NIHR Signal Vaginal cleansing before caesarean delivery reduces risk of infections

Published on 31 October 2017

Cleaning the vagina with an antiseptic solution before a caesarean delivery halves the risk of subsequent womb infection. This evidence applies mainly to women who are having a caesarean delivery when already in labour or if their waters have broken.

Womb infections can occur up to six weeks after giving birth and are more common after caesarean delivery. Symptoms include fever, pain and increased vaginal discharge.

This review included 4,837 women who had a planned or unplanned caesarean delivery. It provides evidence of the benefits of this simple, low-cost procedure. Though it is not yet recommended in UK guidance, in theory it could prevent serious illness and future fertility problems secondary to infection.

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Why was this study needed?

A womb infection (postpartum endometritis) occurs after about 27% of caesarean deliveries. This is five to 20 times more common than after vaginal delivery. There are about 167,000 planned and emergency caesarean deliveries each year in English NHS hospitals.

Womb infections are often caused by vaginal bacteria that migrate to the womb. These infections need prompt antibiotic treatment to avoid sepsis, complications of the reproductive system and future fertility problems. Genital and urinary tract infections caused seven out of 200 pregnancy-related deaths in 2012 to 2014, in the UK. Less serious infections and fever can also disrupt the early days after birth, interfering with bonding and affecting the wellbeing of mother and child.

Previous evidence suggests that cleaning the vagina with a povidone-iodine antiseptic solution before caesarean delivery may reduce the risk of post-operative womb infection. However, uptake of this procedure has been sporadic. Seven further trials have been done since a Cochrane review was published in 2014. This previous review pooled fewer data from 1,766 women in five trials.

This review aimed to assess the efficacy of vaginal cleansing before caesarean delivery in preventing postoperative womb infections.

What did this study do?

This systematic review identified 16 randomised controlled trials involving 4,837 women undergoing a caesarean delivery.

Trials compared rates of postoperative womb infection. The vagina was cleansed with a topical antiseptic solution, usually povidone-iodine 10%, using a sponge, wipe or douche, for at least 30 seconds just before surgery. Women in the control group received a placebo or no cleansing.

Other outcomes included wound infection and fever above 38°C. All trials used prophylactic antibiotics because this is standard care. Participants with known allergies were excluded.

Nine of the sixteen trials took place in low or middle-income countries, and seven were based in the US. None was from the UK, so rates of infection after caesarean delivery here may differ. Risk of bias was low, suggesting we can be reasonably confident in the findings.

What did it find?

  • Post-operative womb infection occurred in 4.5% of women who had vaginal cleansing compared with 8.8% in the control group (risk ratio [RR] 0.52, 95% confidence interval [CI] 0.37 to 0.72; 15 trials, 4,726 women).
  • The risk of postoperative fever was reduced in women who had vaginal cleansing with 9.4% of women developing fever compared to 14.9% in the control group (RR 0.65, 95% CI 0.50 to 0.86; 11 trials, 4,098 women).
  • A subgroup analysis found that 8.1% of women in labour when the decision to deliver by caesarean delivery was made, were likely to have a post-caesarean infection if they received vaginal cleansing. This compared with 13.8% of those who didn’t receive cleansing (RR 0.52, 95% CI 0.28 to 0.97; 4 trials, 440 women). There was no significant difference between the intervention and the control groups in those who were not in labour at the time of caesarean delivery.
  • A subgroup analysis found that 4.3% of women whose waters had broken were likely to have a post-caesarean infection if they received vaginal cleansing, compared with 20.1% of the control group (RR 0.23, 95% CI 0.10 to 0.52; 3 trials, 272 women). There was no significant difference seen between the intervention and the control groups in those whose waters hadn’t broken.
  • One small study (93 participants) compared two different antiseptic solutions. It found no statistically significant difference between womb infection rates after caesarean with the use of povidone-iodine compared with chlorhexidine.

Benefits of vaginal cleansing before caesarean delivery

What does current guidance say on this issue?

NICE guidance in 2011 recommends offering women prophylactic antibiotics at caesarean delivery before skin incision to reduce the risk of infection. It does not mention the use of vaginal cleansing to prevent infection after caesarean delivery.

The World Health Organization recommends using vaginal cleansing with povidone-iodine immediately before caesarean delivery.

What are the implications?

This review suggests that antiseptic preparation of the vagina is an effective method of reducing morbidity after caesarean delivery.

The World Health Organization already recommends this prophylactic procedure. It is a simple, low-cost intervention that requires minimal additional training. This evidence could inform future guidance in the UK.

Along with protocols of when and how the intervention should be delivered for the higher risk groups, it would be helpful to have better evidence on whether there are clear benefits for women not in labour or who have already broken their waters.

Citation and Funding

Caissutti C, Saccone G, Zullo F, et al. Vaginal cleansing before cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol. 2017;130(3):527-38.

No funding information was provided for this study.

Bibliography

Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014;9:CD007892.

NICE. Caesarean section. CG132. London: National Institute for Health and Care Excellence; 2011 (updated 2012).

Patient. Postpartum endometritis. Leeds: Patient; 2017.

The Maternal, Newborn and Infant Clinical Outcome Review Programme. Saving Lives, Improving Mothers’ Care. Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14. Oxford: The Maternal, Newborn and Infant Clinical Outcome Review Programme; 2016.

WHO. WHO recommendations for prevention and treatment of maternal peripartum infections. Geneva: World Health Organization; 2015.

Why was this study needed?

A womb infection (postpartum endometritis) occurs after about 27% of caesarean deliveries. This is five to 20 times more common than after vaginal delivery. There are about 167,000 planned and emergency caesarean deliveries each year in English NHS hospitals.

Womb infections are often caused by vaginal bacteria that migrate to the womb. These infections need prompt antibiotic treatment to avoid sepsis, complications of the reproductive system and future fertility problems. Genital and urinary tract infections caused seven out of 200 pregnancy-related deaths in 2012 to 2014, in the UK. Less serious infections and fever can also disrupt the early days after birth, interfering with bonding and affecting the wellbeing of mother and child.

Previous evidence suggests that cleaning the vagina with a povidone-iodine antiseptic solution before caesarean delivery may reduce the risk of post-operative womb infection. However, uptake of this procedure has been sporadic. Seven further trials have been done since a Cochrane review was published in 2014. This previous review pooled fewer data from 1,766 women in five trials.

This review aimed to assess the efficacy of vaginal cleansing before caesarean delivery in preventing postoperative womb infections.

What did this study do?

This systematic review identified 16 randomised controlled trials involving 4,837 women undergoing a caesarean delivery.

Trials compared rates of postoperative womb infection. The vagina was cleansed with a topical antiseptic solution, usually povidone-iodine 10%, using a sponge, wipe or douche, for at least 30 seconds just before surgery. Women in the control group received a placebo or no cleansing.

Other outcomes included wound infection and fever above 38°C. All trials used prophylactic antibiotics because this is standard care. Participants with known allergies were excluded.

Nine of the sixteen trials took place in low or middle-income countries, and seven were based in the US. None was from the UK, so rates of infection after caesarean delivery here may differ. Risk of bias was low, suggesting we can be reasonably confident in the findings.

What did it find?

  • Post-operative womb infection occurred in 4.5% of women who had vaginal cleansing compared with 8.8% in the control group (risk ratio [RR] 0.52, 95% confidence interval [CI] 0.37 to 0.72; 15 trials, 4,726 women).
  • The risk of postoperative fever was reduced in women who had vaginal cleansing with 9.4% of women developing fever compared to 14.9% in the control group (RR 0.65, 95% CI 0.50 to 0.86; 11 trials, 4,098 women).
  • A subgroup analysis found that 8.1% of women in labour when the decision to deliver by caesarean delivery was made, were likely to have a post-caesarean infection if they received vaginal cleansing. This compared with 13.8% of those who didn’t receive cleansing (RR 0.52, 95% CI 0.28 to 0.97; 4 trials, 440 women). There was no significant difference between the intervention and the control groups in those who were not in labour at the time of caesarean delivery.
  • A subgroup analysis found that 4.3% of women whose waters had broken were likely to have a post-caesarean infection if they received vaginal cleansing, compared with 20.1% of the control group (RR 0.23, 95% CI 0.10 to 0.52; 3 trials, 272 women). There was no significant difference seen between the intervention and the control groups in those whose waters hadn’t broken.
  • One small study (93 participants) compared two different antiseptic solutions. It found no statistically significant difference between womb infection rates after caesarean with the use of povidone-iodine compared with chlorhexidine.

Benefits of vaginal cleansing before caesarean delivery

What does current guidance say on this issue?

NICE guidance in 2011 recommends offering women prophylactic antibiotics at caesarean delivery before skin incision to reduce the risk of infection. It does not mention the use of vaginal cleansing to prevent infection after caesarean delivery.

The World Health Organization recommends using vaginal cleansing with povidone-iodine immediately before caesarean delivery.

What are the implications?

This review suggests that antiseptic preparation of the vagina is an effective method of reducing morbidity after caesarean delivery.

The World Health Organization already recommends this prophylactic procedure. It is a simple, low-cost intervention that requires minimal additional training. This evidence could inform future guidance in the UK.

Along with protocols of when and how the intervention should be delivered for the higher risk groups, it would be helpful to have better evidence on whether there are clear benefits for women not in labour or who have already broken their waters.

Citation and Funding

Caissutti C, Saccone G, Zullo F, et al. Vaginal cleansing before cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol. 2017;130(3):527-38.

No funding information was provided for this study.

Bibliography

Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014;9:CD007892.

NICE. Caesarean section. CG132. London: National Institute for Health and Care Excellence; 2011 (updated 2012).

Patient. Postpartum endometritis. Leeds: Patient; 2017.

The Maternal, Newborn and Infant Clinical Outcome Review Programme. Saving Lives, Improving Mothers’ Care. Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14. Oxford: The Maternal, Newborn and Infant Clinical Outcome Review Programme; 2016.

WHO. WHO recommendations for prevention and treatment of maternal peripartum infections. Geneva: World Health Organization; 2015.

Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis

Published on 11 August 2017

Caissutti, C.,Saccone, G.,Zullo, F.,Quist-Nelson, J.,Felder, L.,Ciardulli, A.,Berghella, V.

Obstet Gynecol , 2017

OBJECTIVE: To assess the efficacy of vaginal cleansing before cesarean delivery in reducing postoperative endometritis. DATA SOURCES: MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library were searched from their inception to January 2017. METHODS OF STUDY SELECTION: Selection criteria included all randomized controlled trials comparing vaginal cleansing (ie, intervention group) with a control group (ie, either placebo or no intervention) in women undergoing cesarean delivery. Any method of vaginal cleansing with any type of antiseptic solution was included. The primary outcome was the incidence of endometritis. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% CI. TABULATION, INTEGRATION, AND RESULTS: Sixteen trials (4,837 women) on vaginal cleansing immediately before cesarean delivery were identified as relevant and included in the review. In most of the included studies, 10% povidone-iodine was used as an intervention. The most common way to perform the vaginal cleansing was the use of a sponge stick for approximately 30 seconds. Women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% compared with 8.8%; RR 0.52, 95% CI 0.37-0.72; 15 studies, 4,726 participants) and of postoperative fever (9.4% compared with 14.9%; RR 0.65, 95% CI 0.50-0.86; 11 studies, 4,098 participants) compared with the control group. In the planned subgroup analyses, the reduction in the incidence of endometritis with vaginal cleansing was limited to women in labor before cesarean delivery (8.1% compared with 13.8%; RR 0.52, 95% CI 0.28-0.97; four studies, 440 participants) or those with ruptured membranes (4.3% compared with 20.1%; RR 0.23, 95% CI 0.10-0.52; three studies, 272 participants). CONCLUSION: Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. Because it is generally inexpensive and a simple intervention, we recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds. More data are needed to assess whether this intervention may be also useful for cesarean deliveries performed in women not in labor and for those without ruptured membranes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO International prospective register of systematic reviews, https://www.crd.york.ac.uk/PROSPERO/, CRD42017054843.

Expert commentary

This meta-analysis of vaginal cleansing before caesarean delivery demonstrates a reduced incidence of post-operative endometritis or fever. The effect was greatest after a caesarean section was conducted for women already in labour. Women developed endometritis in 8.1% of treated cases compared to 13.8% in the control group. With prior ruptured membranes, the improvement was even greater – 4.3% compared to 20.1%.

The commonest intervention was with a vaginal application of povidone-iodine 10% for 30 seconds or longer. Notably, one study of povidone-iodine versus chlorhexidine showed no difference.

This report should lead to a change in practice with all women having a caesarean section in labour or with ruptured membranes receiving vaginal cleansing pre-op. Cleansing should probably use povidone-iodine. Further studies might compare this preparation to other antiseptics.

Dr Malcolm Griffiths, Obstetrician and Gynaecologist, Luton and Dunstable Hospital