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


  • 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 


  • 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 


  • 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 


  • 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.