What is perineal wound breakdown?
Stitches to repair an episiotomy or tear usually dissolve within 10 to 15 days. However, somewhere between 4% to 20 of stitches break down earlier than this.. In 80% of cases, this breakdown is caused by an infection but it can also be caused by pressure on the stitches which leaves an open or gaping wound.
Infection is responsible for 80% of wound breakdowns.
Symptoms that this is happening include:
- An increase in pain
- An increase in bleeding
- Pus
- Stitch material coming away
- Feeling unwell
This research paper by Childs et al. 2020 includes photographs of perineal wound breakdown on page s8 (http://shura.shu.ac.uk/id/eprint/27557).
Treatment options
For most women, the wound is left to heal naturally, this is called healing by secondary intention or it might also be referred to as ‘expectant’ management. The wound will heal by generating new tissue from the bottom of the wound upwards, the new tissue will look red and may bleed. This type of healing can take several weeks and results in persistent pain and discomfort at the wound.
It is also possible for the wound to be re-stitched once the infection has cleared. The recommended surgical treatment of perineal wound infections consists of removing any remaining stitches and removing any damaged tissue under local, regional or general anaesthesia.
There is a lack of research into which of these approaches has the best outcome.
Self-management tips
- Keep the area as clean and dry as possible
- After washing do not rub the area with a towel, let it dry naturally
- Wash with water only
- Change your maternity pad regularly. Until the wound has closed only use maternity pads. Plastic based sanitary pads can cause sweating which could increase the risk of infection
- Allow air to circulate to the wound by not wearing underwear
- Restrict baths to 10 minutes to prevent the edges of the wound softening
- Washing the perineum regularlu with a cup or jug of water, especially after using the toilet
- Do not sit directly on the wound as this can restrict the blood flow. Change your position regularly
- Do pelvic floor exercises to encourage blood flow to the area
- Try sitting on two small cushions on either side of your bottocks so your wound sits in between the cushions to reduce the pain
- Avoid constipation. Consider taking a stool softener to prevent hard, dry poo which could create further pain and discomfort
- Use a stool when going to the toilet to keep your knees higher than your hips, lean forwards so your elbows rest on your knees
- Support your perineum when you go to the toilet using a pad of toilet paper, a clean maternity pad or clean flannel when you have a poo
- In the first 48 hours after delivery regular rest is recommended to allow the recovery of the injured pelvic floor muscles and reduce swelling. Activities that increase intra-abdominal pressure should be avoided for 6-12 weeks after birth
- Good nutrition is important to encourage healing and good bowel habits
Complications
Overgranulation
Perineal wounds can overheal and lead to raised patches of tissue. This tissue can be painful and bleed. Granulation tissue may settle on its own or it may need to be treated with silver nitrate or if this treatment is not effective surgery may be needed.
This webpage includes a photo of granulation tissue (https://www.woundsource.com/blog/getting-know-granulation-tissue-and-what-it-means-wound-care)
Haematoma
A haematoma is a blood clot which can form underneath the wound. This can impede the healing of the wound so it is important that it is identified early.
Symptoms include:
- Intense pain
- Inability to sit directly onto the wound
- Feeling like you are sat on a ball
- Difficulty walking
Sepsis
Infected perineal wounds can lead to systemic infection whereby sepsis and septic shock may occur.
Sepsis can initially look like flu, gastroenteritis or a chest infection.
The UK Sepsis Trust recommends that you seek medical help urgently if you develop any of these signs:
- Slurred speech or confusion
- Extreme shivering or muscle pain
- Passing no urine (in a day)
- Severe breathlessness
- It feels like you’re going to die
- Skin mottled or discoloured
Impact on maternal mental health
Perineal wound breakdown can cause psychological trauma that women can experience for many years following the birth. Women may feel unable to bond with their baby due to the pain and discomfort they experienced following the birth. The ability to breastfeed can also be affected due to discomfort experienced whilst sitting for long periods. Being unable to leave the house can lead to feelings of isolation, low mood and postnatal depression.
Organisations such as the Birth Trauma Association (https://www.birthtraumaassociation.org.uk/), MASIC (https://masic.org.uk/) and PaNDAS Foundation (https://pandasfoundation.org.uk/) provide much needed support in this area.
References
Cardiff and Vale University Helath Board (2011). ‘Perineal wound care’. Access via: http://www.cardiffandvaleuhb.wales.nhs.uk/sitesplus/documents/1143/perineal%20wound%20care%20Jan11.pdf
Childs, C., Sandy-Hodgetts, K., Broad, C., Cooper, R., Manresa, M., & Verdú-Soriano, J. (2020). Birth-Related Wounds: Risk, Prevention and Management of Complications After Vaginal and Caesarean Section Birth. Journal of Wound Care, 29(Sup11a), S1-S48. Access via: http://shura.shu.ac.uk/27557/
Dudley, L., Kettle, C., & Ismail, K. ‘Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth.’ Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD008977. DOI: 10.1002/14651858.CD008977.pub2. Access via:https://www.cochrane.org/CD008977/PREG_re-stitching-broken-down-perineal-the-area-between-the-vagina-and-back-passage-wounds-compared-with-non-stitching
Dudley, L., Kettle, C., Carter, P., Thomas, P., & Ismail, K. (2012). ‘Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): protocol for a pilot and feasibility randomised controlled trial.’ BMJ open, 2(4), e001458. Access via: https://bmjopen.bmj.com/content/2/4/e001458
Kamel, A., & Khaled, M. (2014). Episiotomy and obstetric perineal wound dehiscence: beyond soreness. Journal of Obstetrics and Gynaecology, 34(3), 215-217. Access via: https://www.tandfonline.com/doi/full/10.3109/01443615.2013.866080
Naughton, B. (2021). ‘Getting to Know Granulation Tissue and What it Means for Wound Care.’ Access via:
https://www.woundsource.com/blog/getting-know-granulation-tissue-and-what-it-means-wound-care
Royal College of Obstetricians & Gynaecologists (2022). ‘Perineal wound breakdown:
Overview of perineal wound breakdown and what to expect.’ Access via: https://www.rcog.org.uk/for-the-public/perineal-tears-and-episiotomies-in-childbirth/perineal-wound-breakdown/
The UK Sepsis Trust (2022). ‘What is Sepsis?’. Access via: https://sepsistrust.org/about/about-sepsis/