Cleansing the vagina with an antiseptic solution before a cesarean delivery significantly decreased the risk for postcesarean endometritis, particularly among women in labor or with ruptured membranes at the time of the intervention, a systematic review and meta-analysis has shown.
“The most important risk factor for postpartum maternal infection is cesarean delivery. Women undergoing cesarean delivery have a 5- to 20-fold greater risk for infection and infectious morbidity compared with those undergoing a vaginal birth,” the researchers explain.
Claudia Caissutti, MD, from the Department of Experimental Clinical and Medical Science, Clinic of Obstetrics and Gynecology, University of Udine, Italy, and colleagues report their findings in an article published online August 8 in Obstetrics & Gynecology.
The study included randomized controlled trials comparing vaginal cleansing with any type of antiseptic solution immediately before cesarean delivery with either placebo or no intervention.
The authors included 16 randomized trials (n = 4837 women) in the systematic review, including 15 studies (n = 4744 women) in the meta-analysis. They note that one trial compared two different vaginal preparations, and they analyzed that study separately.
Eleven trials used various percentages of a povidone–iodine cleansing solution, three used a chlorhexidine diacetate solution, one used a metronidazole vaginal gel prep, and one used Cetrimide. All studies used prophylactic or intraoperative surgical antibiotics, and three used them postoperatively.
The incidence of endometritis in women who received preoperative vaginal cleansing was 4.5%, which is significantly lower than the 8.8% observed in women randomly assigned to the control condition (relative risk [RR], 0.52; 95% confidence interval [CI], 0.37 – 0.72), the authors report. Similarly, postoperative fever occurred in significantly fewer women who received the intervention than those who did not (9.4% compared with 14.9%; RR, 0.65; 95% CI, 0.50 – 0.86).
There were no significant differences in the incidence of postoperative wound infection or other wound complications.
“Subgroup analyses demonstrated that the reduction in postoperative endometritis is significant only for women in labor and for those with ruptured membranes,” the authors explain.
Three trials stratified data on the basis of whether a woman was in labor, and a fourth included only women who were in labor. Those who were in labor before their cesarean delivery who received vaginal cleansing were significantly less likely to develop endometritis than those in the control group (8.1% compared with 13.8%; RR, 0.52; 95% CI, 0.28 – 0.97), whereas no similar benefit was observed among those not in labor before surgery (3.5% compared with 6.6%; RR, 0.62; 95% CI, 0.34 – 1.15), the authors write.
In a separate analysis, a statistically significant reduction in the rate of endometritis was observed for women receiving vaginal cleansing with ruptured membranes (4.3% compared with 20.1%; RR, 0.23; 95% CI, 0.10 – 0.52), but not among women intact membranes at the time of cesarean delivery (4.4% compared with 6.8%; RR, 0.71; 95% CI, 0.40 – 1.24).
“Ruptured membranes are a known risk factor for postcesarean infectious morbidity and therefore the use of vaginal preparation in this subset of women makes particular sense,” the authors explain.
In subgroup analyses comparing the effect of cleansing by preparation type and presurgical antibiotic use, the findings concurred with the overall analysis.
With respect to the prophylactic antibiotic treatment, the investigators observed a 67% decrease in endometritis incidence associated with vaginal cleansing. “Surgical prophylaxis with intravenous antibiotics before cesarean delivery has been clearly demonstrated as beneficial in reducing postoperative infection morbidity,” they write. “Thus, it is the standard of care and these findings could translate to current practice.”
Although the findings of the current study confirm and expand those of a previous meta-analysis (reported by Medscape Medical News), “there remains a lack of widespread uptake and previously published guidelines on vaginal preparation have not been modified to include cesarean delivery,” the authors write.
“Because it is generally an inexpensive and simple intervention, we recommend preoperative vaginal preparation in these women before cesarean delivery with a sponge stick preparation of povidone–iodine 10% for at least 30 seconds,” the authors write. “More data are needed to assess whether this intervention may be also useful before cesarean delivery in women not in labor and for those without ruptured membranes.”
The authors have disclosed no relevant financial relationships.
Obstet Gynecol. Published online August 8, 2017. Abstract
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