Don’t bust your stitches - support your wound!

by Leonie Rastas, Registered Nurse and Registered Midwife, Queensland, Australia

All surgical wounds need support during sudden movement such as, coughing, sneezing, vomiting and even hearty laughter to avoid wound breakdown.

Surgical wounds are at risk of complications, and we can do much to help prevent them. One complication is when stitches breakopen. The medical term for broken or busted stitches after an operation is surgical wound dehiscence (SWD)

The incidence of wound breakdown after caesarean birth is significant and women need to have knowledge and understanding to help reduce their risks. The incidence breakdown after c-section is 1.9%–7.6%. as reported in the World Union of Wound Healing Specialist 2018, Consensus document.

SWD can occur between 1and 20 days after surgery but more commonly occurs between 4 and 14 days. SWD can occur without warning and be very frightening.

The three main causes SWD

• Technical issues with the closure of the incision – e.g., unravelling of suture knots
• Mechanical stress – e.g., coughing can cause breakage of the sutures or rupture of the healing incision after suture or clip removal/reabsorption
• Disrupted healing – e.g., due to other conditions or treatments that hamper healing, or as a result of a surgical site infection (SSI) ¹

General risk factors for SWD

• Vertical incision
• Stapled wound closure
• Chorioamnionitis
• Multiple caesarean sections
• Operative blood loss >1.5litres
• Pre-eclampsia
• African-American race

SIGNS of Probable SWD

• signs of inflammation beyond the time and extent expected for normal healing e.g.,
• more exaggerated redness along stitch line
• swelling around the incision
• warmth and pain extending beyond post-operative day 5
• palpation area surrounding incision may reveal warmth and a collection of fluid under some or all of the incision could be a collection of blood, clear body fluid, or pus
• a sudden increase in pain or discharge of blood and clear fluid mixed.
• Areas of separation wound margins varying from tiny ‘pin pricks’ to larger gaping areas to the entire length and depth of the incision.
• If the incision opens into a body cavity, SWD may result internal organs protruding outside the wound opening.
• Sutures or clips may be visible in the separated area and may be broken.
• In patients with abdominal incisions, dehiscence may follow an episode of retching, vomiting or coughing.
• Patients may describe a sensation of pulling or ripping in the area of the incision or the feeling that something has given way.¹

Keys to prevention of burst stitches (SWD)

• Support the wound during movement with a rolled towel, cushion or other wound splint
• Avoid mechanical stress, heavy lifting, sudden movements,driving
• Address tension on sutures & staples
• Identifying patients at risk & modifying risk of SWD and SSI
• Post-operative monitoring for healing progress and signs of infection or possible dehiscence.
• Assessment by a healthcare provider if concerned.¹

Consistent, sustainable and comprehensive education after caesarean birth is essential to facilitating uncomplicated healing. An innovative visual tool the ‘Five Guide’ was developed by UK Nurse & Midwife Janine McKnight-Cowan to improve women’s knowledge and understanding of the five-layers involved in caesarean birth and the healing process. The five layers are the skin, fat, muscle, peritoneum and the womb or uterus.²

Equip yourself with knowledge about your surgery

The World Union of Wound Healing Specialists (WUWHS)1 say that education for patient, carer and family regarding management of expectations during the planning, pre-operative and postoperative period is highly recommended as an intervention for the reduction of surgical site complications (SWC). Ask your healthcare provider for information about the risks and signs and symptoms of SWC before your caesarean birth so you can be well prepared.

References

1. World Union of Wound Healing Societies (WUWHS)Wounds International. London. (2018) Consensus Document. Surgical wound dehiscence: improving prevention and outcomes.https://www.woundsinternational.com/resources/details/consensus-document-surgical-wound-dehiscence-improving-prevention-and-outcomes.
2. NHS Derbyshire Community Health Services.(2019) NHS trust. Five Guide, Enhancing Caesarean Recovery. https://www.youtube.com/watch?v=EwbLFdjHH_0

Leonie is a nurse, midwife, author, educator, wife and mother to six adult children all born by C-section. Her own birthing experiences have given Leonie a great sense of empathy for women recovering after caesarean birth and led her to establish ‘Caesarcare’, an online childbirth education service helping women understand and self-manage the postpartum period. Leonie believes all women should be treated with dignity and respect and be given the accurate, research-based risks and benefits of their surgery and information about the recovery process.