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Abstract: Wound disruption after cesarean section is a common complication that may cause additional stress postpartum. The treatment options are secondary closure with the risk of reinfection or healing by secondary intention. In some cases, negative pressure wound therapy can be a useful alternative. Three cases of superficial wound disruption after cesarean section performed for failure to progress are presented. Successful closure with negative pressure wound therapy was achieved after conventional surgical treatment options were exhausted or unacceptable to the patients. Negative pressure wound therapy is a safe, feasible, and well-tolerated treatment option.
After cesarean section, patients commonly experience wound disruption, which leads to additional stress postpartum. As an alternative to secondary closure or healing by secondary intention, negative pressure wound therapy may be useful. The authors present 3 cases of superficial wound disruption treated with negative pressure wound therapy after cesarean section was performed for failure to progress.
Case Reports Case 1. A 30-year-old woman pregnant with her first child at 41+1 weeks of gestation was admitted to the labor ward with regular contractions. The patient’s pregnancy had been uneventful. In the labor ward, the patient failed to progress into the second stage of labor, and a cesarean section was performed. Antibiotic prophylaxis (amoxicillin/clavulanate potassium 2.2 g intravenously) was administered due to positive group-B-streptococcus (GBS) carrier status. A healthy male infant was born. On the fifth day, antibiotic treatment was started for a suspected wound infection with pain, localized heat, and redness. On the ninth day, the wound disrupted spontaneously and prompted healing by secondary intention. The patient refused surgical closure as well as further conservative treatment. Negative pressure wound therapy (NPWT, V.A.C.® Therapy™, KCI, San Antonio, Tex) was initiated with a subatmospheric pressure of 125 mmHg on a continuous cycle. In an outpatient setting, treatment was ceased after 25 days when the wound was fully closed.
Case 2. A 33-year-old woman pregnant with her second child at 41+2 weeks of gestation was admitted for labor induction with prostaglandin due to preeclampsia. After 2 hours in the second stage with signs of fetal distress and no progress, a cesarean section was performed. Antibiotic prophylaxis (amoxicillin/clavulanate potassium 2.2 g intravenously) was administered due to positive GBS carrier status and the detection of Ureaplasma urealyticum. A healthy male infant was born. On the second day, antibiotic treatment for a urinary tract infection was started. On postoperative Day 7, the skin suture was removed in an outpatient setting. Upon removal, the wound disrupted and emptied a seroma. Since the wound appeared clean, treatment with NPWT was started, initially only to protect and prepare the wound for surgical closure. The patient, however, was completely satisfied with the treatment and refused the additional surgery. The bacterial culture was negative. The patient continued on continuous 125-mmHg subatmospheric pressure for 41 days, at which point the treatment was stopped. The wound was fully closed, and the result was aesthetically satisfactory.
Case 3. A 29-year-old woman pregnant with her first viable child at 40+1 weeks of gestation was referred to the authors’ facility from a birth center because the patient failed to progress into the second stage of labor. A proposed cesarean section was refused. However, after an additional 2 hours with failure to progress, the patient agreed to have a cesarean section, which was routinely performed under antibiotic prophylaxis (amoxicillin/clavulanate potassium 2.2 g intravenously). The patient was in negative GBS carrier status. A healthy male infant was born. Six hours later, the wound disrupted spontaneously; it was closed again immediately in the operating room with single stitches using a monofilament suture 2.0 (Prolene, Ethicon Inc., Somerville, NJ). Antibiotic treatment was started and given for 5 subsequent days. Nine days later, the patient presented with a fever and an irritated, painfully swollen wound. After removal of the stitches, the wound produced a purulent discharge. The patient refused surgical treatment. Therefore, NPWT was started without additional antibiotics. The bacterial culture from the last swab was positive for coryneform bacteria. After 37 days of continuous application of a subatmospheric pressure of 125 mmHg, the wound was fully closed with an acceptable aesthetic result.
Discussion Abdominal wound disruption occurring hours or days after abdominal surgery can be defined as a separation of the wound edges exceeding 1 cm in width and/or the development of a hematoma, seroma, or infection in the tissue between the rectus fascia and the skin.1 In a study by Martens et al,2 only 1.7% of wound disruptions presented without infection. The incidence rate varies between 1.6% and 16% in the literature.3
Treatment options for post-cesarean superficial wound disruption include healing by secondary intention and superficial wound closure. The former method considers modern wound care factors, such as the phase of healing, volume of the exudate, and presence of necrotic tissue. A wide range of wound care products is available to maintain an optimal physiological environment for the wound to heal. Examples of such products include non-toxic solutions for cleansing, enzymatic debriding agents for removing necrotic tissue, and highly absorbent dressing material for controlling drainage.4 Healing by secondary intention is a time consuming process that leads to prolonged hospital stays and additional costs, even in an outpatient setting.5 In 2 studies, the mean time required for healing by secondary intention was 61 to 71 days, and for secondary closure, the mean was 15.8 to 17 days.5,6 With the latter option, the wound is surgically closed as soon as there are no signs of exudate or necrotic debris and granulation tissue is forming. The waiting time varies from 2 to 4 days.5,6 The main problem is the potential for reinfection, which leads to re-opening and usually to healing by secondary intention. The incidence rate of reinfection after secondary closure in post-cesarean wound disruption is poorly documented; a rate of 14% is reported in a mixed group of obstetrical and gynecological patients.5
An alternative therapeutic option could be NPWT, which is used in surgery to treat chronic (eg, diabetic, dysvascular) and pressure ulcers; acute, subacute, traumatic, and dehisced wounds; meshed grafts; fresh and compromised flaps; or burns. The effects of NPWT on wounds are the evacuation of localized wound edema, reduced bacterial colonization, increased local blood flow, better oxygenation, and stimulation of granulation-tissue growth.
The application of NPWT starts with placing a skin-protection foil around the wound margins. A fitted piece of polyurethane foam is then inserted to cover the entire wound bed. A tube is placed on top of the foam and an airtight, clear, adhesive foil secures both foam and tube over the wound. With the help of a computerized vacuum pump, any wound fluid is evacuated into a small container. The dressing is changed every 2 to 3 days, depending on the type of foam used and position of the wound.
The authors treated 3 cases of post-cesarean wound disruption using NPWT. To the authors’ knowledge, this is the first report on the specific use of NPWT in superficial wound disruptions after cesarean sections. In an already stressful postpartum period with recovery from delivery, caring for a newborn, and hormonal fluctuations, a wound disruption further complicates the difficult setting for the patient and her care providers. In all 3 cases, the incision disrupted a length of 10 cm or more and reached the rectus fascia. All wounds were successfully closed after 25, 41, and 37 days, respectively, without complications or adverse effects, such as pain, bleeding, or infection. Both the course of treatment and the aesthetic results were well accepted by the patients. Problems with breastfeeding or caring for their newborns during treatment with NPWT were not reported.
Conclusion Negative pressure wound therapy is a valuable alternative in selected cases when a surgical closure was not indicated, as in Case 3, or not desired by the patient, as in Case 1 and Case 2.
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