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

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?