SAN FRANCISCO — If a cesarean wound must be opened days after the surgery, one of the best ways to help it heal by secondary intention is to get the patient into the shower, Harriet W. Hopf, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.
Even with the best of care, some cesarean section wounds need to be opened 4–7 days after the surgery, because they either fail to heal or become infected, said Dr. Hopf of the university. Open wounds heal best when you reduce the bacterial load, keep the wound moist, and pay attention to nutrition and perfusion.
A wound requires several elements for good healing—the right amount of inflammation, protein, oxygen (perfusion), and a proper environment. An infected wound is too inflamed and slow to heal. Most infection comes from bacteria on the skin. Rinsing a wound with normal saline doesn't provide enough volume to remove bacteria. The cold saline induces local vasoconstriction, while a warm shower induces local vasodilation, enhancing perfusion of the wound.
“Just get them in the shower” daily, said Dr. Hopf. “It works so well. That's the primary intervention that I make when I see a patient.” Have patients shower with mild soap and not with bacteriocidal products that not only kill bacteria but inactivate white cells and harm granulating tissue, which delays healing.
If you need to open a cesarean wound, usually by that time the patient no longer has an intravenous line or catheter to get in the way of showering. If she's still on an intravenous line, saline lock it, cover it with a Tegaderm dressing, and have her shower, Dr. Hopf said in an interview. If the patient still has a bladder catheter, skip the shower but use a basin of warm tap water and a 60-mL syringe to irrigate the wound.
For women on steroids, which interfere with healing, applying ointment containing vitamins A and D (typically used for diaper rash) will reverse the steroid effect and help pull macrophages into the wound for healing.
Make sure the patient has adequate pain control, which promotes healing by reducing vasoconstriction and enables dressing changes. Optimize perfusion by keeping the patient warm, giving her plenty of fluids, aggressively managing pain and edema, and encouraging smokers to quit.
Wounds need protein to heal, and lactation uses much of the body's protein. Encourage women who've had C-sections to eat plenty of protein.
“It's hard to get the protein to the wound because the protein is going someplace else,” she said. Over-the-counter protein supplements that contain the amino acid arginine can improve wound healing if needed.
Patients deficient in vitamin A, vitamin C, or zinc will heal more slowly. To replenish them, Dr. Hopf recommends a 10-day course of daily vitamin A (25,000 international units) and zinc (220 mg). A larger amount can be toxic. Vitamin C is nontoxic, and all patients with wounds should get 500–100 mg daily.
Try to keep the wound moist and the surrounding skin dry for best healing. Wounds often start off exudating and later become dry, so don't necessarily use the same dressing throughout healing.
Any of the more than 1,000 wound dressing products available will enable significantly better healing than traditional “wet-to-damp” dressings with saline and gauze, Dr. Hopf stressed.
The commercial products cost more initially, but get changed once daily instead of t.i.d. changes for wet-to-damp dressings, which require more labor and materials. In the end, the cost is about the same, and the patient experiences less pain with commercial dressings, she said. Dr. Hopf said she has no financial relationship with wound-dressing companies.
For an exudating wound, fluff calcium alginate (Sorbsan) and fill the wound loosely with it to absorb exudate, maintain a moist environment, and protect skin from maceration.