Moreover, a study of tissue concentrations of prophylactic cefazolin in obese women demonstrated that concentrations within adipose tissue at the site of the skin incision were inversely proportional to maternal body mass index (BMI).15 Given these findings, consideration should be given to using a higher dose of preoperative antibiotic prophylaxis in obese women, specifically 3 g of intravenous (IV) cefazolin for women with a BMI greater than 30 kg/m2 or an absolute weight of more than 100 kg.12
5 Use clippers for preoperative hair removal
If hair removal is necessary to perform the skin incision for cesarean delivery, the use of clippers is preferred
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2011;11:CD004122.
In a Cochrane review of 3 randomized clinical trials comparing preoperative hair-removal techniques, shaving was associated with an increased risk of SSI, compared with clipping (RR, 2.09; 95% CI, 1.15–3.80).15 Shaving is thought to result in microscopic skin abrasions that can serve as foci for bacterial growth.
Interestingly, in this same Cochrane review, a separate analysis of 6 studies failed to show a benefit of preoperative hair removal by any means, compared with no hair removal,15 suggesting that routine hair removal may not be indicated for all patients.
6 Use chlorhexidine-alcohol for skin prep
Prepare the skin with chlorhexidine-alcohol immediately before surgery
Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med. 2010;362(1):18–26.
Kunkle CM, Marchan J, Safadi S, Whitman S, Chmait RH. Chlorhexidine gluconate versus povidone iodine at cesarean delivery: a randomized controlled trial. J Matern Fetal Neonatal Med. 2014;18:1–5.
Data from a randomized multicenter trial of 849 patients showed that the use of a chlorhexidine-alcohol skin preparation immediately before surgery lowered the rate of SSI after clean-contaminated surgery, compared with povidone-iodine (RR, 0.59; 95% CI, 0.41–0.85).16 Studies focusing on cesarean delivery alone are limited, although 1 small randomized trial found that chlorhexidine treatment significantly reduced bacterial growth at 18 hours after cesarean, compared with povidone-iodine (RR, 0.23; 95% CI, 0.07–0.70).17
7 Consider an alcohol-based hand rub for preoperative antisepsis
Alcohol-based hand rubs may be more effective than conventional surgical scrub
Shen NJ, Pan SC, Sheng WH, et al. Comparative antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center [published online ahead of print September 21, 2013]. J Microbiol Immunol Infect. pii:S1684–1182(13)00150–3.
Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2008;1:CD004288.
Several agents are available for preoperative surgical hand antisepsis, including newer alcohol-based rubs and conventional aqueous scrubs that contain either chlorhexidine gluconate or povidone-iodine. In a prospective cohort study of 128 health care providers, use of an alcohol-based rub for surgical hand antisepsis was associated with a lower rate of positive bacterial culture (6.2%), compared with a chlorhexidine-based conventional scrub (47.6%; P<.001).18 However, if an aqueous-based scrub is the only option available for surgical hand antisepsis, a Cochrane review found that chlorhexidine gluconate scrubs were more effective than povidone-iodine scrubs in 3 trials, resulting in fewer colony-forming units of bacteria on the hands of the surgical team.19
8 Close the skin with subcuticular sutures
Use of subcuticular sutures for skin closure is associated with a lower risk of wound complications, compared with staples
Mackeen AD, Schuster M, Berghella V. Suture versus staples for skin closure after cesarean: a meta-analysis [published online ahead of print December 19, 2014]. Am J Obstet Gynecol. doi:10.1016/j.ajog.2014.12.020.
A meta-analysis of 12 randomized controlled trials including 3,112 women demonstrated that subcuticular closure is associated with a decreased risk of wound complications, compared with staple closure (RR, 0.49; 95% CI, 0.28–0.87). The reduced risk remained significant even when stratified by obesity. Both closure techniques were shown to be equivalent with regard to postoperative pain, cosmetic outcome, and patient satisfaction.20
9 Close the subcutaneous tissue
Closure of the subcutaneous fat is associated with a decreased risk of wound disruption for women with a tissue thickness of more than 2 cm
Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis. Obstet Gynecol. 2004;103(5 pt 1):974–980.
Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol. 2013;209(4):294–306.
A meta-analysis of 5 randomized controlled trials demonstrated that suture closure of subcutaneous fat is associated with a 34% decrease in the risk of wound disruption in women with fat thickness greater than 2 cm (RR, 0.66; 95% CI, 0.48–0.91).21