Post Caesarean Section Surgical Site Infection: A Literature Review

This literature review provides a comprehensive overview of Caesarean sections (C-sections) and the associated risks, particularly focusing on surgical site infections (SSIs). It explores the increasing rates of C-sections, the various complications involved, and the factors contributing to SSI development, including host-related and host-unrelated factors. The review delves into preoperative, intraoperative, and postoperative strategies for SSI prevention, such as skin preparation, antibiotic prophylaxis, and vaginal preparation. It examines the impact of SSI on patient outcomes, including prolonged hospital stays, increased blood loss, and the potential for readmission. Furthermore, the review discusses the management of SSI, including the use of antibiotics, and analyzes the relationship between SSI and factors like length of labor, rupture of membranes, and overall recovery. The review synthesizes findings from various studies to offer insights into the prevention, management, and implications of SSIs following C-sections, highlighting the need for effective strategies to improve maternal and infant health outcomes. The student's work is available on Desklib, a platform offering study tools and resources for academic success.

Running head: LITERATURE REVIEW
Literature Review
Name of the Student
Name of the University
Author Note

1LITERATURE REVIEW
Background
The concept of the caesarean section (C-section) refers to the method of surgery
during the delivery of a baby and in this process the baby is taken out from the abdomen of
the mother by cutting out the mother’s abdomen. Therefore, it is stated that, a few C-section
surgeries are pre planner and on the other hand in most of the cases this surgery is performed
to manage the emergency situation during the process of delivery (Taha et al. 2019). In this
essay a brief literature review of C-section deliveries is performed.
Review of Literature
Overview of Caesarean sections (cs) and Related Facts
In UAE, the rate of CS has enhanced a lot and it was observed that in the year of 1995
the rate of CS was almost 10 per cent and it touched the amount of 24 per cent in the year of
2014. According to the report of World Health Organization (WHO) it is reported that the
rate of CS in case of all type of live births is almost 10 per cent to 15 per cent that is much
lower than that of the overall CS rate of UAE (Taha et al. 2019). According to the study of
Jasim et al. (2017), it is stated that the consequences of CS is correlated with not only with
the infants but also with the mothers. In this regard it can be stated that the consequences are
mainly associated with problems such as haemorrhage, cystitis, endometritis, respiration
related complications, and hypoglycaemia and it is reported by the researchers that such type
of problems can hamper the breastfeeding practices of the infants. As a result the level of
immunity among the infants is lowered.
Complications of CS
While discussing about the complications of the CS, it can be stated that excessive
bleeding is one of the major problems associated with CS delivery. In this regard it is

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commendable that during the time of active labour almost 20 to 30 per cent of the blood are
supplied to that region and during the CS delivery , the surgeon cuts the uterus and as a result
a huge amount of blood loss is reported (Jido and Garba 2012). In another study by Haas et
al. (2018), it is observed that the amount of blood loss is almost twice in case of CS compared
to normal delivery.
Overview of SSI and Related Risk Factors
Another crucial factor that is associated with the CS among the mothers is the risk of
infection that is Caesarean Surgical Site Infection or SSI. The cases of SSI among the patients
with CS is comparatively higher and in this context, it can be stated that breaching of the skin
or mucosa during the process of CS allows the bacteria and other microbial elements to enter
the blood system and thus the chances of SSI is enhanced among those patients having the
problem of CS (Jalil et al. 2017). According to the study of Zejnullahu et al. (2019), it is
reported that due to CS a wide range of SSI can take place and in most of the cases health
care related infections are reported by the different authors and health care professionals.
Around the world, it is reported that SSI is correlated with the enhanced level of mortality
and morbidity, poor quality of life, prolonged antibiotic treatment. In the study of Jalil et al.
(2017), it is reported that in hospital of Jordan high rate of SSI was found to be very high and
it was detected as 14.4 per cent along with a pregnancy odds ratio (OR) 3.8, 95% confidence
interval (95% CI) 1.6–9.4. In case of patients with more than 3.5 days of hospital stay the OR
was almost 2.3 along with a CI of 1.4-3.6.
Types of CS SSI infection
While discussing about the type of CS infections, it can be stated that there are mainly
two type of CS infection. The first one is host related SSI and the other one is host unrelated
SSI. As a part of host related SSI, the hosts that can create such infection are mainly

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Staphylococcus epidermidis, Escherichia coli, Ureaplasma urealyticum and Enterococcus
faecalis (Jalil et al. 2019).
As per the data, there are mainly three types of SSI and they are Superficial
incisional SSI, Deep incisional SSI and Organ or space SSI. According to the study of
Kawakita and Landy (2017), it is reported that all type of SSI generally occurs within 30 days
of the CS surgery.
Post-discharge surveillance
As a part of the post surveillance strategy for the CS surgery it can be stated that the
main goal is to reduce the risks of infections during post-operative sessions. As a part of this
there are various aspects and they are mainly preoperative, intraoperative, and postoperative
practices. As a part of preoperative strategies, hair removal before the CS surgery can be
applied. According to the study of Zuarez-Easton et al. (2017), it is stated that shaving the
surgical site is highly associated with higher rate of SSI infection compared to clipping due to
microscopic disruptions in the skin caused by the razor. Another preventive measure of post-
operative management of SSI is skin preparation and in a study it was reported that use of
alcohol with chlorhexidine compared to povidone–iodine with alcohol for skin antisepsis has
been proven to be successful in skin preparation before the CS surgery. The use of
chlorhexidine–alcohol caused in an expressively lesser risk of complete SSI (4.0%) after CS
compared to iodine–alcohol (7.3%).
Vaginal Preparation
The vaginal preparation is one of the management of part of SSI following CS.
Therefore, it can be stated that it is one of the most crucial post-surgery management
technique of those who have undergone the process of CS (Haas et al. 2014). In the study of

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Haas et al. (2014), it is reported that vaginal preparation along with povidone–iodine solution
before starting the cesarean section lowered the chances of postcesarean endometritis from
7.2 per cent to 3.6 per cent along with risk ratio of 0.39 and confidence interval of 95 per
cent (RR: 0.39, 95% CI: 0.16–0.97), predominantly among the women with the problem of
ruptured membranes along with a risk ratio of 0.13 and confidence interval of 95 per cent
(from 15.4% to 1.4%; RR: 0.13; 95% CI: 0.02–0.66). However, no significant differences
were reported by the researchers regarding postoperative fever and wound infection.
Management of SSI
In the study of Jasim et al. (2017) the management of the SSI infection during post
opearative condition of CS surgery was described in a brief manner. The main aim of this
study is to determine the incidence and risk factors of SSI during post CS surgery among the
patients. In this regard, it can be stated that a cases of wound infection not only consequences
in higher morbidity but also associated with far-reaching consequences by causing pelvic
organ infection, disruption of the bonding procedure between baby and mother in the
puerperium, and along with this a extended hospital stays are reported along with intrinsic
problems in mother and children. In this retrospective cross sectional study, almost 400
women were included and all of them had undergone cesarean section procedures from
January 2013 to June 2014 (an 18-month period) at Hospital Pulau Pinang, Malaysia (Jasim
et al. 2017). In this study a few risk factors of SSI during post CS surgery was reported and
the authors reported that the main risk factors of SSI during post CS surgery are case-mix
issues present in the surgical patient population such as type of CS (elective vs emergency),
age, and patient care procedures such as antibiotic prophylaxis. In most of the cases, it is
reported that SSI occurs in those places that have undergone the process of surgery. On the
other hand, in some cases superficial infections are also reported by the patients and in those
cases mainly a few areas of skin infections are reported by the researchers as well (Corcoran

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et al. 2013). Other types of SSIs are more severe and may include organs, tissues under the
skin, or fixed materials in the body (Jasim et al. 2017).
As a part of SSI management in the post-operative stage of the surgery, it can be
stated that the use of antibiotic prophylaxis is very crucial and in most of the cases the
application of this antibiotic is reported by the various authors in multiple studies around the
world. In this regard, the study of Swank et al. (2015), can be mentioned. In this study by
Swank et al. (2015), the application of this antibiotic was reported and along with this the
effectiveness of this antibiotic application were reported by the authors. It is observed in this
study that the application of antibiotic prophylaxis is associated with the reduction of post-
operative SSI infection among the patients along with a risk ratio of 0.40 and confidence
interval of 95 per cent (RR: 0.40, 95% CI: 0.35–0.46). Not only this, but the chances of
endometritis was also reduced along with a risk ratio of 0.38 and confidence interval of 95
per cent. (RR: 0.38, 95% CI: 0.34–0.42). Furthermore, the cases of maternal severe infectious
problems were also reduced due to the application of antibiotic prophylaxis along with a risk
ratio of 0.31 and confidence interval of 95 per cent (RR: 0.31, 95% CI: 0.20–0.49). Another
crucial tool of management of SSI after CS is use of Cephalosporins and penicillins and they
also showed effectiveness in management of SSI during post SSI surgery (Swank et al. 2015).
According to the study of Jasim et al. (2017) reported about the use of ampicillin and
sodium/sulbactam sodium as a part of the preventive measures during the post- operative
stage of CS surgery. During this process, it is reported by the authors that the abdomen is
washed carefully by disinfectant to reduce the bacteria present on the skin and it will help in
the reduction of infection cases during the post delivery period (Dhar et al. 2014).

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Length of Labour following CS SSI
In another study by Jido and Garba (2012), it is reported that the length of labour
following CS SSI was reported to be enhanced along with a longer operation time and huge
amount of blood loss among the patients. In this study, the maternity record of all the patients
admitted in Aminu Kano Teaching Hospital between 1st January 2001 and 31st December
2002 were studied by the researchers.
Post-operative stay following CS SSI
The study result showed that the hospital stay days were enhanced among the patients
who had undergone CS SSI. In case of the controls, the mean hospital stay days were almost
6.3±0.5 days and in case of the post-operative patients the mean hospital stay days were
almost 16.6±7.5 days (P<0.001). Moreover, the patients of the case groups were more
amount of blood loss during the surgery and the prolonged labour time was also reported by
the patients (Mackeen et al. 2014). Among all the patients, it was observed that CS obstructed
labor/failure in the development process in 86 patients that is almost 17.7 per cent of total
patients among those patients 13 patients had wound infection that is almost 15.1 per cent of
the total infected people (Jido and Garba 2012).
Rupture of membrane (ROM) following CS SSI
The rate of wound infection in this group was almost 27.8 per cent overall and 60 per
cent among these patients reported about retained second twin. Equally, 5 out of the 7
patients in whom CS was preceded by pre-labor rupture of membranes (PROM) had infection
in their wound region. Among them, almost 19 patients had CS due to fetal distress and only
3 had (that is 15.7 per cent of them) wound infection. On the contrary, only 1 out of 9 patients
along with long pregnancy had the problem of infection and any cases with antepartum

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haemorrhage were reported by the patients as well. Moreover, it was reported that almost 17
patients had the problem of failed instrumental delivery (Jido and Garba 2012).
Conclusion
Therefore, it can be concluded that the issue of post CS surgery and related SSI
among the patients are very crucial as it is highly correlated with the various other problems
and thereby enhances the chances of SSI, prolonged hospital stays, labour time among the
patients. Therefore, in order to prevent such severe consequences among the patients during
post CS period proper management of this condition is very important.

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References
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2013. Surgical site infection after cesarean section: implementing 3 changes to improve the
quality of patient care. American journal of infection control, 41(12), pp.1258-1263.
Dhar, H., Al-Busaidi, I., Rathi, B., Nimre, E.A., Sachdeva, V. and Hamdi, I., 2014. A study
of post-caesarean section wound infections in a regional referral hospital, Oman. Sultan
Qaboos University Medical Journal, 14(2), p.e211.
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Haas, D.M., Morgan, S., Contreras, K. and Enders, S., 2018. Vaginal preparation with
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Jalil, M.H.A., Hammour, K.A., Alsous, M., Awad, W., Hadadden, R., Bakri, F. and Fram, K.,
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Nigeria. Annals of medical and health sciences research, 2(1), pp.33-36.

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