Infection prevention


stay, the overall rate of SSI following Caesarean section could be significantly higher, as it has been documented that 91% of SSIs occur after discharge from hospital.14


Also, there is no


reporting system for post-Caesarean SSIs, so data may be difficult to locate.


Potential risk factors for CS SSI A high BMI,15,16


existing Type 1 diabetes),15 emergency CS,16


diabetes (gestational or pre- smoking and an


have been identified as potential


risk factors for post CS SSI. A high BMI (≥ 35 kg/ m2


) at the first assessment appears to be the strongest predictor of post CS SSI.16


This risk is


accentuated among smokers with a high BMI,16 yet both factors are modifiable risks, which could be addressed pre-pregnancy, but this is outside the scope of this article. A high BMI has also been shown to be an added risk among patients undergoing an emergency Caesarean section. It is possible that in an emergency Caesarean section, there is less preparation time, including the prompt provision of prophylactic antimicrobials.16


Common


indications for emergency Caesarean birth include slow progression of labour or concern about the condition of the mother or baby. 10 The mechanisms for increased SSIs among


smokers are thought to involve carbon monoxide, nitric oxide and nicotine. These agents may have a direct action on endothelial dysfunction that may lead to impairment of the inflammatory healing response.16


Reducing the


risk of infections following Caesarean section is an important health issue for many women who are otherwise generally young and healthy.2


Reducing caesarean section surgical site infections Hospitals have a duty to avoid harm to patients, reduce antimicrobial prescribing and to improve patients’ experience of care. Reducing post CS SSI has a positive impact on all these goals.2 While preventing severe infection is a priority, superficial incisional SSIs are still likely to result in pain and discomfort, require antimicrobial therapy and may progress to affect deeper tissues. Therefore, reducing both deep and more superficial infections should form part of an overall infection prevention approach.2 The NICE 2021 Guideline on Caesarean Birth


aims to improve the consistency and quality of care. It reviews available clinical evidence and makes recommendations which include a number of non-pharmacological interventions that may be carried out before, during, and after surgery with the aim of reducing the risk of surgical site infection – such as the use of pre-operative skin or vaginal preparations and different types of wound dressings.10 The Guideline states that alcohol-based


chlorhexidine solution skin preparations reduce the risk of surgical site infections, compared with alcohol-based iodine solutions; and that aqueous iodine vaginal preparations reduce the risk of endometritis in women with ruptured membranes. Although negative pressure wound therapy (NPWT) reduces the risk of surgical site infections for women with a BMI of 30 kg/m2


or


more, NICE comments that economic evidence indicates this is not cost effective in those with a BMI of less than 35 kg/m2.10


There was no


difference in wound infection or readmissions to hospital when the dressing was removed either 6 hours or 24 hours after surgery; and evidence on different types of dressings was described as limited. Besides the NICE Guideline, there is data


available from a number of studies exploring the impact of various intervention strategies to reduce SSI following Caesarean delivery, some of which are summarised here. A quality improvement (QI) project aimed to reduce Caesarean related SSI by 50%.12


A care bundle was designed targeting pre-operative


SSI is a significant cause of maternal morbidity and can give rise to more severe complications such as sepsis and necrotising fasciitis. Caesarean section SSI also places an additional burden on service provision and healthcare costs.


54 www.clinicalservicesjournal.com I October 2024


personal patient preparation, preoperative prophylactic antibiotics, and strict skin preparation technique; all measured using a patient survey. The rate of SSI was followed for 14 months. After the implementation of a reducing SSI care bundle, the infection rate reduced by 50%, from 6.7% to 3.4% over a sustained 14-month period. These figures were deduced from a cohort of almost 4,000 patients. The authors concluded “this clinically and statistically significant reduction in SSI has reduced morbidity for new mothers and is associated with reduced readmission rates, inpatient bed days, postoperative antibiotic prescribing, treatment cost, and workload for the infection prevention and control team”.12 A multi-disciplinary quality improvement


project was designed to improve clinical practice and reduce the risk of Caesarean section SSI.17


Intra-operative measures were


introduced, which included standardised skin preparation with 2% chlorhexidine gluconate (CHG) and 70% isopropyl alcohol (IPA) and the administration of intravenous antibiotic prophylaxis prior to surgery. Midwifery staff were trained to recognise the signs and symptoms of SSI by infection control and tissue viability teams. A patient information wound care leaflet was developed and distributed on discharge.17 With these measures, SSI rates reduced from a peak of 18% in 2012, to 6% in 2015.17


The use of


a post-discharge wound care leaflet may be particularly valuable. The majority of wound infections do not become clinically apparent until postoperative days 4 to 7, when most women have already been discharged into the community.18 Health Innovation West of England (part of


the Royal United Hospitals Bath Foundation Trust) is currently undertaking a project (known as PreCiSSIon) to prevent surgical site infections following Caesarean birth. This


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