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10 evidence-based recommendations to prevent surgical site infection after cesarean delivery

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Data-driven guidance on multiple aspects of cesarean delivery, from preoperative glycemic control to strategies for obese patients



Infection is the second leading cause of pregnancy-related mortality in the United States, responsible for 13.6% of all maternal deaths.1 Cesarean delivery is the single most important risk factor for puerperal infection, increasing its incidence approximately 5- to 20-fold.2

Given that cesarean deliveries represent 32.7% of all births in the United States,3 the overall health and socioeconomic burden of these infections is substantial. In addition, more than half of all pregnancies are complicated by maternal obesity, which is associated with an increased risk of cesarean delivery as well as subsequent wound complications.4

In this review, we offer 10 evidence-based strategies to prevent surgical site infection (SSI) after cesarean delivery.

1 Maintain strict glycemic control in women with diabetes

Perioperative hyperglycemia is associated with an increased risk of postoperative infection in patients with diabetes

Ramos M, Khalpey Z, Lipsitz S, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg. 2008;248(4):585–591.

Hanazaki K, Maeda H, Okabayashi T. Relationship between perioperative glycemic control and postoperative infections. World J Gastroenterol. 2009;15(33):4122–4125.

Although data are limited on the impact of perioperative glycemic control on post­cesarean infection rates, the association has been well documented in the general surgery literature. Results of a retrospective cohort study of 995 patients undergoing general or vascular surgery demonstrated that postoperative hyperglycemia increased the risk of infection by 30% for every 40-point increase in serum glucose levels from normoglycemia (defined as <110 mg/dL) (odds ratio, 1.3; 95% confidence interval [CI], 1.03–1.64).5 Hyperglycemia causes abnormalities of leukocyte function, including impaired granulocyte adherence, impaired phagocytosis, delayed chemotaxis, and depressed bactericidal capacity. And all of these abnormalities in leukocyte function appear to improve with strict glycemic control, although the target range for blood glucose remains uncertain.6

2 Recommend preoperative antiseptic showering

Ask patients to shower with 4% chlorhexidine gluconate the night before surgery to reduce the presence of bacterial skin flora

Mangram AJ, Horan TC, Pearson ML, et al; Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20(4):247–278.

Chlebicki MP, Safdar N, O’Horo JC, Maki DG. Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis. Am J Infect Control. 2013;41(2):167–173.

According to the Centers for Disease Control and Prevention, preoperative showering with chlorhexidine reduces the presence of bacterial skin flora. A study of more than 700 patients showed that preoperative showers with chlorhexidine reduced bacterial colony counts 9-fold, compared with only 1.3-fold for povidone-iodine.7 Whether this translates into a reduction in SSI remains controversial, in large part because of poor quality of the existing prospective trials, which used different agents, concentrations, and methods of skin preparation.8

Small clinical trials have found a benefit to chlorhexidine treatment the day before surgery.9,10 However, a recent meta-analysis of 16 randomized trials failed to show a significant reduction in the rate of SSI with chlorhexidine compared with soap, placebo, or no washing (relative risk [RR], 0.90; 95% CI, 0.77–1.05).11

3 Administer intravenous antibiotic prophylaxis

All patients who undergo cesarean delivery should be given appropriate antibiotic prophylaxis within 60 minutes before the skin incision

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 120: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011;117(6):1472–1483.

Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: a meta-analysis. Am J Obstet Gynecol. 2008;199(3):301.e1–e6.

The American College of Obstetricians and Gynecologists (ACOG) recommends the use of a single dose of a narrow-spectrum, first-generation cephalosporin (or a single dose of clindamycin with an aminoglycoside for those with a significant penicillin allergy) as SSI chemoprophylaxis for cesarean delivery.12 Due to concerns about fetal antibiotic exposure, such prophylaxis traditionally has been given after clamping of the umbilical cord. However, results of a recent meta-analysis of 5 randomized controlled trials demonstrated that antibiotic prophylaxis significantly reduced infectious morbidity (RR, 0.50; 95% CI, 0.33–0.78) when it was given 60 minutes before the skin incision, with no significant effect on neonatal outcome.13

4 Give a higher dose of preoperative antibiotics in obese women

Given the increased volume of distribution and the increased risk of postcesarean infection in the obese population, a higher dose of preoperative antibiotic prophylaxis is recommended

Robinson HE, O’Connell CM, Joseph KS, McLeod NL. Maternal outcomes in pregnancies complicated by obesity. Obstet Gynecol. 2005;106(6):1357–1364.

Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol. 2011;117(4):877–882.

The impact of maternal obesity on the risk of SSI after cesarean delivery was illustrated in a 2005 retrospective cohort study of 10,134 obese women. Moderately obese women with a prepregnancy weight of 90 to 100 kg were 1.6 times (95% CI, 1.31–1.95) more likely to have a wound infection, and severely obese women (>120 kg) were 4.45 times (95% CI, 3.00–6.61) more likely to have a wound infection after cesarean delivery, compared with women of normal weight.14


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