getting wet while you bathe. A week after discharge from the hospital, you will usually be asked to return to your doctor for wound inspection after which you may bathe if no problem exists with the wound. Soaking in the tub is not allowed until 6 weeks postpartum when the wound is completely healed.

After an episiotomy from a normal delivery you may bathe anytime you can walk normally without feeling dizzy. Otherwise you may lose your balance and slip in the bathroom.

DOES IT HURT TO REMOVE THE CLOSURE MATERIALS?

Most of the time, Cesarean sections and episiotomies are closed with absorbable sutures that need not be removed. Sometimes, there may be a knot on one side of the incision but this may be snipped after a week or just be allowed to fall in time.

Staples, Steri-strips and interrupted sutures may be removed 7-10 days from surgery. There may be some discomfort but not pain associated with the removal of any of these closure materials. Usually the discomfort or pain is from removing the sticky bandage. One can use a cotton ball with alcohol and apply it underneath the dressing to facilitate separating the dressing from the skin.

Although caring for your post-partum wound is an important step to insure a good outcome, remember that your immune system is what will heal your wound. How you eat and what supplements you take can do much to help you strengthen your immune system at a time when you have very little sleep since you are caring for your newborn. A good wound outcome depends on how you have been caring for your body throughout your pregnancy. Bear in mind that a healthy body will have a good wound outcome with minimal complications.