After years of decline, rates of cesarean deliveries (CDs) in the US increased to 32% of all births in 2017.[1] As a result, over a million mothers in the US are sent home from the hospital every year nurturing a newborn infant while simultaneously recovering from major surgery.
This is of particular concern in the US, where the average maternity leave is just 10 weeks.[2] Cesarean delivery is an invasive procedure that requires a substantially longer healing process than vaginal delivery, and a mother’s limited time is undoubtedly best-spent bonding with her newborn and healing.
Mother‐Baby Care Practice
We know that post‐CD care needs for the mother are both physical and emotional. The postpartum period can leave any new mother feeling overwhelmed and drained, particularly those who have had CDs.[3] These feelings can be particularly acute if the CD was due to an emergency or if the mother has negative feelings about her experience, necessitating time to decompress emotionally to enable the mother to best care for her newborn.[3]
In terms of her physical care, it must be recognized that CD is major surgery, and the mother’s activity will be limited once she transitions home from the hospital, typically for a period of 4 to 6 weeks. These recommendations include [4]:
- Avoid lifting heavy objects (“don’t lift anything heavier than the baby”)
- Taking care getting around and avoiding going up and down stairs as much as possible (changing stations and feeding supplies should be close‐at‐hand)
- Holding abdomen to protect the incision when sneezing or coughing
- Avoiding exercise until healthcare provider approves
- Monitoring the incision for signs of infection[5]
CD surgical site infections
Unfortunately, surgical site infections (SSIs) are a not particularly rare event after a CD. They occur in approximately 12% of CDs in the US, adding up to 136,000 CD‐related SSIs every year.[6] Numerous factors have been identified that increase the risk of post‐CD SSI, including[5]:
- Obesity
- Diabetes
- Chorioamnionitis
- Long‐term steroid use
- Poor prenatal care
- Previous CDs
- Lack of cautionary antibiotics or pre‐incision antimicrobial care
- A long labor or surgery
- Excessive blood loss during surgery
Post CD‐SSIs typically develop 4‐7 days after delivery, although some develop within 48 hours.[7] The first signs and symptoms usually manifest as redness, swelling and tenderness at the incision site, accompanied by lower abdominal pain and fever.[5] It is critically important to monitor the incision for signs of redness and swelling, as wound appearance is one of the first signs of infection.[5]
Consequences for mother and baby
It’s important to remember that post CD‐SSIs impact two people: both the mother and her newborn. Serious complications associated with post CD‐SSIs can include[5]:
- Necrotizing fasciitis
- Ruptured fascia or wound dehiscence
- Evisceration
Should these occur, hospital readmission for IV antibiotics and surgical intervention may be necessary, resulting in a separation of mother and baby that can interrupt critical bonding time.6 Additionally, antibiotics prescribed for the infection can potentially impact breastfeeding.
Preventing SSI: a primary US healthcare priority
The US healthcare industry has prioritized SSI prevention as reimbursements for hospitals to treat SSIs are being reduced or denied. In fact, in 2006 the Centers for Medicare & Medicaid Services (CMS) began basing hospital reimbursement, in part, on patient satisfaction scores.[8] The results of a recent patient survey indicate that SSI was, by far, the greatest concern of any potential surgical complication.[8] Preventing CD‐related SSIs is arguably of heightened importance, as they can have a significant impact on two people – mother and baby.
A recent meta‐analysis revealed a 67% reduction in CD‐related SSI associated with implementation of at least 3 evidenced‐based surgical bundle interventions. While no 2 studies analyzed used identical bundles, the majority included antibiotic prophylaxis, chlorhexidine (CHG) skin preparation, hair clipping rather than shaving, and removing the placenta with gentle traction.[6]
A 2015 study described the experience of one large center in the US (performing on average ~1,000 CDs per year) after implementing sequential changes in practice over a 5‐year period to prevent CD‐related SSIs. Numerous evidence‐based measures were implemented pre‐, intra‐ and post‐operatively[9]:
Pre‐operative measures
- Patients were taught hygiene and basic infection prevention strategies and were asked notto wear makeup or jewelry, which can harbor bacteria
- Hair was removed via clipping, not shaving
- Pre‐operative showers were implemented
- CHG wipes, rather than povidone‐iodine, were used to prep the incision site
Intra‐operative measures
- Extra care was taken when removing drapes
- Sutures rather than staples were used on fat layers > 2cm
Post‐operative measures
- Dressings were changed on day 3 unless required earlier due to saturation
- Staples were removed on day 7 – 10, not at discharge
- Patients were separated into a low‐ and high‐risk categories based mainly on the criteriacited above, and post‐op dressing bundles were developed for each group. Among other measures, both groups received anti‐microbial surgical barrier dressings.
As a result of these interventions, over 5‐years the rate of CD‐related SSI at this center decreased from 2.13% to 0.10% (p<0.0001), resulting in an estimated 92 prevented infections and a total cost savings of nearly $5,000,000.
The potential benefits of a CHG‐impregnated, transparent, waterproof surgical dressing for CDs are clear:
- CHG can provide significant reduction of gram negative and gram positive bacteria and yeast forup to 7 days
- Transparency allows visual inspection of incision without removing the dressing, facilitating SSI monitoring
The data show that sustainable, substantial reductions in CD‐related SSI are possible. Is your institution doing all it can to reduce rates of post‐CD SSIs?
Eloquest Healthcare is committed to providing solutions that can help you reduce the risk of conditions like CD‐related SSI. For more information, please contact your sales consultant or Eloquest Healthcare®, Inc., call 1‐877‐433‐7626 or visit www.eloquesthealthcare.com.
References
1. Births: Final data for 2017. National Vital Statistics Reports. 2018;67:1‐49. 2. How Long is the Average Maternity Leave? Maternity leave is a time for bonding with baby. The Balance Website. https://www.thebalance.com/how‐long‐is‐the‐average‐ maternity‐leave‐4590252. Accessed April 29, 2019. 3. Cesarean birth after care. American Pregnancy Association Website. https://americanpregnancy.org/labor‐and‐birth/cesarean‐aftercare/. Accessed April 29, 2019. 4. Watson S. C‐Section: Tips for a fast recovery. Healthline Newsletter Website. https://www.healthline.com/health/pregnancy/c‐section‐tips‐for‐fast‐ recovery#rest. Accessed May 7, 2019. 5. Wilson DR. Post‐cesarean wound infection: How did this happen? Healthline Newsletter Website. https://www.healthline.com/health/pregnancy/post‐cesarean‐wound‐infection. Accessed April 30, 2019. 6. Carter EB, Temming LA, Fowler S et al. Evidence‐based bundles and Cesarean delivery surgical site infections. A systematic review and meta‐analysis. Obstet Gynecol. 2017;130:735‐46. 7. Kawakita T, Landy HJ. Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Maternal Health, Neonatology and Perinatology. 2017;3:12. DOI 10.1186/s40748‐017‐0051‐3 8. Barnes S. Smith L. What is a C‐section? Medical News Today Website. https://www.medicalnewstoday.com/articles/299502.php. Accessed April 29, 2019. Erickson M, Dumoneaux P. Reduction of surgical site infections after Cesarean. AWHONN poster 2017. 9. Hickson E. Harris J. Brett D. A journey to zero: reduction of post‐operative surgical site infections over a five‐year period. Surgical Infections.
2015;16. DOI: 10.1089/sur.2014.145
