Childbirth often results in injury to the perineum, the tissue located between the vagina and the anus. These injuries, which include natural tears or a surgical incision called an episiotomy, are classified by depth, ranging from a first-degree tear involving only the skin to a fourth-degree tear extending into the rectal lining. Suturing is performed to reapproximate the tissue layers, supporting proper healing and restoring the anatomy of the area. When these stitches fail, or the wound edges separate after the repair, the condition is referred to as perineal wound dehiscence or wound breakdown.
Recognizing Dehiscence: Signs That Stitches Have Opened
The most common indication that a perineal wound has opened is a significant increase in localized pain, often making it difficult to walk or sit comfortably. This pain may be accompanied by a sensation that the wound is separating or gaping, which is sometimes confirmed by a visual inspection. A persistent malodorous discharge, which may appear yellow or green, suggests the presence of an underlying infection, a frequent cause of wound breakdown.
New or increased bleeding from the wound site, or the discharge of clear or yellowish fluid, can also signal that the repair has failed. Patients may experience flu-like symptoms or a high temperature, indicating a systemic response to infection. While some stitch material naturally comes away as absorbable sutures dissolve, seeing a clear opening or gap in the wound edges confirms dehiscence.
Immediate Steps and When to Seek Care
If there is any suspicion that the perineal stitches have opened, contact the healthcare provider, such as an obstetrician, midwife, or general practitioner, to arrange an urgent examination. While waiting for a medical assessment, maintaining hygiene is important to preventing or managing infection. Gentle cleansing of the area with water, such as rinsing with a perineal irrigation bottle after using the toilet, is advised.
Sitz baths, which involve soaking the perineum in warm water, can offer soothing relief and help keep the area clean. Pain management can be addressed with over-the-counter medications like paracetamol and anti-inflammatory drugs such as ibuprofen, which are generally safe during breastfeeding. Applying a cold compress or ice pack to the area can also help reduce swelling and discomfort.
It is important to seek emergency medical care immediately if signs of a worsening systemic infection are present. These signs include a high fever, a rapid heart rate, or feeling significantly unwell with symptoms beyond localized pain. Heavy, uncontrollable bleeding from the wound site also warrants immediate emergency attention. These symptoms suggest a potential for severe postpartum sepsis, which requires prompt hospital admission and often intravenous antibiotics.
Clinical Management and Treatment Options
A healthcare professional will perform an assessment of the wound to determine the degree of separation and check for signs of infection, such as redness, swelling, or pus. A swab of the wound discharge is typically taken to identify any specific bacteria present, which guides the choice of antibiotic if an infection is confirmed. The presence of infection is a defining factor in the subsequent treatment plan for dehiscence.
If infection is present, the wound is generally not re-stitched immediately, as closing an infected wound can trap bacteria and impair healing. In this scenario, the preferred medical approach is to allow the wound to heal by secondary intention. This process involves leaving the wound open to heal naturally from the bottom up, where new tissue, called granulation tissue, forms to fill the gap and gradually contracts the wound edges.
If the wound is clean, and the dehiscence is discovered early after the initial repair, the option of secondary suturing (re-stitching) may be offered. This procedure is typically performed in a controlled environment, like an operating theatre, after any non-viable tissue is surgically removed. Secondary suturing can potentially result in a faster healing time compared to the secondary intention method. However, the decision between the two approaches varies among practitioners, with most dehisced wounds being managed expectantly by secondary intention.
The Healing Process and Long-Term Outlook
The duration of the healing process is variable and depends on the size of the wound and the chosen treatment path. Wounds healing by secondary intention, which is common for infected dehiscences, can take several weeks or even months to fully close as the granulation tissue slowly fills the defect. While re-sutured wounds may heal more quickly, there is a small potential for the new repair to break down again.
The newly formed tissue will initially look red and may be delicate, gradually maturing into a less noticeable scar over time, which can take up to two years to fully fade. Long-term outcomes are positive, with most women experiencing no further problems once the wound is completely healed. The healed wound will not spontaneously break down again during activities like exercise or sexual intercourse.
Extended healing may be accompanied by a prolonged period of discomfort, sometimes managed with pelvic floor physical therapy to improve function and support. Studies suggest that secondary suturing may allow women to resume sexual intercourse sooner than those who heal by secondary intention, though there is no significant long-term difference in pain or sexual function six months after the initial repair. The prognosis for functional recovery after perineal wound dehiscence, regardless of the treatment method, remains favorable.