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

David M Haas; Sarah Morgan; Karenrose Contreras; Savannah Enders

doi:10.1002/14651858.CD007892.pub6

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Figure 1

Study flow diagram.

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Figure 2

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 3

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Analysis 1.1

Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 1 Post‐cesarean endometritis.

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Analysis 1.2

Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 2 Postoperative fever.

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Analysis 1.3

Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 3 Postoperative wound infection.

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Analysis 1.4

Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 4 Composite wound complication.

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Analysis 1.5

Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 5 Composite wound complication or endometritis.

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Analysis 2.1

Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 1 Post‐cesarean endometritis.

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Analysis 2.2

Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 2 Postoperative fever.

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Analysis 2.3

Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 3 Postoperative wound infection.

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Analysis 2.4

Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 4 Composite wound complication.

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Analysis 2.5

Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 5 Composite wound complication or endometritis.

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Analysis 3.1

Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 1 Post‐cesarean endometritis.

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Analysis 3.2

Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 2 Postoperative fever.

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Analysis 3.3

Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 3 Postoperative wound infection.

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Analysis 3.4

Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 4 Composite wound complication.

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Analysis 3.5

Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 5 Composite wound complication or endometritis.

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Summary of findings for the main comparison. Vaginal preparation with antiseptic solution compared to control (no preparation or saline preparation) for preventing postoperative infections

Vaginal preparation with antiseptic solution compared to control (no preparation or saline preparation) for preventing postoperative infections
Patient or population: pregnant women who were about to receive a cesarean delivery. This included women receiving elective, laboring, or urgent cesareans Setting: multiple countries (United States‐5, Pakistan‐2, Turkey‐2, Iran‐1, Saudi Arabia‐1) mostly in academic centers or large hospitals Intervention: vaginal preparation ‐ 9 trials using iodine solution and 2 using chlorhexidine solution Comparison: control ‐ 9 trials with no vaginal cleansing and 2 with a saline vaginal cleansing
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with control	Risk with vaginal preparation
Post‐cesarean endometritis	Study population		Average RR 0.36 (0.20 to 0.63)	3283 (10 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	86 per 1000	31 per 1000 (17 to 54)
Postoperative fever	Study population		RR 0.87 (0.72 to 1.05)	3109 (8 RCTs)	⊕⊕⊕⊝ MODERATE ²
	125 per 1000	109 per 1000 (90 to 131)
Postoperative wound infection	Study population		RR 0.74 (0.49 to 1.11)	2839 (8 RCTs)	⊕⊕⊕⊝ MODERATE ²
	36 per 1000	27 per 1000 (18 to 41)
Composite wound complication or endometritis	Study population		RR 0.46 (0.26 to 0.82)	499 (2 RCTs)	⊕⊕⊕⊝ MODERATE ¹
	135 per 1000	62 per 1000 (35 to 111)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Over 40% of included studies had some design limitations. ² Wide confidence intervals in included studies.

Summary of findings for the main comparison. Vaginal preparation with antiseptic solution compared to control (no preparation or saline preparation) for preventing postoperative infections

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Comparison 1. Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐cesarean endometritis Show forest plot	10	3283	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.20, 0.63]

1.1 Iodine‐based solution	8	3069	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.21, 0.69]
1.2 Chlorhexidine‐based solution	2	214	Risk Ratio (M‐H, Random, 95% CI)	0.22 [0.07, 0.75]
2 Postoperative fever Show forest plot	8	3109	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.72, 1.05]

2.1 Iodine‐based solution	7	2909	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.72, 1.06]
2.2 Chlorhexidine‐based solution	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.09, 2.56]
3 Postoperative wound infection Show forest plot	8	2839	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.49, 1.11]

3.1 Iodine‐based solution	7	2639	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.50, 1.19]
3.2 Chlorhexidine‐based solution	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.55 [0.17, 1.82]
4 Composite wound complication Show forest plot	2	729	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.37, 1.07]

5 Composite wound complication or endometritis Show forest plot	2	499	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.26, 0.82]

Comparison 1. Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation)

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Comparison 2. Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐cesarean endometritis Show forest plot	5	1846	Risk Ratio (M‐H, Random, 95% CI)	0.58 [0.32, 1.06]

1.1 Women in labor	4	960	Risk Ratio (M‐H, Random, 95% CI)	0.41 [0.19, 0.89]
1.2 Women not in labor	4	886	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.35, 2.84]
2 Postoperative fever Show forest plot	3	1402	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.57, 1.03]

2.1 Women in labor	3	741	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.43, 0.96]
2.2 Women not in labor	2	661	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.61, 1.49]
3 Postoperative wound infection Show forest plot	3	1402	Risk Ratio (M‐H, Fixed, 95% CI)	0.59 [0.32, 1.08]

3.1 Women in labor	3	741	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.23, 1.24]
3.2 Women not in labor	2	661	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.27, 1.57]
4 Composite wound complication Show forest plot	2	729	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.38, 1.09]

4.1 Women in labor	2	314	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.36, 1.61]
4.2 Women not in labor	2	415	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.25, 1.16]
5 Composite wound complication or endometritis Show forest plot	2	499	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.27, 0.85]

5.1 Women in labor	2	164	Risk Ratio (M‐H, Fixed, 95% CI)	0.34 [0.13, 0.87]
5.2 Women not in labor	2	335	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.29, 1.26]

Comparison 2. Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor

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Comparison 3. Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐cesarean endometritis Show forest plot	4	1329	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.27, 0.62]

1.1 Women with ruptured membranes	3	272	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.10, 0.55]
1.2 Women with intact membranes	4	1057	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.31, 0.82]
2 Postoperative fever Show forest plot	3	1169	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.59, 1.11]

2.1 Women with ruptured membranes	2	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.34, 1.12]
2.2 Women with intact membranes	3	969	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.61, 1.30]
3 Postoperative wound infection Show forest plot	4	1329	Risk Ratio (M‐H, Random, 95% CI)	0.74 [0.43, 1.30]

3.1 Women with ruptured membranes	3	272	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.16, 6.70]
3.2 Women with intact membranes	4	1057	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.36, 1.28]
4 Composite wound complication Show forest plot	1	300	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.28, 1.44]

4.1 Women with ruptured membranes	1	76	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.15, 1.89]
4.2 Women with intact membranes	1	224	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.25, 2.10]
5 Composite wound complication or endometritis Show forest plot	2	500	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.27, 0.85]

5.1 Women with ruptured membranes	2	134	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.13, 1.13]
5.2 Women with intact membranes	2	366	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.26, 1.04]

Comparison 3. Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes

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