Prophylactic Negative Pressure Wound Therapy for Obese Women After Cesarean Delivery

Peripartum interventions for people with class III obesity: a systematic review and meta-analysis

OBJECTIVE

This study aimed to identify evidence-based peripartum interventions for people with a body mass index ≥40 kg/m2.

DATA SOURCES

PubMed, MEDLINE, EMBASE, Cochrane, CINAHL, and ClinicalTrials.gov were searched from inception to 2022 without date, publication type, or language restrictions.

STUDY ELIGIBILITY CRITERIA

Cohort and randomized controlled trials that implemented an intervention and evaluated peripartum outcomes of people with a body mass index ≥40 kg/m2 were included. The primary outcome depended on the intervention but was commonly related to wound morbidity after cesarean delivery (ie, infection, separation, hematoma).

METHODS

Meta-analysis was completed for interventions with at least 2 studies. Pooled risk ratios with 95% confidence intervals and heterogeneity (I2 statistics) were reported.

RESULTS

Of 20,301 studies screened, 30 studies (17 cohort and 13 randomized controlled trials) encompassing 10 types of interventions were included. The interventions included delivery planning (induction of labor, planned cesarean delivery), antibiotics during labor induction or for surgical prophylaxis, 6 types of cesarean delivery techniques, and anticoagulation dosing after a cesarean delivery. Planned cesarean delivery compared with planned vaginal delivery did not improve outcomes according to 3 cohort studies. One cohort study compared 3 g with 2 g of cephazolin prophylaxis for cesarean delivery and found no differences in surgical site infections. According to 3 cohort studies and 2 randomized controlled trials, there was no improvement in outcomes with a non-low transverse skin incision. Ten studies (4 cohort and 6 randomized controlled trials) met the inclusion criteria for the meta-analysis. Two randomized controlled trials compared subcuticular closure with suture vs staples after cesarean delivery and found no differences in wound morbidity within 6 weeks of cesarean delivery (n=422; risk ratio, 1.09; 95% confidence interval, 0.75-1.59; I2=9%). Prophylactic negative-pressure wound therapy was compared with standard dressing in 4 cohort and 4 randomized controlled trials, which found no differences in wound morbidity (cohort n=2200; risk ratio, 1.19; 95% confidence interval, 0.88-1.63; I2=66.1%) or surgical site infections (randomized controlled trial n=1262; risk ratio, 0.90; 95% confidence interval, 0.63-1.29; I2=0).

CONCLUSION

Few studies address interventions in people with a body mass index ≥40 kg/m2, and most studies did not demonstrate a benefit. Either staples or suture are recommended for subcuticular closure, but available data do not support prophylactic negative-pressure wound therapy after cesarean delivery for people with a body mass index ≥40 kg/m2.

Prevention of surgical site infection and sepsis in pregnant obese women

Obesity is a major determinant of health outcomes and is on the increase in women worldwide. It predisposes to surgical site infection (SSI). Risk factors for the SSI include extremes of age, smoking, comorbidities such as hypertension and diabetes, inappropriate vertical abdominal and or uterine wall incisions, increased operating time, subcutaneous layer of 3 cm or more, and unnecessary use of subcutaneous drain. Most bacteria that cause SSIs are human commensals. Common organisms responsible for SSI include Staphylococcus aureus and coliforms such as Proteus mirabilis, and Escherichia coli. A surgeon's gloves post caesarean section in the obese has a preponderance of Firmicutes and Bacteroidetes, which increases SSI risk. The interaction of skin commensals and vaginal microbiome at the surgical incision site increases the risk of SSI in the obese compared to non-obese. Minimizing the risk of SSI involves modification of risk factors, timely treatment of SSI to prevent sepsis and compliance with the recommended care bundles.

Optimizing Surgical Wound Care in Obstetrics and Gynecology

Importance

Obstetrics and gynecology (OB/GYN) accounts for at least half of all open abdominal surgeries performed. Rates of surgical wound complications after open procedures in OB/GYN range from 5% to 35%. Therefore, optimizing management of surgical wound complications has the potential to significantly reduce cost and morbidity. However, guidelines addressing best practices for wound care in OB/GYN are limited.

Objective

The objectives of this review are to describe the fundamentals of wound healing and to evaluate available evidence addressing surgical wound care. Based on these data, we provide recommendations for management of extrafascial surgical wound dehiscence after OB/GYN procedures.

Evidence Acquisition

Literature search was performed in PubMed, Medline, OVID, and the Cochrane database. Relevant guidelines, systematic reviews, and original research articles investigating mechanisms of wound healing, types of wound closure, and management of surgical wound complications were reviewed.

Results

Surgical wound complications in OB/GYN are associated with significant cost and morbidity. One of the most common complications is extrafascial dehiscence, which may occur in the setting of hematomas, seromas, or infection. Management includes early debridement and treatment of any underlying infection until healthy granulation tissue is present. For wounds healing by secondary intention, advanced moisture retentive dressings reduce time to healing and are cost-effective when compared with conventional wet-to-dry gauze dressings. Negative pressure wound therapy can be applied to deeper wounds healing by secondary intention. Review of published evidence also supports the use of delayed reclosure to expedite wound healing for select patients.

Conclusions

Optimizing surgical wound care has the potential to reduce the cost and morbidity associated with surgical wound complications in OB/GYN. Advanced moisture retentive dressings should be considered for wounds healing by secondary intention. Data support delayed reclosure for select patients, although further studies are needed.

Incisional negative pressure wound therapy for the prevention of surgical site infection: an up-to-date meta-analysis and trial sequential analysis

Background

The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. We aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA).

Methods

PubMed, Embase and Cochrane CENTRAL databases were searched from database inception to October 24, 2022. We identified existing meta-analyses covering all surgical specialties and RCTs studying the effect of iNPWT compared with standard dressings in all types of surgery on the incidence of SSI, wound dehiscence, reoperation, seroma, hematoma, mortality, readmission rate, skin blistering, skin necrosis, pain, and adverse effects of the intervention. We calculated relative risks (RR) with corresponding 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. We assessed publication bias with a comparison-adjusted funnel plot. TSA was used to assess the risk of random error. The certainty of evidence was evaluated using the Cochrane Risk of Bias-2 (RoB2) tool and GRADE approach. This study is registered with PROSPERO, CRD42022312995.

Findings

We identified eight previously published general meta-analyses investigating iNPWT and compared their results to present meta-analysis. For the updated systematic review, 57 RCTs with 13,744 patients were included in the quantitative analysis for SSI, yielding a RR of 0.67 (95% CI: 0.59-0.76, I2 = 21%) for iNPWT compared with standard dressing. Certainty of evidence was high. Compared with previous meta-analyses, the RR stabilised, and the confidence interval narrowed. In the TSA, the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate from the meta-analysis.

Interpretation

In this up-to-date meta-analysis, GRADE assessment shows high-certainty evidence that iNPWT is effective in reducing SSI, and uncertainty is less than in previous meta-analyses. TSA indicated that further trials are unlikely to change the effect estimate for the outcome SSI; therefore, if future research is to be conducted on iNPWT, it is crucial to consider what the findings will contribute to the existing robust evidence.

Funding

Dutch Association for Quality Funds Medical Specialists.

Prevention of Postoperative Surgical Site Infection Following Cesarean Delivery

Cesarean delivery is the most common major surgical procedure performed among birthing persons in the United States, and surgical-site infection is a significant complication. Several significant advances in preventive measures have been shown to reduce infection risk, while others remain plausible but not yet proven in clinical trials.

Obesity in Pregnancy: A Comprehensive Review of Influential Guidelines

Importance

Obesity is one of the most common clinical entities complicating pregnancies and is associated with short- and long-term consequences for both the mother and the offspring.

Objective

The aim of this study were to review and compare the most recently published influential guidelines on the management of maternal obesity in the preconceptional, antenatal, intrapartum, and postpartum period.

Evidence Acquisition

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynecologists of Canada, the Royal College of Obstetricians and Gynecologists, and the Royal Australian and New Zealand College of Obstetricians and Gynecologists on obesity in pregnancy was carried out.

Results

There is an overall agreement among the reviewed guidelines regarding the importance of prepregnancy weight loss with behavioral modification, optimization of gestational weight gain, and screening for comorbidities in improving pregnancy outcomes of obese women. Women with previous bariatric surgery should be screened for nutritional deficiencies and have a closer antenatal surveillance, according to all guidelines. In addition, folic acid supplementation is recommended for 1 to 3 months before conception and during the first trimester, but several discrepancies were identified with regard to other vitamins, iodine, calcium, and iron supplementation. All medical societies recommend early screening for gestational diabetes mellitus and early anesthetic assessment in obese women and suggest the use of aspirin for the prevention of preeclampsia when additional risk factors are present, although the optimal dosage is controversial. The International Federation of Gynecology and Obstetrics, Society of Obstetricians and Gynecologists of Canada, Royal College of Obstetricians and Gynecologists, and Royal Australian and New Zealand College of Obstetricians and Gynecologists point out that specific equipment and adequate resources must be readily available in all health care facilities managing obese pregnant women. Moreover, thromboprophylaxis and prophylactic antibiotics are indicated in case of cesarean delivery, and intrapartum fetal monitoring is justified during active labor in obese patients. However, there are no consistent protocols regarding the fetal surveillance, the monitoring of multiple gestations, the timing and mode of delivery, and the postpartum follow-up, although weight loss and breastfeeding are unanimously supported.

Conclusions

Obesity in pregnancy is a significant contributor to maternal and perinatal morbidity with a constantly rising global prevalence among reproductive-aged women. Thus, the development of uniform international protocols for the effective management of obese women is of paramount importance to safely guide clinical practice and subsequently improve pregnancy outcomes.

Effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery: A meta-analysis

We performed a meta-analysis to evaluate the effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery. A systematic literature search up to April 2022 was performed and 1537 total number of groin vascular surgery incisions at the baseline of the studies; 729 of them were using the prophylactic negative pressure treatment, and 808 were using control. Odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic negative pressure treatment for post-surgery groin wounds management in vascular surgery using the dichotomous, and contentious methods with a random or fixed-effect model. The prophylactic negative pressure treatment subjects had a significantly lower surgical site wound infection (OR, 0.26; 95% CI, 0.16-0.42, P < .001) in subjects after vascular surgery compared with control. However, prophylactic negative pressure treatment did not show any significant difference in revision surgery (OR, 0.73; 95% CI, 0.52-1.00, P = .05), readmission (OR, 0.93; 95% CI, 0.66-1.32, P = .69), mortality in hospital (OR, 0.54; 95% CI, 0.29-1.01, P = .05), and length of hospital stay (MD, -0.24; 95% CI, -0.91-0.44, P = .49) compared with control in subjects after vascular surgery. The prophylactic negative pressure treatment subjects had a significantly lower surgical site wound infection and no significant difference in revision surgery, readmission, mortality in hospital, and length of hospital stay compared with control in subjects after vascular surgery. The analysis of outcomes should be with caution because of the low sample size of 2 out of 10 studies in the meta-analysis and a low number of studies in certain comparisons.

Prophylactic negative pressure wound therapy on wound complications after cesarean delivery in women with obesity: a meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials aimed to assess whether negative pressure wound therapy affects the rate of wound complications when applied to women with obesity after cesarean delivery compared with standard postoperative dressings.

DATA SOURCES

This research used PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials as electronic databases, from the inception of each database to January 2021, with randomized controlled trial as the publication type. There was no restriction applied for language or geographic location.

STUDY ELIGIBILITY CRITERIA

The selection criteria included only randomized controlled trials comparing the effect of negative pressure wound therapy with that of standard dressings on wound complications in women with obesity undergoing cesarean delivery.

METHODS

The primary outcome was a wound complication composite outcome (wound infection, separation or dehiscence, hematoma, seroma, or readmission secondary to a wound concern). The wound complication composite was analyzed by counting events once per patient. The summary measures were reported as relative risk or as mean difference with 95% confidence intervals using the random-effects model of DerSimonian and Laird. An I-squared (Higgins I²) value of >0% was used to identify heterogeneity.

RESULTS

Overall, 11 randomized controlled trials, which included 5746 participants with obesity undergoing cesarean delivery, were included. Of those participants, 2869 (49.9%) were randomized to the intervention group (negative pressure wound therapy), and 2877 (50.1%) were randomized to the control group (standard dressing). Prophylactic negative pressure wound therapy was not associated with a significant change in the rate of wound complications (relative risk, 1.00; 95% confidence interval, 0.81-1.23) compared with standard postoperative dressings. However, the use of negative pressure wound therapy decreased the rate of wound infections (relative risk, 0.79; 95% confidence interval, 0.66- 0.96) and increased the frequency of skin reactions (relative risk, 4.59; 95% confidence interval, 1.29-16.38). Negative pressure wound therapy did not result in a significant difference in the rate of dehiscence, hematoma, seroma, readmission, reoperation, and antibiotic use for wound infection.

CONCLUSION

Compared with standard postoperative incision dressings, negative pressure wound therapy did not affect the rate of wound complications but decreased the frequency of wound infections when applied to women with obesity after cesarean delivery. However, results should be interpreted with caution, as wound infection outcome includes different definitions per the individual trials.

CONDENSATION

Prophylactic negative pressure wound therapy has no effect on overall wound complications in women with obesity after cesarean delivery compared with standard dressings.

Prophylactic negative pressure wound therapy on surgical site infection in obese women after cesarean section: A systematic review and meta-analysis

Prevention of surgical site infection (SSI) is a public health challenge. The objective of the study was to evaluate the efficacy of negative pressure wound therapy (NPWT) for preventing SSI and other wound complications in obese women undergoing cesarean section. The search terms included "negative pressure wound therapy", "obesity" and "cesarean section/delivery". Randomized controlled trials were used to compare the use of NPWT to standard dressings in preventing SSI in obese women after cesarean section. A comprehensive literature search of four databases was performed up to June 2021. The primary outcome was SSI. Secondary outcomes were seroma, hematoma, overall wound complications, and adverse skin reactions. Ten RCTs involving 5586 patients met the inclusion criteria. The use of NPWT reduced SSI (RR = 0.76, 95%CI: 0.63-0.92, P = 0.004). No statistically significant difference was detected in the incidence of overall wound complications (RR = 0.93, P = 0.48), seroma (RR = 1.10, P = 0.79), hematoma (RR = 0.63, P = 0.36) and hospital readmission (RR = 1.41, P = 0.15). NPWT significantly increased the occurrence of skin blistering with a RR of 4.60 (P = 0.04). Use of prophylactic NPWT after cesarean delivery among obese women is associated with a significant reduction of surgical site infection.

Effect of negative-pressure wound therapy on wound complications in obese women after caesarean birth: a systematic review and meta-analysis

BACKGROUND

Obesity is associated with increased surgical-site infection (SSI) following caesarean section (CS).

OBJECTIVE

To summarise the evidence on the effectiveness of negative-pressure wound therapy (NPWT) for preventing SSI and other wound complications in obese women after CS.

SEARCH STRATEGY

MEDLINE, Embase, CINAHL, Cochrane CENTRAL databases and ClinicalTrials.gov were systematically searched in March 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of NPWT compared with standard dressings after CS birth.

DATA COLLECTION AND ANALYSIS

Pooled effect sizes were calculated using either fixed or random effects models based on heterogeneity. The Cochrane risk of bias and Grading of Recommendations Assessment, Development and Evaluation tools were used to assess the quality of studies and overall quality of evidence.

MAIN RESULTS

Ten RCTs with 5583 patients were included; studies were published between 2012 and 2021. Nine RCTs with 5529 patients were pooled for the outcome SSI. Meta-analysis results suggest a significant difference favouring the NPWT group (relative risk [RR] 0.79, 95% CI 0.65-0.95, P < 0.01), indicating an absolute risk reduction of 1.8% among those receiving NPWT compared with usual care. The risk of blistering in the NPWT group was significantly higher (RR 4.13, 95% CI 1.53-11.18, P = 0.005). All studies had high risk of bias relative to blinding of personnel/participants. Only 40% of studies reported blinding of outcome assessments and 50% had incomplete outcome data.

CONCLUSIONS

The decision to use NPWT should be considered both in terms of its potential benefits and its limitations.

TWEETABLE ABSTRACT

NPWT was associated with fewer SSI in women following CS birth but was not effective in reducing other wound complications.

Prophylactic incisional negative pressure wound therapy for gynaecologic malignancies

Wound complications are an important cause of postoperative morbidity among patients with gynaecologic malignancies. We evaluated whether the placement of closed-incisional negative pressure therapy (ciNPT) at the time of laparotomy for gynaecologic cancer surgery reduced wound complication rates. A retrospective cohort study with primary wound closure performed by a gynaecologic oncologist was carried out. We evaluated two cohorts of patients who underwent surgery in 2017 with standard closure and patients who underwent surgery in 2019 with the placement of prophylactic ciNPT. Postoperative outcomes were examined. A total of 143 patients were included, 85 (59.4%) vs 58 (40.6%) with standard closure and ciNPT, respectively. The total complication rate in our sample was 38.71%. The rate of surgical complications in patients treated with ciNPT was 6.9% compared with 31.8% (P = .000) in patients treated with standard closure. In the analysis of complications, a significant reduction in infections (17.1%), seromas (15.4%), and wound dehiscence (17.1%) were observed when ciNPT was applied. The median hospital stay was 8 vs 6 days in the standard closure vs ciNPT groups (P = .048). The use of the prophylactic ciNPT following a laparotomy may decrease wound complications and hospital stays in oncological patients. ciNPT could be considered as part of clinical practice in patients at high risk of wound complications, such as patients with gynaecological malignancies.

Randomized controlled trial of single-use negative-pressure wound therapy dressings in morbidly obese patients undergoing cesarean delivery

BACKGROUND

The single-use negative-pressure wound therapy dressings are designed to use over a closed surgical wound. Early prospective studies suggested that these dressings may be of potential benefit in reducing cesarean wound complications.

OBJECTIVE

This study aimed to test the hypothesis that incisional negative-pressure wound therapy decreases postoperative wound morbidity compared with standard surgical dressing in patients with class III obesity undergoing cesarean delivery.

STUDY DESIGN

In a single-site, parallel, randomized controlled trial, participants with class III obesity (body mass index ≥40 kg/m²) were recruited to participate in the study. Patients were consented in the ambulatory obstetrical units, on admission to the antepartum service, and on labor and delivery before active labor. Patients who had a cesarean delivery were randomized to either the standard surgical dressing or a prophylactic negative-pressure wound therapy device. The randomization was achieved using permuted blocks of 4, 6, and 8 in a 1:1 allocation ratio. The primary outcome was a composite outcome of wound complications. The planned enrollment of 242 subjects was based on the power to detect a 50% decrease in the composite wound outcome, assuming a 30% baseline wound morbidity rate for this population. The outcomes were assessed by study staff blinded to the patient's treatment arm.

RESULTS

An unplanned interim analysis was performed because of the slow enrollment and publication of larger trials showing no benefit of the negative-pressure wound therapy. Of 411 eligible patients during the study period, 212 participants with class III obesity were enrolled. Of these, 110 underwent cesarean delivery and were subsequently randomized (55 to standard dressing and 55 to prophylactic negative-pressure wound therapy device). The primary outcome occurred in 29.1% in the standard surgical dressing compared with 20% in the negative-pressure wound therapy group (risk difference, 9.1%; 95% confidence interval, -8.3 to 25.8%; P=.38). The study was stopped early because of a low enrollment rate and lower likelihood of seeing a clinically significant benefit.

CONCLUSION

The trial was stopped after an unplanned, interim analysis showed the use of a prophylactic negative-pressure wound therapy device used for cesarean delivery did not reduce wound complications compared with a standard surgical dressing.

Surgical site infection risk in cesarean delivery patients with obesity after negative pressure wound therapy: A retrospective cohort study

BACKGROUND

There are conflicting reports of postoperative efficacy of negative pressure wound therapy in patients with obesity after cesarean delivery.

METHODS

Retrospective cohort study for patients with obesity and negative pressure wound therapy or abdominal dressing after cesarean delivery between April 1, 2014 and January 31, 2018. Postoperative surgical site infection was defined from medical record charting or positive wound culture and confirmed by the hospital's Infection Prevention team. Multivariable logistic regression model for surgical site infection was conducted including additional potential confounding variables. Mantel-Haenszel tests were conducted to stratify by body mass index class and operative time, and we performed quasi-Poisson regression to determine which factors were associated with an increased operative time.

RESULTS

We included 4,391 Black or White patients with obesity, 696 (15.9%) underwent negative pressure wound therapy and 3,695 (84.1%) abdominal dressing after cesarean delivery. Incidence of surgical site infection after negative pressure wound therapy and abdominal dressing were 6.1% and 3.4%, respectively (2-sample test of proportions P < .001). The multivariable logistic regression (covariates: race, diabetes, body mass index category, insurance, scheduled/emergency, artificial rupture, previous c-section, operative time, age, closure type) found negative pressure wound therapy dressing was associated with an increased risk of surgical site infection (adjusted odds ratio 1.54; 95% confidence interval, 1.01-2.34), as did a Mantel-Haenszel test which was stratified by body mass index (odds ratio 1.62; 95% confidence interval, 1.08-2.43) and a Mantel-Haenszel test stratified by operative time (odds ratio 1.85; 95% confidence interval, 1.28-2.65). Negative pressure wound therapy dressing also led to an increase in operative time in the Quasi-Poisson regression, which was the primary predictor of infection.

CONCLUSION

Negative pressure wound therapy was associated with an increased the risk of postoperative surgical site infection after cesarean delivery in our obstetric patients with obesity. Future prospective studies are needed to determine a dressing type and other intervention to decrease postoperative cesarean surgical site infection in women with obesity.

A Systematic Review and Meta-Analysis of Wound Complications after a Caesarean Section in Obese Women

(1) Background: Caesarean sections in obese patients are associated with an increased risk of surgical wound complications, including hematomas, seromas, abscesses, dehiscence, and surgical site infections. The aim of the present study is to perform a meta-analysis and systematic review of the current literature focusing on the strategies available to decrease wound complications in this population. (2) Methods: We reviewed the data available from the PubMed and the Science Direct databases concerning wound complications after caesarean sections in obese women. The following key words were used: “caesarean section”, “cesarean section”, “wound complication”, “wound morbidity”, and “wound infection”. A total of 540 papers were retrieved, 40 of which were selected for the final systematic review and whereas 21 articles provided data for meta-analysis. (3) Results: The conducted meta-analyses revealed that the use of prophylactic drainage does not increase the risk of wound complications in obese women after a caesarean sections (pooled OR = 1.32; 95% CI 0.64–2.70, p = 0.45) and that vertical skin incisions increase wound complications (pooled OR = 2.48; 95% CI 1.85–3.32, p < 0.01) in obese women, including extremely obese women. (4) Conclusions: Subcutaneous drainage does not reduce the risk of a wound complications, wound infections, and fever in obese women after caesarean sections. Negative prophylactic pressure wound therapy (NPWT) may reduce the risk of surgical site infections. The evidence of using a prophylactic dose of an antibiotic before the caesarean section is still lacking.

Effectiveness of negative pressure wound therapy in the prevention of surgical wound complications in the cesarean section at-risk population: a parallel group randomised multicentre trial-the CYGNUS protocol

INTRODUCTION

Caesarean delivery is steadily becoming one of the more common surgical procedures in Australia with over 100 000 caesarean sections performed each year. Over the last 10 years in Australia, the caesarean section rate has increased from 28% in 2003 to 33% in 2013. On the international stage, the Australian caesarean delivery rates are higher than the average for the Organisation for Economic Co-operation and Development, Australia ranked as 8 out of 33 and is second to the USA. Postoperative surgical site infections (SSIs) and wound complications are the most common and costly event following a caesarean section. Globally, complication rates following a caesarean delivery vary from 4.9% to 9.8%. Complications such as infection and wound breakdown affect the postpartum mother's health and well-being, and contribute to healthcare costs for clinical management that often spans the acute, community and primary healthcare settings. Published level one studies using advanced wound dressings in the identified 'at-risk' population prior to surgery for prophylactic intervention are yet to be forthcoming.

METHODS AND ANALYSIS

A parallel group randomised control trial of 448 patients will be conducted across two metropolitan hospitals in Perth, Western Australia, which provide obstetric and midwifery services. We will recruit pregnant women in the last trimester, prior to their admission into the healthcare facility for delivery of their child. We will use a computer-generated block sequence to randomise the 448 participants to either the interventional (negative pressure wound therapy (NPWT) dressing, n=224) or comparator arm (non-NPWT dressing, n=224). The primary outcome measure is the occurrence of surgical wound dehiscence (SSWD) or SSI. The Centres for Disease Control reporting definition of either superficial or deep infection at 30 days will be used as the outcome measure definition. SWD will be classified as per the World Union of Wound Healing Societies grading system (grade I-IV). We will assess recruitment rate, and adherence to intervention and follow-up. We will assess the potential effectiveness of NPWT in the prevention of postpartum surgical wound complications at three time points during the study; postoperative days 5, 14 and 30, after which the participant will be closed out of the trial. We will use statistical methods to determine efficacy, and risk stratification will be conducted to determine the SWD risk profile of the participant. Follow-up at day 30 will assess superficial and deep infection, and wound dehiscence (grade I-IV) and the core outcome data set for wound complications. This study will collect health-related quality of life (European Quality of Life 5-Dimensions 5-Level Scale), mortality and late complications such as further surgery with a cost analysis conducted. The primary analysis will be by intention-to-treat. This clinical trial protocol follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) and the Consolidated Standards of Reporting Trials guidelines.

ETHICS AND DISSEMINATION

Ethics approval was obtained through St John of God Health Care (HREC1409), Western Australia Department of Health King Edward Memorial Hospital (HREC3111). Study findings will be published in peer-reviewed journals and presented at international conferences. We used the SPIRIT checklist when writing our study protocol.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ACTRN12618002006224p).

Effect of Prophylactic Negative Pressure Wound Therapy vs Standard Wound Dressing on Surgical-Site Infection in Obese Women After Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

Obesity increases the risk of both cesarean delivery and surgical-site infection. Despite widespread use, it is unclear whether prophylactic negative pressure wound therapy reduces surgical-site infection after cesarean delivery in obese women.

OBJECTIVE

To evaluate whether prophylactic negative pressure wound therapy, initiated immediately after cesarean delivery, lowers the risk of surgical-site infections compared with standard wound dressing in obese women.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized trial conducted from February 8, 2017, through November 13, 2019, at 4 academic and 2 community hospitals across the United States. Obese women undergoing planned or unplanned cesarean delivery were eligible. The study was terminated after 1624 of 2850 participants were recruited when a planned interim analysis showed increased adverse events in the negative pressure group and futility for the primary outcome. Final follow-up was December 18, 2019.

INTERVENTIONS

Participants were randomly assigned to either undergo prophylactic negative pressure wound therapy, with application of the negative pressure device immediately after repair of the surgical incision (n = 816), or receive standard wound dressing (n = 808).

MAIN OUTCOMES AND MEASURES

The primary outcome was superficial or deep surgical-site infection according to the Centers for Disease Control and Prevention definitions. Secondary outcomes included other wound complications, composite of surgical-site infections and other wound complications, and adverse skin reactions.

RESULTS

Of the 1624 women randomized (mean age, 30.4 years, mean body mass index, 39.5), 1608 (99%) completed the study: 806 in the negative pressure group (median duration of negative pressure, 4 days) and 802 in the standard dressing group. Superficial or deep surgical-site infection was diagnosed in 29 participants (3.6%) in the negative pressure group and 27 (3.4%) in the standard dressing group (difference, 0.36%; 95% CI, -1.46% to 2.19%, P = .70). Of 30 prespecified secondary end points, 25 showed no significant differences, including other wound complications (2.6% vs 3.1%; difference, -0.53%; 95% CI, -1.93% to 0.88%; P = .46) and composite of surgical-site infections and other wound complications (6.5% vs 6.7%; difference, -0.27%; 95% CI, -2.71% to 2.25%; P = .83). Adverse skin reactions were significantly more frequent in the negative pressure group (7.0% vs 0.6%; difference, 6.95%; 95% CI, 1.86% to 12.03%; P < .001).

CONCLUSIONS AND RELEVANCE

Among obese women undergoing cesarean delivery, prophylactic negative pressure wound therapy, compared with standard wound dressing, did not significantly reduce the risk of surgical-site infection. These findings do not support routine use of prophylactic negative pressure wound therapy in obese women after cesarean delivery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03009110.

Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care

OBJECTIVE

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.

TARGET POPULATION

Women with obesity who are pregnant or planning pregnancies.

EVIDENCE

Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetric anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.

GUIDELINE UPDATE

SOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

SPONSORS

This guideline was developed with resources funded by the SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

The association of skin incision placement during cesarean delivery with wound complications in obese women: a systematic review and meta-analysis

OBJECTIVE

To determine the risk of wound complications by skin incision type in obese women undergoing cesarean delivery.Data sources: Electronic databases (MEDLINE, Scopus, and Ovid) were searched from their inception through August 2018.Methods of study selection: We included all randomized controlled trials and cohort studies reporting the placement of skin incision during cesarean section in obese women, defined as those with BMI ≥30 kg/m². Studies were included if they compared one placement of skin incision with a different one as comparison group. The primary outcome was incidence of wound complications, while secondary outcomes included wound infection, hematoma, seroma, postpartum hemorrhage, and endometritis. Demographics and outcomes for each individual study identified were reported as part of the review. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). Sub-group analyses (vertical versus Pfannenstiel) were also reported.Tabulation, integration and results: Seventeen studies (including 3 RCTs; 8960 participants among the 15 non-overlapping studies) were included in the systematic review. Vertical incisions were associated with a relative risk of 2.07 (95% CI1.61-2.67) for wound complications compared to transverse incisions, however significant possible confounders were present. Studies were mildly-moderately heterogeneous (I² 44.81%, 95% CI 0.00-71.85%) with varying definitions of obesity and wound complications. High transverse incisions (3 studies, 218 participants) trend toward a lower risk of wound complications compared to low transverse incisions (RR 0.338, 95% CI 0.114-1.004).

CONCLUSIONS

Vertical incisions may be associated with an increased risk for wound complications compared to transverse incisions for cesarean delivery in obese women. Randomized controlled trials are needed to evaluate optimal cesarean skin incisions for these women.

Closed Incision Negative Pressure Therapy in Morbidly Obese Women Undergoing Cesarean Delivery: A Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of incisional negative pressure wound therapy in the prevention of postoperative wound morbidity in women with class III obesity undergoing cesarean delivery.

METHODS

In an open label randomized controlled trial, women admitted for delivery with class III obesity (body mass index 40 or higher) measured within 2 weeks of admission for delivery were offered participation in the study. They were consented either in the outpatient maternal-fetal medicine specialty clinic, during admission to labor and delivery and before a decision to perform cesarean delivery, or in the preoperative area of the hospital before scheduled cesarean delivery. Exclusion criteria included anticoagulation therapy, human immunodeficiency virus infection, and silver or acrylic allergy. Those who ultimately underwent cesarean delivery were randomized to standard surgical dressing or incisional negative pressure wound therapy dressing. The primary outcome was wound morbidity. Preplanned secondary outcomes included characteristics of composite wound morbidity, and hospital, emergency room, and clinic utilization. The sample size estimate required randomization of 440 women to detect a 50% decrease in composite outcome.

RESULTS

Between January 1, 2015, and July 31, 2016, 850 women were screened and 677 women with class III obesity were enrolled. Of these, 441 underwent cesarean delivery and were subsequently randomized (219 to standard dressing and 222 to incisional negative pressure wound therapy). The primary outcome, overall composite wound morbidity rate, was 18%. This was not different between the two cohorts (incisional negative pressure wound therapy 17% vs standard dressing 19%, relative risk 0.9 [95% CI 0.5-1.4]).

CONCLUSION

Prophylactic incisional negative pressure wound therapy use did not reduce postoperative wound morbidity when compared with a standard surgical dressing in women with class III obesity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02289157.

Systematic review of negative pressure wound therapy for head and neck wounds with fistulas: Outcomes and complications

Fistula formation in head and neck wounds is considered one of the most challenging complications that a head and neck reconstructive surgeon may encounter. The current mainstay of treatment is aggressive surgical debridement followed by vascularised soft tissue coverage. Negative pressure wound therapy (NPWT) has been successfully used for the closure of complicated wounds for decades. This study analysed the outcomes and complications of NPWT in the management of head and neck wounds with fistulas. A systematic search of studies published between January 1966 and September 2019 was conducted using the PubMed, MEDLINE, EMBASE, and SCOPUS databases and using the following key words: "negative pressure wound therapy," "head and neck," and "fistula." We included human studies with abstract and full text available. Analysed endpoints were rate of fistula closure, follow-up duration, and complications if present. Nine retrospective case series (Level IV evidence) that collectively included 122 head and neck wounds with orocutaneous fistulas, pharyngocutaneous fistulas, and salivary contamination were examined. The number of patients included in each study ranged from 5 to 64. The mode of NPWT varied among the included studies, with most adopting a continuous pressure of -125 mm Hg. Mean durations of NPWT ranged from 3.7 to 23 days, and the reported fistula closure rate ranged from 78% to 100%. To achieve complete wound healing, six studies used additional procedures after stopping NPWT, including conventional wound dressings and vascularised tissue transfer. Information regarding follow up was provided in only three of the nine studies, where patients were followed for 5, 10, and 18 months. No serious adverse events were reported. NPWT for head and neck wounds with fistulas may be considered a safe treatment method that yields beneficial outcomes with a low risk of complications. The current data originated mainly from studies with low levels of evidence characterised by heterogeneity. Therefore, definitive recommendations based on these data cannot be offered. Additional high-quality trials are warranted to corroborate the findings of this systematic review.

Directive clinique No 392 - Grossesse et obésité maternelle Partie 2 : Planification en équipe de l'accouchement et soins post-partum

OBJECTIF

La présente directive clinique aborde les aspects essentiels des soins prénataux chez les femmes atteintes d'obésité. La partie 1 porte sur la préconception et les soins prénataux. La partie 2 porte sur la planification en équipe de l'accouchement et les soins post-partum. UTILISATEURS CONCERNéS: Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières, anesthésiologistes) qui prodiguent des soins relatifs à la grossesse auprès de femmes atteintes d'obésité.

POPULATION CIBLE

Femmes atteintes d'obésité qui sont enceintes ou prévoient le devenir. DONNéES PROBANTES: Des recherches ont été menées en consultant les ressources de Statistique Canada, de Medline et de Cochrane Library en vue d'en tirer la littérature relativement aux effets de l'obésité durant la grossesse sur les soins prénataux et intrapartum, la morbidité et la mortalité maternelles, l'anesthésie obstétricale ainsi que sur la morbidité et la mortalité périnatales. Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été mises à jour régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en septembre 2018. Nous avons également tenu compte de la littérature grise (non publiée) obtenue sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes pertinents, dans des collections de directives cliniques et des registres d'essais cliniques, et auprès d'associations nationales et internationales de médecins spécialistes. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. Les membres du comité de médecine fœto-maternelle ont ensuite passé en revue le contenu et formulé des commentaires aux fins d'examen. Enfin, le conseil d'administration de la Société des obstétriciens et gynécologues du Canada (SOGC) a approuvé la publication de la version définitive de la directive. Les points de désaccord ont été abordés lors de réunions pour enfin arriver à un consensus. La qualité des données et des recommandations a été déterminée à l'aide des critères d'évaluation décrits par le Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICE ET COûTS: La mise en place des recommandations des présentes directives peut améliorer la reconnaissance des fournisseurs de soins obstétricaux relativement aux problèmes qui touchent les personnes enceintes atteintes d'obésité, notamment au moyen de stratégies de prévention clinique; de la communication entre l'équipe de soins de santé, la patiente et la famille; et de la planification de l'équipement et des ressources humaines. Il est à espérer que les organismes régionaux, provinciaux et fédéraux participeront à la formation et au soutien en matière de soins coordonnés pour les personnes enceintes atteintes d'obésité. MISE à JOUR DE LA DIRECTIVE CLINIQUE: Les directives de la SOGC sont automatiquement passées en revue 5 ans après leur publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de 5 ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière.

PROMOTEURS

La présente directive a été élaborée à l'aide de ressources financées par la SOGC. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Prophylactic negative pressure wound therapy for surgical site infection in obese women undergoing cesarean section: an evidence synthesis with trial sequential analysis

OBJECTIVE

Current evidence for negative pressure wound therapy (NPWT) on surgical site infection (SSI) and wound complications in cesarean section is conflicting. The objective of this study was to evaluate the efficacy of prophylactic NPWT for preventing SSI and other wound complications in obese women undergoing cesarean section (CS).

METHODS

We systematically searched PubMed, Embase, the Cochrane Library and clinicaltTrial.gov to identify randomized controlled trials (RCTs) that compared NPWT with standard dressing for cesarean section. The primary outcome was SSI. Secondary outcomes were overall wound complications and hospital readmission. Risk ratio (RR) with 95% confidence intervals (CIs) was calculated using random-effects models. Review Manager 5.3 was applied to analyze the collected data.

RESULTS

Eight RCTs involving 1972 patients were included in this meta-analysis. The pooled results showed that the risk of SSI was significantly lower with the use of NPWT when compared with standard dressing (RR = 0.68, 95%CI = 0.51-0.90, p = .008). However, there was no difference in overall wound complications (RR = 0.93, 95%CI = 0.74-1.17, p = 0.52) and hospital readmission (RR = 1.03, 95%CI = 0.67-1.60, p = .89) between two groups. Current evidence was not confirmed by trial sequential analysis.

CONCLUSION

On the basis of our findings, NPWT decreases the risk of SSI after cesarean section in obese women after CS, despite this approach does not reduce the overall wound complications and hospital readmission. However, further RCTs are needed to make conclusive evidence.

Prophylactic Negative Pressure Wound Therapy and Wound Complication After Cesarean Delivery in Women With Class II or III Obesity: A Randomized Controlled Trial

OBJECTIVE

To compare the occurrence of superficial surgical site infections in obese women using prophylactic negative pressure therapy with standard dressings after cesarean delivery.

METHODS

We conducted a randomized controlled, nonblinded, two-center study of prophylactic negative pressure therapy compared with standard surgical dressings placed at the time of primary closure at cesarean delivery in obese women with body mass indexes (BMI) of 35 or higher (ie, class II and III obesity). Our primary outcome was occurrence of a superficial surgical site infection. We assumed a superficial surgical site infection occurrence rate of 20% and intended to recruit 400 women. However, after low enrollment of 166 women over 24 months, an interim analysis for futility was conducted and the decision was made to halt the study.

RESULTS

Women were recruited between January 5, 2015, and January 7, 2017, from two sites. The mean BMI on admission was 44.9 (±8) for the prophylactic negative wound therapy group and 43.4 (±7) for the standard dressing group. There were no differences in the occurrence of observed superficial surgical site infections between women using prophylactic negative pressure wound therapy (12/80 [15%]) compared with women who received the standard dressing (8/81 [10%], P=.35, relative risk 1.52, 95% CI 0.66-3.52). There were no differences in the occurrence of composite wound complications between women using prophylactic negative pressure wound therapy (25/80 [31%]) compared with women who received the standard dressing (24/81 [30%], P=.87).

CONCLUSION

In this randomized controlled trial that did not achieve full anticipated enrollment, we did not observe a decrease in superficial surgical site infections after cesarean delivery in obese women with the use of prophylactic negative pressure wound therapy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02390401.

Reducing post-caesarean delivery surgical site infections: a narrative review

Surgical site infection complicates 1-10% of caesarean deliveries. With the rate of caesarean delivery increasing, it is important to identify effective measures of preventing surgical site infection and to consider their impact on maternal and neonatal outcomes. Compelling evidence supports the use of prophylactic antibiotics, prior to skin incision, to reduce surgical site infection. However, there remain international variations in terms of the recommended agent, dose and body weight-adjusted dosing. Advances in wound dressings are an evolving area of interest and surgical technique can influence outcomes. This narrative review explores pharmacological and non-pharmacological methods of preventing surgical site infection following caesarean delivery.

Infections complicating cesarean delivery

PURPOSE OF REVIEW

Cesarean sections are common surgical procedures performed in a healthy population and are unique because of a relatively high rate of postoperative infection. There have been many important advances in understanding the pathogenesis of infection and evaluation of interventions to prevent post cesarean section infections in the last few years. Our purpose in this review is to analyze these new data, discuss unanswered questions, and propose changes in standard of care.

RECENT FINDINGS

Wound closure techniques including subcuticular sutures and subcutaneous suturing have been shown to be effective at reducing surgical site infections. Wound dressings including negative pressure dressings likely do not decrease infection rates. The type, timing, and duration of preoperative prophylactic antibiotics, including adjunctive azithromycin for laboring women and multidose antibiotics in obese women, have also yielded mixed results. Our understanding of normal uterine microbiome and the impact of intrapartum antibiotics on the newborn is emerging.

SUMMARY

The pathogenesis of surgical site infections after Cesarean section is complex and multifactorial. Many interventions to reduce infections have been studied with varying degrees of effectiveness. Despite advances in the area, important questions remain unanswered.

Meta-analysis and trial sequential analysis of prophylactic negative pressure therapy for groin wounds in vascular surgery

BACKGROUND

Negative pressure therapy has been proposed as a prophylactic measure to promote surgical wound healing and reduce surgical site complications.

METHODS

We conducted a systematic review of the literature to identify randomized controlled trials (RCTs) comparing prophylactic negative pressure therapy with standard practice in closed groin incisions in vascular surgery. We calculated the pooled odds ratio (OR) or risk difference and 95% confidence interval (CI) with the use of the fixed-effect model. To control the risk of type I error, we adjusted the thresholds for the Z-values with the use of the O'Brien-Fleming α-spending function, and the risk of type II error was controlled with the use of the β-spending function and futility boundaries.

RESULTS

We selected six RCTs reporting on a total of 733 groin wounds. Patients with negative pressure wound therapy had a lower risk of developing surgical site infection (OR, 0.36; 95% CI, 0.24-0.54; P < .001), a lower risk of revision surgery (OR, 0.44; 95% CI, 0.22-0.88; P = .02) and a shorter hospital stay (weighted mean difference, -2.14; 95% CI, -3.78 to 0.49; P = .01). There was no difference in in-hospital mortality (risk difference, 0.01; 95% CI, -0.02 to 0.05; P = .53) or readmission (OR, 0.46; 95% CI, 0.17-1.29; P = .14). The Z-curve for surgical site infection crossed the O'Brien-Fleming significance boundaries for superiority (before the required information size was reached).

CONCLUSIONS

Prophylactic negative pressure wound therapy confers improved outcomes in patients undergoing arterial surgery via a groin incision compared with standard surgical wound care.

Negative pressure wound therapy system in extremely obese women after cesarean delivery compared with standard dressing

Objective: Data regarding the use of the negative pressure wound therapy (NPWT) system in extremely obese women (body mass index [BMI] ≥ 50 kg/m²) undergoing cesarean delivery are limited. We sought to examine the rate of wound complications in extremely obese women according to postcesarean dressings (NPWT [PICO, Smith & Nephew, St. Peterburg, FL] versus standard dressings).Study design: This was a retrospective cohort study of all extremely obese women (BMI ≥ 50 kg/m²) at 23 weeks' gestation or greater who underwent cesarean delivery at an academic teaching hospital in Washington, DC, between January 2009 and September 2017. During this period, a PICO Single Use NPWT system was used at our institution. Women who missed a postpartum follow-up were excluded. Since 2014, Medstar Washington Hospital Center recommended the use of a PICO Single Use NPWT system for extremely obese women at the time of delivery. However, the ultimate decision to use the NPWT was made by attending physicians, considering the cost of the device and the risk of wound complication. Our primary outcome was a composite of cellulitis, hematoma/seroma, and wound dehiscence. Coarsened exact matching with k-to-k solution was performed using BMI, rupture of membranes, and labor.Results: Of 179 extremely obese women, 73 (40.8%) and 106 (59.2%) received NPWT and standard dressings, respectively; 61 women who received NPWT were matched to 61 women who received standard dressings. The rates of the primary outcome in the unmatched cohort were similar between women who received NPWT and those who received standard dressings (20.6 versus 16.0%; p = .44). The rates of primary outcome remained similar between women who received NPWT and those who received standard dressings after matching (18.0 versus 18.0%; p = 1.00).Conclusion: In extremely obese women undergoing cesarean delivery, prophylactic PICO NPWT was not associated with a decreased risk of the primary outcome compared with standard dressings. A large prospective randomized controlled trial would be useful to answer if NPWT is beneficial for extremely obese women.

Evidence-based interventions to reduce obstetric-related infections at an army training facility

BACKGROUND

OBJECTIVE: Obstetric-related infections are a major cause of maternal morbidity and mortality worldwide. Our team implemented an evidence-based infection control bundle aimed at reducing obstetric-related infections at our facility.

METHODS

A multidisciplinary team at Tripler Army Medical Center developed, implemented, and evaluated an evidence-based maternal safety infection control bundle (MSICB) on labor and delivery aimed at reducing the incidence of surgical site infections (SSI) and chorioamnionitis. Adenosine triphosphate testing of patient care-related surfaces was performed while behavioral and environmental interventions were implemented. Incidence rates for chorioamnionitis, SSI, and endometritis were compared between pre- and during-MSICB implementation using Fisher exact test and Poisson regression, adjusting for year and quarter. The decision science analysts at US Army Medical Command, Fort Sam Houston, Texas responsible for our facility utilized diagnosis-related group and ICD-10 Procedure Coding to determine infection-related costs.

RESULTS

Prior to implementation of the MSICB, the rates of chorioamnionitis, SSI, and endometritis in the first half of 2016 were 6.3%, 3.4%, and 0.4%, respectively. After implementation of the MSICB, in the first 6 months of 2017, the rates of chorioamnionitis and SSI decreased to 1.7% and 1.0%, respectively, with no change in the rate of endometritis. The rate was significantly lower after implementation for chorioamnionitis (P < .001), and there was a statistically nonsignificant decrease for SSI (P = .060) and no difference for postpartum endometritis (P = 1.00). These reductions resulted in an estimated net cost savings of $671,218.

CONCLUSIONS

A multidisciplinary approach with evidence-based strategies resulted in a significant decrease (P < .001) in chorioamnionitis and a statistically nonsignificant decrease (P = .060) in the SSI rate, which resulted in a significant cost savings for the hospital. There was no change in our postpartum endometritis rate.

Prophylactic incisional negative pressure wound therapy reduces the risk of surgical site infection after caesarean section in obese women: a pragmatic randomised clinical trial

OBJECTIVE

To evaluate the reduction of surgical site infections by prophylactic incisional negative pressure wound therapy compared with standard postoperative dressings in obese women giving birth by caesarean section.

DESIGN

Multicentre randomised controlled trial.

SETTING

Five hospitals in Denmark.

POPULATION

Obese women (prepregnancy body mass index (BMI) ≥30 kg/m2 ) undergoing elective or emergency caesarean section.

METHOD

The participants were randomly assigned to incisional negative pressure wound therapy or a standard dressing after caesarean section and analysed by intention-to-treat. Blinding was not possible due to the nature of the intervention.

MAIN OUTCOME MEASURES

The primary outcome was surgical site infection requiring antibiotic treatment within the first 30 days after surgery. Secondary outcomes included wound exudate, dehiscence and health-related quality of life.

RESULTS

Incisional negative pressure wound therapy was applied to 432 women and 444 women had a standard dressing. Demographics were similar between groups. Surgical site infection occurred in 20 (4.6%) women treated with incisional negative pressure wound therapy and in 41 (9.2%) women treated with a standard dressing (relative risk 0.50, 95% CI 0.30-0.84; number needed to treat 22; P = 0.007). The effect remained statistically significant when adjusted for BMI and other potential risk factors. Incisional negative pressure wound therapy significantly reduced wound exudate whereas no difference was found for dehiscence and quality of life between the two groups.

CONCLUSION

Prophylactic use of incisional negative pressure wound therapy reduced the risk of surgical site infection in obese women giving birth by caesarean section.

TWEETABLE ABSTRACT

RCT: prophylactic incisional NPWT versus standard dressings postcaesarean in 876 women significantly reduces the risk of SSI.

Use of Closed-Incision Negative-Pressure Therapy in Obstetrics

BACKGROUND

Cesarean delivery is one of the most commonly performed surgeries in the United States. Compared with other surgical procedures, surgical site infection tends to be a relatively uncommon outcome after cesarean delivery in the general population with an incidence rate between 1.46 and 3.82% in the United States in 2006-2008. Despite this lower incidence, surgical site infections following cesarean delivery result in a 6-day increase in mean length of stay at an additional cost of $13,968. Specifically, closed-incision negative-pressure therapy (ciNPT) has been developed for use over clean, closed surgical incisions. A brief literature review on ciNPT use over cesarean delivery incisions is described.

METHODS

A literature search was performed using PubMed and Google Scholar. The search included publications between January 1, 2005, and April 30, 2018, and focused on studies reporting the use of a specific ciNPT system (PREVENA Incision Management System; KCI, an Acelity Company, San Antonio, TX) over cesarean incisions.

RESULTS

Five published articles were identified in the literature search that compared ciNPT use to traditional dressings. Positive clinical outcomes were reported in 2 studies, similar outcomes between ciNPT and traditional dressings were reported in 2 studies, and negative outcomes were reported in 1 study.

CONCLUSIONS

A lack of published literature reporting clinical outcomes following ciNPT use over cesarean delivery incisions exists, and the currently reported evidence is heterogeneous. As such, increased published evidence from large, randomized studies and a reexamination of ciNPT use over cesarean delivery incisions are needed.

Team Planning in Obstetrical Care for Women With Obesity

This paper provides a practical perspective on some parts of care planning for pregnant women with obesity class III and beyond. Obesity affects childbirth, as there are medical risks to mother and fetus. Moreover, the psychological concerns of the mother and family require careful consideration, notably with an interprofessional team of obstetricians, midwives, anaesthesiologists, pediatricians, and lactation specialists, as well as learners. Pregnant women with obesity likely experience stigmatization and weight bias, as such the health care team should be cognizant of evidence-based medical expertise and of the individual sensitivities of mother. Every opportunity must be taken to provide women with a normal birth experience.

Effect of intra-operative glove changing during cesarean section on post-operative complications: a randomized controlled trial

PURPOSE

To compare the rates of wound-related complications among women undergoing a cesarean section when the surgical team used intra-operative glove changing versus usual care.

METHODS

All women undergoing a cesarean section at a single, county hospital were randomized to usual care or intra-operative glove changing prior to abdominal closure. Participants were randomized at the time of decision for cesarean section; surgeons were not blinded to the randomization arm. The primary outcome was any wound-related complication, including wound hematoma, seroma, skin separation of at least 1 cm, wound infection, or other incisional abnormality requiring treatment within 8 weeks of surgery. To detect a reduction in the primary outcome from 17% in the control group to 9% in the intervention group with 80% power, a total of 554 women (277 per group) were required. Secondary outcomes included other infectious complications including endometritis and other superficial or deep soft tissue infections.

RESULTS

From August 2015 to November 2016, 277 women were randomized to usual care and 276 women were randomized to intra-operative glove changing. The two groups were well balanced in terms of demographic data, comorbid conditions and surgical characteristics. Intra-operative glove changing led to a significant decrease in composite wound complications from 13.6% in the control group to 6.4% in the intervention group (p = 0.008).

CONCLUSION

Intra-operative glove changing prior to abdominal closure during cesarean section significantly reduced the incidence of post-operative wound complications.