[CG] Maternity wound guideline

This guideline will be applied to all women who attend for caesarean section, have an episiotomy or perineal suturing irrespective of their ethnicity, disability, religion and beliefs, sexual orientation or age.

This guideline will provide advice and guidance on effective clinical practice for all registered healthcare personnel when caring for postpartum wounds. It is not intended to address specific clinical issues that relate to individual women.

Note: This guideline should be read in conjunction with the Wound Classification Product Selection Guide (2018)

The Guideline has been developed to standardise wound care postpartum, ensuring evidence based, cost effective practice is implemented and delivered throughout Greater Glasgow and Clyde.

Registered Health Care Practitioners are responsible for: 

• Informing women of the wound dressing protocol in the event of a caesarean section and informing of appropriate wound care post caesarean section/episiotomy/tear suturing.
• Liaising with carers and the interdisciplinary team to promote compliance of dressing protocol, ensuring that Interdisciplinary Women Focused Care Plans are in place and interventions are recorded and dated in line with the Board’s Record Keeping Policy.
• Maintaining and updating their knowledge, skills and competence in line with their roles and responsibilities to care for women who undergo caesarean section, episiotomy or tear suturing.
• Seeking the advice of the Tissue Viability Service where appropriate, whilst maintaining ongoing responsibility for the woman’s episode of care.
• Referring all non-progressing wounds after two weeks to the Tissue Viability Service.

A DATIX must be completed for every woman that is admitted to hospital for a wound related issue. 

Many factors can potentially lead to a woman developing wound complications. These will be influenced by both intrinsic (from within the patient) and extrinsic (from out with the patient) these factors must be considered when performing a holistic assessment and developing a plan of care.  

Intrinsic issues: 

• High/low BMI
• Reduced mobility / Immobility
• Sensory impairment
• Altered level of consciousness
• Poor nutritional intake and dehydration
• Prolonged surgery
• Poor tissue perfusion/oxygenation
• Incontinence
• Excess moisture
• Acute/Chronic/Terminal illness
• Certain medications
• Psychological factors
• Previous tissue damage or wound healing complications
• Colonisation with a resistant organism

Extrinsic issues:

• Friction
• Shearing
• Increased Moisture

Underlying medical conditions will vary from woman to woman. It is also recognised that in some cases it is not always possible to prevent or manage some risk factors. Care planning should reflect this.

• Refer to Maternity Wound Algorithm (Appendix I)
• When undertaking wound assessment all staff must follow NHS GGC standard infection control precautions.
• Wound/dressing inspection should take place as per women centred plan of care (note: this can be carried out with dressing in place). Refusal to allow wound inspection should be documented and the risks fully explained to the woman.
• If a woman shows signs of any wound complications, wound assessment and treatment plan documentation must be completed using the paper copy of the NHSGGC Wound Assessment and Management Plan. The NHSGGC Wound Assessment and Management Plan will be scanned into Clinical Portal.

NHS GGC Wound assessment Chart

• Tissue viability requests are now on TrakCare. Order under “new request”/others/Tissue Viability
• Appropriate dressings and product selection should be based on the wound management objectives and specific woman’s needs. Refer to Maternity Core Wound Product List (Appendix II)
• If a Caesarean section Surgical Site Infection (SSI) is suspected the woman should be referred to the Named Obstetrician and the SSI details fully recorded on BadgerNet.

Provide wound products for one weeks supply and record dressing regime in Clinical Portal.

This guideline will be reviewed every three years.

Maternity core wound product list.