Postpregnancy Genital Tract and Wound Infections

Nell Tharpe, CNM, CRNFA, MS

Disclosures

J Midwifery Womens Health. 2008;53(3):236-246. 

In This Article

Infection of the Perineum

Maintaining intact vaginal and perineal tissues is a common goal in midwifery practice. In a study evaluating the effect of second-stage midwifery practices on perineal trauma, a group of 12 experienced midwives maintained an intact genital tract in women they attended in more than 23% of vaginal births, and had only minimal trauma (i.e., trauma that did not require suturing) in 73% of vaginal births.[43] Maintaining genital tract tissue integrity is particularly important for women who have factors that predispose to infection, such as diabetes mellitus. Evidence-based recommendations for the performance of episiotomy are restricted to maternal or fetal indications rather than routine performance of this procedure.[44]

Most women who give birth vaginally and require perineal repair experience rapid and uneventful perineal healing. However, a small subset of women experience significant pain and a delay in healing secondary to infection. Postpartum perineal infection is most often associated with midline episiotomy, third- or fourth-degree laceration or episiotomy extension, and vaginal hematoma.[45]

The differential diagnosis of perineal infection is based on the presence of either purulent drainage from the episiotomy or laceration site, or the presence of a perineal abscess.[28] Evaluation includes assessment of the presence and level of perineal pain, and examination for approximation of tissues and the presence of edema, redness, ecchymosis, temperature elevation, and wound discharge.[46,47] Women with perineal infections require a rectovaginal examination to rule out occult rectal injury with its devastating potential for rectovaginal fistula formation. Occult rectal injury has been noted in the absence of episiotomy.[29] The rectovaginal examination also provides an opportunity to assess for the presence of inadvertent rectal stitches, undetected rectal injury that may result in fistula formation, or the presence of a hematoma.

Women with localized perineal infection, as evidenced by heat, redness and erythema and an absence of systemic signs or symptoms, or those with superficial breakdown of a first- or second-degree repair, are commonly treated with expectant management and perineal wound care, such as frequent sitz baths and meticulous attention to perianal hygiene.[44] In the absence of co-morbidities, antibiotic therapy is rarely indicated for these women.

For women with serious perineal wound infection, as evidenced by the presence of perineal abscess, purulent drainage, systemic symptoms and/or extensive repair breakdown, prompt referral for evaluation and treatment is indicated. Initiation of antibiotic therapy and surgical debridement may be required to remove devitalized tissue.[44] Severe systemic symptoms may be an indication of sepsis from organisms such as community-acquired methicillin-resistant S aureus, which is derived from an infected episiotomy site.[40]

The recommended surgical treatment of perineal wound infections consists of taking down the repair; removal of all suture material; and thorough debridement of infected or necrotic tissue under local, regional, or general anesthesia. Careful inspection is performed to identify the development or presence of necrotizing fasiitis.[48] Unlike infected abdominal incisions, which are left to close by secondary intention, the early closure of perineal wounds may be attempted in order to maintain perineal integrity.[44,45]

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