Single-dose cefazolin versus cefonicid for antibiotic prophylaxis in cesarean delivery

The purpose of this prospective investigation was to compare a single intravenous dose of cefazolin to a single dose of cefonicid as prophylaxis for women having unscheduled cesarean delivery. In a double-blind, randomized design, 96 patients were assigned to receive a 1-g dose of cefazolin and 103 patients were designated to receive a 1-g dose of cefonicid. The antibiotics were administered after delivery of the infant. The two groups were comparable with respect to recognized risk factors for postcesarean infection. There were no statistically significant differences between the groups in the incidence of standard febrile morbidity, endomyometritis, urinary tract infection, wound infection, and bacteremia. There were also no significant differences between the groups in the fever index or the duration of hospitalization. We conclude that cefazolin and cefonicid provide a similar degree of prophylaxis against infection in patients having unscheduled cesarean delivery.     

Why patients fail antibiotic prophylaxis at cesarean delivery: histologic evidence for incipient infection.

A prospective, blinded study was conducted to test the hypothesis that antimicrobial prophylaxis failure after cesarean delivery is associated with incipient infection of the uterus, as determined by histologic evaluation of bacterial invasion and acute inflammatory cell response. One hundred nineteen patients undergoing cesarean delivery and receiving antibiotic prophylaxis were included in this study. At the time of the operation, a hysterotomy biopsy was obtained for hematoxylin and eosin staining. Marked histologic differences were noted in decidual inflammation, myometrial inflammation, and myometrial polymorphonuclear cell invasion in those patients who subsequently developed endometritis (N = 7) compared with subjects without postpartum endometritis. Using two techniques for in situ identification of bacteria within myometrial tissue (acridine orange and fluorescein DNA probe to bacterial ribosomal RNA), all clinically infected parturients demonstrated large numbers of organisms in the myometrial layer of the biopsy specimen, compared with few organisms seen in a matched subset of noninfected controls. These data support the concept that incipient infection at the time of cesarean delivery may limit the effectiveness of antimicrobial prophylaxis. Use of rapid-diagnosis methodologies may allow timely identification of these at-risk patients so that therapeutic antibiotics can be initiated.     

Endomyometritis after cesarean delivery in the era of antibiotic prophylaxis: incidence and risk factors

Purpose: To identify the rate of postpartum endomyometritis (PPE) after cesarean delivery (CD) in the era of antibiotic prophylaxis and determine risk factors.

Methods: A single institution retrospective study was performed in women undergoing CD. Data regarding obstetrical and surgical variables were collected. Diagnosis of PPE was made clinically.

Results: Among 2419 patients, the rate of PPE was 1.6% (n?=?38) and was associated with lower age (27.0 versus 31.0; p?p?p?=?.0081). There was no difference in PPE for cefazolin 2?g versus 1?g (OR: 1.91; p?=?.17) or 3?g versus 1?g (OR: 3.69; p?=?.29), gentamicin/clindamycin versus cefazolin (OR: 5.60; p?p?=?.001), sexually transmitted infection during the pregnancy (OR: 4.197; p?=?.02) or blood transfusion (OR: 9.50; p?Conclusions: While the overall rate of PPE was low, several risk factors were identified. Preoperative diagnosis of chorioamnionitits is associated with a higher rate of PPE. Further studies are needed to identify optimal regimens for antimicrobial prophylaxis in women undergoing CD.     

剖宫产子宫切口感染的防治

子宫切口感染是剖宫产术后严重并发症之一,近年来,随着剖宫产率升高,剖宫产子宫切口因感染导致围生期不良结局的报道有增加的趋势。文章通过复习文献,并进一步阐述子宫切口感染的相关因素、诊断、治疗及预防措施,希望能引起足够的关注,采取有效的防范措施。     

The effect of birth weight on vaginal birth after cesarean delivery success rates

OBJECTIVE: The purpose of this study was to evaluate the effect of increasing birth weight on the success rates for a trial of labor in women with one previous cesarean delivery. STUDY DESIGN: To evaluate the effect of increasing birth weight for women who undergo a trial of labor, the medical records of women who had attempted a vaginal birth after cesarean delivery (VBAC) from 1995 through 1999 in 16 community and university hospitals were reviewed retrospectively by trained abstractors. Information was collected about demographics, medical history, obstetric history, neonatal birth weight, complications, treatment, and outcome of the index pregnancy. The analysis was limited to women with singleton gestations with a history of 1 previous cesarean delivery. Because women with previous vaginal deliveries have higher vaginal birth after cesarean delivery success rates, the women were divided into four risk groups on the basis of their birth history. Groups were defined as women with no previous vaginal deliveries (group 1), women with a history of a previous vaginal birth after cesarean delivery (group 2), women with a history of a vaginal delivery before their cesarean delivery (group 3), and a group of women with a vaginal delivery both before and after the previous cesarean delivery (group 4). RESULTS: There were 9960 women with a singleton gestation and a history of one previous cesarean delivery. The overall vaginal birth after cesarean delivery success rate for the cohort was 74%. The overall vaginal birth after cesarean delivery success rates for groups 1, 2, 3, and 4 were 65%, 94%, 83%, and 93%, respectively. An analysis of neonatal birth weights of <4000 g, 4000 to 4249 g, 4250 to 4500 g, and >4500 g in group 1 showed a reduction in vaginal birth after cesarean delivery success rates from 68%, 52%, 45%, and 38%, respectively. In the remaining groups, there was no success rate below 63% for any of the birth weight strata. For group 1, vaginal birth after cesarean delivery success rates were decreased when the indication for the previous cesarean delivery was cephalopelvic disproportion or failure to progress or when the treatment was either an induction or augmentation of labor. The uterine rupture rate was higher in women for group 1 with birth weights of > or =4000 g (relative risk, 2.3; P <.001). CONCLUSION: Women with macrosomic fetuses and a history of a previous vaginal delivery should be informed of the favorable vaginal birth after cesarean delivery success rates. Given the risks of vaginal birth after cesarean delivery, those women with no history of a vaginal delivery should be counseled that the success rates may be <50% when the neonatal birth weight exceeds 4000 g and that the success rates may be even lower if the indication for the previous cesarean delivery was cephalopelvic disproportion or failure to progress or if the treatment requires either induction or augmentation of labor. The uterine rupture rate was 3.6% in women for group 1 with a birth weight > or =4000 g.     

Extraperitoneal cesarean section: A surgical form of infection prophylaxis?

The suggestion that extraperitoneal cesarean section might be a useful method of preventing postoperative infectious complications prompted a prospective study of 91 primary extraperitoneal cesarean sections on afebrile laboring patients with ruptured membranes longer than 4 hours. Fifty of 91 patients having extraperitoneal cesarean sections (group A) were compared with 36 patients having low cervical transperitoneal primary cesarean sections (control group) meeting the same entry criteria in a prospective randomized fashion. The other 41 patients (group B = 25 of 41, group C = 16 of 41) were selected from qualifying high-risk patients depending on the availability of an experienced operator with group C receiving perioperative prophylactic antibiotics. The only significant difference in outcome was: four of 16 (25%) patients in group C (extraperitoneal cesarean section plus prophylactic antibiotics) developed postoperative endomyometritis versus 20 of 36 (56%), 28 of 50 (56%), and 12 of 25 (48%) patients in the transperitoneal primary cesarean section control group and extraperitoneal cesarean section group A and B, respectively (p less than 0.05). There was a trend toward enhanced postoperative recovery in all extraperitoneal cesarean section groups compared with the transperitoneal primary cesarean section control group. Thus, the technique of extraperitoneal cesarean section apparently offers no significant advantage in the prevention of postcesarean endomyometritis, but the use of perioperative prophylactic antibiotics apparently has significant impact.     

The effect of midwifery care on rates of cesarean delivery

Objective

To examine whether changing to a midwifery-led maternity service model was associated with a lower national rate of cesarean delivery.

Methods

We analyzed trends in the rate of cesarean delivery per 1000 live births between 1996 and 2010 in New Zealand. Estimates of relative increases in rate were calculated via Poisson regression for several maternal age groups over the study period.

Results

Rates of cesarean delivery increased over the study period, from 156.9 per 1000 live births in 1996 to 235 per 1000 in 2010: a crude increase of 49.8%. Increasing trends were apparent in each age group, with the largest increases occurring before 2003 and relatively stable rates in the subsequent period. The smoothed estimate showed that the increase in cesarean rate across all age groups was 43.7% (95% confidence interval, 41.6–45.8) over the 15-year period.

Conclusion

A national midwifery-led care model was not associated with a decreased rate of cesarean delivery but, instead, with an increase similar to that in other high-resource countries. This indicates that other factors may account for the increase. Further research is needed to examine maternity outcomes associated with different models of maternity care.     

Cabergoline versus bromocriptine in suppression of lactation after cesarean delivery

We evaluated the efficacy of cabergoline, a new ergoline derivative, in blocking puerperal lactation in a group of women delivered by cesarean section. In a single-blind controlled trial 36 women were randomly allocated to treatment with cabergoline 1 mg in a single dose p.o. (n = 18) or bromocriptine 5 mg/day p.o. for 14 days (n = 18). Treatment was started about 50 h after delivery. Clinical assessment of breast signs and determination of serum prolactin were performed just before treatment and at 3, 5, 7 and 14 days. In the cabergoline-treated group milk secretion was inhibited in 17 women (94.4%). Maximum decrease of serum prolactin was -89.7% at 5 days, and the prolactin-lowering effect of cabergoline was still present at 14 days. In the bromocriptine group milk secretion was inhibited in 16 women (88.9%). Maximum prolactin decrease (-86.9%) was reached at 3 days. Persistent side effects were comparable in the two groups. This study demonstrates that a single oral dose of 1 mg cabergoline is as effective in suppressing puerperal lactation as a full treatment with bromocriptine, even in women delivered by cesarean section.     

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution

Purpose: To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution.

Methods: This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors.

Results: In 2419 patients, the rate of SSI was 5.5% (n?=?133) with cellulitis in 4.9% (n?=?118), deep incisional infection in 0.6% (n?=?15) and intra-abdominal infection in 0.3% (n?=?7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6–3.5; p?<.001). Preterm labor (OR 2.8; 95%CI 1.3–6.0; p?=?.01) and general anesthesia (OR 4.4; 95%CI 2.0–9.8; p?=?.003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05–1.09; p?=?.02), asthma (OR 1.9; 95%CI 1.1–3.2; p?=?.02) and smoking (OR 1.9; 95%CI 1.1–3.2; p?=?.02) were associated with increased SSI.

Conclusions: Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.     

Superficial incisional surgical site infection rate after cesarean section in obese women: a randomized controlled trial of subcuticular versus interrupted skin suturing

Purpose

To compare the superficial incisional surgical site infection (SSI) rate after cesarean section (CS) in obese women using subcuticular versus interrupted skin suturing.

Methods

The current randomized controlled clinical trial was conducted at Ain Shams University Maternity Hospital. Obese non-diabetic women who underwent elective CS were randomized into two groups: group I included women who had their skin closed with interrupted mattress suture using non-absorbable polypropylene, and group II included women who had their skin closed with subcuticular suture using the same suture material. Primary outcome measure was superficial incisional SSI and secondary outcome measures were skin closure time, postoperative pain assessed by ten-point visual analog scale (VAS) and short-term cosmetic wound outcome according to the Stony Brook Scar Evaluation Scale (SBSES).

Results

A total of 130 obese women were finally analyzed. Group II (n = 67) was associated with higher incidence of superficial incisional SSI. There were nine cases (13.4 %) compared to three cases (4.8 %) in group I (n = 63); however, this difference was statistically not significant (P = 0.088). Skin closure time was significantly prolonged in group I (8.6 ± 2.3 min versus 5.7 ± 2.2 min, respectively, P < 0.001). Postoperative pain was significantly lower in group I and the mean VAS in group I was 4.7 ± 2 versus 5.5 ± 1.8 in group II (P = 0.017). Using SBSES, group II had mean score 4.5 ± 0.7, while group I had mean score 2.7 ± 1.1. This was statistically significant (P < 0.001), which means a better cosmetic outcome in group II.

Conclusion

Subcuticular skin closure during CS for non-diabetic obese women was significantly associated with better short-term cosmetic outcome, less skin closure time, yet, with slightly higher risk of superficial incisional SSI and significantly more postoperative pain.     

Puerperal infection after cesarean delivery: evaluation of a standardized protocol

OBJECTIVE: Our goal was to evaluate an antibiotic protocol for treatment of postcesarean endometritis. STUDY DESIGN: Endometritis was diagnosed as a persistent fever > or =100.4 degrees F beyond 24 hours after cesarean delivery and one or more of the following: uterine tenderness, tachycardia, foul lochia, or leukocytosis. Antibiotic therapy included gentamicin plus clindamycin and ampicillin (or vancomycin) as a triple antimicrobial in 148 women. Antibiotic failure was defined as persistent fever after 5 days of antibiotics and 72 hours of triple antibiotics. RESULTS: Between 1993 and 1996, 322 of 1643 (20%) women were diagnosed with postcesarean endometritis. One hundred seventy-four patients (54%) were cured with clindamycin-gentamicin, and 129 who additionally received ampicillin or vancomycin (40%) were cured. Nineteen of the 322 (6%) women had persistent fever despite triple antibiotics. Of these, 6 had a wound complication, 12 were suspected to have antimicrobial resistance, and 1 had an infected hematoma. CONCLUSION: A prospective protocol consisting of clindamycin-gentamicin plus the selective addition of ampicillin or vancomycin cured 303 of 322 (94%) women with postcesarean endometritis.     

Effect of skin coverage method following subcuticular suturing on wound infection rates at cesarean delivery*

Objective: The objective of this study was to determine whether the use of cyanoacrylate skin glue following subcuticular skin closure was associated with a decrease in wound outcomes in comparison with subcuticular closure plus Steri-strips at cesarean delivery.

Methods: This was a retrospective cohort study of patients undergoing cesarean delivery at a single center over a two-year period. The primary outcome of wound infection and secondary outcomes of wound separation and composite wound complication rate were assessed throughout the six-week postpartum period.

Results: Of 660 women who met inclusion criteria, 35 (5.3%) experienced a wound infection and 90 (13.6%) experienced a wound separation. The composite wound complication rate was 16.4% (n?=?108). Of the 515 cases with a skin coverage method noted, use of skin glue was associated with a marginal decrease in wound infections (p?=?0.057), as well as a significantly reduced incidence of wound separation (p?=?0.03) and composite wound complications (p?=?0.006).

Conclusion: Cyanoacrylate skin glue may be superior to Steri-strips for wound separation and composite wound complication rates when utilized with subcuticular suture at the time of cesarean delivery and may yield some benefit for prevention of wound infection.     

The course of delivery after previous cesarean section

Of 249 women whose last pregnancy was terminated by a cesarean section, 57 (22.9%) were delivered again by a primary cesarean section. The other 192 (77.1%) were allowed to attempt vaginal birth. Of these, 151 (60.6%) were successful, and 41 (16.5%) underwent a secondary cesarean section. The percentage of successful vaginal births was correlated with the indication for the previous cesarean section. There was one case of incomplete uterine rupture. The maternal morbidity was lowest in the group who had a vaginal delivery. One child developed an Erb-Duchenne paralysis in addition to a shoulder dystocia. The condition of the vaginally delivered children was not different from the condition of the children born by a primary cesarean section. It is concluded that there are sufficient arguments for continuing the policy of 'once a cesarean section, trial of labor after selection'.     

Using active management of labor and vaginal birth after previous cesarean delivery to lower cesarean delivery rates: A 10-year experience

Objective: Our objective was to analyze the statistics on cesarean delivery rates and the factors that have led to a reduction in these rates. Study Design: A retrospective analysis was done of delivery statistics from a 10-year period, January 1, 1989, to December 31, 1998. We investigated the changes made in the methods of delivery during the study period. The data were divided into 1-year periods and analyzed by χ² tables. Results: The overall cesarean delivery rate decreased from 16.59% to 10.92%; the primary cesarean delivery rate decreased from 9.22% to 7.11% and the repeated cesarean delivery rate from 7.37% to 3.81%. All these decreases were statistically significant. An increase in the rate of active management of labor by increasing oxytocin use and encouraging a trial of labor after previous cesarean delivery was also statistically significant. No changes in the outcome were observed in terms of neonatal morbidity and mortality rates. Conclusion: We found that our working plan for management of labor and delivery yielded and maintained a successful decline in the cesarean delivery rates without any negative effect on neonatal or maternal mortality rates. This low rate was maintained for a 10-year period. (Am J Obstet Gynecol 2001;184:1535-43.)     

Effect of irrigation or intravenous antibiotic prophylaxis on infectious morbidity at cesarean section

The efficacy of intraoperative irrigation with cefamandole nafate at cesarean section was evaluated in a prospective, randomized double-blind study. Two hundred and eight patients were treated with antibiotic irrigation and intravenous placebo or with perioperative intravenous cefamandole and irrigated with normal saline. The rate of endometritis was 10.9% in the irrigation group and 14% in the intravenous group, but the difference was not statistically significant. The rate of any infection, the number of days with fever, additional hospitalization days, and number of antibiotics used for treatment were similar in the two groups. It thus was concluded that irrigation with antibiotic is equal but not superior to perioperative intravenous antibiotics.     

Neonatal impact of elective repeat cesarean delivery at term: a comment on patient choice cesarean delivery

OBJECTIVE: The object of this study was to compare neonatal outcomes of term uncomplicated pregnancies delivered by scheduled repeat cesarean with outcomes of babies born to mothers intending to deliver vaginally. STUDY DESIGN: This retrospective cohort study describes neonatal outcomes of term uncomplicated pregnancies. Neonates of mothers intending to deliver vaginally (n = 3134) are compared with neonates born by elective repeat cesarean delivery prior to labor (n = 117). RESULTS: Neonates born by elective repeat cesarean are more frequently admitted to advanced care nurseries than infants born to mothers intending to deliver vaginally (risk ratio 3.58, 95% confidence interval 3.35-3.58). CONCLUSION: The decision to undergo scheduled cesarean delivery appears to negatively impact immediate neonatal outcomes.