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#Grand Rounds

Does Vaginal Cleansing Prevent Endometritis Following Cesarean Section?

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BACKGROUND AND PURPOSE:

  • Cesarean section is associated with a 5-20 fold increase in maternal infection related complications
    • Primarily ascending anaerobic bacteria
  • Cochrane review demonstrated (based on low quality evidence) that vaginal cleansing may reduce infection risk
  • Caissutti et al. (Obstet Gynecol, 2017) assessed whether vaginal cleansing before cesarean delivery reduced rates of postoperative endometritis

METHODS:

  • Systematic review and meta-analysis
  • Selection criteria included all randomized controlled trials (RCTs) comparing vaginal cleansing (any type) with a control group in women undergoing cesarean
  • Primary outcome
    • Incidence of endometritis
  • Secondary outcomes
    • Postoperative wound infection
    • Postoperative fever greater than 38°C or 100.4°F
    • Other wound complications (e.g. postoperative wound seroma or hematoma)

RESULTS:

  • Pooled 4,837 women from 16 trials on vaginal cleansing immediately before cesarean section
  • 4,744 women were involved in 15 RCTs, where they were randomized to vaginal cleansing or control (placebo or no treatment)
    • I trial analyzed separately as it compared povidone-iodine with chlorhexidine
  • In 11 RCTs povidone-iodine used (ranging from 1% to 10%), most commonly using a sponge stick for 30 seconds
  • When comparing vaginal cleansing to controls, there was
    • Lower incidence of endometritis (4.5% vs 8.8%; relative risk [RR] 0.52, 95% CI 0.37-0.72)
    • Postoperative fever (9.4% vs 14.9%; RR 0.65, 95% CI 0.50-0.86)
  • Reduction in the incidence of endometritis with vaginal cleansing was limited to either
    • Women in labor before cesarean delivery (8.1% vs 13.8%; RR 0.52, 95% CI 0.28-0.97)
    • Women with ruptured membranes (4.3% vs 20.1%; RR 0.23, 95% CI 0.10-0.52)

CONCLUSION:

  • Current study is aligned with previous Cochrane Review
  • Authors recommend preoperative vaginal preparation before cesarean delivery for women in labor and/or with ruptured membranes
    • povidone-iodine 10% for at least 30 seconds using a sponge stick
  • More research required to extend this intervention to women not laboring and who do not have ruptured membranes

Learn More – Primary Sources:

Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis

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Related ObG Topics:

Can Evidence Based Interventions Reduce C-section Complications?
Plastic-Sheath Wound Retractors Decrease C-Section Infection
What Risk Factors Increase Likelihood of C-Section Infection?
Which is the Better Suture to Prevent C-Section Wound Complications? 

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