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Cuidados de la herida quirúrgica tras cesárea

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Elena González Plaza at Hospital Clínic de Barcelona
Elena González Plaza
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Abstract

Introducción La cesárea es un procedimiento quirúrgico que puede pre-venir la mortalidad materna y neonatal cuando se utiliza por razones médicas indicadas. La Organización Mundial de la Salud (OMS) concluyó que la tasa de cesárea no de-bía ser superior al 10-15%, ya que tasas superiores contri-buyen a un aumento en la morbilidad materna y del neo-nato. Recientemente, sin embargo, la OMS aconsejó realizar una cesárea a toda mujer que lo precise, y no tan-to por ajustarse a alcanzar una tasa de cesárea específica 1. La tasa media de cesáreas en Europa es del 27% (en Es-paña se sitúa en el 24,8%) 2. Dada la elevada prevalencia de cesáreas, es relevante explorar qué cuidados se propor-cionan a la herida quirúrgica tras una cesárea, ya que una alteración en la cicatrización conlleva efectos secundarios indeseables locales que se asocian a restricción de movi-mientos, secuelas estéticas y, en ocasiones, psicológicas 3. El objetivo de este artículo es actualizar los conocimien-tos del cuidado de la herida quirúrgica tras una cesárea. Metodología La pregunta de intervención se describió en forma de PICO para diseñar la estrategia de búsqueda bibliográfica: ¿Qué cuidados postoperatorios en la herida quirúrgica son efec-tivos tras una cesárea? Se realizó una búsqueda bibliográfica en las bases de da-tos Cochrane Library, Cinahl, Medline, Cuiden y Cuidat-ge. Las palabras clave usadas fueron: caesarean, c-section, wound closure, cosmetic outcomes, scar, dressing y healing. Se limitó la búsqueda por idioma (inglés y castella-no) y por tiempo (desde 2010 hasta 2019). Se examinaron 26 referencias bibliográficas, de las cua-les 20 se ajustaron a la pregunta (1 revisión sistemática, 8 ensayos clínicos, 1 estudio cualitativo, 1 caso clínico, 8 es-tudios observacionales y 1 artículo especial). Cuidados tras la cesárea En la tabla se pueden ver los procesos y técnicas de cura-ción de la herida.
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profesión
matr nas Matronas Prof. 2019; 20(2): 63-64
Artículo especial
Introducción
La cesárea es un procedimiento quirúrgico que puede pre-
venir la mortalidad materna y neonatal cuando se utiliza
por razones médicas indicadas. La Organización Mundial
de la Salud (OMS) concluyó que la tasa de cesárea no de-
bía ser superior al 10-15%, ya que tasas superiores contri-
buyen a un aumento en la morbilidad materna y del neo-
nato. Recientemente, sin embargo, la OMS aconsejó
realizar una cesárea a toda mujer que lo precise, y no tan-
to por ajustarse a alcanzar una tasa de cesárea específica1.
La tasa media de cesáreas en Europa es del 27% (en Es-
paña se sitúa en el 24,8%)2. Dada la elevada prevalencia
de cesáreas, es relevante explorar qué cuidados se propor-
cionan a la herida quirúrgica tras una cesárea, ya que una
alteración en la cicatrización conlleva efectos secundarios
indeseables locales que se asocian a restricción de movi-
mientos, secuelas estéticas y, en ocasiones, psicológicas3.
El objetivo de este artículo es actualizar los conocimien-
tos del cuidado de la herida quirúrgica tras una cesárea.
Metodología
La pregunta de intervención se describió en forma de PICO
para diseñar la estrategia de búsqueda bibliográfica: ¿Qué
cuidados postoperatorios en la herida quirúrgica son efec-
tivos tras una cesárea?
Se realizó una búsqueda bibliográfica en las bases de da-
tos Cochrane Library, Cinahl, Medline, Cuiden y Cuidat-
ge. Las palabras clave usadas fueron: caesarean, c-section,
wound closure, cosmetic outcomes, scar, dressing y hea-
ling. Se limitó la búsqueda por idioma (inglés y castella-
no) y por tiempo (desde 2010 hasta 2019).
Se examinaron 26 referencias bibliográficas, de las cua-
les 20 se ajustaron a la pregunta (1 revisión sistemática, 8
ensayos clínicos, 1 estudio cualitativo, 1 caso clínico, 8 es-
tudios observacionales y 1 artículo especial).
Cuidados tras la cesárea
En la tabla se pueden ver los procesos y técnicas de cura-
ción de la herida.
Cuidados de la herida quirúrgica tras cesárea
Elena González-Plaza
Matrona. Departamento de Medicina Fetal BCNatal del Hospital Clínico de Barcelona. Profesora asociada. Departamento
Medicoquirúrgico y Maternoinfantil de la Facultad de Medicina y Ciencias de la Salud de la Universidad de Barcelona
Procesos y técnicas de curación de la herida quirúrgica poscesárea
Fase de cicatrización Técnica aplicada Beneficios
Previo al cierre de la herida
(nivel subcutáneo)
Espongostan® empapado
en bupivacaína
• Disminuir el dolor, la ansiedad y la depresión
posparto (a los 7 días)
• Aumentar la satisfacción
Herida
suturada
Cuidados a las 24 h
postoperatorias
Gel de aloe vera • Obtener mayor puntuación en la escala REEDA
(valoración del enrojecimiento, edema, equimosis
y aproximación de los dos bordes de la herida)
Cuidados a los 2 y 7 días
postoperatorios
Gasa impregnada en plata • No aportó diferencias significativas respecto
al cuidado habitual
Cuidados a los 7 días
postoperatorios
Dispositivos de campo
electromagnético pulsado
(PEMF)
• Disminuir el dolor, el exudado y el edema
• Aumentar la satisfacción
Cuidados a los 7 días
postoperatorios
Terapia del cierre al vacío
(VAC) o apósito de presión
negativa
• No aportó diferencias significativas respecto
al cuidado habitual
Dehiscencia de la herida • Cicatrización por segunda intención de las heridas
que requieren cuidados en el domicilio
Herida
cerrada
Desde de la cicatrización total
hasta los 6 meses postratamiento
Láser de dióxido de carbono
ablativo fraccional (AFXL)
• Mejorar la textura e hiperpigmentación de la cicatriz
A partir de la semana de la herida
quirúrgica hasta los 3 meses
postratamiento
Apósito/gel silicona • Prevenir malformaciones y alteraciones durante el
proceso de cicatrización
• Aumentar la satisfacción
• Disminuir el dolor y el prurito
64
Matronas Prof. 2019; 20(2): 63-64
Técnicas de curación
• Espongostan®. Es una esponja de gelatina reabsorbible
aproximadamente en 2 semanas, empapada en anestési-
co (bupivacaína). La longitud de la esponja y la dosis de
bupicaína se calcula mediante una fórmula (dosis máx.:
2 mg/kg). La esponja se coloca a nivel subcutáneo y se
sutura la herida quirúrgica según la técnica habitual4.
• Aloe Vera. La aplicación tópica de aloe vera ha sido reco-
mendada para acelerar el proceso de curación de las lesiones
dérmicas. En heridas quirúrgicas poscesárea, el cirujano apli-
ca el gel de aloe vera de manera estéril y cubre la herida con
una gasa seca. Debe revisarse la herida pasadas 24 horas5.
• Gasa impregnada en plata. Es un apósito revestido con
un sustrato polimérico que ofrece protección antimicro-
biana contra la bacterias introducidas en el quirófano. Tras
el cierre de la herida poscesárea, se aplica dicha gasa hu-
medecida con suero salino y se ocluye con una gasa. Debe
revisarse la herida a los 2 y 7 días posteriores6.
• Dispositivos de campo electromagnético pulsado
(PEMF). Esta técnica consiste en aplicar, sobre la herida
quirúrgica ya cerrada, un campo de radiofrecuencia tera-
péutica de bajo voltaje y de manera temporizada, que pro-
mueve la cicatrización7.
• Terapia del cierre al vacío (vacuum assited closure, VAC)
o apósito de presión negativa. Consiste en un sistema no
invasivo que estimula la curación de heridas suministran-
do presión negativa en la zona de la herida, donde se apli-
ca un apósito de espuma de forma continua, o intermiten-
te, mediante un tubo que somete a descompresión. Se ha
estudiado como tratamiento de dehiscencias8,9.
• Láser de dióxido de carbono ablativo fraccional
(AFXL). Genera columnas microscópicas verticales de
ablación en la epidermis y en la dermis que provocan una
cascada de citoquinas y factores de crecimiento por la ac-
tivación de fibroblastos y síntesis de fibras de elastina e
inducen la formación de nuevo tejido10.
• Apósito/gel silicona. Favorece un ambiente húmedo en
contacto con la cicatriz que, junto con la oclusión, produ-
ce un incremento de la temperatura, lo que causa un au-
mento de la actividad de fibroblastos y colágeno. Los apó-
sitos/gel silicona, igual que en el tratamiento de heridas
hipertróficas y queloides, ayudan a aquellas personas que
presentan un proceso de cicatrización insuficiente11-13.
Factores independientes y cicatrización
La comorbilidad y otros factores como la malnutrición pre-
disponen a una peor cicatrización. El índice de masa cor-
poral elevado, el tabaquismo, el haber recibido corticoides
durante el embarazo, la rotura prematura de membranas y
la corioamnionitis son factores independientes que conlle-
van una peor cicatrización y un mayor riesgo de infección
de la herida quirúrgica poscesárea3,14.
Inconvenientes durante la cicatrización
En un estudio cualitativo se analizaron las experiencias de
personas durante el proceso de curación de la herida qui-
rúrgica y se destacaron los siguientes factores: la incomodi-
dad; el impacto del exudado; las reacciones cutáneas al apó-
sito; la dificultad de retirar el apósito; la sensación de
desprotección de la herida; la interferencia en la movilidad
o en actividades de la vida diaria; la ansiedad y la aparien-
cia de la herida quirúrgica15.
Aplicabilidad para la práctica clínica
Un número elevado de mujeres paren mediante cesárea, de
modo que es importante actualizar los conocimientos acer-
ca de los cuidados de la herida quirúrgica, ya que contri-
buyen a mejorar el proceso de cicatrización y el dolor, re-
ducen la aparición de infecciones, disminuyen la ansiedad
y el riesgo de depresión posparto, favorecen el vínculo ma-
ternofilial y aumentan la satisfacción de las puérperas que
han tenido el parto mediante cesárea.
Bibliografía
1. World Health Organitatition. WHO recommendations: intrapartum care for a positive
childbirth experience. 2018. Disponible en: http://www.who.int/reproductivehealth/
publications/intrapartum-care-guidelines/en/.
2. Euro-Peristat Project. Core indicators of the health and care of pregnant women and
babies in Europe in 2015. 2018. Disponible en: www.europeristat.com.
3. Zuarez-Easton S, Zafran N, Garmi G, Salim R. Postcesarean wound infection:
prevalence, impact, prevention, and management challenges. Int J Womens Health.
2017; 9: 81-88.
4. Simavli S, Kaygusuz I, Kafali H. Effect of bupivacaine-soaked spongostan in cesarean
section wound on postoperative maternal health. Arch Gynecol Obstet. 2014; 290(2):
249-256.
5. Molazem Z, Mohseni F, Younesi M, Keshavarzi S. Aloe Vera gel and cesarean wound
healing. A Randomized Controlled Clinical Trial. Glob J Health Sci. 2014; 7(1): 203-209.
6. Connery SA, Downes KL, Young C. A retrospective study evaluating silver-impregnated
dressings on cesarean wound healing. Adv Ski Wound Care. 2012; 25(9): 414-419.
7. Khooshideh M, Latifi Rostami SS, Sheikh M, Ghorbani Yekta B, Shahriari A. Pulsed
electromagnetic fields for postsurgical pain management in women undergoing
cesarean section. Clin J Pain. 2016; 33(2): 142-147.
8. Hyldig N, Joergensen JS, Wu C, Bille C, Vinter CA, Sorensen JA, etal. Cost-effectiveness
of incisional negative pressure wound therapy compared with standard care after
caesarean section in obese women: a trial-based economic evaluation. An Int J Obstet
Gynaecol. 2019; 126(5): 619-627.
9. Sánchez-Cabezón C, Montes-Olangua MI, García-Suárez S, García-Carretero R.
Dehiscencia de una herida abdominal tras una cesárea tratada con terapia de cierre al
vacío en el domicilio. Enferm Clin. 2013; 23(2): 73-78.
10. Karmisholt KE, Taudorf EH, Wulff CB, Wenande E, Philipsen PA, Haedersdal M.
Fractional CO2 laser treatment of caesarean section scars-A randomized controlled
split-scar trial with long term follow-up assessment. Lasers Surg Med. 2017; 49(2):
189-197.
11. Lin Y-S, Ting P-S, Hsu K-C. Does the form of dressings matter? Medicine (Baltimore).
2018; 97(32): e11767.
12. Hoeksema H, De Vos M, Verbelen J, Pirayesh A, Monstrey S. Scar management by
means of occlusion and hydration: A comparative study of silicones versus a hydrating
gel-cream. Burns. 2013; 39(7): 1.437-1.448.
13. O’Brien L, Jones DJ. Silicone gel sheeting for preventing and treating hypertrophic and
keloid scars. Cochrane Database Syst Rev. 2013; 12(9): CD003826.
14. Ávila C, Bhangoo R, Figueroa R, Santorelli J, Ogburn P, Desan PH. Association of
smoking with wound complications after cesarean delivery. J Matern Neonatal Med.
2012; 25(8): 1.250-1.253.
15. Elliott D. Developing outcome measures assessing wound management and patient
experience: a mixed methods study. BMJ Open. 2017; 7(11): 1-7.
ResearchGate has not been able to resolve any citations for this publication.
Cost-effectiveness of incisional negative pressure wound therapy compared to standard care after caesarean section in obese women: A trial-based economic evaluation
Article
Full-text available
Objective: To evaluate the cost-effectiveness of incisional negative pressure wound therapy (iNPWT) in preventing surgical site infection in obese women after caesarean section. Design: A cost-effectiveness analysis conducted alongside a clinical trial. Setting: Five obstetric departments in Denmark. Population: Women with a pregestational body mass index (BMI) ≥30 kg/m2 . Method: We used data from a randomised controlled trial of 876 obese women who underwent elective or emergency caesarean section and were subsequently treated with iNPWT (n = 432) or a standard dressing (n = 444). Costs were estimated using data from four Danish National Databases and analysed from a healthcare perspective with a time horizon of 3 months after birth. Main outcome measures: Cost-effectiveness based on incremental cost per surgical site infection avoided and per quality-adjusted life-year (QALY) gained. Results: The total healthcare costs per woman were €5793.60 for iNPWT and €5840.89 for standard dressings. Incisional NPWT was the dominant strategy because it was both less expensive and more effective; however, no statistically significant difference was found for costs or QALYs. At a willingness-to-pay threshold of €30,000, the probability of the intervention being cost-effective was 92.8%. A subgroup analysis stratifying by BMI shows that the cost saving of the intervention was mainly driven by the benefit to women with a pre-pregnancy BMI ≥35 kg/m2 . Conclusion: Incisional NPWT appears to be cost saving compared with standard dressings but this finding is not statistically significant. The cost savings were primarily found in women with a pre-pregnancy BMI ≥35 kg/m2 . Tweetable abstract: Prophylactic incisional NPWT reduces the risk of SSI after caesarean section and is probably dominant compared with standard dressings #healtheconomics.
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Postcesarean wound infection: Prevalence, impact, prevention, and management challenges
Article
Full-text available
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Sivan Zuarez-Easton,1 Noah Zafran,1,2 Gali Garmi,1,2 Raed Salim1,2 1Department of Obstetrics and Gynecology, Emek Medical Center, Afula, 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Abstract: Surgical site infection (SSI) is one of the most common complications following cesarean section, and has an incidence of 3%–15%. It places physical and emotional burdens on the mother herself and a significant financial burden on the health care system. Moreover, SSI is associated with a maternal mortality rate of up to 3%. With the global increase in cesarean section rate, it is expected that the occurrence of SSI will increase in parallel, hence its clinical significance. Given its substantial implications, recognizing the consequences and developing strategies to diagnose, prevent, and treat SSI are essential for reducing postcesarean morbidity and mortality. Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and evidence-based surgical techniques are some of the practices proven to be effective in reducing the incidence of SSI. In this review, we describe the biological mechanism of SSI and risk factors for its occurrence and summarize recent key clinical trials investigating preoperative, intraoperative, and postoperative practices to reduce SSI incidence. It is prudent that the surgical team who perform cesarean sections be familiar with these practices and apply them as needed to minimize maternal morbidity and mortality related to SSI. Keywords: cesarean section, management, surgical site infection
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Aloe Vera Gel And Cesarean Wound Healing;A Randomized Controlled Clinical Trial
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Failure in complete healing of the wound is one of the probable complications of cesarean. The present study aimed to determine the effectiveness of dressing with aloe vera gel in healing of cesarean wound. This prospective randomized double-blind clinical trial was conducted on 90 women who had undergone cesarean operation in Amir-al-Momenin hospital (Gerash, Iran). The participants were randomly divided into two groups each containing 45 patients. In one group, the wound was dressed with aloe vera gel, while simple dressing was used in the control group. Wound healing was assessed 24 hours and 8 days after the cesarean operation using REEDA scale. The data were analyzed through Chi-square and t-test. The participants' mean age was 27.56±4.20 in the aloe vera group and 26.62±4.88 in the control group, but the difference was not statistically significant. However, a significant difference was found between the two groups concerning body mass index, heart rate, and systolic blood pressure (P<0.05). Also, a significant difference was observed between the two groups with respect to the wound healing score 24 hours after the operation (P=0.003). After 8 days, however, the difference in the wound healing score was not significant (P=0.283). Overall, 45 participants in the aloe vera group and 35 ones in the control group had obtained a zero score 24 hours after the operation. These measures were respectively obtained as 42 and 41eight days after the operation. According to the findings of this study, the women are recommended to be informed regarding the positive effects of dressing with aloe vera gel.
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Developing outcome measures assessing wound management and patient experience: A mixed methods study
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  • Nov 2017
Objectives: To develop outcome measures to assess practical management of primary surgical wounds and patient experience. Design: Mixed methods, including qualitative interviews and data extraction from published RCTs. Setting: Two university-teaching NHS hospitals and three district NHS hospitals in the South West and Midlands regions of England. Participants: Sixty-four patients and 15 health care professionals from abdominal general surgical specialities and obstetrics (caesarean section). Methods: Measures were developed according to standard guidelines to identify issues relevant to patients’ experiences of surgical wounds and dressings, including analysis of existing RCT outcomes and interviews. These were written into provisional questionnaire items for a single outcome measure. Cognitive interviews with patients and health care professionals assessed face validity, acceptability and relevance. Findings from interviews were regularly shared with the study team who suggested amendments to modify and reword items to improve understanding before further iterative testing with patients and health care professionals. Results: Analyses of existing RCT outcomes and interviews produced a total of 69 issues. Pre-testing and iterative revision established the need for two separate measures. One measure addresses health care professionals’ experience of wound management in two key areas: exudate and its impact, and allergic reactions to the dressing. The other measure addresses patients’ experience of wounds in seven key areas: wound comfort, dressing removal, dressings to protect the wound, impact on daily activities, ease of movement, anxiety about the wound and satisfaction with dressing. Each measure took less than five minutes to complete and were understood and acceptable to patients and health care professionals. Conclusion: This in-depth study has developed two measures to assess practical management of primary surgical wounds and patient experience. Further work to test their validity and reliability and application to other settings is now required.
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Silicon gel sheeting for preventing and treating hypertrophic and keloid scars
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Fractional CO 2 laser treatment of caesarean section scars-A randomized controlled split-scar trial with long term follow-up assessment: LASER TREATMENT OF CAESAREAN SECTION SCARS
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Background and objectives: Caesarean section (c-section) scars can be pose functional and cosmetic challenges and ablative fractional laser (AFXL) treatment may offer benefit to patients. We evaluated textural and color changes over time in AFXL-treated versus untreated control scars. Materials and methods: A randomized, controlled, intra-individual split-scar trial with three sessions of AFXL-treatments for mature c-section scars. Settings of AFXL were adjusted to each individual scar. End-points were blinded on-site clinical evaluations at 1, 3, and 6 months follow-up (Patient and Observer Scar Assessment Scale [POSAS] and Vancouver Scar Scale [VSS]), blinded photo-evaluations, reflectance measurements, tissue histology, and patients satisfaction. Results: Eleven of 12 patients completed the study. At 1 month follow-up, AFXL-treated scars were significantly improved in pliability (POSAS P = 0.01 VSS P = 0.02) and smoother in surface relief (POSAS P = 0.03) compared to control scars. At 1-3 months, overall scar appearance was dominated by transient erythema and hyperpigmentation, confirmed by reflectance measurements (erythema% and pigmentation% peaked at 1 and 3 month follow-up, respectively). At 6 months follow-up, AFXL-treated scars improved on POSAS-total score though not significantly (P = 0.06). Correspondingly, blinded photo-evaluation found AFXL-treated scars significantly improved compared to controls (VAS P = 0.02). Histology indicated new dermal collagen and elastic fibers on AFXL-treated scars. At 6 months follow-up, a majority of patients (64%) favored subsequent AFXL-treatment of their untreated control scar tissue. Conclusions: Scar remodeling is initiated 1 month after AFXL treatment, but overall scar improvement is concealed until laser-induced color changes resolve. At 6 months follow-up, the benefit of AFXL treatment on c-section scars emerges. Lasers Surg. Med. © 2016 Wiley Periodicals, Inc.
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Effect of bupivacaine-soaked spongostan in cesarean section wound on postoperative maternal health
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Dehiscencia de una herida abdominal tras una cesárea tratada con terapia de cierre al vacío en el domicilio
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  • Mar 2013
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Scar management by means of occlusion and hydration: A comparative study of silicones versus a hydrating gel-cream
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Despite the worldwide use of silicones in scar management, its exact working mechanism based on a balanced occlusion and hydration, is still not completely elucidated. Moreover, it seems peculiar that silicones with completely different occlusive and hydrating properties still could provide a similar therapeutic effect. The objective of the first part of this study was to compare the occlusive and hydrating properties of three fluid silicone gels and a hydrating gel-cream. In a second part of the study these results were compared with those of silicone gel sheets. Tape stripped skin was used as a standardized scar like model on both forearms of 40 healthy volunteers. At specific times, trans epidermal water loss (TEWL) and the hydration state of the stratum corneum were measured and compared with intact skin and a scar-like control over a 3-4h period. Our study clearly demonstrated that fluid silicone gels and a hydrating gel-cream have comparable occlusive and hydrating properties while silicone gel sheets are much more occlusive, reducing TEWL values far below those of normal skin. A well-balanced, hydrating gel-cream can provide the same occlusive and hydrating properties as fluid silicone gels, suggesting that it could eventually replace silicones in scar treatment.
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