Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2018 Jul 17;7(7):CD007892.
doi: 10.1002/14651858.CD007892.pub6.

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections

David M Haas  1 , Sarah Morgan, Karenrose Contreras, Savannah Enders
Affiliations
Meta-Analysis

Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections

David M Haas et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Cesarean delivery is one of the most common surgical procedures performed by obstetricians. Infectious morbidity after cesarean delivery can have a tremendous impact on the postpartum woman's return to normal function and her ability to care for her baby. Despite the widespread use of prophylactic antibiotics, postoperative infectious morbidity still complicates cesarean deliveries. This is an update of a Cochrane review first published in 2010 and subsequently updated in 2012, and twice in 2014.

Objectives: To determine if cleansing the vagina with an antiseptic solution before a cesarean delivery decreases the risk of maternal infectious morbidities, including endometritis and wound complications. We also assessed the side effects of vaginal cleansing solutions to determine adverse events associated with the intervention.

Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (10 July 2017), and reference lists of retrieved studies.

Selection criteria: We included randomized trials and one quasi-randomized trial assessing the impact of vaginal cleansing immediately before cesarean delivery with any type of antiseptic solution versus a placebo solution/standard of care on post-cesarean infectious morbidity. Cluster-randomized trials were eligible for inclusion but none were identified. We excluded trials that utilized vaginal preparation during labor or that did not use antibiotic surgical prophylaxis. We also excluded any trials using a cross-over design.

Data collection and analysis: At least three of the review authors independently assessed eligibility of the studies. Two review authors were assigned to extract study characteristics, quality assessments, and data from eligible studies.

Main results: We included 11 trials reporting results for 3403 women evaluating the effects of vaginal cleansing (eight using povidone-iodine, two chlorhexidine, one benzalkonium chloride) on post-cesarean infectious morbidity. Additionally, some trials used vaginal preparations using sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (eight trials) or the use of a saline vaginal preparation (three trials). The risk of bias in the studies reduced our confidence in the results for endometritis outcomes.Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 8.7% in control groups to 3.8% in vaginal cleansing groups (average risk ratio (RR) 0.36, 95% confidence interval (CI) 0.20 to 0.63, 10 trials, 3283 women, moderate quality of evidence). Subgroup analysis could not rule out larger reductions in endometritis with antiseptics in women who were in labor or in women whose membranes had ruptured when antiseptics were used. Risks of postoperative fever and postoperative wound infection may be slightly lowered by antiseptic preparation, but the confidence intervals around the effects for both outcomes are consistent with a large reduction in risk and no difference between groups (fever: RR 0.87 (0.72 to 1.05; wound infection: RR 0.74 (95% CI 0.49 to 1.11), both moderate-quality evidence). Two trials reported a lower risk of a composite outcome of wound complication or endometritis in women receiving preoperative vaginal preparation (RR 0.46, 95% CI 0.26 to 0.82, two trials, 499 women, moderate-quality evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing.

Authors' conclusions: Vaginal preparation with povidone-iodine or chlorhexidine solution compared to saline or not cleansing immediately before cesarean delivery probably reduces the risk of post-cesarean endometritis. Subgroup analysis could not rule out larger reductions in endometritis with antiseptics in women who were in labor or in women whose membranes had ruptured when antiseptics were used.The quality of the evidence using GRADE was moderate for all reported outcomes. We downgraded the outcome of post-cesarean endometritis and composite of wound complications or endometritis for risk of bias and postoperative fever and postoperative wound infections for wide CIs.As a simple, generally inexpensive intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries.

PubMed Disclaimer

Conflict of interest statement

David Haas is the Principal Investigator for a randomized trial included in this review (Haas 2010). He has no financial conflicts of interest to disclose.

Sarah Morgan is also an investigator in the Haas 2010 trial. She has no financial conflicts of interest to disclose.

Trial authors for Haas 2010 were not involved in assessing trial quality or extracting data from the Haas 2010 study. This task was carried out by Karenrose Contreras and a third party (Dr Jon Hathaway, MD, PhD).

Karenrose Contreras has no financial conflicts of interest to disclose.

Savannah Enders has no financial conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Figure 3
Figure 3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 1 Post‐cesarean endometritis.
Analysis 1.2
Analysis 1.2
Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 2 Postoperative fever.
Analysis 1.3
Analysis 1.3
Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 3 Postoperative wound infection.
Analysis 1.4
Analysis 1.4
Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 4 Composite wound complication.
Analysis 1.5
Analysis 1.5
Comparison 1 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation), Outcome 5 Composite wound complication or endometritis.
Analysis 2.1
Analysis 2.1
Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 1 Post‐cesarean endometritis.
Analysis 2.2
Analysis 2.2
Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 2 Postoperative fever.
Analysis 2.3
Analysis 2.3
Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 3 Postoperative wound infection.
Analysis 2.4
Analysis 2.4
Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 4 Composite wound complication.
Analysis 2.5
Analysis 2.5
Comparison 2 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of labor, Outcome 5 Composite wound complication or endometritis.
Analysis 3.1
Analysis 3.1
Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 1 Post‐cesarean endometritis.
Analysis 3.2
Analysis 3.2
Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 2 Postoperative fever.
Analysis 3.3
Analysis 3.3
Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 3 Postoperative wound infection.
Analysis 3.4
Analysis 3.4
Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 4 Composite wound complication.
Analysis 3.5
Analysis 3.5
Comparison 3 Vaginal preparation with antiseptic solution versus control (no preparation or saline preparation) ‐ stratified by presence of ruptured membranes, Outcome 5 Composite wound complication or endometritis.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

    1. Ahmed MR, Aref NK, Sayed Ahmed WA, Arain FR. Chlorhexidine vaginal wipes prior to elective cesarean section: does it reduce infectious morbidity? A randomized trial. Journal of Maternal‐Fetal & Neonatal Medicine 2017;30(12):1484‐7. - PubMed
    1. Asad S, Batool Mazhar S, Khalid Butt N, Habiba U. Vaginal cleansing prior to caesarean section and postoperative infectious morbidity. BJOG: an international journal of obstetrics and gynaecology 2017;124:45.
    1. Asghania M, Mirblouk F, Shakiba M, Faraji R. Preoperative vaginal preparation with povidone‐iodine on post‐caesarean infectious morbidity. Journal of Obstetrics and Gynaecology 2011;31(5):400‐3. - PubMed
    2. Asgharnia M. The effect of preoperative vaginal povidone iodine preparation on post cesarean infection. en.search.irct.ir/view/229 (date received 9 February 2009).
    1. Goymen A, Simsek Y, Ozdurak HI, Ozkaplan SE, Akpak YK, Ozdamar O, et al. Effect of vaginal cleansing on postoperative factors in elective caesarean sections: a prospective, randomised controlled trial. Journal of Maternal‐Fetal & Neonatal Medicine 2017;30(4):442‐5. - PubMed
    1. Guzman MA, Prien SD, Blann DW. Post‐cesarean related infection and vaginal preparation with povidone‐iodine revisited. Primary Care Update for OB/GYNS 2002;9(6):206‐9.

References to studies excluded from this review

    1. Abdallah AA. RETRACTED: Evaluation of the risk of postcesarean endometritis with preoperative vaginal preparation with povidone‐iodine: a randomized controlled study. Middle East Fertility Society Journal 2015;20(4):246‐50.
    2. Abdallah AA. Retraction notice to "evaluation of the risk of postcesarean endometritis with preoperative vaginal preparation with povidone‐iodine: a randomized controlled study" (middle east fertility society journal (2015) 20(4) (246‐250) (s1110569014200379) (10.1016/J.mefs.2015.03.002)). Middle East Fertility Society Journal 2017;22(3):240.

References to studies awaiting assessment

    1. Ghanbarpour A, IRCT2016061425292N6. Effect of vaginal preparation with povidone iodine on post cesarean infection in women admitted to hospital. http://en.search.irct.ir/view/30891 (first received 27 June 2016).
    1. Ghomian N, IRCT201105146467N1. Preoperative vaginal preparation with Povidone–Iodinand the risk of post cesarean endometritis. http://en.search.irct.ir/view/6008 (first received 16 June 2011).

References to ongoing studies

    1. Ben‐Asher H, NCT03093194. Vaginal antimicrobacterial preparation before cesarean section for endometritis prevention. clinicaltrials.gov/show/NCT03093194 (first received 12 March 2017).
    1. Bianco A, NCT03423147. Preoperative application of chlorhexidine to reduce infection with cesarean section after labor (PRACTICAL). clinicaltrials.gov/ct2/show/NCT03423147 (first received 6 February 2018).
    1. Irving B, NCT03133312. A single site prospective randomized controlled trial comparing chlorhexidine gluconate and povidone‐iodine as vaginal preparation antiseptics for cesarean section to determine effect on bacterial load. clinicaltrials.gov/ct2/show/NCT03133312 (first received 3 April 2017).
    1. Lakhi N, NCT02915289. Chlorhexidine gluconate vs povidone‐iodine vaginal cleansing solution prior to cesarean delivery: a randomized comparator controlled trial. clinicaltrials.gov/show/NCT02915289 (first received 23 September 2016).
    1. Riad AA, NCT02693483. Preoperative vaginal cleansing with povidone iodine and the risk of post cesarean endometritis. clinicaltrials.gov/ct2/show/NCT02693483 (first received 15 February 2016).

Additional references

    1. Betran AP, Ye J, Moller A‐B, Zhang J, Gulmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: global, regional and national estimates: 1990‐2014. PLOS One 2016;11(2):e0148343. - PMC - PubMed
    1. Caissutti C, Saccone G, Zullo F, Quist‐Nelson J, Felder L, Ciardulli A, et al. Vaginal cleansing before cesarean delivery: a systematic review and meta‐analysis. Obstetrics and Gynecology 2017;130(3):527‐38. - PubMed
    1. Carter EB, Temming LA, Fowler S, Eppes C, Gross G, Srinivas SK, et al. Evidence‐based bundles and cesarean delivery surgical site infections: a systematic review and meta‐analysis. Obstetrics and Gynecology 2017;130(4):735‐46. - PubMed
    1. Disgupta RK, Rao RS, Rjaram P, Natarajan MK. Anaerobic infections in pregnant women undergoing cesarean section and associated risk factors. Asia‐Oceania Journal of Obstetrics and Gynaecology 1988;14:437‐41. - PubMed
    1. Duignan NM, Lowe PH. Pre‐operative disinfection of the vagina. Journal of Antimicrobial Chemotherapy 1975;1(1):117‐20. - PubMed

References to other published versions of this review

    1. Haas DM, Al Darei S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2009, Issue 3. [DOI: 10.1002/14651858.CD007892] - DOI - PubMed
    1. Haas DM, Morgan Al Darei S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2010, Issue 3. [DOI: 10.1002/14651858.CD007892.pub2] - DOI - PubMed
    1. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2013, Issue 1. [DOI: 10.1002/14651858.CD007892.pub3] - DOI - PubMed
    1. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2014, Issue 9. [DOI: 10.1002/14651858.CD007892.pub4] - DOI - PubMed
    1. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2014, Issue 12. [DOI: 10.1002/14651858.CD007892.pub5] - DOI - PubMed

Publication types

MeSH terms