Grand Rounds

CMECNE

What is the Best Practices Prevention Bundle for Post Cesarean Infection?

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the necessity for identifying a suite of surgical techniques and strategies to reduce the SSI rate following cesarean section
2. State the 3 recommended practices to reduce post cesarean SSIs based on the data reported in this study by Martin et al.

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from April 8 2018 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

BACKGROUND AND PURPOSE:

Following cesarean section, surgical site infection (SSI) is a major health risk for women
Some report risk of SSI as high as 9%
There are quality studies and meta-analyses, but they tend to look at individual techniques and ‘evidence syntheses’ are necessary to summarize best practices, while assessing consistency and quality across studies
- Studies may have ‘Strong Recommendations’, but quality of evidence may be low
Martin et al. (BJOG, 2018) assessed a group of perioperative strategies and surgical techniques to determine the bundle that would reduce post cesarean SSI rates

METHODS:

Systematic review
- Includes literature reviews
- Systematic reviews
- Meta-analyses
Studies were reviewed that included
- Competing perioperative strategies and surgical techniques
- Reported infection outcomes
SSI risk-reducing strategies were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach

RESULTS:

Data were collected from 44 studies
82 intervention comparator pairs were examined and of those, 3 interventions demonstrated strong evidence for reducing risk

‘Suite of Infection Control Strategies’

Administer pre-incision antibiotic prophylaxis 15-60 minutes before incision

46% reduced risk of endometritis
- Endometritis relative risk (RR) 0.54 (95% CI, 0.36–0.79)
41% reduced risk of wound infection
- Wound infection RR 0.59 (95% CI, 0.44–0.81)

Prepare the vagina with iodine-povidone solution

55% reduced the risk of endometritis
- Endometritis RR 0.45 (95% CI, 0.25–0.81)
No change in wound infection

Spontaneous placenta removal using gentle cord traction

64% increased risk of endometritis when manual removal of the placenta was used instead of gentle cord traction
- Endometritis RR 1.64 (95% CI, 1.42–1.90)

Other beneficial strategies

Fewer unintended uterine extensions and a trend towards less blood loss with blunt cephalad‐caudad uterine expansion
Closing the skin with subcuticular sutures had a significantly lower risk of wound complication (e.g., wound dehiscence)

Strategies that were strongly not recommended

The following strategies led to longer OR times with no benefit

Supplemental oxygen
Mechanical dilation of the cervix
Subcutaneous drain (even in obese women or women with subcutaneous tissue greater than 2 cm thick)
Intra-abdominal irrigation received a ‘do not implement’ recommendation because aside from extra resource and not benefit, it was also associated with increased intraoperative nausea

CONCLUSION:

This study suggests that clinicians should implement a pre-incision antibiotic prophylaxis, vaginal preparation and spontaneous placenta removal infection control bundle for C-section

Learn More – Primary Sources:

Best practice perioperative strategies and surgical techniques for preventing caesarean section surgical site infections: a systematic review of reviews and meta-analyses.

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