Impact of Timing of Wound Dressing Removal After Cesarean Section

Immediate wound coverage is one of the cornerstones of post-operative wound management.
Dressings are typically left in place for 24 to 48 hours following cesarean section to allow
ample time for healing and re-epithelialization. The functions of a surgical dressing for
wound healing by primary intention are to control postoperative bleeding, absorb exudate,
ease pain, and provide protection for newly-formed epithelium. The skin is an important
anatomical barrier against microbes; the reformation of an intact epithelial system
following injury is an important milestone for the prevention of infection.

Wound healing is a dynamic process that involves the coordinated interaction of a variety of
cells, including cytokines, blood cells, extracellular matrix proteins, and parenchyma
cells. Wound healing has been artificially divided into three phases: inflammation, tissue
formation (proliferation), and tissue remodeling. These phases do not correspond to a
precise period of time following injury, and all of the phases overlap to some degree.
Re-epithelialization occurs during the proliferation phase and it is defined as the process
of restoring an intact epidermis after injury. It involves several processes, including the
migration and proliferation of adjacent epidermal keratinocytes into the wound, the
differentiation of the neo-epithelium into a stratified epidermis, and the restoration of an
intact basement membrane zone (BMZ) that will connect the epidermis and the underlying
dermis. Re-epithelialization of wounds begins within hours after injury. Within 24 hours,
keratinocytes are actively proliferating from the margins of the wound to cover the defect.

Surgical wounds that are closed by primary intention usually heal rapidly, and
re-epithelialization is thought to occur within 24 to 48 hours. Early studies into wound
care demonstrated that dressings influence the repair process. The post-operative wound
dressing acts to ensure the wound bed stays moist, decrease pain and inflammation, and
improve scar appearance. Additionally, occlusive dressings increase the rate of
re-epithelialization post-operatively compared to those wounds left open. The importance of
dressings has been established, but the ideal time that postoperative dressings should
remain in place remains elusive. Studies have shown that early removal of dressings (6 hours
after wounding) markedly decreases the rate of resurfacing, while leaving the bandage on for
greater than 48 hours produced no greater benefit. The United States Centers for Disease
Control and Prevention recommends that the sterile dressing stay in place for 24-48 hours
post-operatively on an incision that has been closed by primary intention. Although the
window of benefit provided by bandages has not been further refined since these earlier
studies. By defining the period during which dressings will promote epithelial resurfacing,
our ability to use the dressing optimally will be enhanced.

Our goal of this study is to investigate if there is a difference in outcomes in dressings
that are left in place for 24 hours versus 48 hours. While epithelial proliferation begins
within hours of closure, it is not at its maximum until 48 to 72 hours following injury.
Current standard of care is to keep the dressing in place 24 to 48 hours post-operatively.
However, there is no data comparing the optimum timing between 24 and 48 hours. We will
therefore assess the benefit of leaving the dressing in place for 24 vs 48 hours
post-operatively by evaluating its impact on wound appearance and incidence of surgical site
infections using the ASEPSIS scoring method.

The ASEPSIS is a quantitative scoring method that provides a numerical score related to the
severity of wound infection using objective criteria based on wound appearance and the
clinical consequences of the infection. Severity of impaired wound healing is indicated by
the total score as follows: satisfactory healing 0 to 10; disturbance of healing 11 to 20;
minor wound infection 21 to 30; moderate wound infection 31 to 40; and severe wound
infection more than 40.

Inclusion Criteria:

- Pregnant Patients between the ages of 18-50 planning to undergo cesarean section for
delivery.

Exclusion Criteria:

- Intra-operative findings suggestive of underlying cancerous condition

- Known preoperative infectious disease.

- Hysterectomy during cesarean section.