Clinical Review
Should the 30-minute rule for emergent cesarean delivery be applied universally?
4 cases cast doubt on the universality of a 30-minute decision to incision interval when the fetal heart-rate tracing is nonreassuring
There are approximately 4,000,000 births annually in the United States, and about 32% of them occur by cesarean delivery. Compared with vaginal birth, cesarean delivery is associated with an increased risk of endometritis (defined as fever plus uterine or abdominal tenderness). Although surgical complications cannot be eliminated entirely, surgeons are deeply dedicated to the continuous improvement of surgical practice in order to reduce the risk of complications.
With cesarean delivery, many surgical practices have been adopted universally to reduce postoperative complications, including administration of intravenous (IV) antibiotics before skin incision to minimize postoperative infection and the use of postoperative mechanical or pharmacologic interventions to help prevent venous thromboembolism and pulmonary embolism. Preoperative vaginal cleansing with povidone-iodine may reduce the risk of postoperative endometritis, but the practice is not currently common in the United States.
Should you adopt a policy of preoperative vaginal cleansing prior to cesarean delivery? The data suggest perhaps you should.
Data-driven support for povidone-iodine precesareanThree large randomized trials published within the past 10 years concluded that preoperative vaginal cleansing with povidone-iodine reduced the risk of postcesarean endometritis in women who also received prophylactic IV antibiotics (TABLE).1−3 Vaginal cleansing did not reduce the rate of postpartum fever or wound infection in these studies.
Clinical factors that increased the risk of postpartum endometritis independent of vaginal cleansing included:
- extended duration of cesarean surgery
- being in labor prior to cesarean delivery
- ruptured membranes
- advanced cervical examination
- maternal anemia
- use of intrapartum internal monitors
- prior history of genitourinary infection.
Authors of two recent, large nonrandomized studies also have reported that vaginal cleansing reduced the risk of postcesarean endometritis.4,5 By contrast, investigators from one large trial from 2001 did not observe a decrease in endometritis with vaginal cleansing.6
Prevention of postcesarean endometritis with vaginal metronidazole gel 5 g
To test the impact of metronidazole vaginal gel on post‑cesarean endometritis, 224 women undergoing cesarean delivery for various indications were randomly assigned to placebo vaginal gel or metronidazole vaginal gel 5 g prior to surgery initiation.1 Most women also received intravenous antibiotics. The rates of endometritis were 17% and 7% in the placebo and metronidazole groups, respectively (relative risk, 0.42; 95% confidence interval, 0.19−0.92).
Vaginal antibiotic administration shows promise as an alternative to povidone-iodine cleansing in the prevention of postcesarean endometritis. Additional randomized clinical trials are necessary to fully evaluate the benefits and risks of this practice.
Reference
1. Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of postcesarean endometritis: a randomized controlled trial. Obstet Gynecol. 2001;98(5 pt 1):745−750.
Cochrane review of precesarean vaginal cleansingAuthors of a Cochrane review, in which they synthesized 7 studies involving 2,635 women, reported that vaginal cleansing with povidone-iodine immediately before cesarean delivery was associated with a reduced risk of postcesarean endometritis: 8.3% vs 4.3% in the control and vaginal cleansing groups, respectively, (risk ratio [RR], 0.45; 95% confidence interval [CI], 0.25−0.81).7
The positive effect of vaginal cleansing was particularly noteworthy in the subgroup of women with ruptured membranes (3 trials involving 272 women). The rates of endometritis in the control versus vaginal cleansing groups were 17.9% and 4.3%, respectively (RR, 0.24; 95% CI, 0.10−0.55).
Women who went into labor prior to cesarean delivery (523 women from 3 trials) also benefitted from vaginal cleansing, with endometritis rates of 13.0% and 7.4% in the control and vaginal cleansing groups, respectively (RR, 0.56; 95% CI, 0.34−0.95).
In this review, again, vaginal cleansing did not significantly reduce the rate of postoperative fever or wound infection.
Vaginal cleansing with povidone-iodine or chlorohexidine gluconate with low alcohol contentPovidone-iodine is formally approved for vaginal surgical site cleansing. In women with allergies to iodine or povidone-iodine, the options for vaginal cleansing are very limited. Some centers use saline cleansing or dilute hydrogen peroxide cleansing.
The American College of Obstetricians and Gynecologists has noted that chlorohexidine gluconate solutions with high concentrations of alcohol are contraindicated for vaginal cleansing.1 However, although not approved for vaginal cleansing, solutions of chlorohexidine gluconate with low alcohol content (4% alcohol concentration) are safe and may be effective for off-label use as vaginal cleansings.
Reference
1. American College of Obstetricians and Gynecologists Women’s Health Care Physicians; Committee on Gynecologic Practice. Committee Opinion No. 571: solutions for surgical cleansing of the vagina. Obstet Gynecol. 2013;122(3):718−720.
Is vaginal cleansing prior to cesarean delivery best practice?In the United States, precesarean vaginal cleansing is not a common practice. To close the gap between current practice and what is potentially a best practice, two approaches to using vaginal cleansing could be instituted in delivery units.
