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Vaginal Cleansing prior to Cesarean Section and Post
Operative Infectious Morbidity
Prof. Dr Syeda Batool Mazhar, Dr. Sara Asad MCH Centre, PIMS, SZABMU,
Islamabad, Pakistan
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Vaginal Cleansing Prior to LSCS & Post Operative Infectious Morbidity
Declaration of interests: None
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INTRODUCTION
Cesarean sections account for approximately 29.1% of deliveries in United States and 21.5% in England.
According to hospital based
studies, the rate of caesarean section in Pakistan ranges from 21- 40%.
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Vaginal Cleansing Prior to LSCS & Post Operative Infectious Morbidity
Post-operative infectious morbidity is a significant complication of caesarean delivery despite wide spread use of prophylactic antibiotics.
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Post Operative Infectious Morbidity
endometritis
maternal fever
wound infection
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Endometritis (most
common)
Infectious morbidity occurs
in 6 - 27% of cesarean sections
10 times more common in
cesarean vs. vaginal del.
Complications e.g bacteremia, sepsis,
peritonitis and intra abdominal
abscess
Post Operative Infectious Morbidity
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Post Operative Infectious Morbidity: Risk Factors
• Repeated vaginal examinations
• Absence of prophylactic antibiotics
• Prolonged duration of active labor
• Prolonged rupture of membrane
• Internal fetal monitoring
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Post Operative Infectious Morbidity: Pathway Involved
bacteria from lower genital
tract
antibiotic resistant bacteria
failure of antibiotic
prophylaxis
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Strategies to reduce Post-operative Infections
Modifications of surgical techniques
Different methods of placental delivery
Different positions during incision repair for uterus
• Cleansing of all body surfaces that are in contact during a surgical procedure
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OBJECTIVE:
To compare frequency of post operative infectious morbidity in patients undergoing emergency cesarean section with and without immediate pre operative vaginal cleansing.
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Definitions of post operative infectious morbidity for the study
Febrile morbidity
• Oral temperature 38ºC or more after 24 hours of cesarean delivery
Endo-metritis
• Oral temperature 38.4ºC excluding first 24 hours with uterine tenderness and foul smelling lochia clinically up to three weeks postoperatively.
Wound complicatio
ns
• Diagnosed if there is any serous discharge, blood collection or break in incision line clinically in postoperative period up to three weeks
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SETTING: MCHC, PIMS, Islamabad
DURATION: Six months
STUDY DESIGN: Randomized Controlled Trial
SAMPLING TECH: Non probability consecutive
Patients and Methods
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Patients and Methods A total of 434 patients were enrolled in the
study with 217 in each group.
Group A had 217 women receiving vaginal cleansing with pyodine in addition to routine vulval and abdominal scrubbing.
Group B had 217 women receiving only routine vulval and abdominal scrubbing.
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Patients and Methods INCLUSION CRITERIA:
Women undergoing emergency cesarean section in MCH unit1 PIMS during study period
In labor for more than 6 hours after hospital admission with or without rupture of membranes.
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Patients and Methods EXCLUSION CRITERIA:
Gestational diabetes mellitis
Anemia ( Hb < 7g/dl)
Placenta previa (on ultrasound)
Obstructed labor or suffering from any febrile condition
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Patients and Methods DATA ANALYSIS
Data was analyzed using SPSS version 10.
Quantitative data like age and gestational age was presented as means and standard deviations.
Qualitative variables like fever, endometritis and wound infection was measured as frequency and percentages.
Chi-square test was applied to compare the morbidity in two groups. Effect modifiers like age, gestational age, parity, labour duration and PROM was controlled by stratification.
Post stratification chi square test was applied. A p-value of ≤ 0.05 was considered statistically significant.
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Demographics
0
5
10
15
20
25
30
35
40
age gestational age
28.5 38.5
27.4
37 GROUP AGROUP B
N=217
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Comparison of post operative morbidity
02468
10121416
GROUP A GROUP B
9(4.1%)
16(7.4%)
FEVER
FEVER
P value=0.149
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Comparison of Post Operative Morbidity
0
5
10
15
20
GROUP A GROUP B
3 (1.4%)
19 (8.8%)
ENDOMETRITIS
GROUP AGROUP B
P value 0.000
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Comparison of Post Operative Morbidity
012345678
GROUP A GROUP B
3 (1.4%)
8 (3.7%)
WOUND INFECTION
GROUP AGROUP B
P value =0.126
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Stratification of Fever, Endometritis & Wound infection With respect to Duration of Labour and PROM
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Correlation Of Fever With PROM
0
10
20
30
40
50
60
70
GROUP A GROUP B
9(12.9%) 16(51.6%)
61(87.1%)
15(48.4%)
NO FEVERFEVER
P value o.ooo
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Endometritis and duration of labour
020406080
100120140160180
GROUP A GROUP B
2(1.2%) 3(1.7%)
169(98.8%) 171(98.3%) NOYES
For duration of labour 7-9 hours
P value 0.666
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Endometritis and duration of labour
05
101520253035404550
GROUP A GROUP B
1(2.2%) 16(37.2%)
45(97.8%) 27(62.8%) NO
YES
For duration of labour >9 hours P value 0.000
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Endometritis with PROM
0
10
20
30
40
50
60
70
GROUP A GROUP B
3(4.3%) 6(19.4%)
67(95.1%)
25(80.6%)
NOYES
For patients with PROM P value 0.014
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Endometritis without PROM
020406080
100120140160180200
GROUP A GROUP B
0 13(7%) 47
173(93%) NOYES
For patients without PROM P value 0.002
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Wound Infection and Duration Of Labour
020406080
100120140160180
7-9 hrsgroup A
7-9 hrsgroup B
>9hrsgroup A
>9 hrsgroup B
3(1.8%) 7(4%) 0 1
168(98.2%) 167(96%)
46(100%) 42(97.7%)
no wound infectionwound infection
P value 0.209 P value 0.298
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Wound infection and PROM
0
10
20
30
40
50
60
70
GROUP A GROUPB
3(4.3%) 7(22.6%)
67(95.7%)
24(77.4%)
NOYES
For patients with PROM P value 0.004
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Summary Of Results Post op morbidity
Group A N=217 N(%)
Group B N=217 N(%)
P VALUE
Fever 9(4.1%) 16(7.4%) 0.149
Endometritis 3(1.4) 19(8.8%) 0.000
Wound infection 3(1.4%) 8(3.7%) 0.126
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Discussion Vaginal cleansing with different antiseptic solutions before
vaginal and abdominal hysterectomy was reported in 1970
It has resulted in reduction of post operative infectious
morbidity.
Povidone iodine has been used for this purpose in various
studies with varying results
Use of other antiseptic solutions for preoperative vaginal
cleansing has also been reported
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Discussion
Despite Prophylactic parenteral antibiotics which reduce the rate of post operative infections, infectious morbidity after a caesarean delivery remains significant
Osborne and Wright reported a reduction of 98% in the total number of vaginal bacteria with the preoperative vaginal cleansing with Povidone iodine.
Rose et al used chlorhexidine for vaginal scrub, whereas Pitt et al tried intravaginal metronidazole which showed significant reduction in post caesarean endometritis
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Discussion In our study, vaginal cleansing has shown a statistically
significant reduction in post operative composite infectious morbidity after LSCS.
This reduction appears more marked for women undergoing cesarean section with active labour.
Our findings are similar to those of Guzman et al who reported a reduced rate of post cesarean infections.
Studies done by David et al and Reid et al, however did not show a statistically significant difference in post cesarean infectious morbidity.
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Discussion Various risk factors recognized for developing post caesarean
endometritis include cervical dilatation at the time of caesarean section, prolonged labor, prolonged rupture of membranes and maternal anemia.
The association of active labor and longer duration of rupture of membranes as risk factors has also been consistent in our study.
Our study showed a statistically significant reduction in the incidence of post caesarean endometritis as reported in a study by Rosally et al.
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Discussion In the present study, wound Infection reduction was seen
although statistically non significant
Regarding febrile morbidity, our findings are consistent with the previous studies (Reid et al, Guzman, Haas et al) which demonstrate no significant difference in the rate of post operative fever with preoperative vaginal cleansing.
The cleansing solution was well tolerated by the patients with no increase in allergic reactions or skin irritation
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Discussion Within our study population, this intervention
demonstrates a statistically significant reduction in rate
of post caesarean infectious morbidity
The incidence of post caesarean endometritis was
significantly reduced particularly in patients who were in
active labour and with ruptured membranes
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CONCLUSION
Antiseptic vaginal cleaning before cesarean section decreases the frequency of postpartum infectious morbidity particularly endometritis.
Vaginal cleansing, a safe, cheap and well tolerated intervention, can be an adjunct to prophylactic antibiotics immediately before caesarean section.
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References Haeri AD, Kloppers LL, Forder AA, Baillie P. Effect of different pre-operative vaginal
preparations on morbidity of patients undergoing abdominal hysterectomy. S Afr Med J. 1976;50:1984-6.
Reid VC, Hartmann KE, McMahon M, Fry EP. Vaginal preparation with povidone iodine and postcaesarean infectious morbidity: a randomized controlled trial. Obstet Gynecol. 2001;97:147-52
Guzman MA, Prien SD, Blann DW. Post-caesarean related infection and vaginal preparation with povidone-iodine revisited. Prim Care Update. 2002;9:206-9.
Starr RV, Zurawski J, Ismail M. Preoperative vaginal preparation with povidone-iodine and the risk of postcaesarean endometritis. Obstet Gynecol. 2005;105:1024-9
Rouse DJ, Hauth JC, Andrews WW, Mills BB, Maher JE. Chlorhexidine vaginal irrigation for the prevention of periportal infection: a placebo-controlled randomized clinical trial. Am J Obstet Gynecol. 1997;176:617-22.
Osborne NG, Wright RC. Effect of preoperative scrub on the bacterial flora of the endocervix and vagina. Obstet Gynecol. 1977;50:148-50.
Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of postcaesarean endometritis: a randomized controlled trial. Obstet Gynecol. 2001;98:745-50.
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Acknowledgements
Dr Sara Asad
Dr. Nazish Butt
Dr. UmeHabiba
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