A post-cesarean wound infection is a bacterial infection in the surgical incision. This infection can develop after an abdominal (cesarean or C-section) delivery. The infection occurs in about 3-6 percent of women who have a cesarean delivery. In high-risk cases and developing countries, surgical site infection rates can be much higher (15-75 percent) (Habib, 2002). Women who develop a post-cesarean wound infection usually have a slight fever (100.5 to 103 F), wound sensitivity, and lower abdominal pain.
Some patients are more likely than others to get a post-cesarean wound infection. High-risk patients include those who:
- are obese
- have diabetes or an immunosuppressive disorder (like HIV)
- have chorioamnionitis (infection of the amniotic fluid and fetal membrane) during labor
- are taking steroids (by mouth or intravenously)
- receive a staple suture wound closure
- had fewer than 7 prenatal care visits
- previously had a C-section delivery (Gilbert, et al., 2012)
- experienced an emergency C-section
- did not receive cautionary antibiotics or pre-incision antimicrobial care (Owens, et al. 2009)
- experienced a long labor or surgery
- had excessive blood loss during labor, delivery, or surgery
- do not follow proper steps for wound care after leaving the hospital
If you have had a cesarean section, monitor the appearance of your wound and follow postoperative instructions closely. If you are unable to see the wound, have a loved one check the wound every other day to watch for warning signs of a wound infection. In addition to a surgical site infection, having a C-section puts you at risk of other problems, such as blood clots. Do not ignore any signs of illness.
Call your doctor for advice or seek medical care if you have any of these symptoms after your release from the hospital:
- severe abdominal pain, redness, or swelling of the wound
- pus and discharge from the incision site
- pain at the incision site that does not go away or gets worse
- fever higher than 100.4 F
- painful urination or foul-smelling vaginal discharge
- bleeding that soaks a feminine pad within an hour or that contains large clots
- leg pain or swelling
Some C-section wound infections are taken care of prior to being discharged from the hospital. However, many do not arise until women have left the hospital. C-section wound infections usually appear within the first couple of weeks after delivery, so many are diagnosed at follow-up visits with the obstetrician or gynecologist.
Wound infections are diagnosed by the appearance of the wound, healing progress, the presence of common infection symptoms, and the presence of bacteria strains. To find out what type of problem you have, your doctor may have to open the wound. If pus is draining from the incision, the doctor may use a needle to remove pus from the wound. The fluid may be sent to a lab, where any bacteria can be identified.
A post-cesarean wound infection may take one of two forms: wound cellulitis or a wound abscess. C-section wound infections may also spread and cause problems with organs, the skin, the blood, and local tissue.
Cellulitis of the wound is typically caused by staphylococcal and streptococcal organisms. These strains are part of the normal bacterial found on the skin. With cellulitis, infected tissue under the skin becomes inflamed. Redness and swelling spread quickly from the surgical incision outward to the adjacent skin. The infected skin is usually warm and tender to the touch. In general, pus is not present in the incision itself.
A wound abscess or abdominal abscess is caused by the same bacteria as wound cellulitis and multiple other bacteria. Infection at the site of the surgical incision leads to redness, tenderness, and swelling along the edges of the incision. Pus collects in a tissue cavity caused by the bacterial infection. Most wound abscesses also ooze pus from the incision. Abscesses can form at the uterine incision, scar tissue, ovaries, and other tissue or nearby organs when an infection is present after surgery.
Some bacteria that can cause a wound abscess can also cause endometritis (a post-cesarean section irritation of the uterine lining that can cause abnormal bleeding, discharge, swelling, abdominal pain, fever, and malaise).
Other common infections after a C-section include thrush and urinary tract or bladder infections. Thrush is caused by a fungus (Candida) normally present in the human body. This fungus can cause an infection in people taking steroids or antibiotics and in people with weakened immune systems. The fungus can cause a vaginal yeast infection or fragile red and white sores in the mouth. Medication is not always needed, but an anti-fungal drug or mouthwash may help you fight the infection.
Urinary tract and bladder infections can be caused by catheters used during a hospital stay. They are usually the result of E. coli bacteria and treatable with an antibiotic. These infections can cause a burning feeling during urination, a frequent need to urinate, and a fever.
These problems are not always present in women who have an incision site infection, but bacteria in one location may spread to other areas of the body. If bacteria spread, it can cause multiple infections.
If you have wound cellulitis, antibiotics should clear up the infection. Antibiotics specifically target staphylococcal and streptococcal bacteria. In the hospital, wound infections are usually treated with intravenous antibiotics. If you are being treated as an outpatient, you will probably be given oral antibiotics..
Wound abscesses are also treated with antibiotics. In addition, wound abscesses require special care:
- The incision is opened throughout the infected area, and the pus is drained.
- The incision is washed with saline or an antiseptic solution and packed with sterile gauze. This prevents pus from accumulating again.
- The incision is inspected to be certain that the fascia (the fibrous layer that covers the abdominal muscles) has not been disrupted and that the bowel is not rupturing into the incision.
After several days of antibiotic treatment and irrigation, the incision is checked again. At this point, your doctor will decide whether the wound can be closed again or if it must be left open and allowed to heal on its own.
Normal incision healing takes four to six weeks (Mayo Clinic, 2012). A post-cesarean wound infection detected prior to hospital discharge will lengthen your hospital stay by at least a few days. This will increase your hospitalization costs. If you have already been sent home by the time your C-section infection occurs, you may need to be readmitted to receive intravenous drugs or further surgery. Some C-section infections can be treated on an outpatient basis with extra doctor visits and antibiotics.
In some cases, a wound infection can cause serious complications. Examples include necrotizing fasciitis (a bacterial infection that destroys healthy tissue), rupturing of the fascia or dehiscence of the wound (opening of the skin and tissue layers sutured after the surgery), or evisceration (opening of the wound, with the bowel coming through the incision). Women who develop these problems will require surgical repair . They will require a much longer recovery time. In rare cases, complications may be fatal.
Some surgical site infections are out of the control of the patient. However, women who have had a C-section can take certain steps to reduce their chances of getting an infection. In addition, women who are thinking about an elective C-section delivery can take precautions to avoid a C-section wound infection.
If you have already undergone a C-section:
- Follow the wound care instructions and postoperative medication directions given by your physician or nurse. If you have questions, do not hesitate to call your doctor.
- If you have been given antibiotics, do not skip doses or stop using them until you have finished the entire course of treatment.
- Clean your wound and change the wound dressings regularly.
- Do not wear tight clothing or apply body lotions over the wound.
- Ask for advice on holding and feeding the baby to avoid uncomfortable pressure on your wound, particularly if you plan to breastfeed.
- Try to avoid allowing skin folds to cover and touch the incision area.
- Take your temperature with an oral thermometer if you feel feverish. Seek medical care or call your doctor if you experience a fever over 100 F.
- Seek medical care for incision sites that become more painful, swollen, pussy, or that spread redness to skin further from the incision site.
If you have not yet undergone a C-section:
- Maintain a healthy weight. If you are not yet pregnant, exercise and follow a healthy diet to avoid pregnancy with an obese body mass index (BMI).
- Opt for a vaginal, spontaneous labor and delivery if possible. Women with vaginal deliveries – even after a previous C-section – are less likely to get postpartum infections. In some cases, however, vaginal birth after C-section (VBAC) is dangerous because of other risks to the mother and baby. Discuss your personal risk factors with your doctor.
- Request pre-incision antibiotics and thorough wound care instructions from hospital staff (KRAMES Patient Education). Ask to be checked for signs of infection before you go home from the hospital.
- Treat pre-existing conditions that cause you to be immunocompromised. If you have an existing infection or illness, try to have it treated prior to pregnancy or before your due date (if it is safe for you and the baby to do so).
- Ask for the safest suture method for wound closure (Basha, et al., 2010). If your doctor plans to use staples, ask if an alternate method is available (such as stitching).