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Impact of evidence-based interventions on wound complications after cesarean delivery.

ABSTRACT: BACKGROUND:A number of evidence-based interventions have been proposed to reduce post-cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ?2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. OBJECTIVE:We sought to estimate the impact of a group of evidence-based surgical measures (prophylactic antibiotics administered before skin incision, chlorhexidine-alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean delivery and to estimate residual risk factors for wound complications. STUDY DESIGN:We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine-alcohol vs iodine-alcohol for skin antisepsis at cesarean delivery from 2011-2015. The primary outcome for this analysis was a composite of wound complications that included surgical site infection, cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all 4 evidence-based measures (prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision, chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision, closure of subcutaneous layer if ?2 cm of depth, and subcuticular skin closure with suture) were compared with those women who did not. We performed logistic regression analysis limited to patients who received all the evidence-based measures to estimate residual risk factors for wound complications and surgical site infection. RESULTS:Of 1082 patients with follow-up data, 349 (32.3%) received all the evidence-based measures, and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence-based measures compared with those who did not (20.3% vs 28.1%; adjusted relative risk, 0.75; 95% confidence interval, 0.58-0.95). The impact appeared to be driven largely by a reduction in surgical site infections. Among patients who received all the evidence-based measures, unscheduled cesarean delivery was the only significant risk factor for wound complications (27.5% vs 16.1%; adjusted relative risk, 1.71; 95% confidence interval, 1.12-2.47) and surgical site infection (6.9% vs 1.6%; relative risk, 3.74; 95% confidence interval, 1.18-11.92). Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significant among patients who received all of the 4 evidence-based measures. CONCLUSION:Implementation of evidence-based measures significantly reduces wound complications, but the residual risk remains high, which suggests the need for additional interventions, especially in patients who undergo unscheduled cesarean deliveries, who are at risk for wound complications even after receiving current evidence-based measures.

SUBMITTER: Temming LA

PROVIDER: S-EPMC5614824 | biostudies-literature | 2017 Oct

REPOSITORIES: biostudies-literature

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Impact of evidence-based interventions on wound complications after cesarean delivery.

Temming Lorene A LA Raghuraman Nandini N Carter Ebony B EB Stout Molly J MJ Rampersad Roxane M RM Macones George A GA Cahill Alison G AG Tuuli Methodius G MG

American journal of obstetrics and gynecology 20170608 4

<h4>Background</h4>A number of evidence-based interventions have been proposed to reduce post-cesarean delivery wound complications. Examples of such interventions include appropriate timing of preoperative antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear.<h4>Objective</h4>We sought to estimate the impact o ...[more]

PMID: 28601567

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Project description:ImportanceIn recent decades, the global rates of cesarean delivery have rapidly increased. Nonetheless, the influence of cesarean deliveries on surgical complications later in life has been understudied.ObjectiveTo investigate whether previous cesarean delivery increases the risk of reoperation, perioperative and postoperative complications, and blood transfusion when undergoing a hysterectomy later in life.Design, setting, and participantsThis registry-based cohort study used data from Danish nationwide registers on all women who gave birth for the first time between January 1, 1993, and December 31, 2012, and underwent a benign, nongravid hysterectomy between January 1, 1996, and December 31, 2012. The dates of this analysis were February 1 to June 30, 2016.ExposureCesarean delivery.Main outcomes and measuresReoperation, perioperative and postoperative complications, and blood transfusion within 30 days of a hysterectomy.ResultsOf the 7685 women (mean [SD] age, 40.0 [5.3] years) who met the inclusion criteria, 5267 (68.5%) had no previous cesarean delivery, 1694 (22.0%) had 1 cesarean delivery, and 724 (9.4%) had 2 or more cesarean deliveries. Among the 7685 included women, 3714 (48.3%) had an abdominal hysterectomy, 2513 (32.7%) had a vaginal hysterectomy, and 1458 (19.0%) had a laparoscopic hysterectomy. In total, 388 women (5.0%) had a reoperation within 30 days after a hysterectomy. Compared with women having vaginal deliveries, fully adjusted multivariable analysis showed that the adjusted odds ratio of reoperation for women having 1 previous cesarean delivery was 1.31 (95% CI, 1.03-1.68), and the adjusted odds ratio was 1.35 (95% CI, 0.96-1.91) for women having 2 or more cesarean deliveries. Perioperative and postoperative complications were reported in 934 women (12.2%) and were more frequent in women with previous cesarean deliveries, with adjusted odds ratios of 1.16 (95% CI, 0.98-1.37) for 1 cesarean delivery and 1.30 (95% CI, 1.02-1.65) for 2 or more cesarean deliveries. Blood transfusion was administered to 195 women (2.5%). Women having 2 or more cesarean deliveries had an adjusted odds ratio for receiving blood transfusion of 1.93 (95% CI, 1.21-3.07) compared with women having no previous cesarean delivery.Conclusions and relevanceWomen with at least 1 previous cesarean delivery face an increased risk of complications when undergoing a hysterectomy later in life. The results support policies and clinical efforts to prevent cesarean deliveries that are not medically indicated.

Project description:BACKGROUND:To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates. METHODS:We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. One reviewer extracted data and a second reviewer verified for accuracy. Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). RESULTS:Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Methodological quality was good overall for the trials; however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence. CONCLUSIONS:This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD.

Project description:BackgroundPotentially preventable complications are monitored as part of the Maryland Hospital Acquired Conditions Program and are used to adjust hospital reimbursement. Few studies have evaluated racial-ethnic disparities in potentially preventable complications. Our study objective was to explore whether racial-ethnic disparities in potentially preventable complications after Cesarean delivery exist in Maryland.MethodsWe performed a retrospective observational cohort study using data from the Maryland Health Services Cost Review Commission database. All patients having Cesarean delivery, who had race-ethnicity data between fiscal years 2016 and 2020 were included. Multivariable logistic regression modeling was performed to estimate risk-adjusted odds of having a potentially preventable complication in patients of different race-ethnicity.ResultsThere were 101,608 patients who had Cesarean delivery in 33 hospitals during the study period and met study inclusion criteria. Among them, 1,772 patients (1.7%), experienced at least one potentially preventable complication. Patients who had a potentially preventable complication were older, had higher admission severity of illness, and had more government insurance. They also had more chronic hypertension and pre-eclampsia (both P<0.001). Median length of hospital stay was longer in patients who had a potentially preventable complications (4 days vs. 3 days, P<0.001) and median hospital charges were approximately $4,600 dollars higher, (P<0.001). The odds of having a potential preventable complication differed significantly by race-ethnicity group (P=0.05). Hispanic patients and Non-Hispanic Black patients had higher risk-adjusted odds of having a potentially preventable complication compared to Non-Hispanic White patients, OR=1.26 (95% CI=1.05 to 1.52) and OR=1.17 (95% CI=1.03 to 1.33) respectively.ConclusionsIn Maryland a small percentage of patients undergoing Cesarean delivery experienced a potentially preventable complication with Hispanic and Non-Hispanic Black patients disproportionately impacted. Continued efforts are needed to reduce potentially preventable complications and obstetric disparities in Maryland.

Project description:ObjectivesTo evaluate the influence of myoma characteristics on cesarean myomectomy and to demonstrate its additional advantages.MethodsRetrospective data were collected from 292 women with myomas who had undergone cesarean section at Kangnam Sacred Heart Hospital between 2007 and 2019. We performed subgroup analysis according to the type, weight, number, and size of myomas. Preoperative and postoperative hemoglobin levels, operative time, estimated blood loss, length of hospital stay, incidence of transfusion, uterine artery embolization, ligation, hysterectomy, and postoperative complications were compared among subgroups.ResultsThere were 119 patients who had cesarean myomectomy and 173 who had cesarean section only. An increase in postoperative hospitalization and operation time was observed in the cesarean myomectomy group compared to that in the caesarean section only group (mean difference, 0.7 days, p = 0.01, 13.5 minutes, p <0.001). Estimated blood loss, hemoglobin differences, and transfusion rates were higher in the cesarean myomectomy than in the cesarean section only group. There were no differences in postoperative complications (fever, bladder injury, and ileus) between the two groups. No hysterectomy cases were reported in the cesarean myomectomy group. In subgroup analysis, the larger and heavier the myoma, the higher the risk of bleeding that led to transfusion. Estimated blood loss, differences in hemoglobin, and transfusion rate increased depending on myoma size and weight. A significant increase in postoperative hospitalization was observed in women with larger and heavier myomas. However, there was no statistical difference among the three types of myomas.ConclusionIn cesarean myomectomy, larger (≥ 10 cm), and heavier myomas (≥ 500 g), were associated with postoperative outcomes, but not the number or type of myoma. The safety of cesarean myomectomy is not inferior to that of caesarean section only, considering its positive effects such as gynecological symptom relief and avoidance of the next surgery.

Project description:Background: Among contemporary human populations, rates of cesarean delivery vary substantially, making it difficult to know if the procedure is inadequately available, or used excessively relative to medical need. A much-cited evolutionary hypothesis attributed birth complications to an "obstetric dilemma," resulting from antagonistic selective pressures acting on maternal pelvic dimensions and fetal brain growth during hominin evolution. However, the childbirth challenges experienced by living humans may not be representative of those in the past, and may vary in association with trends in ecological conditions. We hypothesized that variability in maternal phenotype (height and nutritional status) may contribute to the risk of cesarean delivery. In many populations, high levels of child stunting contribute to a high frequency of short adult stature, while obesity is also becoming more common. The combination of short maternal stature and maternal overweight or obesity may substantially increase the risk of cesarean delivery. Methods: Using data from two large Indian health surveys from 2005-6 to 2015-2016, we tested associations of maternal somatic phenotype (short stature, overweight) with the risk of cesarean delivery, adjusting for confounding factors such as maternal age, birth order, rural/urban location, wealth and offspring sex. Results: Secular trends in maternal body mass index between surveys were greater than trends in height. Maternal short stature and overweight both increased the risk of cesarean delivery, most strongly when jointly present within individual women. These associations were independent of birth order, wealth, maternal age and rural/urban location. Secular trends in maternal phenotype explained 18% of the increase in cesarean rate over 10 years. Conclusion: Our results highlight how the emerging dual burden of malnutrition (persisting short adult stature which reflects persistent child stunting; increasing overweight in adults) is likely to impact childbirth in low and middle-income countries.

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Impact of evidence-based interventions on wound complications after cesarean delivery.

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Impact of evidence-based interventions on wound complications after cesarean delivery.

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