Infected Episiotomy Diagnosis and Management

Local Signs of Infection

Purulent drainage from the episiotomy site is diagnostic of surgical site infection and the most reliable indicator 1, 2, 3
Spreading erythema extending beyond the wound margins, particularly >5 cm from the incision edge, is a sign of infection 1, 4
Warmth and tenderness at the wound site, beyond what is expected from normal healing, indicate infection 2, 3
Swelling and induration of the perineal tissues surrounding the episiotomy are signs of infection 1, 2
Wound dehiscence or breakdown of the suture line is a sign of infection 2, 3

Fever >38.5°C (101.3°F) is an indicator of serious infection 1, 4, 5
Tachycardia with heart rate >100-110 beats/minute is a sign of serious infection 1, 4, 5
Hypotension suggesting septic shock is a critical sign requiring immediate intervention 4
Oliguria or decreased urine output is a sign of severe infection 4
Altered mental status or decreased alertness is a critical sign requiring immediate intervention 4

Infections developing within 48 hours postpartum are rare but highly concerning, and suggest virulent organisms like Group A Streptococcus or Clostridium species 1, 6
Most episiotomy infections appear between days 4-6 postpartum and are typically polymicrobial 1, 2, 3

Increasingly severe pain beginning 24 hours after delivery is the first reliable symptom of clostridial myonecrosis 7
Skin progressing from pale to bronze to purplish-red is a sign of clostridial myonecrosis 7
Crepitus (gas in tissues) detected on palpation or imaging is a sign of clostridial myonecrosis 7
Bullae filled with reddish-blue fluid are a sign of clostridial myonecrosis 7
Tense, tender infected region is a sign of clostridial myonecrosis 7

Any signs of necrotizing infection (rapidly spreading necrosis, gas in tissues, severe systemic toxicity) require prompt surgical consultation 1
Early infection with severe pain and systemic signs within 48 hours suggests Group A Streptococcus or Clostridium—requires immediate surgical exploration 1, 2, 3
Erythema extending >5 cm from wound edge combined with fever or tachycardia requires urgent reassessment 1, 5