Monday, November 13, 2017

Preventing Complications After Cesarean in All Sizes of Women

In the United States, about 1 in 3 pregnancies end in cesarean. In some areas, the rate is even higher. Many women who have their first baby by cesarean will go on to have other babies by cesarean. That's a lot of cumulative exposure to cesareans, and a lot of potential complications from this common surgical procedure.

Therefore, learning how to prevent complications from cesarean surgery needs to be a high priority among care providers. Fortunately, there has been an increased emphasis on preventing post-surgical complications in the research in recent years.

It has been established that certain risk factors increase your risk for complications like surgical site infections (SSIs), endometritis (uterine infections), hematomas or seromas (collections of blood or fluid in the wound), and wound separations. These risk factors include things like:
  • having your waters broken for a long time before labor
  • waters broken for a long time during labor, especially with numerous vaginal exams
  • being a smoker
  • pregnancy complications like diabetes, gestational diabetes, hypertension, or pre-eclampsia
  • preterm labor
  • an unplanned cesarean
  • having had a prior cesarean
  • use of corticosteroids
  • a high BMI and/or >2 cm of subcutaneous tissue thickness
  • prolonged pushing stage
  • twin gestations
  • a lot of blood loss before or during surgery
However, even if you have multiple risk factors, there are many things that can be done to lower the risk for post-operative complications. The question is whether your hospital and caregiver do as many of them as they should. 

Improving Cesarean Outcomes in General

Not all post-cesarean complications can be prevented, but many of them can. There is recent new research on simple steps that hospitals can take to lower the risk for post-operative complications. These steps include:
  • Antibiotics administered before skin incision
  • Adding an additional antibiotic to the standard cephalosporin
  • Using chlorhexidine-alcohol for disinfecting the skin instead of iodine products
  • Using clippers on body hair instead of shaving the area
  • Removing the placenta through gentle traction instead of by manual removal
  • Closing the skin with sutures instead of with staples
Let's discuss each of these interventions in turn and the data that supports them. 

Timing of Antibiotics

Research is very clear that giving antibiotics helps prevent many infections. A 2014 Cochrane meta-analysis found that giving antibiotics reduced infections by 60-70%. This has become standard practice in modern days, though antibiotic use is still not 100% in some areas. But chances are very strong that if you had a cesarean in recent years, you probably had antibiotics.

Timing of antibiotic administration is probably important. Hospitals used to give antibiotics after the baby was born and the cord was clamped; now the standard of care has become to give antibiotics 30-60 minutes before the first incision.

Giving antibiotics before the first incision has lowered the rate of surgical site infections in a number of studies but not in all. Still, most hospitals now opt to give antibiotics before the operation actually begins. 

Additional Antibiotics

The most recent advance is the addition of extended spectrum antibiotics.

It is customary to use a narrow-spectrum cephalosporin like cezafolin for cesareans, but now many hospitals are adding additional antibiotics that cover a wider spectrum of bacteria. Antibiotics like azithromycin, metronidazole, and others have been added in recent studies.

Adding an additional, wider-spectrum antibiotic has been shown to lower the rate of SSIs in several studies. In one study, the addition of azithromycin to cefazolin during surgery lowered the risk for infection by 60%.

In another very large, randomized, multi-center study, the addition of azithromycin to the usual cephalosporin lowered the risk for infection and serious complications by about half compared to a placebo. The azithromycin group and the placebo group differed in rates of endometritis (3.8% vs. 6.1%), wound infection (2.4% vs. 6.6%), and serious maternal adverse events (1.5% vs. 2.9%).

A different option is to continue antibiotics for a few days after surgery. This can be done either orally or through I.V. fluids. A post-operative course of antibiotics has been shown to lower the risk for SSIs and wound complications in certain populations

If you have a cesarean and are in a group that is at higher-than-usual risk for infections and complications, ask about extended spectrum or longer regimens of antibiotics. If you develop a really serious infection, ask about IV antibiotics instead of oral ones. 

Skin Preparation

How the skin is prepared for surgery may make a difference in Sugical Site Infections as well. 

Some guides recommend showering the night before surgery with chlorhexidine gluconate soap (Hibiclens), but this has not been found to lower the rate of SSIs. It probably won't hurt, but it doesn't seem to help either. Showering with usual soap is probably good enough. However, showering in the morning before a cesarean seems to be common sense and is recommended by many hospitals.

Pre-operatively, the area will be cleaned even more thoroughly. The use of a chlorhexidine-alcohol preparation (instead of povidone-iodine) to disinfect the surgical site has been found in some research to lower SSIs after cesareans, especially when given adequate time to dry before operating. Not all research has found a difference, but even when statistical significance was not reached, a trend towards fewer SSIs and complications has been seen.

The jury is still out on a final answer about the best way to prepare the skin before surgery, but many experts believe that chlorhexidine-alcohol with adequate drying time is the way to go. It may also be that a combination of the two is superior. More research is needed. 

Using Clippers Instead of Shaving 

It used to be that the nurses shaved your body and pubic hair with a razor before a cesarean. Now it is thought that this makes many micro-cuts in the skin that serve as potential entryways for bacteria.

It has become standard practice to use electric clippers just before most surgeries to remove body hair before all different types of surgery, including cesareans. A meta-analysis of research shows that shaving increases the odds of infection as compared to clipping. However, some surgeons still insist on razors, against all evidence.

The very latest thinking is to leave most body hair intact and not shave or clip at all, unless the hair is substantial enough to interfere with surgery. The trend towards a slightly higher transverse skin incision (Joel-Cohen) in cesareans these days often makes hair removal unnecessary. 

Placental Removal Method 

In a normal vaginal birth, the placenta separates on its own and if left alone, the uterus contracts to push it out of the vagina. However, giving birth by cesarean bypasses this process, and caregivers must offer assistance.

In the past, doctors used to go into the uterus to forcibly remove the placenta, scooping it out in a hurried manner ("manual" removal). They reasoned that time was of the essence and there was less risk for infection if they hurried the process.

However, recent research clearly shows that manual removal results in more infections, blood loss, and other complications than spontaneous separation and traction. Research strongly suggests that a little more patience for spontaneous separation and gentle traction to remove the placenta results in less infections and complications.

An additional benefit of waiting a bit longer (at least 1-2 minutes, preferably 2-5 minutes) before cutting the cord and removing the placenta is that the baby gets more blood from the placenta. Delayed cord clamping improves the baby's transition to air breathing (especially in cesareans with no labor). It also lowers the chances of the baby developing anemia and increases the stem cells in baby's circulation.

Still, many care providers resist waiting a couple of minutes to let the placenta deliver spontaneously and to delay cutting the cord, but there is no medical justification for this, even in cesareans. The American College of Obstetricians and Gynecologists (ACOG) now endorses a small delay in cord clamping (at least 1 minute), and the World Health Organization advocates at least 1-3 minutes. 

Sutures vs. Staples vs. Glue

For many years, surgical staples were the standard of care for closing skin incisions after a cesarean. The two edges of the skin incision are approximated and then stapled together. This is much easier than taking the time to stitch together the edges.

Using staples is fast and easy for surgeons, and surgeons do take pride in how quickly they can perform a cesarean. In addition, they point out that a shorter surgery has been shown to lower the risk for infection ─ the longer a patient's insides are exposed to open air, the more time there is for infection to start. As a result, many automatically use staples for skin closure unless the patient requests otherwise.

However, new evidence suggests that using sutures instead of staples results in superior outcomes, both in lowering the rate of wound separations and in preventing infections. One California hospital considerably lowered its wound complication rate when it switched from primarily staples to primarily sutures. 

Two different meta-analyses found that sutures lowered the rate of wound complications considerably. This adds to the argument that most women should receive sutures instead of staples for skin closure.

Sutures do take longer to do, so some doctors are concerned about the risk for infection. However, the difference is usually only 5-10 minutes. Furthermore, if the increased time for suturing really did raise the risk for infection very much, it would show in the studies, yet using sutures decreases the risk by nearly half compared to staples.

Using sutures is probably the research recommendation most resisted by surgeons. Many of the other recommendations found in surgical evidence bundles are being implemented, yet many women today still receive staples instead of sutures after a cesarean. 

Some surgeons are using surgical glue to close cesarean skin incisions now too. There is less research comparing results from glue with sutures or staples, but what research we have is conflicting. A Cochrane meta-analysis of tissue adhesives (glue) in all types of surgical incisions had more problems with wound separations, but a recent randomized controlled trial found similar outcomes in wound complications between sutures and glue. More research is needed but for now, sutures should be the standard of care. 


Research is clear that there are many things providers can do to lower a woman's risk for complications after a cesarean, even in the presence of multiple risk factors.

Some of these interventions have been adopted quickly by the obstetric community, while other interventions are still struggling to find widespread acceptance. Usage is quite inconsistent, despite research.

One recent review of over 1,000 patients found that only one-third of cesarean mothers received all four of the evidence-based bundle recommendations in that study (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) to reduce wound complications. These are extremely basic precautions, and yet two-thirds of women receiving cesareans did not get them! Obviously, there is huge room for improvement here.
  • Antibiotics administered before skin incision - This recommendation seems to have been widely adopted now. Hospitals have done excellent work in quickly changing long-standing protocols
  • Adding additional antibiotics to the standard cephalosporin - This is based on very recent research so it has yet to be widely adopted, but evidence suggests that it is time to expand the use of adjunctive antibiotics, especially in those patients with strong risk factors for infection
  • Using chlorhexidine-alcohol for disinfecting the skin instead of iodine - This is mostly in place nowadays, but personnel may not be allowing proper drying time yet
  • Using clippers on body hair instead of shaving the area - This practice seems to be inconsistent and up to the preferences of the doctor, even through research shows clipping is safer
  • Removing the placenta through gentle traction instead of by manual removal - This practice seems to be left to the preference of the surgeon, though fewer are using manual removal these days
  • Closing the wound with sutures instead of with staples - This practice remains widely unadopted in many areas unless the patient specifically requests sutures. The difference in operating time is minimal, so hospitals need to start emphasizing switching to sutures whenever possible
In addition, there are things that can be done during labor to minimize the risk for infection, should a cesarean be eventually needed. One review suggested:

  • Avoid unnecessary vaginal examinations in labor
  • Avoid unnecessary instrumentation in labor (including fetal scalp electrodes and intrauterine pressure catheters)
  • Maintain strict glycemic control in diabetic women
  • Consider early removal of bladder catheters postoperatively

Of course, the best way to prevent post-cesarean complications is to do fewer cesareans. However, if a cesarean does occur, it's good to know that there are ways to lessen the risk for complications. Now it's up to hospitals and caregivers to ensure that best practices are actually followed.

*Next post: Preventing Complications After Cesarean in High BMI Women


General References
Combinations of Interventions

Am J Obstet Gynecol. 2017 Jun 8. pii: S0002-9378(17)30734-2. doi: 10.1016/j.ajog.2017.05.070. [Epub ahead of print] Impact of evidence-based interventions on wound complications after cesarean delivery. Temming LA, Raghuraman N, Carter EB, Stout MJ, Rampersad RM, Macones GA, Cahill AG, Tuuli MG. PMID: 28601567
...Risk of wound complications in women who received all 4 evidence-based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ≥2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not...RESULTS: Of 1082 patients with follow-up data, 349 (32.3%) received all the evidence-based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence-based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58-0.95)...Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence-based measures....
Matern Health Neonatol Perinatol. 2017 Jul 5;3:12. doi: 10.1186/s40748-017-0051-3. eCollection 2017. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Kawakita T, Landy HJ. PMID: 28690864  Free full text available here.
...Many risk factors for SSI have been described. These include maternal factors (such as tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss), and obstetrical care on the teaching service of an academic institution. Effective interventions to decrease surgical site infection include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples....

N Engl J Med. 2016 Sep 29;375(13):1231-41. doi: 10.1056/NEJMoa1602044. Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. Tita AT, Szychowski JM, Boggess K, Saade G, Longo S, Clark E, Esplin S, Cleary K, Wapner R, Letson K, Owens M, Abramovici A, Ambalavanan N, Cutter G, Andrews W; C/SOAP Trial Consortium. PMID:
...METHODS: In this trial conducted at 14 centers in the United States, we studied 2013 women who had a singleton pregnancy with a gestation of 24 weeks or more and who were undergoing cesarean delivery during labor or after membrane rupture. We randomly assigned 1019 to receive 500 mg of intravenous azithromycin and 994 to receive placebo. All the women were also scheduled to receive standard antibiotic prophylaxis... RESULTS: The primary outcome occurred in 62 women (6.1%) who received azithromycin and in 119 (12.0%) who received placebo (relative risk, 0.51; 95% confidence interval [CI], 0.38 to 0.68; P<0.001). There were significant differences between the azithromycin group and the placebo group in rates of endometritis (3.8% vs. 6.1%, P=0.02), wound infection (2.4% vs. 6.6%, P<0.001), and serious maternal adverse events (1.5% vs. 2.9%, P=0.03)...CONCLUSIONS: Among women undergoing nonelective cesarean delivery who were all receiving standard antibiotic prophylaxis, extended-spectrum prophylaxis with adjunctive azithromycin was more effective than placebo in reducing the risk of postoperative infection.
Am J Obstet Gynecol. 2016 Jun;214(6):751.e1-4. doi: 10.1016/j.ajog.2016.02.037. Epub 2016 Feb 18. A comparison of 3 antibiotic regimens for prevention of postcesarean endometritis: an historical cohort study. Ward E, Duff P. PMID: 26901276
...OBJECTIVE: The purpose of this study was to compare 3 different antibiotic regimens for the prevention of postcesarean endometritis. STUDY DESIGN: This retrospective historical cohort study was conducted at the University of Florida, which is a tertiary care facility that serves a predominantly indigent patient population. In the period January 2003 to December 2007, our standard prophylactic antibiotic regimen for all women who had cesarean delivery was cefazolin (1 g) administered immediately after the baby's umbilical cord was clamped. In November 2008, we began to administer the combined regimen of cefazolin (1 g intravenously) plus azithromycin (500 mg intravenously); both were given 30-60 minutes before the skin incision. In the period of January-December 2014, we continued the dual agent regimen but based the dose of cefazolin on the patient's body mass index: 2 g intravenously if the body mass index was <30 kg/m(2) and 3 g if the body mass index was >30 kg/m(2). The surgical technique was consistent throughout all 3 time periods. Our primary endpoint was the frequency of endometritis in each time period...RESULTS: ... In the period January 2003 to December 2007...16.4% (95% confidence interval, 14.4-18.4%) developed endometritis. In the period November 2008 to December 2013...1.3% (95% confidence interval, 1.0-1.7%) developed endometritis (P < .0001 compared with period 1). In the year 2014...2.3% (95% confidence interval, 1.3-3.3%) developed endometritis (P < .0001 compared with period 1 and P > .5 and <.10 compared with period 2)...CONCLUSIONS: When administered before skin incision, the combination of cefazolin plus azithromycin was significantly more effective in the prevention of endometritis than the administration of cefazolin after cord clamping; the rate of endometritis was reduced to a very low level without increasing the rate of neonatal sepsis evaluations.
Placental Removal Techniques

Acta Obstet Gynecol Scand. 2005 Mar;84(3):266-9. The effect of placental removal method and site of uterine repair on postcesarean endometritis and operative blood loss. Baksu A, Kalan A, Ozkan A, Baksu B, Tekelio─člu M, Goker N. PMID: 15715535
...This prospective randomized study involved 840 women who underwent cesarean section. The patients were grouped into four: (1) manual placental delivery + exteriorized uterine repair; (2) spontaneous placental delivery + exteriorized uterine repair; (3) manual placental delivery + in situ uterine repair; (4) spontaneous placental delivery + in situ uterine repair...The decrease in postoperative hemoglobin (P < 0.05) and hematocrit (P < 0.001) was significantly greater in the manual removal groups (groups 1 and 3) than in the spontaneous expulsion groups (groups 2 and 4) at 48 hr postoperatively. The incidence of postoperative endometritis was significantly higher in manual removal groups (15.2%) (groups 1 and 3) than in spontaneous groups (5.7%) (groups 2 and 4) (P < 0.05). CONCLUSIONS: Manual removal of the placenta at cesarean delivery results in more operative blood loss and a higher incidence of postcesarean endometritis.
Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004737. doi: 10.1002/14651858.CD004737.pub2. Methods of delivering the placenta at caesarean section. Anorlu RI, Maholwana B, Hofmeyr GJ. PMID: 18646109
...CONCLUSIONS: Delivery of the placenta with cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay.
Sutures vs. Staples

J Matern Fetal Neonatal Med. 2016 Nov;29(22):3705-11. doi: 10.3109/14767058.2016.1141886. Epub 2016 Feb 26. Subcuticular sutures versus staples for skin closure after cesarean delivery: a meta-analysis. Wang H, Hong S, Teng H, Qiao L, Yin H. PMID: 26785886
...RESULTS: Ten RCTs were included in this analysis. Subcuticular sutures were associated with significantly decreased incidence of wound complications compared to staples (RR 1.88, 95% CI 1.45-2.45)...CONCLUSIONS: Compared with staples following cesarean delivery, subcuticular sutures are associated with decreased risk of wound complications and better long-term cosmetic outcome, but slightly prolong duration of surgery.
Am J Obstet Gynecol. 2015 May;212(5):621.e1-10. doi: 10.1016/j.ajog.2014.12.020. Epub 2014 Dec 19. Suture versus staples for skin closure after cesarean: a metaanalysis. Mackeen AD, Schuster M, Berghella V. PMID: 25530592
...Twelve randomized trials with data for the primary outcome on 3112 women were identified. Women whose incisions were closed with suture were significantly less likely to have wound complications than those closed with staples (risk ratio, 0.49; 95% confidence interval [CI], 0.28-0.87). This difference remained significant even when wound complications were stratified by obesity. The decrease in wound complications was largely due to the lower incidence of wound separations in those closed with suture (risk ratio, 0.29; 95% CI, 0.20-0.43)...CONCLUSION: For patients undergoing cesarean, closure of the transverse skin incision with suture significantly decreases wound morbidity, specifically wound separation, without significant differences in pain, patient satisfaction, or cosmesis. Suture placement does take 7 minutes longer than staples.