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CMECNE

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

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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 instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

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 April 8 2021, 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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Related ObG Topics:

Can Evidence Based Interventions Reduce C-section Complications?
Does Prophylactic Negative-Pressure Decrease Cesarean Section Wound Infections?
Suture or Staple for Cesarean Section Skin Closure?

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Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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