Postnatal wound infection: perineal stitches, tears and warning signs

The NHS says stitches after a tear or episiotomy usually dissolve by the time the cut or tear has healed, and episiotomy stitches should heal within 1 month. The RCOG says after any tear you are likely to have pain or soreness for 4 to 6 weeks, particularly when walking or sitting, that stitches can irritate as they heal, and that after a third- or fourth-degree tear you may feel some stitches for up to 3 months.

Because soreness is expected, the difference between normal healing and infection is often a change: pain that is getting worse instead of better, a new smell, or new swelling.

The NHS says to call your midwife or GP if your stitches get more painful, there is smelly discharge, or there is red, swollen skin around the cut or tear, noting you can use a mirror to look; any of these may mean infection. It lists the same signs, with discharge of pus or liquid and persistent pain, in its episiotomy guidance. Somerset NHS Foundation Trust says stitches or a wound infection might ooze, smell bad or hurt more than before, and might turn red and feel warm, and that a fever, shaking or feeling flu-ish can accompany it.

NICE instructs midwives at each postnatal contact to ask about pain that is not resolving or is worsening, an increasing need for pain relief, discharge with a strong or unpleasant smell, swelling and wound breakdown. If any concern arises, an examination of the perineum by a midwife or doctor should be offered or arranged, and a breakdown should be referred urgently and seen the same day. The RCOG says to see a healthcare professional about bleeding from a tear, any smell or any increase in pain after a third- or fourth-degree tear, which might signal infection needing antibiotics.

NICE advises daily showering of the perineum, frequent changes of sanitary pads and washing hands before and after. The NHS says to bathe stitches daily with plain warm water and pat dry, to pour warm water over the area when passing urine to reduce stinging, to wipe from front to back, to hold a clean pad against the stitches when opening your bowels, and to expose stitches to air for about 10 minutes once or twice a day. The RCOG advises washing with water only for third- or fourth-degree tears and using no products on the area.

Painkillers help comfort. The NHS says paracetamol is safe to use while breastfeeding, that ibuprofen is thought to be safe but should be checked with a doctor first, and that aspirin is not recommended; check with a pharmacist, midwife or GP before buying anything. The NHS also says not to use tampons until after the 6-week postnatal check.

A professional will examine the wound. The RCOG says that after a deep tear signs of infection may mean you need antibiotics to help it heal, and that rarely another operation is needed to repair a tear. Somerset says if you are worried you should speak to your midwife or GP right away or attend the local maternity triage or assessment unit. Decisions about antibiotics or re-suturing rest with the examining clinician, and you should not start or stop medicine without advice.

The NHS describes necrotising fasciitis as a rare, life-threatening infection of the deeper layers of the skin that needs hospital treatment straight away. It usually begins near a cut or wound, and early features include intense pain or loss of feeling much worse than you would expect from a wound, redness and swelling around the area, and flu-like symptoms; later signs are vomiting, diarrhoea, confusion, and blisters or black, purple or grey blotches. The NHS says to call 999 or go to A&E if you have a cut or wound, or a red or swollen area, that is much more painful than expected, or you also have a high temperature, headache and muscle aches, sudden confusion or dizziness, a pounding heart, or dark blotches; do not drive yourself.

This is extremely rare after childbirth. It is included here because severe pain out of proportion to a perineal or other wound is a red flag that should never be left to settle. NICE's sepsis guideline for pregnant and recently pregnant people lists signs of infection at a surgical site such as redness, swelling, discharge or wound breakdown among features used to grade risk, and the NHS sepsis page lists confusion, very high or low temperature and blotchy skin as reasons to call 999.

NICE notes that perineal pain which persists or worsens in the first few weeks may be associated with depression, long-term perineal pain, difficulties with daily functioning and psychosexual difficulties, and that wound infection or breakdown is among risk factors for persistent perineal pain. If healing is slow or you feel low, mention it at your 6 to 8 week check or sooner. Aftercare and referral routes differ between UK nations.