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Temming LA, Frolova AI, Raghuraman N, Tuuli MG, Cahill AG. Vaginal cleansing before unscheduled cesarean delivery to reduce infection: a randomized clinical trial. Am J Obstet Gynecol 2023; 228:739.e1-739.e14. [PMID: 36462539 PMCID: PMC10227184 DOI: 10.1016/j.ajog.2022.11.1300] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/10/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Cesarean delivery is the most performed major surgery among women, and surgical-site infections following a cesarean delivery are a significant source of postoperative morbidity. It is unclear if vaginal cleansing before a cesarean delivery decreases post-cesarean delivery infectious morbidity. OBJECTIVE This study aimed to evaluate if preoperative vaginal cleansing with povidone-iodine among women undergoing a cesarean delivery after labor decreases postoperative infectious morbidity. STUDY DESIGN This randomized clinical trial was conducted from August 3, 2015 to January 28, 2021, with 30 days of follow-up and the final follow-up completed on February 27, 2021. Patients met the inclusion criteria if they underwent a cesarean delivery after regular contractions with cervical dilation, rupture of membranes, or any cesarean delivery performed at >4 cm dilation. Participants were randomly assigned in a 1:1 ratio to either abdominal cleansing plus vaginal cleansing with 1% povidone-iodine or abdominal cleansing alone. The primary outcome was composite infectious morbidity including surgical-site infection, fever, endometritis, and wound complications within 30 days after the cesarean delivery. Secondary outcomes included individual components of the composite, length of hospital stay, postoperative hospitalization or outpatient treatment related to infectious morbidity, and empirical treatment for neonatal sepsis. RESULTS A total of 608 subjects (304 vaginal cleansing group, 304 control group) were included in the intention-to-treat analysis. Patient characteristics were similar between groups. There was no significant difference in the primary composite outcome between the 2 groups (11.8% vs 11.5%; P=.90; relative risk, 1.0; 95% confidence interval, 0.7-1.6). Individual components of the composite and secondary outcomes were also not significantly different between the groups. Similar findings were observed in the as-treated analysis (11.3% vs 11.8%; P=.9; relative risk, 1.0; 95% confidence interval, 0.7-1.6). CONCLUSION Vaginal cleansing with povidone-iodine before an unscheduled cesarean delivery occurring after labor did not reduce the postoperative infectious morbidity. These findings do not support the routine use of vaginal cleansing for women undergoing a cesarean delivery after labor.
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Affiliation(s)
- Lorene A Temming
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Atrium Health Wake Forest School of Medicine, Carolinas Medical Center, Charlotte, NC.
| | - Antonina I Frolova
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in St Louis, St. Louis, MO
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in St Louis, St. Louis, MO
| | - Methodius G Tuuli
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women and Infant's Hospital of Rhode Island, Alpert Medical School at Brown University, Providence, RI
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX
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Johanna QN, Gomez J, Felder L, Di Mascio D, Eckler R, Paternostro A, Baxter J, Berghella V, Posencheg M. Stepwise implementation of vaginal cleansing and azithromycin at cesarean: a quality improvement study. J Matern Fetal Neonatal Med 2021; 35:5346-5353. [PMID: 33525938 DOI: 10.1080/14767058.2021.1879041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE We aimed to decrease our surgical site infection (SSI) rate by 30% by sequential implementation of vaginal cleansing and azithromycin for women who underwent a cesarean delivery (CD) after having labored or experienced rupture of membranes. METHODS This is a quality improvement project that assessed the stepwise implementation of two interventions within three time periods: (1) 12 months prior to implementation of either intervention; (2) 14 months of vaginal cleansing as infection prophylaxis; (3) 16 months of vaginal cleansing and azithromycin as infection prophylaxis. The primary outcome measure was the SSI as defined by the Center for Disease Control and Prevention and analyzed by control charts. The process measures were compliance rates of vaginal cleansing and azithromycin. Significance was detected by rules for determining a special cause variation. This study followed the SQUIRE 2.0 guidelines for reporting on quality improvement. RESULTS There were 1033 patients included from the three study periods. The total rate of SSI decreased from 22.8% to 15.2% after implementing vaginal cleansing. Special cause variation was detected with an 8-point shift starting 4 months after implementation of vaginal cleansing. This decrease was sustained during the following 26 months. Adding azithromycin did not significantly lower the SSI rate further. When examined separately, deep SSI (p = .009) and endometritis (p = .001) significantly decreased in the post-intervention periods. Pre-operative vaginal cleansing compliance rose to 74%, and then further increased to 85% 1 year after implementation. Azithromycin compliance rose to 75%. Total length of postpartum stay decreased over the study periods from 3.5 ± 1.4 days to 3.2 ± 0.8 days (p = .001). CONCLUSION In this quality improvement study, implementation of vaginal cleansing decreased the SSI rate by 33%, from 22.8% to 15.2%. The addition of azithromycin did not result in any additional change in SSI rate.
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Affiliation(s)
- Quist-Nelson Johanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Julie Gomez
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Laura Felder
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Rebecca Eckler
- Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, BC, Canada
| | - Amanda Paternostro
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Jason Baxter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Posencheg
- Division of Neonatology, Children's Hospital of Philadelphia and the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Ogah CO, Anikwe CC, Ajah LO, Ikeotuonye AC, Lawani OL, Okorochukwu BC, Ikeoha CC, Okoroafor FC. Preoperative vaginal cleansing with chlorhexidine solution in preventing post-cesarean section infections in a low resource setting: A randomized controlled trial. Acta Obstet Gynecol Scand 2021; 100:694-703. [PMID: 33351989 DOI: 10.1111/aogs.14060] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Infection is one of the most common causes of maternal morbidities and mortality and has been reported to be responsible for about 15% of maternal deaths. Any woman is at risk of infection during childbirth, but women undergoing cesarean section are at higher risk. Improvement in surgical procedures with asepsis and the use of antibiotics have helped reduce postoperative infectious morbidities. However, ascending infection from the lower to the upper genital tract is a common but often neglected source of infection. Cleaning the vagina with chlorhexidine antiseptic solution before cesarean section can be a cheap and affordable source of infection control. This study is aimed at evaluating the efficacy of preoperative vaginal cleansing using 1.0% chlorhexidine in the reduction of post-cesarean section infectious morbidities. MATERIAL AND METHODS This prospective randomized control trial was conducted among 322 pregnant women who underwent an emergency cesarean section at Alex Ekwueme Federal University Teaching Hospital, Abakaliki (AE-FUTHA). The women were randomized into two groups. The interventional group received vaginal cleansing with three standard gauzes soaked in 30 mL 1.0% chlorhexidine gluconate solution preoperatively in addition to surgical skin cleaning with chlorhexidine-alcohol. The women in the control group only had surgical skin cleaning with chlorhexidine-alcohol. All the women received pre- and postoperative antibiotics. The primary outcomes were endometritis and wound infections. RESULTS Infectious morbidity was significantly reduced from 36.8% in the control group to 12.0% in the intervention group (P = .001). Endometritis occurred significantly less frequently in the intervention group than the control group (respectively 6.6% compared with 27.6%: relative risk [RR] 0.29, 95% confidence interval [CI] 0.16-0.53; P < .05). Foul-smelling vaginal discharge was significantly more common in the control group than in the intervention group (11.8% vs 1.3%, respectively) but the CI was wide (RR 8.5, 95% CI 1.30-64.55; P < .001). Fever and wound infection were more common in the control group (5.9% vs 3.3% and 9.2% vs 5.3%) but the difference was not significant. The hospital stay was significantly shorter among the intervention group (5.54 ± 1.04 days compared with 6.01 ± 1.55 days, P < 0.05). The most common microbial isolate implicated in endocervical colonization was Staphylococcus aureus followed by Klebsiella species. CONCLUSIONS Vaginal cleansing with 1.0% chlorhexidine gluconate solution before emergency cesarean section appears to be effective in reducing rates of post-cesarean section infectious morbidity in the study area. We recommend its use among women undergoing cesarean section to help reduce the contribution of infections to a poor obstetrics outcome.
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Affiliation(s)
- Christian O Ogah
- Department of Obstetrics and Gynecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Chidebe C Anikwe
- Department of Obstetrics and Gynecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Leonard O Ajah
- Department of Obstetrics and Gynecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Arinze C Ikeotuonye
- Department of Obstetrics and Gynecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Osaheni L Lawani
- Department of Obstetrics and Gynecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | | | - Cyril C Ikeoha
- Department of Obstetrics and Gynecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
| | - Francis C Okoroafor
- Department of Obstetrics and Gynecology, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria
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Conde-Agudelo A, Romero R, Jung EJ, Garcia Sánchez ÁJ. Management of clinical chorioamnionitis: an evidence-based approach. Am J Obstet Gynecol 2020; 223:848-869. [PMID: 33007269 PMCID: PMC8315154 DOI: 10.1016/j.ajog.2020.09.044] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/08/2020] [Accepted: 09/24/2020] [Indexed: 02/09/2023]
Abstract
This review aimed to examine the existing evidence about interventions proposed for the treatment of clinical chorioamnionitis, with the goal of developing an evidence-based contemporary approach for the management of this condition. Most trials that assessed the use of antibiotics in clinical chorioamnionitis included patients with a gestational age of ≥34 weeks and in labor. The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period. In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping. The administration of additional antibiotic therapy does not appear to be necessary after vaginal or cesarean delivery. However, if postdelivery antibiotics are prescribed, there is support for the administration of an additional dose. Patients can receive antipyretic agents, mainly acetaminophen, even though there is no clear evidence of their benefits. Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant. However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate. Once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age. Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications. The time interval between the diagnosis of clinical chorioamnionitis and delivery is not related to most adverse maternal and neonatal outcomes. Patients may require a higher dose of oxytocin to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation. The benefit of using continuous electronic fetal heart rate monitoring in these patients is unclear. We identified the following promising interventions for the management of clinical chorioamnionitis: (1) an antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole that provides coverage against the most commonly identified microorganisms in patients with clinical chorioamnionitis; (2) vaginal cleansing with antiseptic solutions before cesarean delivery with the aim of decreasing the risk of endometritis and, possibly, postoperative wound infection; and (3) antenatal administration of N-acetylcysteine, an antioxidant and antiinflammatory agent, to reduce neonatal morbidity and mortality. Well-powered randomized controlled trials are needed to assess these interventions in patients with clinical chorioamnionitis.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, and U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, and U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University School of Medicine, Detroit, MI; Detroit Medical Center, Detroit, MI; Department of Obstetrics and Gynecology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL.
| | - Eun Jung Jung
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, and U.S. Department of Health and Human Services, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Ángel José Garcia Sánchez
- Department of Biomedical and Diagnostic Sciences, Faculty of Medicine, University of Salamanca, Salamanca, Spain
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Duffy CR, Garcia-So J, Ajemian B, Gyamfi-Bannerman C, Han YW. A randomized trial of the bactericidal effects of chlorhexidine vs povidone-iodine vaginal preparation. Am J Obstet Gynecol MFM 2020; 2:100114. [PMID: 33345865 DOI: 10.1016/j.ajogmf.2020.100114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/20/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Precesarean vaginal preparation significantly reduces postpartum infections. Although povidone-iodine is the most commonly used vaginal antiseptic, evidence suggests that chlorhexidine gluconate may be more effective. OBJECTIVE We aimed to compare the bactericidal effect of chlorhexidine gluconate and povidone-iodine on vaginal bacterial colony counts in pregnancy. MATERIALS AND METHODS We conducted a prospective randomized controlled trial of vaginal preparation with 0.5% chlorhexidine gluconate vs 10% povidone-iodine vs saline in women undergoing cesarean delivery at ≥34 weeks' gestation. Women in labor or those with ruptured membranes, chorioamnionitis, abnormal placentation, or allergy to study agents were excluded. Vaginal specimens were collected aseptically in the operating room immediately before and 5-10 minutes after vaginal cleansing with 3 sterile sponge sticks. Our primary outcome was postintervention aerobic and anaerobic bacterial colony counts, assessed by blinded investigators. Two-way analysis of variance with simple-effects analysis and Tukey post hoc test were used for multiple group comparisons. Secondary outcomes included baseline colony counts, change in colony counts, adverse events, and maternal infections. RESULTS A total of 29 women consented and underwent vaginal preparation with chlorhexidine gluconate (n=10), povidone-iodine (n=9), or saline (n=10). Groups were similar with respect to maternal age, body mass index, race, ethnicity, parity, group B streptococcus status, and gestational age. There were no differences in baseline colony counts. Vaginal preparation with povidone-iodine resulted in lower aerobic and anaerobic colony counts compared with chlorhexidine gluconate and saline (P≤.01 and P≤.0001, respectively). Povidone-iodine eliminated more than 99.9% of bacteria, whereas chlorhexidine gluconate and saline eliminated more than 99% and 95% of bacteria, respectively. Although all agents decreased aerobic and anaerobic bacterial counts, 0.5% chlorhexidine gluconate was no more effective than saline in reducing anaerobic bacteria. There were no reported adverse effects or postpartum infections. CONCLUSION Compared with 0.5% chlorhexidine gluconate, 10% povidone-iodine was more effective in reducing vaginal bacterial colony counts before cesarean delivery.
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Affiliation(s)
- Cassandra R Duffy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY.
| | - Jeewon Garcia-So
- Institute of Human Nutrition, Graduate School of Arts and Sciences, Columbia University, New York, NY
| | - Barouyr Ajemian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Cynthia Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Yiping W Han
- Section of Oral, Diagnostic and Rehabilitation Sciences, College of Dental Medicine, Departments of Microbiology and Immunology, Obstetrics and Gynecology, Medicine (Oncology), Vagelos College of Physicians and Surgeons, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY.
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Hodgetts-Morton V, Hewitt CA, Wilson A, Farmer N, Weckesser A, Dixon E, Brocklehurst P, Hardy P, Morris RK. Vaginal preparation with chlorhexidine at cesarean section to reduce endometritis and prevent sepsis: A randomized pilot trial (PREPS). Acta Obstet Gynecol Scand 2019; 99:231-239. [PMID: 31539171 DOI: 10.1111/aogs.13737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cesarean sections are the most common major operation worldwide. One in 10 women develops a surgical-site infection after cesarean section. The PREPS pilot trial was developed to assess the feasibility of a randomized controlled trial of vaginal cleansing with chlorhexidine before cesarean section, to reduce infectious morbidity. MATERIAL AND METHODS A multi-center, open-label, parallel-group pilot randomized controlled trial across 4 UK maternity units. Women aged ≥16 years, undergoing elective or emergency cesarean section, ≥34 weeks of gestation, and able to give informed consent were eligible. Women were randomized 1:1 to chlorhexidine 0.05% or no cleansing and were followed up until 6 weeks after cesarean section. The feasibility of a larger randomized controlled trial was assessed by the pilot trial's recruitment, ability to use verbal consent in an emergency, adherence, follow-up and withdrawal rates. The main clinical outcome collected was Center for Disease Control and Prevention (CDC) classification of endometritis at 30 days. Trial registration number is ISRCTN33435996. RESULTS A total of 320 women (128% of target) were randomized. Of these, 93% (95% CI 89%-95%) received their allocated intervention. Of the 88 women who had an emergency cesarean section, verbal consent was initially given by 32 (36%) women, with the remainder having sufficient time to give written consent. Endometritis (CDC definition) was collected from medical notes of 96% of women, 68% (95% CI 63%-73%) were followed up at both 14 and 30 days by telephone, and we were able to collect patient-reported outcomes. In the vaginal cleansing arm 2/152 (1.3%) women had endometritis compared with 1/155 (0.7%) in the no cleansing arm (RR 2.08, 95% CI 0.19-22.31). CONCLUSIONS It is possible to perform a randomized controlled trial in women undergoing an elective or emergency cesarean section, using a verbal-followed-by-written consent process, while maintaining high adherence and retaining women in the trial.
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Affiliation(s)
- Victoria Hodgetts-Morton
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Catherine A Hewitt
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Amie Wilson
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola Farmer
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Annalise Weckesser
- Center for Social Care, Health and Related Research, Faculty of Health, Education and Life Sciences, Birmingham City University, City South Campus, Birmingham, UK
| | - Emily Dixon
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Pollyanna Hardy
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Rachel K Morris
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Felder L, Paternostro A, Quist-Nelson J, Baxter J, Berghella V. Implementation of vaginal cleansing prior to cesarean delivery to decrease endometritis rates. J Matern Fetal Neonatal Med 2018; 32:1997-2002. [PMID: 29343134 DOI: 10.1080/14767058.2017.1422717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Endometritis is a postpartum complication that is more common after cesarean delivery. It frequently requires intravenous antibiotic administration, prolonged hospital stays, and carries a risk of sepsis or abscess formation. Precesarean vaginal preparation has been shown to decrease the risk of endometritis in patients who have labored or have ruptured membranes. OBJECTIVE The objective of this study was to assess the practical implementation of a protocol for vaginal cleansing prior to cesarean delivery and the subsequent effect on endometritis rates in a clinical setting. STUDY DESIGN This is a before-after retrospective cohort study evaluating the first 6 months of implementation of a vaginal cleansing protocol at a single institution. The primary outcome was the rate of implementation. Secondary outcomes included endometritis and other postoperative complications. RESULTS The rate of implementation after 6 months was 68.3% (p < .001) and postoperative endometritis rates decreased from 14.0% before implementation to 11.7% after implementation (p .49, OR 0.77, CI 0.36-1.62). Postoperative fever decreased from 22.3% to 18.3% (p .256, OR 0.70, CI 0.37-1.30) and infectious wound complications were 4.5% and 5.8%, respectively (p .76, OR 1.07, CI 0.69-3.64). CONCLUSIONS Implementation of a protocol for vaginal cleansing prior to cesarean delivery in women with ruptured membranes or in labor has high uptake, but in almost a third of eligible women it was not performed. The implementation, has led to a clinical, although not statistical, decrease in postoperative endometritis. Continued research is needed to explore how to improve uptake of this quality improvement measure.
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Affiliation(s)
- Laura Felder
- a Department of Obstetrics and Gynecology , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
| | - Amanda Paternostro
- a Department of Obstetrics and Gynecology , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
| | - Johanna Quist-Nelson
- b Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
| | - Jason Baxter
- b Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
| | - Vincenzo Berghella
- b Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
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