BACKGROUND AND PURPOSE: 

• Chlorhexidine–alcohol and povidone–iodine solutions are most commonly used for skin prep to pevent surgical site infections following cesarean section  
  • No clear recommendation regarding use of one over the other  
  • ACOG states (see ‘Related ObG Topics’ below) that “Chlorhexidine–alcohol is an appropriate choice” and that while iodophors also have broad spectrum coverage, they tend to be aqueous and not alcohol based  
• Tolcher et al. (American Journal of Perinatology, 2019) compared chlorhexidine-alcohol with povidone-iodine solutions for skin antisepsis prior to cesarean delivery

METHODS: 

• Systematic review and meta-analysis 
  • Database search of RCTs 
  • Endometritis excluded (ascending infection, not skin microbes)  
• Skin prep performed with either 
  • Chlorhexidine-alcohol 
  • Povidone-iodine skin 
• Primary outcome: Surgical site infection (CDC definitions)  
  • Superficial: Skin and subcutaneous tissue of the incision 
  • Deep wound infection: deep soft tissue layers of the incision (e.g., fascial and muscle layers) 
• Secondary outomes  
  • Wound seroma | Hematoma | Skin separation | Skin reaction

RESULTS: 

• 4 studies were included, totaling 3,059 women 
• The chlorhexidine-alcohol group showed a significant reduction in surgical site infection rate  
  • Risk ratio (RR) 0.72; 95% CI: 0.52–0.98 
• Subgroup analysis based on superficial or deep infection did not show a significant effect, although underpowered  
  • Superficial infection: RR 0.76; 95% CI, 0.54–1.08 
  • Deep infection: RR 0.50, 95% CI, 0.23–1.10 
• No differences seen in secondary outcomes  
• Comparisons using povidone-iodine without and without alcohol did not alter results

CONCLUSION: 

• Chlorhexidine-alcohol prior to cesarean section lead to fewer surgical site infections when compared to povidone-iodine with or without alcohol  
• Results support majority of studies in the general surgery literature  
• Authors note that any alcohol-based scrub requires 3 minutes for drying (flammability risk) and povidone-iodine is a 2-step procedure 
  • Delay may not be possible for true obstetrical emergencies (e.g., cord prolapse)

Learn More – Primary Sources: 

Chlorhexidine–Alcohol Compared with Povidone–Iodine Preoperative Skin Antisepsis for Cesarean Delivery: A Systematic Review and Meta-Analysis

Related ObG Topics:

ACOG Guidance: Antibiotic Prophylaxis during Labor and Delivery

Can Evidence Based Interventions Reduce C-section Complications?

Chlorhexidine or Povidone-Iodine for abdominal hysterectomy?

ACOG Guidance on Preventing Gynecologic Post-Procedure Infection