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Grand Rounds

2020 Cochrane Review Update: Does Vaginal Cleansing Before Cesarean Reduce Postoperative Infection?

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BACKGROUND AND PURPOSE:

  • Haas et al. (Cochrane Systematic Review – Intervention, 2020) sought to determine if vaginal cleansing with an antiseptic solution before cesarean delivery decreases the risk of maternal infectious morbidities

METHODS:

  • Systematic review and meta-analysis update
  • Data sources (through July 7, 2019)
    • Cochrane Pregnancy and Childbirth’s Trials Register | ClinicalTrials.gov | WHO International Clinical Trials Registry Platform (ICTRP)
  • Study inclusion criteria
    • RCTs and quasi-RCTs
    • Studies that assessed the impact of vaginal cleansing immediately before cesarean delivery on post-cesarean infectious morbidity with any type of antiseptic solution vs a placebo or standard of care
  • Study exclusion criteria
    • Vaginal prep used during labor | Antibiotic surgical prophylaxis was not administered | Cross-over design
  • Data analysis
    • At least three authors independently assessed eligibility of the studies
    • Two authors extracted study characteristics, quality assessments, and data from eligible studies

RESULTS:

  • 21 trials | 7038 women | 10 different countries
    • Povidone-iodine cleansing: 17 studies
    • Chlorhexidine cleansing: 3 studies
    • Benzalkonium chloride cleansing: 1 study
  • Studies used vaginal preparations administered by sponge sticks, douches, or soaked gauze wipes
  • Control groups
    • No vaginal preparation: 17 studies
    • Saline vaginal preparation: 4 trials

Vaginal cleansing and Maternal morbidities

  • Vaginal preparation probably reduces the incidence of post-cesarean endometritis | Moderate-certainty evidence
    • Control groups: 7.1%
    • Cleansing groups: 3.1%
    • Average risk ratio (aRR) 0.41 (95% CI, 0.29 to 0.58; 20 trials, 6918 women)
    • The reduction in endometritis was seen for both iodine-based solutions and chlorhexidine-based solutions
  • Vaginal prep probably reduces the risks of postoperative fever and postoperative wound infection | Both moderate-certainty evidence
    • Fever: aRR 0.64 (95% CI, 0.50 to 0.82; 16 trials, 6163 women)
    • Wound infection: RR 0.62 (95% CI, 0.50 to 0.77; 18 trials, 6385 women)
  • Vaginal prep may reduce the risk of a composite outcome of wound complication or endometritis | Low-certainty evidence
    • RR 0.46 (95% CI, 0.26 to 0.82; 2 trials, 499 women)

Subgroup differences

  • Labor vs nonlaboring women
    • Greater effect for women in labor for the following outcomes
      • Post-cesarean endometritis | Postoperative fever | Postoperative wound infection | Composite wound complication | Endometritis
  • Ruptured vs intact membranes
    • No subgroup differences were identified

Adverse Effects

  • No adverse effects with either povidone-iodine or chlorhexidine

CONCLUSION:

  • Vaginal cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis, fever, and wound infection
    • Benefits remain regardless of whether povidone-iodine or chlorhexidine solution is used for cleansing
  • The authors suggest that preoperative vaginal cleansing with povidone-iodine or chlorhexidine prior to cesarean is a simple intervention that can reduce maternal morbidity
  • The authors also caution when interpreting subgroup analysis results due to small numbers

Learn More – Primary Sources:

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections

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Related ObG Topics:

Cesarean Delivery Best Practices & Guidelines – The ERAS Committee Recommendations
Does Vaginal Cleansing Prevent Endometritis Following Cesarean Section?
Chlorhexidine or Povidone-Iodine for Vaginal Cleansing Prior to Cesarean Delivery?
What is the Best Practices Prevention Bundle for Post Cesarean Infection?

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