Infection concerns over Caesarean rise - Personal Care Magazine

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INFECTION CONCERNS OVER CAESAREAN RISE

January 2011

As rates of Caesarean section continue to rise, the numbers of mothers experiencing surgical site infection (SSI) are also set to increase, warns Claire Banks, a senior specialist registrar in obstetrics and gynaecology. LOUISE FRAMPTON reports.

Speaking at Ethicons annual symposium on surgical site infection, Claire Banks, senior specialist registrar in obstetrics and gynaecology, West of Scotland Deanery, NHS Education for Scotland, pointed out that the rate of Caesarean sections (CS) in the UK has increased from just 9%, in 1980, to around 25% in recent years the equivalent of 155,000 births per year. Of these CS births, 62,000 are elective procedures. However, the percentage varies throughout the UK, with some private units recording rates as high as 35%. This pales into insignificance compared to worldwide figures, however. In China the figure is 46% while, in some parts of Brazil, the figure reaches almost 80%. This is despite the fact that the World Health Organization recommends that the rate should not be more than 10% to 15% i.e. the same rate as 30 years ago. Several factors could be responsible for this rise, including a general increase in levels of obesity. A referral to an anaesthetist was previously made for a BMI of over 30, at booking, but as obesity has become more common, women are now only referred if they have a BMI greater than 40. Obesity is also associated with several other risks in pregnancy, including the development of conditions such as gestational diabetes, hypertension and pre-eclampsia. This may mean an increase in the rates of induction of labour, which in turn leads to failed induction or failure to progress in labour, and these are two significant reasons given for performing a CS. A mothers larger size can sometimes lead to a larger baby, but it may also result in growth restriction (although these babies are also common in women of lower socioeconomic class or smokers). Claire Banks explained that these babies do not tend to tolerate labour as well, leading to another main reason for CS (i.e. fetal distress). Other influential factors include increasing maternal age, increased use of IVF and teenage pregnancies. Increasing maternal age and IVF pregnancies are not necessarily a problem, but among this group are women from the maternal request category. There is also an increased incidence of multiple births with IVF. Unfortunately, a significant number of our patients are also in the teenage category i.e. the 14-16 age group. Although they usually want to avoid CS, sometimes their pelvis is just too immature to allow passage of the baby. Finally, repeat CS accounts for up to a quarter of all CS procedures performed, and is perhaps the only variable that we may be able to do something about by encouraging women to have a trial of vaginal delivery following previous CS. Claire Banks pointed out that, as many of these factors will prove difficult to influence, it is crucial that surgery is made as safe as possible, which includes reducing surgical site infection rates. CS carries several potential complications, which are explained at the time of signing the consent form. Infection is the most common potential problem (4% to 6%), with readmission to hospital a close second (5%). However, the readmission to hospital is invariably due to infection, so the two are, in fact, linked. Risk of haemorrhage requiring transfusion is low, as is trauma to the bladder or ureters, but the risk of thromboembolism is 3.6 times higher than those with a normal delivery, she commented. She explained that, in terms of the symptoms associated with infection, discharge is common and is usually the first thing that a woman will notice and complain of. Dehiscence is not uncommon, but usually happens after release from hospital. Women do not usually have pyrexia or malaise with wound infection alone, and there is usually some other co-existing source of infection if this is the case. Abscesses are rare, she added, although wound haematomas often precede either discharge from the wound or dehiscence. Risks of wound infection She went on to outline the risks of wound infection post CS and cited obesity as one of the biggest risk factors for developing wound infection. Possible biological explanations are that: adipose tissue is relatively avascular; there is an increased wound area, and also potentially poor penetration of prophylactic antibiotics in adipose tissue. In addition, where the transverse incision lies within a fold of skin, the area can become moist and provide an ideal environment in which bacteria can grow. As around 20% of pregnant women are now classed as obese and around 50% of these will deliver by CS, this presents a major issue, she warned. Development of subcutaneous haematomas has also been shown to be an important risk factor. A study carried out by Olsen et al in the US, in 1999-2001, looked at a total of 1,600 women who underwent CS, and found that postoperative development of a haematoma was the strongest independent risk factor for developing wound infection. It is unclear whether or not the use of electrocautery would decrease the rate of haematoma formation, and this may be something that requires closer examination, she suggested. Other potential risk factors have been examined in an Australian study by Webster, in 2008. This was a prospective study of 1,500 women who underwent CS and showed an infection rate of 9%. The factors that had statistical significance in the

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Infection concerns over Caesarean rise - Personal Care Magazine

http://www.clinicalservicesjournal.com/Print.aspx?Story=7643

development of infection were the number of vaginal examinations performed (if in labour), the category of the surgeon, and the length of the operation. Previous wound infection was also found in over half of those affected. However, elective procedures had a lower rate than emergencies. Infection has, in some studies, been shown to occur more frequently with high pre-operative blood glucose levels. Therefore, it is perhaps surprising that there does not appear to be an increased risk with maternal diabetes. This may be due to the fact that pregnant women generally have tight glycaemic control, commented Claire Banks. She went on to examine the role of surgical techniques which have an impact on the rate of wound infection. For example, the issue of adhesive drapes were looked at in two RCTs by Ward et al in 2001, and an earlier study by Cordtz et al. Both examined their use as an isolated intervention in the prevention of wound infection post CS, but did not find any difference in the rates of infection. With regards to type of incision i.e. longitudinal or transverse, the NICE guidelines quote 10 RCTs all of which concluded that there was no difference in the incidence of wound infection. This was also confirmed by the previously mentioned Australian study by Webster in 2008. Claire Banks highlighted the fact that there have been no studies, to date, regarding instruments for incision during CS, and the data available relates to general surgical procedures. However, this has indicated that there is no difference in the rates of wound infection if one scalpel is used solely for the skin, and a further scalpel for deeper layers. No difference was also found when comparing entry with a scalpel or electrocautery. She added that, regarding use of different materials or methods of closing sheath, there is currently no available evidence for CS. Research may be required, therefore, using newer materials, to see if there is any difference. There may be some benefit in closing the subcutaneous layer if it is more than 2 cm deep. Despite this, practice varies widely, with 42% of obstetricians never closing it, 21% always closing it, 8% only closing it if the layer is thin (to prevent tethering of the scar to the sheath), and 28% closing if the layer is thick. Clearly, there is no consensus and this could be an area where following NICE guidelines could be beneficial, she commented. Five RCTs looked at the routine use of superficial wound drains and, from this, NICE guidance has advised that they should not be routinely used, as they do not decrease the incidence of either wound haematoma or infection. Method of skin closure remains contentious, with conflicting evidence. However, a Glasgow-based study, by Johnson et al, found that the use of staples doubled the risk of wound infection. Antibiotics One of the most important factors influencing the development of wound infection is use of antibiotics. A Cochrane database review by Smaill, which looked at 86 studies involving over 13,000 women, showed that the use of prophylactic antibiotics at the time of CS substantially reduced the risk of infection, by up to 70%. It has also been shown that a single dose regime is as effective as multiple doses, and that there is no difference between the use of either a 1st, 2nd or 3rd generation cephalosporin. Timing also appears to be very important, with a study by Owens et al (2004), involving over 9,000 women, showing that administration of antibiotics prior to skin incision, as opposed to after cord clamping, decreased the rate of wound infection although it is uncertain whether this timing has effects on the baby, such as oral thrush. In fact, studies suggest that antibiotics have the potential to significantly reduce the cost burden associated with such infections. A study carried out in the UK, in 1989, by Mugford et al, found there was an additional extra cost of 716 per patient if wound infection occurred. By extrapolating data, it was calculated that the use of prophylactic antibiotics for everyone undergoing CS would reduce the cost of care by between 1,300 and 3,900 per 100 CS. A saving of between 13 and 39 per operation may not seem much, but if we multiply that by the number of procedures performed annually in the UK, that would lead to an average saving of between 2 m and 6 m per year for the NHS, Claire Banks pointed out. Ultimately, the consequences of surgical site infection for mothers can be far reaching and costly, as Claire Banks highlighted. The physical effects include a prolonged recovery time and, on average, a longer hospital stay of an extra two days, but the social impact also needs consideration. The resulting scars can be unsightly and affect the womans self confidence long term sometimes even necessitating further surgery for cosmesis. In addition, infection can affect the bonding process, as mothers may find it difficult and very uncomfortable to hold or pick up their baby. This, in turn, can affect breastfeeding. Reminding the audience of the human impact, she commented: This is meant to be a special time for a woman and her family, and unfortunately wound infection can turn it into a memorable time for all the wrong reasons. Image Credit: www.sxc.hu

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