CASE REPORT

Wound Dehiscence Pasca Caesarian Section

Supervised by:
dr. Mutawakkil J. Paransa, Sp.OG

Presented by:
Michelle (2015-061-045)

Department of Obstetrics and Gynecology

Medical Faculty of Atma Jaya Catholic University
RSUD R. Syamsudin, S.H., Sukabumi
2016
 Chapter I

Introduction

Wound dehiscence is rupture of the wound and a separation of the abdominal wall
layers including the fascia. It is an uncommon problem. It is a severe postoperative
complication, with mortality rates reported as high as 45%.1 It affects about 1% of abdominal
2
wounds and usually occurs about 1 week after operation. Of all the fall outs of abdominal
surgery, dehiscence of abdominal wound is easily the most notorious.3 Despite advances in
perioperative care and suture materials, incidence and mortality rates in regard to abdominal
wound dehiscence have not significantly changed over the past decades. This may be
attributable to increasing incidences of risk factors within patient populations outweighing
the benefits of technical achievements.1
Wound dehiscence’s signs and symptoms are easy to identify : open wound, broken
sutures without healing, pain at the wound site, wound bleeding, and pus and/or frothy
drainage in infected wounds. It can be caused by poor surgical techniques such as improper
suturing, over-tightened sutures or inappropriate type of sutures. Wound dehiscence can also
be caused by increased stress to the wound area as a result of strenuous exercise, heavy
lifting, coughing, laughing, sneezing, vomiting or bearing down too hard with bowel
movement. In some cases, wound dehiscence could be secondary to wound infection or poor
healing as seen in patients with chronic diseases, malnutrition or weak immune systems.
Secondary wound dehiscence can occur in patients with AIDS, renal disease, diabetes
mellitus and those undergoing chemotherapy or radiotherapy.4
Wound healing itself has classically been described to occur in three phases,
regardless of the mechanism of injury. These phases are hemostasis and inflammation,
5,6
proliferation, and maturation and remodelling. (figure 1.1) There are some factors
affecting wound healing such as age, nutrition, trauma, metabolic diseases,
immunosuppression, connective tissue disorders, smoking, mechanical injury, infection,
edema, ischemic / necrotic tissue, topical agents, foreign bodies, etc.
 Figure 1.1. Schematic Diagram of Wound Healing7

Considering the burden and the size of this problem, better knowledge about wound
dehiscence would help the patient and the physician. Therefore, authors conduct an analysis
and discussion related to wound dehiscence cases of Mrs. TK who is diagnosed with wound
dehiscence post caesarian section
 Chapter II
Case

I. Identity
 Name : Mrs. TK
 Age : 30 years old
 Ethnic : Sundanese
 Religion : Moslem
 Education : Senior High School
 Job : Employee
 Date of Admission : March 16th 2015

II. Anamnesis
 Chief Complain
Open wound and liquid discharge from the wound since 1 week before
admission to hospital.

 History Of Present Illness

Patient came to the hospital complaining about her open wound with
liquid and blood discharge from her caesarian section wound. Patient didn’t
feel any pain from the wound. Patient had the caesarian section on February
29th 2016 with indication of fetal distress and was allowed to be discharged on
March 3rd 2016 with clean and dry wound. She came to midwife one week
before she came to the hospital because there was blood and pus discharge
from her wound 3 days before she came to midwife. Before she came to
midwife she cleaned her wound by herself at home without using any
antiseptic and without excessive rubbing. She admitted that she didn’t wash
her hand before she clean her wound. She changed her gauze with a new and
clean gauze daily. She also admitted that she still do her usual activity in her
house, and didn’t rest well. She was pissed on her wound by her baby when
she was lactated the baby. She didn’t change her gauze then. She was given
cefixime and her gauze was changed by midwife then. She admited that she
take her medication routinely and change her gauze by herself daily. Her
 wound discharge slightly decreased, but it was still present. She felt that her
wound opened more widely.

 Family History
Patient denied any similar complain in her family.

 History of Past Illness:

 History of hypertension : gestational hypertension
 History of diabetes mellitus : Denied
 History of allergy : Denied
 History of epilepsy : Denied
 History of hematologic disease : Denied
 History of urinary tract/kidney disease : Denied
 History of trauma : Denied
 History of surgery : Denied

 History of menstrual cycle:

o Menarche :15 years old
o Menstrual cycle : regular (cycle : ±30 days), with
duration of 5-6 days, ±60 cc/day,
dysmenorhae (-)
o First day of last menstrual cycle : May 15th 2015

 Marital History
Married twice. Has been married since June 2015 with present husband.

 Contraception History: Patient didn’t use any contraception.

 Obstetric History
No Husband Year Gestational Labor Sex Birth Breast complication
age history weight feeding
1 second 2016 40-41 Caesarian male 2953 8 days, Gestational
weeks section gr then hypertension,
formula fetal distress
III. Physical examination
A. Vital Signs
 General Condition : moderately ill condition
 Level of Consciousness : compos mentis
 Blood Pressure : 120/70 mmHg
 Heart Rate : 79 beats per minute
 Respiratory Rate : 18 times per minute
 Temperature : 37̊ C
B. Body Weight : 60 kilograms
C. Body Height : 155 cm
D. BMI : 24,9 kg/m2
E. General Examination
Eyes Anemic conjunctiva -/-, anicteric sclera, pupil 3mm/3mm, Iight
reflex +/+
Thorax  Cardiac: Regular first and second heart sound, murmur -, gallop -
 Pulmo : Vesicular +/+, rhonchi -/-, wheezing -/-
 Mammae : Areola hyperpigmentation +/+, retraction -/-, Breast
milk +/+

Abdomen  Inspection: convex, with open operation wound of 2-3 cm

 Palpation: supple, tenderness (-), mass (-)
 Percussion : tympanic
 Auscultation: bowel sound (+) 6 times per minute

Extremities Edema : -/- , Physiologic reflex: +/+/+/+, Pathologic reflex: -/-

F. Wound Description
Open wound at pervious operation wound seen, necrotic tissue (+) at the edge
of wound wall, minimal granulation tissue, there was discharge of pus, blood (-
), facia layer was hard to be seen.

IV. Laboratory Examination

A. 16th of March 2016
 Hematology Result
Hb 10 g/dL (↓)
Ht 32% (↓)
Leukocyte 5500/μL
Eritrocyte 4.1million/μL
MCV 79fL (↓)
MCH 24pg (↓)
MCHC 31g/dL
Trombocyte 592.000/μL (↑)
BT 2 minutes
CT 7.30 minutes
Glucose 69 gr/dL (↓)
AST (SGOT) 16 U/L
ALT (SGPT) 10 U/L
Albumin 3.0 g/dL (↓)
Ureum 12 mg/dL (↓)
Kreatinin 0.68 mg/dL
Natrium 145 mmol/L
Kalium 3.6 mmol/L
Calsium 8.2 mmol/L
Clorida 108 mmol/L

B. 17th of March 2016

Urine Result
Color yellow
Clarity slightly cloudy
pH 6.0
Specific gravity 1.015
Leukocyte Positive (+++/500)
Nitrit Negative
Protein Negative
Glucose Negative
 Keton Negative
Urobilinogen Normal
Bilirubin Negative
Eritrosit Positive (+++/50)
Microscopic
Leukocyte 15-18/high power
field (↑)
Erythrocyte 17-20/high power
field (↑)
Epitel Positive (+)
Cylinder Negative
Crystal Negative
Bacteria Negative
Other Negative

V. Working Diagnosis
P1A0, 30 years old, with wound dehiscence post caesarian section with local
infection

VI. Follow Up
March 16th 2016
S Headache
O  Blood Pressure : 160/90 mmHg
 Heart rate : 85 bpm
 Respiration rate : 20 times/minute
 Temperature : 36,3˚C
A P1A0, 30 years old, with wound dehiscence post caesarian section day 16
P Dextrose 40%, IV
Paracetamol 1 gr, IV
Urine check
Dopamet 2 tab, po
March 17th 2016
S No complain
O  General condition : well
 Level of conciousness : compos mentis
 Blood pressure : 120/80 mmHg
 Heart rate : 80 bpm
 Respiration rate : 20 times/minute
 Temperature : 35˚C
 Breast milk +/+
 Abdomen : convex, sutures in good condition, bowel sound (+), tympanic,
fundus height 3 fingers below umbilicus
 Miction (+), defecation (+)
A P1A0, 30 years old, with wound dehiscence post caesarian section day 17
P* Ceftriaxone 2 x 1 gr IV
Metronidazole 3 x 500 mg
Nifedipine 3 x 10 mg
GV 3 times/day
March 18th 2016
S No complain
O  General condition : well
 Level of conciousness : compos mentis
 Blood pressure : 160/100 mmHg
 Heart rate : 52 bpm
 Respiration rate : 21 times/minute
 Temperature : 36.4˚C
 Abdomen : convex, bowel sound (+), tenderness (-), tympanic, fundus height 3
fingers below umbilicus
A P1A0, 30 years old, with wound dehiscence post caesarian section day 18
P Continue previous therapy
Metildopa 3 x 500 mg, po
Nifedipin 3 x 10 mg, po
March 19th 2016
S No complain
O  General condition : well
 Level of conciousness : compos mentis
  Blood pressure : 150/100 mmHg
 Heart rate : 83 bpm
 Respiration rate : 22 times/minute
 Temperature : 35,3˚C
 Abdomen : convex, sutures in good condition, open wound on the upper part,
bowel sound (+), tenderness (-), tympanic, fundus height 3 fingers below
umbilicus
 Miction (+), defecation (+)
A P1A0, 30 years old, with wound dehiscence post caesarian section day 19
P Change gauze 2 x 1
Continue previous therapy
Plan of rehecting after granulation tissue (+)
March 20th 2016
S No complain
O  General condition : well
 Level of conciousness : compos mentis
 Blood pressure : 120/80 mmHg
 Heart rate : 84 bpm
 Respiration rate : 22 times/minute
 Temperature : 36.1˚C
 Abdomen : convex, sutures in good condition, open wound on the upper part,
bowel sound (+), tenderness (-), tympanic, fundus height 3 fingers below
umbilicus
 Miction (+), defecation (+)
A P1A0, 30 years old, with wound dehiscence post caesarian section day 20
P Change gauze 2 x 1
Continue previous therapy
Plan of rehecting
March 21st 2016
S No complain
O  General condition : well
 Level of conciousness : compos mentis
 Blood pressure : 120/80 mmHg
  Heart rate : 80 bpm
 Respiration rate : 22 times/minute
 Temperature : 37.1˚C
 Abdomen : convex, sutures in good condition, open wound on the upper part,
bowel sound (+), tympanic, fundus height 3 fingers below umbilicus
 Miction (+), defecation (+)
A P1A0, 30 years old, with wound dehiscence post caesarian section day 21
P Continue previous therapy
Change gauze 2 times/day
Metildopa 3 x 500 mg, p.o.
Nifedipin 3 x 10 mg, p.o.
Plan of rehecting tomorrow
March 22nd 2016treat
S No complain
O  General condition : well
 Level of conciousness : compos mentis
 Blood pressure : 120/80 mmHg
 Heart rate : 80 bpm
 Respiration rate : 22 times/minute
 Temperature : 35.7˚C
 Abdomen : open wound on the upper part
A P1A0, 30 years old, with wound dehiscence post caesarian section day 22
P Continue previous therapy
Plan of rehecting this day
Post operation instruction :
• Ceftriaxone 2 x 1 gr IV
• Metronidazole 3 x 500 mg IV
• Kaltrofen 2 x 100 mg supp
• Lay in supine position for 24 hours
• Do not fasting
March 23rd 2016
S Patient complained about pain on the operation wound
O  General condition : well
  Level of conciousness : compos mentis
 Blood pressure : 150/90 mmHg
 Heart rate : 72 bpm
 Respiration rate : 24 times/minute
 Temperature : 35.7˚C
A P1A0, 30 years old, post repair hecting with indication of wound dehiscence
post caesarian section day 1
P Aff catheter
Aff IV line
Levofoxacin 2 x 1
Change gauze the next day
Nutriflam
March 24th 2016
S No complain
O  General condition : well
 Level of conciousness : compos mentis
 Blood pressure : 120/80 mmHg
 Heart rate : 100 bpm
 Respiration rate : 24 times/minute
 Temperature : 35.7˚C
A P1A0, 30 years old, post repair hecting with indication of wound dehiscence
post caesarian section day 2
P Discharge patient
Follow up at the clinic in the next 7 days.

VII. Operation Report

 Mediana inferior incision was done at the edge of the previous wound
 Operation wound was sutured layer by layer
 Musculus was sutured with Chromic 2.0
 Subcutis was sutured one by one with Rolisorb 2.0. Skin was sutured with
Polysorb with vertical matress suture
 Instruction post operation :
o Ceftriaxone 2 x 1 gr IV
o Metronidazole 3 x 500 mg IV
o Kaltrofen 2 x 100 mg supp
o Lay in supine position for 24 hours
o Do not fasting
 Chapter III
Discussion

Problems:
1. What is wound dehiscence?
2. What are the etiology and risk factor in this case?
3. What are the clinical manifestasion of this patient?
4. What is the treatment for this patient?
5. What is the follow up for this patient ?

Wound dehiscence
Wound dehiscence is rupture of the wound and a separation of the abdominal wall
layers including the fascia. Wound dehiscence’s signs and symptoms are open wound, broken
sutures without healing, pain at the wound site, wound bleeding, and pus and/or frothy
drainage in infected wounds. It can be caused by poor surgical techniques such as improper
suturing, over-tightened sutures or inappropriate type of sutures. It can also be caused by
increased stress to the wound area as a result of strenuous exercise, heavy lifting, coughing,
laughing, sneezing, vomiting or bearing down too hard with bowel movement. In some cases,
wound dehiscence could be secondary to wound infection or poor healing as seen in patients
with chronic diseases, malnutrition or weak immune systems. Secondary wound dehiscence
can occur in patients with AIDS, renal disease, diabetes mellitus and those undergoing
chemotherapy or radiotherapy.2,4,8,9
Wound healing itself has classically been described to occur in three phases,
regardless of the mechanism of injury. These phases are the inflammatory, the proliferative
and the remodelling phases. The inflammatory phase is the body’s natural response to injury
and takes place immediately after the wound is formed. The wounding triggers a localised
release of inflammatory mediators that encourage vasodilation. Increased blood flow to the
region then results in an influx of phagocytic leucocytes, such as neutrophils and
macrophages, which play a key part in digesting bacteria and autolysing devitalised tissue.
The inflammatory phase of wound healing is responsible for the classical signs of
inflammation that occur in response to an injury: erythema, heat, oedema, pain and decreased
function. The wound starts to rebuild itself in the proliferative phase. Granulation tissue,
comprising collagen and extracellular matrix, fills the wound defect and angiogenesis also
occurs. As the wound defect fills, the wound gradually contracts and epithelial tissue begins
to form at the wound edges. Eventually, complete epithelialisation happens, with epithelial
cells fully resurfacing the wound. The final stage of wound healing is remodelling, which
occurs once the wound is closed. In this phase, the wound regains its tensile strength as the
collagen fibres within the wound remodel and reorganise themselves. It is also during this
phase that the wound devascularises and returns to its original state of blood supply. 6
There are two main types of wound healing: primary healing and secondary healing.
Most surgical wounds undergo primary closure in which there is minimal tissue loss and the
wound edges can be satisfactorily approximated. This allows for primary healing in which
there is rapid epithelialisation of the wound and minimal scarring. Secondary healing refers to
the process where a full-thickness wound is intentionally left open. This may be due to the
presence of infection or an inability to satisfactorily approximate the wound edges. In
secondary healing the wound heals by the natural way of granulation, eventual contraction
and slow epithelialisation. Wounds that undergo secondary healing often result in larger
scars6

Etiology and Risk Factor

Case Theory
This patient had a clean and planned risk of infection depends on type of
procedure procedure 8
This patient is 30 years old female, wasn’t  clean (elective, nontraumatic without
chronically ill and doesn’t have genetic inflammation) - < 1.5%
disorder  clean-contaminated (GI, biliary, urinary)
She had anemia and hypoproteinemia (her - < 3%
Hb, Ht, MCV, MCH, glucose, albumin, and  contaminated (surgery on unprepped
ureum level was below the normal value. bowel, emergency surgery for GI
Other findings : her platelet was above the bleeds/perforation/trauma with acute
normal value, her leukocyte and eritrocyte in inflammation) - 5%
her urine was above normal)  dirty (penetrating trauma, pus present) -
She had infection from her wound and her 33%
personal hygiene wasn’t so good. predisposing factors 1,3,4,8–13
She did heavy wight lifting.  patient characteristics: age, gender
(male), diabetes, steroids,
 immunosuppression, obesity, burn,
malnutrition
 patient with other infections, traumatic
wound, radiation, chemotherapy
 patient condition : anemia,
hypoproteinemia , chronically ill
(diabetes mellitus, AIDS, lung disease,
smoking, malignancy)
 genetic disorder : type IV Ehlers-Danlos
Syndrome
 Non-compliance with post-operative
instructions (such as early excessive
exercise or lifting heavy objects)
 other factors: prolonged preoperative
hospitalization, duration of surgery (> 2
hrs), reduced blood flow, break in sterile
technique (poor suturing), use of drains,
multiple antibiotics, hematoma, seroma,
foreign bodies (drains, sutures, grafts)
Etiology 2,4,10,11,14
 poor surgical techniques (improper
suturing, overtightenen sutures,
inappropiate type of sutures) 
interrupted suturing was associated with
significant reduction risk of burst when
continuous closure
 increased stress/stretch to the wound area
(heavy lifting, coughing, laughing,
sneezing, etc)
 infection at the wound
 injury to the wound area
 weak tissue / muscle at the wound area
Clinical Manifestasion
Case Theory
Her wound description : open wound at clinical presentation 2,8,9,4,10
pervious operation wound seen, necrotic  first sign is often a high volume of clear,
tissue (+) at the edge of wound wall, minimal strawcoloured, serous discharge from the
granulation tissue, there was discharge of wound, indicating that the deeper tissue
pus, blood (-), facia layer was hard to be layers are no longer in close contact and
seen. this allows peritoneal fluid to leak out.
Pus was seen by the patient 3 days post  If the skin and subcutaneous layers also
caesarian section break down, the patient is left with
History of fever was denied and she said omentum or loops of bowel protruding
there was no pain from her wound into the wound
 typically fever post operative day (POD)
# 3-6
 open wound pain, wound erythema,
induration, frank pus or purulosanguinous
discharge, warmth
complications (8)
 fistula, sinus tracts, sepsis, abscess,
suppressed wound healing, superinfection

Treatment
Case Theory
Her gauze was changed daily and she was Treatment 4,8–11,15
given antibiotics  Provided there is no strangulation of the
Rehecting was done after granulation tissue bowel loops in the wound, repair can be
(+) left until the next suitable operating slot.
Rehecting was done by making new incision  Wound should be kept as clean as
at the edge of the older wound and was possible. (clear the wound of debris –
sutured layer by layer (from muscle to skin) devitalised tissue / excessive exudats with
The patient was closely monitored after the warm sterile saline / water via a syringe).
procedure and she was given antibiotics.  The wound should be dressed with soft
swabs and an occlusive dressing to
 prevent excessive fluid losses from the
exposed bowel. Frequent changes in
wound dressing to prevent infection—
when appropriate.
 A good dressing should maintain moist
wound environment, able to remove
excessive exudat, provide a good barrier
against bacterial / fluid contamination,
and be adherent to skin but atraumatic
when removal
 Wound exposure to air to accelerate
healing and prevent infection, and allow
growth of new tissue from below—when
appropriate
 Mesh-mediated fascial closure and
vacuum-assisted wound closure could be
an alternative for treating contaminated
patients until definitive closure is
possible
 Re-open affected part of incision, remove
contaminated and/or dead tissuue,
resuture the wound
 Antibiotics only if an infection is present
or possible
 Closely monitor patient’s wound to
prevent dehiscence from recurring
Prophylaxis 8,4
 consider IV antibiotics
 debridement of necrotic and non-viable
tissue

Follow Up
If the patient had another surgery to repair her wound dehiscence, it should be treated
and monitored as new surgical wound. Look out for another poor healing, infection, wound
dehiscence. Teach patient how to treat her wound and tell the patient to see a clinician if
infection and dehiscence is suspected. Tell the patient to do another check up about 7 days
after she is discharged.
 Chapter IV
Conclusion

Wound dehiscence is an operative complication that must be identified and treated

well. Wound dehiscence’s signs and symptoms are easy to identify : open wound, broken
suturres without healing, pain at the wound site, wound bleeding, and pus and/or frothy
drainage in infected wounds. It can be caused by poor surgical techniques, increased stress to
the wound area, infection or poor healing as seen in patients with chronic diseases,
malnutrition or weak immune systems. There are a lot of factors that afffect wound healing
such as age, nutrition, trauma, immunosupression, chronic disease, connective tissue disorder,
etc. Wound dehiscence should be treated by repairing the wound. Antibiotics should be used
if there is infection or used as prophylaxis.
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