Infection prevention


Reducing post-Caesarean surgical site infections


Sandra Quinn, Project Lead for Surgical Site Infection Surveillance, at the York and Scarborough Teaching Hospitals NHS Foundation Trust, examines the rise in Caesarean births, why Caesarean section SSIs are common, and considers some measures which could help reduce infection rates.


The latest NHS data shows that, in England, 42% of babies were delivered by Caesarean section (CS)1


, compared to just 9% in 1980.2 One of the


most frequent complications of CS is surgical site infection (SSI); with an estimated incidence of around 16%.3


Post-caesarean SSI potentially


extends the period of hospitalisation by four days, and is estimated to cost an additional £3,173 per patient.4


and it is


estimated that around 60% of SSIs could be prevented.6


While SSIs are common, they


have been described as “the most preventable” healthcare-associated infection,5


Based on reported evidence and


guidelines, measures including skin and wound care may be effective in helping prevent infections.


Caesarean section Caesarean section (CS) is one of the most frequently performed surgical procedures and rates are increasing, not just in the UK but across the world.4


Global CS rates have


escalated from around 7% in 1990 to 21% in 2021 and are projected to continue increasing over the current decade.7


In some countries,


Caesarean births now outnumber vaginal deliveries.7


CS is usually recommended when a vaginal delivery (VD) may pose risks to either the mother, baby, or both. These situations include prolonged or obstructed labour, foetal distress, elevated blood pressure or glucose, multiple pregnancies, or abnormal presentation/ position of the baby among others.8


methods of birth.10 These recommendations are


not mandatory. Several reasons appear to have contributed


to the rise in CS rates. Increased maternal requests may be due to anxiety or fear of pain from VD.8


CS, whether


undertaken as a planned or an emergency procedure, reduces both maternal and neonatal morbidity and mortality significantly.8 Not all Caesarean sections are performed


for purely medical reasons. There has been an increase in planned ‘Maternal Request Caesarean Sections’ (MRCS). Access to MRCS is variable and CS is sometimes viewed as an intervention only reserved for difficult or high- risk births.9 However, it is becoming increasingly


recognised that some women in some situations may prefer a Caesarean rather than a vaginal delivery, in the absence of a clinical need.9 NICE Guidance on Caesarean Birth (2021) recommends that women who request an MRCS should be able to give birth this way, if appropriate. Their reasons for requesting a CS should be discussed and they should be informed about the associated risks of different


Different social‐cultural and religious


reasons have also been found to influence the preferred method of delivery.8


Surgical site infections (SSI) SSI describes wound infections following invasive surgical procedures. They represent a major healthcare burden accounting for 14.5% of all hospital acquired infections in the UK and an estimated 34-226% increase in associated costs.3


They are associated with increased morbidity and mortality,11 yet it is estimated SSIs can be prevented in around 60% of cases.6


Caesarean section surgical site infections Caesarean associated surgical site infection (SSI) may be defined as a surgical wound site infection occurring within 30 days of surgery.12 It is one of the most frequent complications of a Caesarean birth, with an estimated incidence of around 16%.3


to 8.6% for large bowel surgery and 9.7% for cholecystectomy.13 SSI is a significant cause of maternal morbidity and can give rise to more severe complications such as sepsis and necrotising fasciitis.10


on service provision and healthcare costs.12


This is high compared


CS SSI also places an additional burden Most


post-Caesarean SSIs are superficial infections of the skin and subcutaneous tissue which can be managed in the community. However, 10%–13% are more serious deep infections of the muscle and fascial layer or organ/space infections (endometritis and reproductive tract infections) which may require readmission to hospital.2 Most wound infections do not become clinically apparent until 4 to 7 days postoperatively, when most women have already been discharged from hospital. Given the short length of hospital


October 2024 I www.clinicalservicesjournal.com 53


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