UPDATE: INFECTIOUS DISEASE
The focus here is twofold: dealing with H1N1 influenza in vulnerable populations and taking up strategies to prevent postoperative infection in women undergoing cesarean delivery
IN THIS ARTICLE
If there is a clinical suspicion of influenza in a pregnant or postpartum patient, treat her immediately with one of the antiviral regimens outlined on page 38—regardless of the outcome of the rapid test for influenza.
Blunt needles reduce needle sticks during cesarean delivery
Sullivan S, Williamson B, Wilson LK, Korde JE, Soper D. Blunt needles for reduction of needlestick injuries during cesarean delivery. Obstet Gynecol. 2009;114 (2 Pt 1):211–216.
Using glove perforation as a proxy for needlestick injuries, Sullivan and colleagues compared blunt needles with sharp needles during cesarean delivery. Ninety-seven women had all anatomic layers reapproximated using blunt needles, and 97 had them reapproximated using sharp needles. The overall glove perforation rate was 12.3%. For sharp needles, the perforation rate was 17.5%, and for blunt needles it was 7.2% (relative risk [RR], 0.66; 95% CI, 0.49–0.89). The key protective effect of the blunt needles was confined to the assistant surgeon (RR, 0.54; 95% CI, 0.41–0.71). The RR for glove perforation involving the primary surgeon was 0.8 (95% CI, 0.53–1.2).
Details of the trial
Glove type, number of gloves, needle size, and type and gauge of suture material were left to the discretion of the surgeon. Glove perforations were identified by filling the gloves with 1,000 mL of water and applying pressure to the palm and each finger. The secondary endpoint of the study was physician satisfaction with the needle. Primary and assistant surgeons reported comparable levels of dissatisfaction with blunt needles, compared with sharp needles (P < .001). However, 92% of primary surgeons and 93% of assistant surgeons rated the blunt needles as at least “acceptable” for use.
Needle stick has led to hepatitis B transmission
Earlier studies reported a rate of glove perforation of 20% to 26% during open abdominal procedures. In an investigation at our center, we noted glove perforation in 13% of cesarean deliveries.5 In this and another investigation, the frequency of perforation did not vary with the level of training of the surgeon or time of day of the procedure.5,6 The most common sites of perforation were the thumb, index finger, and middle finger of the non-dominant hand. The most common mechanism of injury was handling the needle with the operator’s gloved hand rather than with an instrument.
Double-gloving significantly reduces the risk of injury to the inner glove and, subsequently, to the surgeon’s skin. (Note: Double-gloving does not decrease tactile sensation or increase the risk of mishap.6)
The study by Sullivan and colleagues demonstrates that use of blunt needles offers an additional measure of protection against a penetrating injury to the surgeon’s bare skin. Although no surgeon has yet contracted HIV infection from a surgical needle, the transmission of hepatitis B via contaminated surgical needle has been well documented.
Prudence dictates that we use all proven measures to prevent intraoperative blood exposure. Use of blunt needles should be added to interventions such as double-gloving and use of a neutral zone in which to pass sharp objects.
Prophylactic antibiotics reduce postcesarean infection, even in low-risk women
Dinsmoor MJ, Gilbert S, Landon MB, et al, for Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Perioperative antibiotic prophylaxis for nonlaboring cesarean delivery. Obstet Gynecol. 2009;114(4):752–756.
Infection is the most common postoperative complication of cesarean delivery, now the most frequently performed major operation in America. The principal infection is endometritis, followed by wound infection and urinary tract infection. The frequency of wound infection is on the rise because of the steadily increasing prevalence of obesity in the obstetric population.
Dinsmoor and coworkers conducted this secondary analysis using data from an earlier observational study of 9,432 women who underwent cesarean delivery before the onset of labor. Of these women, 6,006 (64%) received antibiotic prophylaxis.
Women treated prophylactically had a significantly lower rate of endometritis (adjusted odds ratio [OR], 0.40; 95% CI, 0.28–0.59) and of wound infection (adjusted OR, 0.49; 95% CI, 0.28–0.86). The frequency of other infection-related complications was not significantly reduced (adjusted OR, 0.39; 95% CI, 0.13–1.12).
Overall, the size of the effect for endometritis was small; endometritis developed in 2.0% of women in the group that received prophylaxis and 2.6% of women in the group that did not. The size of the effect was even smaller for wound infection.
In this uncontrolled series, 113 patients had to be treated to prevent one case of endometritis or wound infection.
Details of the trial
The original observational study from which this analysis derives was performed by the Maternal-Fetal Medicine Units Network at 13 centers in 1999–2000. The choice of antibiotics and the timing of administration were left to the discretion of the attending physician.
