Education should be provided to all patients who are undergo-

ing a scheduled cesarean section and should include a component related to skin care before the surgery.8 Recommendations from the Centers for Disease Control and

Prevention and current research state that all patients should shower with an antiseptic soap or use a chlorhexidine wipe the night before surgery; if possible, use an additional chlorhexidine wipe at the surgi- cal site the morning of surgery.9,10

Chlorhexidine works by disrupting

the cell membrane of common organisms, such as Staphylococcus and Lactobacillus, which are often found in cultures of the incision line. It usually works within 20 seconds of application and because it is not removed before surgery, it provides ongoing protection for up to 48 hours.11

ampicillin, which makes them a better choice for surgical proce- dures although the efficacy rate is very similar. Patients without a documented allergy to cephalosporin-based antibiotics should receive the antibiotic based on patient weight within 60 minutes before incision. Most common dosing is 1 g of cefazolin (Ancef) (amount may increase if the patient weighs more than 80 kg or has a BMI greater than 30). If a penicillin or cephalosporin allergy has been documented, the next choice would be a single dose of clindamycin (Cleocin). To reduce the potential for antibiotic resistance, all prophylactic antibiotics should be given as a single dose unless other medical complications arise indicating the need for additional antibiotic support.15

It is not affected by blood or body fluids, which

makes it more stable during surgery. It can be supplied to patients in a premoistened cloth or in a bottle. The patient should be instructed to wash the suprapubic area as directed by the manufacturer. Hair removal before surgery can be conducted by using a clipper,

razor or depilatory cream. Patients should be instructed not to shave or wax the pubic and suprapubic hair for at least 24 hours before surgery. Studies have not identified a definitive time frame in which to refrain from shaving, and no statistical difference was found between removing hair on the day of surgery versus the day before. A Cochrane Review showed that removing hair with a method that creates breaks in the skin, such as waxing or using a razor, should be avoided due to the significant increase in postsurgical infections. Further research needs to be completed to determine the safety of depilatory creams.12 Before the introduction of prophylactic antibiotics, the infection rate following surgical birth was around 3% to 15%.10,13


2002, antibiotics were given primarily only if the patient had a prolonged rupture of membrane or became febrile during labor. After the development of several initiatives, including the Centers for Medicare & Medicaid Services Surgical Care Improvement Project, a significant decrease in postsurgical infections was noted with the use of antibiotic prophylaxis when antibiotics were ad- ministered before incision time. In 2003, The Joint Commission adopted this practice as part of its core measures with the goal of patients’ receiving specific broad-spectrum antibiotics within one hour before incision.2 Although the directive has been to administer antibiotics within

one hour of incision time, studies have failed to show whether the greatest benefit occurred from receiving the antibiotics preincision or at the time of cord clamping. In a randomized control trial, no statistical difference existed in rate of infection between the patient receiving the antibiotics 30 or 60 minutes before incision time or at the time the cord was cut.13

This is most beneficial for patients who

undergo an emergent C-section, when there is not time to administer the antibiotics until the surgery is under way. However, additional randomized trials have indicated that infection rates may be twice as high if the antibiotics are given more than one hour before incision time or after cord clamping.14

The American College of Obstetrics

and Gynecology recommends that the antibiotics be administered before incision to ensure the greatest coverage possible.15 Antibiotic type and dose should be based on the patient’s

allergies, body mass index and concurrent medical conditions, such as premature rupture of membranes with or without labor.15 First-generation cephalosporins have a longer half-life than


Emerging therapies Methicillin-resistant Staphylococcal aureus (MRSA) has been linked directly to serious, soft-tissue infections following surgery. What started as a community-acquired infection has become the most common isolated bacteria in hospital-acquired infections. It is also one of the leading causes of morbidity and mortality. Colonization may occur without subsequent infection, which makes treating the bacteria more of a challenge, as it is not known whether a patient will develop postsurgical complications simply because they are MRSA positive. Recent research supports the use of decolonizing patients with known MRSA before surgery, but screening all patients before surgery or using a decolonization method across the board has not proven to be cost-effective or able to reduce the numbers of postsurgical infections.16 The most common method currently available for decoloniza-

tion of MRSA is the application of topical mupirocin (Bactroban). Mupirocin 2% is an ointment that is applied in the nares for four to seven days before surgery and has shown a 90% decolonization rate at one week post-treatment. However, ongoing studies are beginning to show evidence of mupirocin resistance, which could directly impact organizations that use this medication routinely.16 Other methods, such as povidone-iodine and tea tree oil, have not been proved to be as effective.

The perioperative period During the perioperative period, basic strategies such as good hand hygiene, correct nail care and proper surgical attire can contribute to an environment that supports a decrease in hospital-acquired infections. One study shows hand hygiene has been proven to decrease the transmission of multi-drug resistant organisms by up to 48% and can have a direct impact on the safety of patients.17 Hand hygiene should be performed before entering the surgery suite, following patient contact and after doffing gloves that were used during procedures, such as placing a urinary catheter. Nails should be kept at ¼-inch length or shorter, and extensions, gels, or bonding should not be worn. Regular nail polish may be worn as long as it is not chipped or cracked. Jewelry should not be worn on the hands or wrist as it may create an area where bacteria can hide.18 The Association of periOperative Registered Nurses has created

a practice bulletin regarding surgical attire in the OR that sup- ports the optimal level of practice. Surgical attire should never be laundered at home due to the risk of home water temperatures not reaching levels hot enough to destroy microbes. Personal clothing should not be worn unless it can be hidden under the

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