Effect of anesthesia for primary cesarean section on postoperative infectious morbidity

It has been stated that general anesthesia is a risk factor for postcesarean infectious morbidity. A retrospective review of 252 women who had undergone primary cesarean section at the University of Iowa Hospital was conducted. Regional anesthesia was successfully administered to 170 patients, and general anesthesia was administered to 82 patients. Patients receiving general anesthesia were more likely to be indigent, to receive a vertical skin incision, and to be transfused intraoperatively and/or postoperatively. There were no statistically significant differences between the two groups with regard to multiple indexes of postoperative fever or infection, including febrile morbidity, diagnosis of infection, use of therapeutic antibiotics, fever index, and postoperative hospital stay. General anesthesia, as administered to patients in the present series, did not increase the risk of infectious morbidity after primary cesarean section. However, our surgeons apparently were influenced by the choice of anesthetic technique when selecting a skin incision.     

Increased risk of endometritis and wound infection after cesarean section in insulin-dependent diabetic women

To determine if diabetic women have an increased risk for post-cesarean section endometritis and/or wound infection, all insulin-requiring diabetic women who were delivered by cesarean section between 1977 and 1981 were compared with a group of nondiabetic patients delivered by cesarean section. Patients were divided into low-risk or high-risk groups on the basis of labor and ruptured membranes. Compared with control subjects, diabetic patients were at significantly greater risk for postoperative infectious morbidity. Among diabetic patients, risk for postoperative infections was independent of White's classification of diabetes and gestational age at delivery. The increased rate of infection among the diabetic patients suggests that prophylactic antibiotics might be efficacious for insulin-requiring diabetic patients undergoing cesarean section.     

Effect of intrauterine antibiotic lavage after cesarean birth on postoperative morbidity

Intrauterine lavage using broad-spectrum antibiotics after cesarean section has been reported to reduce maternal morbidity, but many such patients are not at high risk for postoperative infection. This study tested intrauterine antibiotic lavage in patients at risk for infectious morbidity. The patients were randomly assigned to one of three groups based on the last digit of the hospital admission number. Group I received no lavage, group II received lavage with 800 ml of saline plus 2 gm of cefamandole nafate in the intrauterine incision, bladder flap and peritoneal cavity, and group III received a similar lavage using 800 ml of saline alone. There was a significant decrease in maternal hyperpyrexia (simple morbidity) as well as serious infection in both lavage groups as compared to the control group (p less than 0.01 and 0.05, respectively). Also, there was significantly reduced morbidity when the antibiotic lavage was compared to the saline technique (p less than 0.001). The use of intrauterine lavage with saline, with or without antibiotics, appears helpful in reducing postoperative morbidity in patients at high risk for infectious morbidity after cesarean section.     

Puerperal infectious morbidity: Relationship to route of delivery and to antepartum Chlamydia trachomatis infection

We investigated the relationship of route of delivery and of antepartum Chlamydia trachomatis cervical infection to selected forms of puerperal infectious morbidity, including intrapartum fever, or early (<48 hours) postpartum fever not attributable to infections of sites outside the uterus and late (48 hours to 6 weeks) postpartum endometritis. Infectious morbidity occurred in 27 (44%) of 62 women who underwent cesarean section and in 33 (10%) of 329 who underwent vaginal delivery (p < 0.001). Postsection infectious morbidity was not correlated with C. trachomatis infection and was largely limited to early postpartum fever. Among women who underwent vaginal delivery, infectious morbidity occurred in 10 (34%) of 29 women with and in 23 (8%) of 300 without C. trachomatis infection (p < 0.001), and chlamydial infection was associated only with intrapartum fever and late postpartum endometritis. Separate matched case-control analyses confirmed that cesarean section was associated with an increased risk of early postpartum fever (p = 4 × 10^?8); whereas among women who underwent vaginal delivery, antepartum C trachomatis infection was associated with an increased risk of development of intrapartum fever or late postpartum endometritis (p = 0.002).     

Effect of type of anesthesia on blood loss at elective repeat cesarean section.

It has recently been reported that the use of halogenated agents during balanced general anesthesia may result in an increase in blood loss associated with cesarean section. This report has been criticized for failure to control for a variety of other factors that may have contributed to the increased blood loss, particularly the indication for and type of cesarean section. The present study was designed in an attempt to resolve this criticism. Blood loss was evaluated in uncomplicated patients undergoing elective repeat cesarean section under either general anesthesia using a halogenated agent (isoflurane) or regional anesthesia (spinal/epidural). All 117 singleton term, nonlaboring women underwent repeat low transverse cesarean section performed through a midline abdominal incision. Exclusion criteria included maternal medical complications, abnormal placentation, polyhydramnios, presence of uterine leiomyomas, and intraoperative complications. Seventy-five patients (64%) received regional and 42 (36%) received general anesthesia. A greater proportion of women undergoing general anesthesia experienced a postoperative decrease in hematocrit of 5 vol% or more compared with patients receiving regional anesthesia (10 of 42 versus 5 of 75, p = 0.018). Thus, we conclude that women undergoing uncomplicated elective repeat cesarean section under general anesthesia supplemented with a halogenated agent are at risk for increased blood loss compared with those women receiving regional anesthesia. However, the increased blood loss was not clinically significant in this study, since none of the patients required transfusion.     

Simplified cesarean section: a strategic surgical approach to minimize postoperative infectious morbidity

Objective: A simplified method of cesarean delivery aimed at minimizing postoperative morbidity is illustrated.Methods: Two hundred consecutive cesarean deliveries were performed by the authors’ simplified cesarean technique. Mean patient age was 27 years (range 17–46), and mean weight was 169 pounds (range 112–414). Indications for cesarean delivery included dystocia or failure to progress in labor (38%), repeat cesarean (32%), malpresentation (11.5%), fetal distress (9.5%), and other (9%).Results: Simplified cesarean delivery was successfully completed in all cases. Mean operating time was 16 minutes (range 9–33), mean blood loss was 460 mL (range 100–1150), and mean postsurgical hospitalization time was 72 hours (range 36–120). No bowel, bladder, or vascular injuries occurred. Postoperative febrile morbidity occurred in one patient (0.5%), ileus occurred in one patient (0.5%), and blood transfusion was administered to one patient (0.5%). No cases of wound infection, wound dehiscence, hematoma, or incisional hernia occurred. All patients were ambulatory on the first postoperative day. All but one patient (99.5%) tolerated a regular diet on the first postoperative day.Conclusions: The authors’ technique of cesarean section appears to be a safe and efficient method for cesarean delivery associated with minimal postoperative infectious morbidity and rapid resumption of bowel and ambulatory function.     

Prophylactic use of antibiotics for nonlaboring patients undergoing cesarean delivery with intact membranes: a meta-analysis

OBJECTIVE: We performed a meta-analysis to examine the role of antibiotic prophylaxis in preventing postoperative infections among nonlaboring women undergoing cesarean delivery with intact membranes. STUDY DESIGN: A computerized literature search was performed with MEDLINE. Studies were included if they contained data on patients undergoing cesarean delivery in the absence of labor and ruptured membranes. Only randomized trials with a placebo control group were included. RESULTS: Seven studies were found. Use of antibiotics decreased the risk of all infectious outcomes reported. When the results of 4 studies were pooled, prophylactic antibiotic use was associated with a significant reduction in postoperative fever (relative risk, 0.25; 95% confidence interval, 0.14-0.44). A similar reduction was noted for endometritis in 4 studies (relative risk, 0.05; 95% confidence interval, 0.01-0.38). Two studies reported on wound infection and showed a trend toward a protective effect (relative risk, 0.59; 95% confidence interval, 0.24-1.45). CONCLUSION: The prophylactic use of antibiotics reduces the risk of postoperative infectious complications after cesarean delivery even in the population at lowest risk.     

Vaginal preparation with povidone iodine and postcesarean infectious morbidity: a randomized controlled trial

OBJECTIVE: To determine whether vaginal preparation with povidone iodine before cesarean decreased the incidence of postpartum infectious morbidity. METHODS: Participants were randomly assigned to vaginal preparation with povidone iodine (n = 247) or no preparation (n = 251). Postpartum infectious morbidity included fever, defined as temperature of 38C or greater after the day of surgery; endometritis, defined as fever with abdominal or uterine tenderness and initiation of intravenous antibiotics; and wound separation, defined as disruption of the abdominal incision that required wound care. We calculated overall rates of postpartum infectious morbidity, relative risks (RR), and 95% confidence intervals (CI) for the effect of vaginal preparation. As designed and reported, the trial had at least 80% power to detect a 10% or greater absolute difference in rates of overall infectious morbidity, fever, and endometritis (two-tailed, alpha = 0.05). RESULTS: There was no difference between groups in maternal age, parity, race, education, prior cesarean, type of anesthesia, labor before current cesarean, number of vaginal examinations during labor, internal monitoring, prophylactic antibiotic use, gestational age at delivery, or payment status. Excluding 68 women with chorioamnionitis, incidence of postoperative fever was 19.3%, endometritis 7.2%, and wound separation 7.0%. Vaginal preparation with povidone iodine before cesarean had no effect on risk for fever (RR 1.1, 95% CI 0.8, 1.6), endometritis (RR 1.6, 95% CI 0.8, 3.1), or wound separation (RR 0.6, 95% CI 0.3, 1.3). CONCLUSION: Vaginal preparation with povidone iodine before cesarean had no effect on the incidence of fever, endometritis, or wound infection.     

Risk factors for fever, endometritis and wound infection after abdominal delivery

Risk factors for postoperative fever, endometritis and wound infection were analyzed in 761 consecutive cesarean sections. Postoperative fever was observed in 12%, endometritis in 4.7% and wound infection in 3% of cases. The relative risk for postoperative fever was increased in cases with postoperative hematoma (relative risk = 16.0), in cases with blood loss over 500 g (relative risk = 1.8) and if the duration of labor exceeded 6 h (relative risk = 1.9). The only significant risk factors for endometritis were amnionitis (relative risk = 8.7), postoperative hematoma (relative risk = 5.0) and age under 24 years (relative risk = 3.0). Wound infections were less frequent in cases with previous cesarean sections (relative risk = 0.15) and after elective cesarean sections (relative risk = 0.22), but duration of operation over 1 h (relative risk = 2.8), induction of labor (relative risk = 3.2) and puerperal endometritis (relative risk = 7.9) increased the risk of wound infection. By elimination of amnionitis and postoperative hematomas the rate of endometritis would have diminished only from 4.7% to 3.8%, a percentage equally unacceptable; diagnostics and prevention should be directed to young patients undergoing caesarean section. Besides technical procedures prevention of endometritis is important for the prevention of wound infection. In hospitals with low postcesarean infectious morbidity antibiotic prophylaxis seems to be unwarranted.     

When should we perform prophylactic antibiotics in elective cesarean cases?

Objective  The aim of this study was to determine whether the timing of prophylactic antibiotics at cesarean delivery influences maternal and neonatal infectious morbidity. Study design  This was a prospective, randomized trial. Four hundred patients that underwent elective cesarean section between June and December 2007 formed the study population. Eleven patients were excluded from the study because they needed transfusion during the cesarean section. The population was divided into two groups: Group A, antibiotic prophylaxis was applied to 194 women before skin incision and Group B, antibiotic prophylaxis was applied to 195 women after umbilical cord clamping. The occurrence of endomyometritis/endometritis, wound infection, febrile morbidity, total infectious morbidity, and neonatal complications were compared. Results  There were 389 patients enrolled. No demographic differences were observed between groups. No significant difference was found between the groups for total infectious morbidity [relative risk (RR) 1.39, 95% confidence interval (CI) 0.71–2.69] and endometritis (RR 1.40, 95% CI 0.43–4.51). There was no increase in neonatal sepsis (RR 1.47, 95% CI 0.61–3.53), sepsis workup (RR 1.35, 95% CI 0.75–2.42), need for neonatal intensive care (RR 1.77, 95% CI 0.51–6.16), and intensive care stay period (P = 0.16). Conclusions  Time of antibiotic prophylaxis application does not change maternal infectious morbidity in cesarean section deliveries. Preoperative prophylaxis application does not affect neonate morbidity rates as stated in literature.     

Antibiotic prophylaxis to prevent postoperative infectious morbidity in low-risk elective cesarean deliveries: a prospective randomized clinical trial

Objective: To determine the effectiveness and cost of antibiotic chemoprophylaxis in reducing infectious morbidity in low-risk women undergoing elective cesarean delivery.

Methods: A prospective randomized clinical trial was performed at a single tertiary care center in Jinan, China between November 2012 and December 2013. Women were randomized to receive either antibiotic prophylaxis or no antibiotics prior to elective cesarean delivery at term. The infectious morbidity (fever, surgical site infection – SSI, endometritis and urinary tract infection), routine blood tests and hospital costs were measured.

Results: Total of 414 women were enrolled into the study; and 202 women received antibiotic chemoprophylaxis and 212 women received no antibiotics. Demographic and clinical characteristics were similar between the two groups. Total of one case in the treatment group and four case in the non-treatment group developed endometritis, giving the postoperative infection rate of 1.2%, which was not statistically significant between the two groups (χ²?=?1.679, p?=?0.195). The secondary outcomes were also not different between the two groups, except the costs of hospitalization, which was significantly higher in the treatment group (p?<?0.001).

Conclusions: In low-risk women undergoing elective cesarean delivery at term, prophylactic antibiotics did not reduce the risk of postoperative infection, but significantly increased the cost of hospitalization.     

Prophylactic antibiotics in cesarean section: a double-blind study of cefazolin.

One hundred twenty-two patients were evaluated prospectively to determine the clinical efficacy of prophylactic cefazolin (Ancef) in cesarean section. The cefazolin was administered intravenously in a high-dose, short perioperative regimen. Postoperatively, each patient was evaluated for morbidity. Over all, the post operative morbidity rate was reduced from 30 per cent in the placebo group to 18 per cent in the cefazolin group. More important, the infection rate associated with primary cesarean section was significantly lessened from 38 per cent in the placebo group to 16 per cent in the drug group (p less than 0.025). In repeat cesarean sections, the postoperative morbidity rate was greater in the antibiotic-treated group (20 per cent) than in the placebo group (14 per cent). Of major importance, a predominant organism, Group D streptococcus, was encountered in the postoperative cultures of the cefazolin group.     

Single-dose antibiotic prophylaxis in high-risk patients undergoing cesarean section

A prospective, double-blind, placebo-controlled study was performed to determine the effectiveness of single-dose antibiotic prophylaxis in decreasing infectious complications after primary cesarean section. One hundred women at high risk for postoperative infectious morbidity were randomly assigned to receive either placebo or one 2-g dose of ceftizoxime at cord clamping. The incidence of endometritis in the antibiotic group was 6.0 versus 24.5% in the placebo group (P less than .05). The incidence of febrile morbidity in the group receiving one dose of ceftizoxime was 14.0 versus 32.7% in the placebo group (P less than .05). Single-dose ceftizoxime prophylaxis significantly reduced the incidence of endometritis and febrile morbidity in high-risk patients undergoing cesarean section.     

Epidural analgesia vs. general anesthesia for cesarean section

A prospective study based upon interviews included 92 women who had undergone cesarean section, 38% with epidural analgesia and 62% under general anesthesia. The two groups were compared with respect to anesthesiological complications, postoperative morbidity and birth experience. The puerperal period was less complicated after epidural analgesia than after general anesthesia. There was a quicker re-establishment of the gastrointestinal function after epidural analgesia and the patients were more quickly mobilized and less tired. The overall morbidity after cesarean section, 16%, was lower than in other studies. Nearly half of the patients in the epidural experienced slight peroperative pain. In the case of repeated cesarean section, 86% of women who had epidural analgesia wanted the same anesthesia again. On the basis of this study, epidural analgesia is recommended for cesarean section.     

Routine cervical dilatation during elective cesarean section and its influence on maternal morbidity: a randomized controlled study

AIM: To determine the effect of routine intraoperative cervical dilatation during elective cesarean section on maternal morbidity. SUBJECTS AND METHODS: Patients with even numbers in the operative elective cesarean section list were included in the study. Of these, every second patient underwent intraoperative cervical dilatation. All participants in the two groups had otherwise similar preoperative care, operative procedures and subsequent clinical care. Blood loss was estimated and maternal infection status was assessed postoperatively by any rise of temperature or wound infection. RESULTS: Of the 131 patients included in the study, 67 underwent cervical dilation and 64 served as controls. There was no significant difference in postoperative hemoglobin, incidence of fever, or wound infection between the two groups. Only two of the cervical dilation group and one control patient developed postoperative fever. A hemoglobin drop of more than 0.5 g/dL was noted in 27 and 26 patients in the cervical dilation and the no dilation groups, respectively (NS). None of the study patients had signs of wound infection. CONCLUSION: Intraoperative cervical dilatation during elective cesarean section did not reduce the risk of postoperative maternal fever, wound infection or change in hemoglobin concentration.     

Elective repeat cesarean section. Effect of anesthesia type on blood loss

Halothane depresses uterine contractility and may increase cesarean blood loss during the use of general anesthesia. We retrospectively compared the medical records of 399 elective repeat cesarean section patients. We excluded medical and obstetric conditions that may predispose such patients to increased blood loss. Subsequent detailed record analysis included 84 patients receiving epidural anesthesia, 23 receiving halothane-supplemented nitrous oxide for general anesthesia and 14 receiving unsupplemented nitrous oxide for general anesthesia. No patient received a blood transfusion. The incidence of low postoperative hematocrits (less than 32%) following surgery was similar with all the anesthetic methods. Low-dose halothane supplementation of general anesthesia for elective cesarean section did not increase blood loss.     

Trial of labor after cesarean section in twin pregnancies: Maternal and neonatal safety

Objective.?To assess maternal and perinatal morbidity in patients undergoing a trial of labor after cesarean section (TOLAC) in twin gestations.

Methods.?A retrospective study including all twin pregnancies with a single prior cesarean section was performed. Stratified analysis using a multiple logistic regression model was performed to control for confounders. Patients who had a clear medical indication for a cesarean section (i.e. previous corporeal cesarean section, breech or transverse presentation, placenta previa, placental abruption, and herpes infection) were excluded from the analysis.

Results.?During the years 1988–2007, 134 patients met the inclusion criteria. Of these, 25 patients underwent a trial of labor and the remaining 109 underwent a repeat cesarean delivery. There were no cases of uterine rupture, maternal mortality, or peripartum fever in our population. Higher rates of perinatal mortality were noted in patients undergoing a trial of labor (8% vs. 1.8%, p?=?0.042, OR?=?4.652, 95% CI?=?1.122–19.286). However, a trial of labor was not found to be an independent risk factor for perinatal mortality after controlling for confounders such as gestational age, ethnicity, and fetal malformations (adjusted OR?=?1.07, 95% CI?=?0.07–15.95, p?=?0.95).

Conclusions.?A TOLAC is not associated with an increased risk for maternal morbidity, including uterine rupture. Nevertheless, in our population TOLAC was noted as a risk factor for perinatal mortality, although residual confounding cannot be excluded. Further prospective randomized studies should evaluate the safety of TOLAC in twin gestations to establish appropriate guidelines.     

Uterine incision and maternal morbidity after cesarean section for delivery of the very low birthweight fetus

The maternal morbidity associated with the type of uterine incision used for the delivery of the very low birthweight (VLBW) fetus was examined. Maternal morbidity factors evaluated included the incidence of infection, bleeding, wound complications, estimated blood loss, blood transfusions, fever and days in hospital. Cesarean section was performed in 115 of 197 VLBW infants, with 31 low transverse and 84 vertical cesarean sections. There were no significant differences in antepartum, intrapartum or postpartum data between these two groups. Short term maternal morbidity was not increased with the use of vertical compared with low transverse cesarean section for the delivery of the VLBW fetus.     

Risk factors in the development of cesarean section infection

Fifty consecutive patients undergoing cesarean section were evaluated prospectively. A data collection form was developed and 113 variables relating to demographic features, antepartum care, intrapartum events and postpartum course were evaluated. All of the patients were seen and evaluated within 24 hours of delivery and all forms were completed when the patients were discharged from the hospital. Twenty-five of the 50 patients had postpartum febrile morbidity develop. There were 14 instances of endometritis; five, wound infections; two, urinary tract infections; two, upper respiratory tract infections; three pulmonary infections; one patient with phlebitis, and two with febrile morbidity and no apparent source. Factors significantly associated with an increased risk of developing febrile morbidity included antepartum infections, resident staff as primary surgeon, extension of the uterine incision and positive endometrial culture at the time of the operation. Patients undergoing elective repeat cesarean section had less febrile morbidity than others (p less than 0.025). Statistically significant differences between the two groups were not found for the variables obesity, anemia, rupture of membranes, number of pelvic examinations, fetal monitoring, fetal tachycardia, general anesthesia and skin preparation. Operative blood loss was greater in the patients having febrile morbidity develop, but this difference was not statistically significant.     

Desmoid tumor during pregnancy

Although many reports concerning risk factors for post-cesarean section febrile morbidity have been published, few have considered the antibacterial activity of amniotic fluid. This study, in which the amniotic fluid phosphate-to-zinc ratios were used as a reflection of antibacterial activity, demonstrates that, among 85 patients who underwent elective repeat cesarean sections, less febrile morbidity was present when the patient's amniotic fluid had greater antibacterial activity. There was less standard fever, use of antibiotics, and endometritis among patients whose amniotic fluid had lower phosphate-to-zinc ratios.