Grand Rounds

Chlorhexidine or Povidone-Iodine for Vaginal Cleansing Prior to Cesarean Delivery?

BACKGROUND AND PURPOSE:

Lakhi et al. (AJOG MFM, 2019) compared vaginal cleansing with chlorhexidine gluconate (4%) vs povidone-iodine prior to cesarean section to
- Determine whether chlorhexidine reduces wound infection rates
- Assess patient-reported side effects

Block randomized, comparator-controlled, open-label trial (RCT)
Participants
- Undergoing nonemergent cesarean delivery, including
- Arrest | Maternal request | Category II tracings | Failed TOLAC
Randomized to receive vaginal cleansing prior to incision (3 passes) with either
- 4% chlorhexidine solution
- 10% povidone-iodine solution
Prophylactic antibiotics (at least 30 minutes prior to skin incision) provided to all patients
Primary outcome
- Wound site infection (superficial or deep) within 14 days of surgery
Secondary outcomes
- Rates of endometritis
  - ≥100.4°F occurring 24 hours post-surgery | Uterine fundal tenderness or foul-smelling vaginal discharge
- Postoperative fever
- Side effects (e.g., vaginal dryness, irritation, and desquamitization) within 14 days of cesarean delivery
  - Patient reported
Statistical analysis
- 1,050 patients (total) required for 80% power
- Based on 7% rate of post-op wound infection rate at study site

524 patients received chlorhexidine gluconate cleansing | 590 received povidone-iodine
- Both groups were similar with regard to age, parity, body mass index, gestational age at delivery, indication for cesarean delivery, and incidence of membrane rupture
Rate of wound infection was significantly lower in the chlorhexidine group (p = 0.039)
- Chlorhexidine group: 0.6%
- Povidone-iodine group: 2.0%
- Odds ratio (OR) 0.28 (95% CI, 0.08–0.98)
Rates of endometritis and postoperative fever were similar for both groups
- Endometritis: 0.4% chlorhexidine vs 0.5% povidone-iodine (p = 1.000)
- Postoperative fever: 2.5% and 2.7% (P = 0.892)
Adverse effects: Not observed in either group

Authors note overall low infection rates, particularly for endometritis
- Standardization of vaginal prep because of this study
- The study center has a protocol in place to reduce wound infection, including adherence to prophylactic antibiotics, skin prep, instrument glove changes etc. (see ‘Learn More – Primary Sources’ below; Table 4 in the discussion section of the paper)
- Single site protocols may limit generalization of findings
Vaginal cleansing with a 4% chlorhexidine solution reduces wound infection rates vs to povidone-iodine
- Consistent with previous studies

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