Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections
Abstract
Background
Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries.
Objectives
To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 December 2014).
Selection criteria
We included randomized and quasi‐randomized trials assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post‐cesarean infectious morbidity.
Data collection and analysis
We independently assessed eligibility and quality of the studies.
Main results
Seven trials randomizing 2816 women (2635 analyzed) evaluated the effects of vaginal cleansing (all with povidone‐iodine) on post‐cesarean infectious morbidity. The risk of bias was generally low, with the quality of most of the studies being high. Vaginal preparation immediately before cesarean delivery significantly reduced the incidence of post‐cesarean endometritis from 8.3% in control groups to 4.3% in vaginal cleansing groups (average risk ratio (RR) 0.45, 95% confidence interval (CI) 0.25 to 0.81, seven trials, 2635 women). The risk reduction was particularly strong for women who were already in labor at the time of the cesarean delivery (7.4% in the vaginal cleansing group versus 13.0% in the control group; RR 0.56, 95% CI 0.34 to 0.95, three trials, 523 women) and for women with ruptured membranes (4.3% in the vaginal cleansing group versus 17.9% in the control group; RR 0.24, 95% CI 0.10 to 0.55, three trials, 272 women). No other outcomes realized statistically significant differences between the vaginal cleansing and control groups. No adverse effects were reported with the povidone‐iodine vaginal cleansing.
The quality of the evidence using GRADE was low for post‐cesarean endometritis, moderate for postoperative fever, and low for wound infection.
Authors' conclusions
Vaginal preparation with povidone‐iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis. This benefit is particularly realized for women undergoing cesarean delivery, who are already in labor or who have ruptured membranes. As a simple, generally inexpensive intervention, providers should consider implementing preoperative vaginal cleansing with povidone‐iodine before performing cesarean deliveries.
PICOs
Plain language summary
Vaginal cleansing before cesarean delivery to reduce post‐cesarean infections
Cesarean deliveries are very common today, with almost one in three babies born by cesarean in some countries. Antibiotics are routinely given before or during the surgery to reduce the risk of infections, but some women still suffer from these complications. Between one in four and one in 10 women develop an infection of the uterus (endometritis) or a problem with their skin incision, respectively. These complications slow recovery from the surgery and may affect the mother's ability to take care of her baby. Other interventions are needed to further reduce the risk of infections of the uterus and wound problems after cesarean delivery.
This review found that cleansing the vagina with an antiseptic solution immediately before the cesarean delivery reduced the risk of post‐cesarean infection of the uterus (womb) (low quality of evidence). The benefit was greater if the woman's water had already broken (the membranes had ruptured) or if they were already in labor at the time of the cesarean delivery. This review did not find that vaginal cleansing reduced the number of women experiencing fever or wound complications after cesarean delivery. The antiseptic was povidone‐iodine, and no adverse events such as allergy or irritation were noted in any of the seven randomized trials, reporting on 2635 women, from vaginal preparation solution.
