Episiotomy dehiscence is most commonly associated with infection. Other factors include coagulation disorders, smoking, and human papillomavirus infection (Ramin, 1994). Local pain and dysuria, with or without urinary retention, are frequent symptoms. Ramin and colleagues (1992), evaluating a series of 34 women with episiotomy dehiscence, reported that the most common indings were pain in 65 percent, purulent discharge in 65 percent, and fever in 44 percent. In extreme cases, the entire vulva may become edematous, ulcerated, and covered with exudate.
Vaginal lacerations may also become infected directly or by extension from the perineum. he epithelium becomes red and swollen and may then become necrotic and slough. Parametrial extension can lead to lymphangitis. Cervical lacerations are common but seldom are noticeably infected, which may manifest as metritis. Deep lacerations that extend directly into the base of the broad ligament may become infected and cause lymphangitis, parametritis, and bacteremia.
Treatment. Infected episiotomies are managed similar to other infected surgical wounds. Drainage is established, and in most cases, sutures are removed and the infected wound debrided. In women with obvious cellulitis but no purulence, close observation and broad-spectrum antimicrobial therapy alone may be appropriate. With dehiscence, local wound care is continued along with intravenous antimicrobials.
Early Repair of Infected Episiotomy. Hauth and colleagues (1986) were the irst to advocate early episiotomy repair after infection subsided, and other studies have confirmed the eicacy of this approach. Hankins and coworkers (1990) described early repair in 31 women with an average duration of 6 days from dehiscence to repair. All but two had a successful repair. Each of the two women with failures developed a pinpoint rectovaginal istula that was treated successfully with a small rectal lap. With episiotomy dehiscence due to infection, Ramin and coworkers (1992) reported successful early repair in 32 of
TABLE 37-3. Preoperative Protocol for Early Repair of Episiotomy Dehiscence
Open wound, remove sutures, begin intravenous or general anesthesia may be necessary for the first
Scrub wound twice daily with a povidone-iodine solution
Closure when afebrile and pink, healthy granulation tissue 34 women (94 percent), and Uygur and colleagues (2004) noted a similarly high percentage. Rarely, intestinal diversion may be required to allow healing (Rose, 2005).
Before performing early repair, diligent preparation is essential as outlined in Table 37-3. The surgical wound must be properly cleaned and cleared of infection. Once the surface of the episiotomy wound is free of infection and exudate and covered by pink granulation tissue, secondary repair can be accomplished. The tissue must be adequately mobilized, with special attention to identiy and mobilize the anal sphincter muscle. Secondary closure of the episiotomy is accomplished in layers, as described for primary episiotomy closure (Chap. 27, p. 531). Postoperative care includes local wound care, stool softeners, and nothing per vagina or recrum until healed.