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There are approximately 4,000,000 births annually in the United States, and about 32% of them occur by cesarean delivery. Compared with vaginal birth, cesarean delivery is associated with an increased risk of endometritis (defined as fever plus uterine or abdominal tenderness). Although surgical complications cannot be eliminated entirely, surgeons are deeply dedicated to the continuous improvement of surgical practice in order to reduce the risk of complications.
With cesarean delivery, many surgical practices have been adopted universally to reduce postoperative complications, including administration of intravenous (IV) antibiotics before skin incision to minimize postoperative infection and the use of postoperative mechanical or pharmacologic interventions to help prevent venous thromboembolism and pulmonary embolism. Preoperative vaginal cleansing with povidone-iodine may reduce the risk of postoperative endometritis, but the practice is not currently common in the United States.
Should you adopt a policy of preoperative vaginal cleansing prior to cesarean delivery? The data suggest perhaps you should.
Data-driven support for povidone-iodine precesareanThree large randomized trials published within the past 10 years concluded that preoperative vaginal cleansing with povidone-iodine reduced the risk of postcesarean endometritis in women who also received prophylactic IV antibiotics (TABLE).1−3 Vaginal cleansing did not reduce the rate of postpartum fever or wound infection in these studies.
Clinical factors that increased the risk of postpartum endometritis independent of vaginal cleansing included:
- extended duration of cesarean surgery
- being in labor prior to cesarean delivery
- ruptured membranes
- advanced cervical examination
- maternal anemia
- use of intrapartum internal monitors
- prior history of genitourinary infection.
Authors of two recent, large nonrandomized studies also have reported that vaginal cleansing reduced the risk of postcesarean endometritis.4,5 By contrast, investigators from one large trial from 2001 did not observe a decrease in endometritis with vaginal cleansing.6
To test the impact of metronidazole vaginal gel on post‑cesarean endometritis, 224 women undergoing cesarean delivery for various indications were randomly assigned to placebo vaginal gel or metronidazole vaginal gel 5 g prior to surgery initiation.1 Most women also received intravenous antibiotics. The rates of endometritis were 17% and 7% in the placebo and metronidazole groups, respectively (relative risk, 0.42; 95% confidence interval, 0.19−0.92).
Vaginal antibiotic administration shows promise as an alternative to povidone-iodine cleansing in the prevention of postcesarean endometritis. Additional randomized clinical trials are necessary to fully evaluate the benefits and risks of this practice.
Reference
1. Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of postcesarean endometritis: a randomized controlled trial. Obstet Gynecol. 2001;98(5 pt 1):745−750.
Cochrane review of precesarean vaginal cleansingAuthors of a Cochrane review, in which they synthesized 7 studies involving 2,635 women, reported that vaginal cleansing with povidone-iodine immediately before cesarean delivery was associated with a reduced risk of postcesarean endometritis: 8.3% vs 4.3% in the control and vaginal cleansing groups, respectively, (risk ratio [RR], 0.45; 95% confidence interval [CI], 0.25−0.81).7
The positive effect of vaginal cleansing was particularly noteworthy in the subgroup of women with ruptured membranes (3 trials involving 272 women). The rates of endometritis in the control versus vaginal cleansing groups were 17.9% and 4.3%, respectively (RR, 0.24; 95% CI, 0.10−0.55).
Women who went into labor prior to cesarean delivery (523 women from 3 trials) also benefitted from vaginal cleansing, with endometritis rates of 13.0% and 7.4% in the control and vaginal cleansing groups, respectively (RR, 0.56; 95% CI, 0.34−0.95).
In this review, again, vaginal cleansing did not significantly reduce the rate of postoperative fever or wound infection.
The American College of Obstetricians and Gynecologists has noted that chlorohexidine gluconate solutions with high concentrations of alcohol are contraindicated for vaginal cleansing.1 However, although not approved for vaginal cleansing, solutions of chlorohexidine gluconate with low alcohol content (4% alcohol concentration) are safe and may be effective for off-label use as vaginal cleansings.
Reference
1. American College of Obstetricians and Gynecologists Women’s Health Care Physicians; Committee on Gynecologic Practice. Committee Opinion No. 571: solutions for surgical cleansing of the vagina. Obstet Gynecol. 2013;122(3):718−720.
Is vaginal cleansing prior to cesarean delivery best practice?In the United States, precesarean vaginal cleansing is not a common practice. To close the gap between current practice and what is potentially a best practice, two approaches to using vaginal cleansing could be instituted in delivery units.
Approach #1: A liberal clinical protocol. In this scenario, all women (who are not allergic to iodine or povidone-iodine) undergoing cesarean delivery should undergo vaginal cleansing. The World Health Organization conditionally recommends vaginal cleansing for all women undergoing a cesarean delivery.8
Approach #2: A focused clinical protocol. For this protocol, only women (again, who are not allergic to iodine or povidone-iodine) who have ruptured membranes or are in labor upon advanced cervical examination should receive vaginal cleansing.
The advantage of a liberal protocol is that vaginal preparation becomes embedded within the standard practice of cesarean delivery and, hence, is seldom overlooked. The upside of the focused protocol is that only those women most likely to benefit receive the intervention.
Tell me what you thinkWill you consider using vaginal cleansing in your practice? Please let me know your views on vaginal cleansing for cesarean delivery, as well as your clinical pearls on cesarean delivery surgery, at obgmanagement.com. In addition, weigh in on the Quick Poll posted to OBG Management’s homepage. Send your letter to the editor to [email protected].
- Starr RV, Zurawski J, Ismail M. Preoperative vaginal preparation with povidone-iodine and the risk of postcesarean endometritis. Obstet Gynecol. 2015;105(5 pt 1):1024–1029.
- Haas DM, Pazouki F, Smith RR, et al. Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. 2010;202(3):310.e1–e6.
- Yildrim G, Gungorduk K, Asicioglu O, et al. Does vaginal preparation with povidone-iodine prior to cesarean delivery reduce the risk of endometritis?A randomized controlled trial. J Matern Fetal Neonatal Med. 2012;25(11):2316–2321.
- Asghania M, Mirblouk F, Shakiba M, Faraji R. Preoperative vaginal preparation with povidone-iodine on post-cesarean infectious morbidity. J Obstet Gynaecol. 2011;31(5):400–403.
- Memon S, Qazi RA, Bibi S, Parveen N. Effect of preoperative vaginal cleansing with an antiseptic solution to reduce post caesarean infectious morbidity. J Pak Med Assoc. 2011;61(12):1179–1183.
- Reid VC, Hartmann KE, McMahon M, Fry EP. Vaginal preparation with povidone-iodine and postcesarean infectious morbidity: a randomized controlled trial. Obstet Gynecol. 2001;97(1):147–152.
- Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014;12:CD007892.
- Yildrim G, Gungorduk K, Asicioglu O, et al. Does vaginal preparation with povidone-iodine prior to
Dr. Barbieri is Editor in Chief, OBG Management; Chair, Obstetrics and Gynecology, Brigham and Women’s Hospital; and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts.
Dr. Barbieri reports no financial relationships relevant to this article.
Dr. Barbieri is Editor in Chief, OBG Management; Chair, Obstetrics and Gynecology, Brigham and Women’s Hospital; and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts.
Dr. Barbieri reports no financial relationships relevant to this article.
Dr. Barbieri is Editor in Chief, OBG Management; Chair, Obstetrics and Gynecology, Brigham and Women’s Hospital; and Kate Macy Ladd Professor of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts.
Dr. Barbieri reports no financial relationships relevant to this article.
There are approximately 4,000,000 births annually in the United States, and about 32% of them occur by cesarean delivery. Compared with vaginal birth, cesarean delivery is associated with an increased risk of endometritis (defined as fever plus uterine or abdominal tenderness). Although surgical complications cannot be eliminated entirely, surgeons are deeply dedicated to the continuous improvement of surgical practice in order to reduce the risk of complications.
With cesarean delivery, many surgical practices have been adopted universally to reduce postoperative complications, including administration of intravenous (IV) antibiotics before skin incision to minimize postoperative infection and the use of postoperative mechanical or pharmacologic interventions to help prevent venous thromboembolism and pulmonary embolism. Preoperative vaginal cleansing with povidone-iodine may reduce the risk of postoperative endometritis, but the practice is not currently common in the United States.
Should you adopt a policy of preoperative vaginal cleansing prior to cesarean delivery? The data suggest perhaps you should.
Data-driven support for povidone-iodine precesareanThree large randomized trials published within the past 10 years concluded that preoperative vaginal cleansing with povidone-iodine reduced the risk of postcesarean endometritis in women who also received prophylactic IV antibiotics (TABLE).1−3 Vaginal cleansing did not reduce the rate of postpartum fever or wound infection in these studies.
Clinical factors that increased the risk of postpartum endometritis independent of vaginal cleansing included:
- extended duration of cesarean surgery
- being in labor prior to cesarean delivery
- ruptured membranes
- advanced cervical examination
- maternal anemia
- use of intrapartum internal monitors
- prior history of genitourinary infection.
Authors of two recent, large nonrandomized studies also have reported that vaginal cleansing reduced the risk of postcesarean endometritis.4,5 By contrast, investigators from one large trial from 2001 did not observe a decrease in endometritis with vaginal cleansing.6
To test the impact of metronidazole vaginal gel on post‑cesarean endometritis, 224 women undergoing cesarean delivery for various indications were randomly assigned to placebo vaginal gel or metronidazole vaginal gel 5 g prior to surgery initiation.1 Most women also received intravenous antibiotics. The rates of endometritis were 17% and 7% in the placebo and metronidazole groups, respectively (relative risk, 0.42; 95% confidence interval, 0.19−0.92).
Vaginal antibiotic administration shows promise as an alternative to povidone-iodine cleansing in the prevention of postcesarean endometritis. Additional randomized clinical trials are necessary to fully evaluate the benefits and risks of this practice.
Reference
1. Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of postcesarean endometritis: a randomized controlled trial. Obstet Gynecol. 2001;98(5 pt 1):745−750.
Cochrane review of precesarean vaginal cleansingAuthors of a Cochrane review, in which they synthesized 7 studies involving 2,635 women, reported that vaginal cleansing with povidone-iodine immediately before cesarean delivery was associated with a reduced risk of postcesarean endometritis: 8.3% vs 4.3% in the control and vaginal cleansing groups, respectively, (risk ratio [RR], 0.45; 95% confidence interval [CI], 0.25−0.81).7
The positive effect of vaginal cleansing was particularly noteworthy in the subgroup of women with ruptured membranes (3 trials involving 272 women). The rates of endometritis in the control versus vaginal cleansing groups were 17.9% and 4.3%, respectively (RR, 0.24; 95% CI, 0.10−0.55).
Women who went into labor prior to cesarean delivery (523 women from 3 trials) also benefitted from vaginal cleansing, with endometritis rates of 13.0% and 7.4% in the control and vaginal cleansing groups, respectively (RR, 0.56; 95% CI, 0.34−0.95).
In this review, again, vaginal cleansing did not significantly reduce the rate of postoperative fever or wound infection.
The American College of Obstetricians and Gynecologists has noted that chlorohexidine gluconate solutions with high concentrations of alcohol are contraindicated for vaginal cleansing.1 However, although not approved for vaginal cleansing, solutions of chlorohexidine gluconate with low alcohol content (4% alcohol concentration) are safe and may be effective for off-label use as vaginal cleansings.
Reference
1. American College of Obstetricians and Gynecologists Women’s Health Care Physicians; Committee on Gynecologic Practice. Committee Opinion No. 571: solutions for surgical cleansing of the vagina. Obstet Gynecol. 2013;122(3):718−720.
Is vaginal cleansing prior to cesarean delivery best practice?In the United States, precesarean vaginal cleansing is not a common practice. To close the gap between current practice and what is potentially a best practice, two approaches to using vaginal cleansing could be instituted in delivery units.
Approach #1: A liberal clinical protocol. In this scenario, all women (who are not allergic to iodine or povidone-iodine) undergoing cesarean delivery should undergo vaginal cleansing. The World Health Organization conditionally recommends vaginal cleansing for all women undergoing a cesarean delivery.8
Approach #2: A focused clinical protocol. For this protocol, only women (again, who are not allergic to iodine or povidone-iodine) who have ruptured membranes or are in labor upon advanced cervical examination should receive vaginal cleansing.
The advantage of a liberal protocol is that vaginal preparation becomes embedded within the standard practice of cesarean delivery and, hence, is seldom overlooked. The upside of the focused protocol is that only those women most likely to benefit receive the intervention.
Tell me what you thinkWill you consider using vaginal cleansing in your practice? Please let me know your views on vaginal cleansing for cesarean delivery, as well as your clinical pearls on cesarean delivery surgery, at obgmanagement.com. In addition, weigh in on the Quick Poll posted to OBG Management’s homepage. Send your letter to the editor to [email protected].
There are approximately 4,000,000 births annually in the United States, and about 32% of them occur by cesarean delivery. Compared with vaginal birth, cesarean delivery is associated with an increased risk of endometritis (defined as fever plus uterine or abdominal tenderness). Although surgical complications cannot be eliminated entirely, surgeons are deeply dedicated to the continuous improvement of surgical practice in order to reduce the risk of complications.
With cesarean delivery, many surgical practices have been adopted universally to reduce postoperative complications, including administration of intravenous (IV) antibiotics before skin incision to minimize postoperative infection and the use of postoperative mechanical or pharmacologic interventions to help prevent venous thromboembolism and pulmonary embolism. Preoperative vaginal cleansing with povidone-iodine may reduce the risk of postoperative endometritis, but the practice is not currently common in the United States.
Should you adopt a policy of preoperative vaginal cleansing prior to cesarean delivery? The data suggest perhaps you should.
Data-driven support for povidone-iodine precesareanThree large randomized trials published within the past 10 years concluded that preoperative vaginal cleansing with povidone-iodine reduced the risk of postcesarean endometritis in women who also received prophylactic IV antibiotics (TABLE).1−3 Vaginal cleansing did not reduce the rate of postpartum fever or wound infection in these studies.
Clinical factors that increased the risk of postpartum endometritis independent of vaginal cleansing included:
- extended duration of cesarean surgery
- being in labor prior to cesarean delivery
- ruptured membranes
- advanced cervical examination
- maternal anemia
- use of intrapartum internal monitors
- prior history of genitourinary infection.
Authors of two recent, large nonrandomized studies also have reported that vaginal cleansing reduced the risk of postcesarean endometritis.4,5 By contrast, investigators from one large trial from 2001 did not observe a decrease in endometritis with vaginal cleansing.6
To test the impact of metronidazole vaginal gel on post‑cesarean endometritis, 224 women undergoing cesarean delivery for various indications were randomly assigned to placebo vaginal gel or metronidazole vaginal gel 5 g prior to surgery initiation.1 Most women also received intravenous antibiotics. The rates of endometritis were 17% and 7% in the placebo and metronidazole groups, respectively (relative risk, 0.42; 95% confidence interval, 0.19−0.92).
Vaginal antibiotic administration shows promise as an alternative to povidone-iodine cleansing in the prevention of postcesarean endometritis. Additional randomized clinical trials are necessary to fully evaluate the benefits and risks of this practice.
Reference
1. Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of postcesarean endometritis: a randomized controlled trial. Obstet Gynecol. 2001;98(5 pt 1):745−750.
Cochrane review of precesarean vaginal cleansingAuthors of a Cochrane review, in which they synthesized 7 studies involving 2,635 women, reported that vaginal cleansing with povidone-iodine immediately before cesarean delivery was associated with a reduced risk of postcesarean endometritis: 8.3% vs 4.3% in the control and vaginal cleansing groups, respectively, (risk ratio [RR], 0.45; 95% confidence interval [CI], 0.25−0.81).7
The positive effect of vaginal cleansing was particularly noteworthy in the subgroup of women with ruptured membranes (3 trials involving 272 women). The rates of endometritis in the control versus vaginal cleansing groups were 17.9% and 4.3%, respectively (RR, 0.24; 95% CI, 0.10−0.55).
Women who went into labor prior to cesarean delivery (523 women from 3 trials) also benefitted from vaginal cleansing, with endometritis rates of 13.0% and 7.4% in the control and vaginal cleansing groups, respectively (RR, 0.56; 95% CI, 0.34−0.95).
In this review, again, vaginal cleansing did not significantly reduce the rate of postoperative fever or wound infection.
The American College of Obstetricians and Gynecologists has noted that chlorohexidine gluconate solutions with high concentrations of alcohol are contraindicated for vaginal cleansing.1 However, although not approved for vaginal cleansing, solutions of chlorohexidine gluconate with low alcohol content (4% alcohol concentration) are safe and may be effective for off-label use as vaginal cleansings.
Reference
1. American College of Obstetricians and Gynecologists Women’s Health Care Physicians; Committee on Gynecologic Practice. Committee Opinion No. 571: solutions for surgical cleansing of the vagina. Obstet Gynecol. 2013;122(3):718−720.
Is vaginal cleansing prior to cesarean delivery best practice?In the United States, precesarean vaginal cleansing is not a common practice. To close the gap between current practice and what is potentially a best practice, two approaches to using vaginal cleansing could be instituted in delivery units.
Approach #1: A liberal clinical protocol. In this scenario, all women (who are not allergic to iodine or povidone-iodine) undergoing cesarean delivery should undergo vaginal cleansing. The World Health Organization conditionally recommends vaginal cleansing for all women undergoing a cesarean delivery.8
Approach #2: A focused clinical protocol. For this protocol, only women (again, who are not allergic to iodine or povidone-iodine) who have ruptured membranes or are in labor upon advanced cervical examination should receive vaginal cleansing.
The advantage of a liberal protocol is that vaginal preparation becomes embedded within the standard practice of cesarean delivery and, hence, is seldom overlooked. The upside of the focused protocol is that only those women most likely to benefit receive the intervention.
Tell me what you thinkWill you consider using vaginal cleansing in your practice? Please let me know your views on vaginal cleansing for cesarean delivery, as well as your clinical pearls on cesarean delivery surgery, at obgmanagement.com. In addition, weigh in on the Quick Poll posted to OBG Management’s homepage. Send your letter to the editor to [email protected].
- Starr RV, Zurawski J, Ismail M. Preoperative vaginal preparation with povidone-iodine and the risk of postcesarean endometritis. Obstet Gynecol. 2015;105(5 pt 1):1024–1029.
- Haas DM, Pazouki F, Smith RR, et al. Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. 2010;202(3):310.e1–e6.
- Yildrim G, Gungorduk K, Asicioglu O, et al. Does vaginal preparation with povidone-iodine prior to cesarean delivery reduce the risk of endometritis?A randomized controlled trial. J Matern Fetal Neonatal Med. 2012;25(11):2316–2321.
- Asghania M, Mirblouk F, Shakiba M, Faraji R. Preoperative vaginal preparation with povidone-iodine on post-cesarean infectious morbidity. J Obstet Gynaecol. 2011;31(5):400–403.
- Memon S, Qazi RA, Bibi S, Parveen N. Effect of preoperative vaginal cleansing with an antiseptic solution to reduce post caesarean infectious morbidity. J Pak Med Assoc. 2011;61(12):1179–1183.
- Reid VC, Hartmann KE, McMahon M, Fry EP. Vaginal preparation with povidone-iodine and postcesarean infectious morbidity: a randomized controlled trial. Obstet Gynecol. 2001;97(1):147–152.
- Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014;12:CD007892.
- Yildrim G, Gungorduk K, Asicioglu O, et al. Does vaginal preparation with povidone-iodine prior to
- Starr RV, Zurawski J, Ismail M. Preoperative vaginal preparation with povidone-iodine and the risk of postcesarean endometritis. Obstet Gynecol. 2015;105(5 pt 1):1024–1029.
- Haas DM, Pazouki F, Smith RR, et al. Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. 2010;202(3):310.e1–e6.
- Yildrim G, Gungorduk K, Asicioglu O, et al. Does vaginal preparation with povidone-iodine prior to cesarean delivery reduce the risk of endometritis?A randomized controlled trial. J Matern Fetal Neonatal Med. 2012;25(11):2316–2321.
- Asghania M, Mirblouk F, Shakiba M, Faraji R. Preoperative vaginal preparation with povidone-iodine on post-cesarean infectious morbidity. J Obstet Gynaecol. 2011;31(5):400–403.
- Memon S, Qazi RA, Bibi S, Parveen N. Effect of preoperative vaginal cleansing with an antiseptic solution to reduce post caesarean infectious morbidity. J Pak Med Assoc. 2011;61(12):1179–1183.
- Reid VC, Hartmann KE, McMahon M, Fry EP. Vaginal preparation with povidone-iodine and postcesarean infectious morbidity: a randomized controlled trial. Obstet Gynecol. 2001;97(1):147–152.
- Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014;12:CD007892.
- Yildrim G, Gungorduk K, Asicioglu O, et al. Does vaginal preparation with povidone-iodine prior to
