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Meta-Analysis
. 2020 Apr 26;4(4):CD007892.
doi: 10.1002/14651858.CD007892.pub7.

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

David M Haas  1 , Sarah Morgan  2 , Karenrose Contreras  1 , Savannah Kimball  3
Affiliations
Meta-Analysis

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

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

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, twice in 2014, in 2017 and 2018.

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 the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (7 July 2019), and reference lists of retrieved studies.

Selection criteria: We included randomized controlled trials (RCTs) and quasi-RCTs 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-RCTs were eligible for inclusion, but we did not identify any. 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. We included trials published in abstract form only if sufficient information was present in the abstract on methods and outcomes to analyze.

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 21 trials, reporting results for 7038 women evaluating the effects of vaginal cleansing (17 using povidone-iodine, 3 chlorhexidine, 1 benzalkonium chloride) on post-cesarean infectious morbidity. Trials used vaginal preparations administered by sponge sticks, douches, or soaked gauze wipes. The control groups were typically no vaginal preparation (17 trials) or the use of a saline vaginal preparation (4 trials). One trial did not report on any outcomes of interest. Trials were performed in 10 different countries (Saudi Arabia, Pakistan, Iran, Thailand, Turkey, USA, Egypt, UK, Kenya and India). The overall risk of bias was low for areas of attrition, reporting, and other bias. About half of the trials had low risk of selection bias, with most of the remainder rated as unclear. Due to lack of blinding, we rated performance bias as high risk in nearly one-third of the trials, low risk in one-third, and unclear in one-third. Vaginal preparation with antiseptic solution immediately before cesarean delivery probably reduces the incidence of post-cesarean endometritis from 7.1% in control groups to 3.1% in vaginal cleansing groups (average risk ratio (aRR) 0.41, 95% confidence interval (CI) 0.29 to 0.58; 20 trials, 6918 women; moderate-certainty evidence). This reduction in endometritis was seen for both iodine-based solutions and chlorhexidine-based solutions. Risks of postoperative fever and postoperative wound infection are also probably reduced by vaginal antiseptic preparation (fever: aRR 0.64, 0.50 to 0.82; 16 trials, 6163 women; and wound infection: RR 0.62, 95% CI 0.50 to 0.77; 18 trials, 6385 women; both moderate-certainty evidence). Two trials found that there may be 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; 2 trials, 499 women; low-certainty evidence). No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing. Subgroup analysis suggested a greater effect with vaginal preparations for those women in labour versus those not in labour for four out of five outcomes examined (post-cesarean endometritis; postoperative fever; postoperative wound infection; composite wound complication or endometritis). This apparent difference needs to be investigated further in future trials. We did not observe any subgroup differences between women with ruptured membranes and women with intact membranes.

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, postoperative fever, and postoperative wound infection. Subgroup analysis found that these benefits were typically present whether iodine-based or chlorhexidine-based solutions were used and when women were in labor before the cesarean. The suggested benefit in women in labor needs further investigation in future trials. There was moderate-certainty evidence using GRADE for all reported outcomes, with downgrading decisions based on limitations in study design or imprecision. As a simple intervention, providers may consider implementing preoperative vaginal cleansing with povidone-iodine or chlorhexidine before performing cesarean deliveries. Future research on this intervention being incorporated into bundles of care plans for women receiving cesarean delivery will be needed.

Trial registration: ClinicalTrials.gov NCT00386477 NCT01437228 NCT02915289 NCT03133312 NCT03925155 NCT03442218 NCT03640507 NCT02495753 NCT02693483 NCT03093194 NCT03397615 NCT03423147.

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Conflict of interest statement

David Haas is the Principal Investigator for a randomized trial included in this review (Haas 2010). He holds grants from the US National Insitute of Health for work unrelated to this review. 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 Kimball has no financial conflicts of interest to disclose.

Figures

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

Ahmed 2017 {published data only}
    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
Aref 2019 {published data only}
    1. Aref NK. Vaginal cleansing prior to caesarian section: to do or not to do?: A randomized trial. Journal of Gynecology Obstetrics and Human Reproduction 2019;48(1):65-8. - PubMed
Asad 2017 {published data only}
    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.
Asghania 2011 {published data only}
    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
    1. Asghania M. The effect of preoperative vaginal povidone iodine preparation on post cesarean infection. irct.ir/trial/441 (date received 9 February 2009).
Barat 2016 {published data only}
    1. Barat S, Bouzari Z, Ghanbarpour A, Zabihi Z. Impact of preoperative vaginal preparation with povidone iodine on post cesarean infection. Caspian Journal of Reproductive Medicine 2016;2:2-8.
Charoenviboonphan 2011 {published data only}
    1. Charoenviboonphan P. Preoperative vaginal painting with 1% povidone-iodine before cesarean delivery to reduce postoperative febrile morbidity: a randomized control trial. Region 4-5 Medical Journal 2011;30:117-214.
Goymen 2017 {published data only}
    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
Guzman 2002 {published data only}
    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.
Haas 2010 {published data only}
    1. Haas DM, Pazouki F, Smith RR, Fry AM, Podzielinski I, Al-Darei SM, et al. Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial. American Journal of Obstetrics and Gynecology 2010;202(3):310.e1-6. - PubMed
    1. NCT00386477. Vaginal cleansing at cesarean delivery to reduce infection: a randomized, controlled trial. clinicaltrials.gov/ct2/show/NCT00386477 (first received 9 October 2006).
Hassan 2016 {published data only}
    1. Hassan Khedr N, Fadel E. Effect of prophylactic preoperative nursing interventions on prevention of endometritis among women undergoing elective cesarean delivery. Journal of Nursing Education and Practice 2016;6(12):142-8.
Hodgetts 2019 {published data only}
    1. Hodgetts Morton V, Hewitt C, Wilson A, Dixon E, Farmer N, Hardy P, et al. Preps: vaginal preparation at caesarean section to reduce endometritis and prevent sepsis: a randomised feasibility study of chlorhexidine. BJOG: an international journal of obstetrics and gynaecology 2019;126:11-2.
    1. Hodgetts Morton V, Wilson A, Hewitt C, Weckesser A, Farmer N, Lissauer D, et al. Chlorhexidine vaginal preparation versus standard treatment at caesarean section to reduce endometritis and prevent sepsis-a feasibility study protocol (the preps trial). Pilot and Feasibility Studies 2018;4:84. - PMC - PubMed
    1. ISRCTN33435996. Vaginal preparation at caesarean section. www.isrctn.com/ISRCTN33435996 (first received 10 July 2017).
    1. Morton VH, Hewitt CA, Dixon E, Wilson A, Farmer N, Hardy P, et al. Preps: vaginal preparation at caesarean section to reduce endometritis and prevent sepsis: a feasibility study of chlorhexidine. BJOG: an international journal of obstetrics and gynaecology 2019;126(6):e135.
Kiani 2018 {published data only}
    1. Kiani SA, Zafar M, Yasmin S, Mazhar SB. Vaginal cleansing prior to cesarean section and post-operative infectious morbidity. Journal of the Society of Obstetrics and Gynaecologists of Pakistan 2018;8(2):95-9.
Memon 2011 {published data only}
    1. Memon S, Qazi RA, Bibi S, Parveen N. Effect of preoperative vaginal cleansing with an antiseptic solution to reduce post caesarean infectious morbidity. Journal of the Pakistan Medical Association 2011;61(12):1179-83. - PubMed
Mohamed 2015 {published data only}
    1. Mohamed H, Hassan S, Hemida R. Vaginal preparation with antiseptic solution before cesarean section for reducing postpartum morbidity. IOSR Journal of Nursing and Health Science 2015;4(3):75-80.
Mwangi 2013 {published data only}
    1. Karanja M, Oyieke JB, Kinuthia J. Effect of preoperative vaginal cleansing with povidone iodine on post-caesarean maternal infections at Kenyatta National Hospital; a randomized controlled trial. Journal of Obstetrics and Gynecology of East and Central Africa 2017;29(2):10-1.
    1. Mwangi KD. Effect of Preoperative Vaginal Cleansing with Povidone Iodine on Post-caesarean Maternal Infections at Kenyatta National Hospital; a randomized controlled trial [thesis]. Nairobi: University of Nairobi, 2013.
Nandi 2015 {published data only}
    1. Nandi J, Saha D, Pal S, Barman S, Mitra A. Antiseptic vaginal preparation before cesarean delivery to reduce post operative infection: a randomised controlled trial. Journal of Medical Science and Clinical Research 2015;3(2):4310-5.
Olmez 2013 {published data only}
    1. Olmez H, Dugan N, Sudolmus S, Fendal Tunca A, Yetkin Yildirim G, Gulkilik A. Does vaginal preparation with povidone-iodine prior to cesarean delivery reduce the risk of endometritis. Jinekoloji Obstetrik Pediatri ve Pediatrik Cerrahi Dergisi 2013;5(2):81-8.
Reid 2001 {published data only}
    1. Reid GC, Hartmann KE, MacMahon MJ. Can postpartum infectious morbidity be decreased by vaginal preparation with povidone iodine prior to cesarean delivery? American Journal of Obstetrics and Gynecology 2000;182(1 Pt 2):S96.
    1. Reid VC, Hartmann KE, McMahon M, Fry EP. Vaginal preparation with povidone iodine and postcesarean infectious morbidity: a randomized controlled trial. Obstetrics & Gynecology 2001;97(1):147-52. - PubMed
Rouse 1997 {published data only}
    1. Rouse DJ, Hauth JC, Andrews WW, Mills BB, Maher JE. Chlorhexidine vaginal irrigation for the prevention of peripartal infection: a placebo-controlled randomized clinical trial. American Journal of Obstetrics and Gynecology 1997;176(3):617-22. - PubMed
Starr 2005 {published data only}
    1. Agbunag R. Preoperative vaginal preparation with povidone-iodine decreases the risk of post-cesarean endometritis. American Journal of Obstetrics and Gynecology 2001;184(1):S182.
    1. Starr RV, Zurawski J, Ismail M. Preoperative vaginal preparation with povidone-iodine and the risk of postcesarean endometritis. Obstetrics & Gynecology 2005;105(5 Pt 1):1024-9. - PubMed
Yildirim 2012 {published data only}
    1. NCT01437228. Does preoperative vaginal preparation with povidone-iodine before cesarean delivery reduce the risk of endometritis? clinicaltrials.gov/ct2/show/record/NCT01437228 (first received 6 September 2011).
    1. Yildirim G, Gungorduk K, Asicioglu O, Basaran T, Temizkan O, Davas I, et al. Does vaginal preparation with povidone-iodine prior to caesarean delivery reduce the risk of endometritis A randomized controlled trial. Journal of Maternal-Fetal and Neonatal Medicine 2012;25(11):2316-21. - PubMed

References to studies excluded from this review

Abdallah 2015 {published data only}
    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.
    1. 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.
Dudko 2018 {published data only}
    1. Dudko Y, Moretti ML, Lakhi NA. Vaginal cleansing with either chlorhexidine gluconate or povidone-iodine prior to cesarean delivery. International Journal of Gynecology and Obstetrics 2018;143(S3):299-300.
Lakhi 2016 {published data only}
    1. Lakhi NA, Tricorico G, Osipova Y, Moretti ML. Vaginal cleansing with chlorhexidine gluconate or povidone-iodine prior to cesarean delivery: a randomized comparator-controlled trial. American Journal of Obstetrics & Gynecology MFM 2019;1(1):2-9. - PubMed
    1. 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).
NCT03133312 {published data only}
    1. 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).
NCT03925155 {published data only}
    1. NCT03925155. A randomized trial to investigate if a pre-operative wash with chlorhexidine vs povidone-iodine vaginal scrub decreases infectious morbidity in patients undergoing cesarean section after ruptured membranes. clinicaltrials.gov/ct2/show/NCT03925155 (first received 24 April 2019).
Pitt 2001 {published data only}
    1. Pitt C, Sanchez-Ramos L, Kaunitz AM. Adjunctive intravaginal metronidazole for the prevention of postcesarean endometritis: a randomized controlled trial. Obstetrics and Gynecology 2001;98(5):745-50. - PubMed
Sweeten 1997 {published data only}
    1. Sweeten KM, Eriksen NL, Blanco JD. Chlorhexidine versus sterile water vaginal wash during labor to prevent peripartum infection. American Journal of Obstetrics and Gynecology 1997;176:426-30. - PubMed
Tewfik 2015 {published data only}
    1. Tewfik H, Ibrahim A, Hanafi S, Fahmy AK, Abdelazim IA. Preoperative vaginal preparation using povidone iodine versus chlorhexidine solutions in prevention of endometritis in elective cesarean section. International Journal of Currrent Microbiology and Applied Sciences 2015;4(8):486-92.

References to studies awaiting assessment

IRCT201105146467N1 {published data only}
    1. IRCT201105146467N1. Preoperative vaginal preparation with Povidone–Iodinand the risk of post cesarean endometritis. en.irct.ir/trial/6902 (first received 16 June 2011).
IRCT2016061425292N6 {published data only}
    1. IRCT2016061425292N6. Effect of vaginal preparation with povidone iodine on post cesarean infection in women admitted to hospital. en.irct.ir/trial/21184 (first received 27 June 2016).
NCT03442218 {published data only}
    1. NCT03442218. Use of antiseptic solution for vaginal wash before cesarean section. clinicaltrials.gov/ct2/show/NCT03442218 (first received 22 February 2018).
NCT03640507 {published data only}
    1. NCT03640507. Vaginal preparation with chlorhexidine-alcohol vs. povidine-iodine vs. saline. clinicaltrials.gov/ct2/show/NCT03640507 (first received 21 August 2018).

References to ongoing studies

NCT02495753 {published data only}
    1. NCT02495753. Vaginal cleansing before cesarean delivery to reduce infection: a randomized trial. clinicaltrials.gov/ct2/show/NCT02495753 (first received 13 July 2015).
NCT02693483 {published data only}
    1. NCT02693483. Preoperative vaginal cleansing with povidone iodine and the risk of post cesarean endometritis. clinicaltrials.gov/ct2/show/NCT02693483 (first received 15 February 2016).
NCT03093194 {published data only}
    1. NCT03093194. Vaginal antimicrobacterial preparation before cesarean section for endometritis prevention. clinicaltrials.gov/show/NCT03093194 (first received 12 March 2017).
NCT03397615 {published data only}
    1. NCT03397615. Effect of vaginal douching with betadine versus non douching before CS for prevention of post operative infections. clinicaltrials.gov/ct2/show/NCT03397615 (first received 12 January 2018).
NCT03423147 {published data only}
    1. NCT03423147. Preoperative application of chlorhexidine to reduce infection with cesarean section after labor (PRACTICAL). clinicaltrials.gov/ct2/show/NCT03423147 (first received 6 February 2018).
PACTR201709002597110 {published data only}
    1. PACTR201709002597110. Effectiveness of preoperative vaginal cleansing with povidone-iodine in post-caesarean infectious morbidity; a randomized controlled trial. pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=2597 (first received 8 September 2017).

Additional references

ACOG 2018
    1. American College of Obstetricians and Gynecologists. Prevention of infection after gynecologic procedures. ACOG Practice Bulletin No. 195. Obstetrics and Gynecology 2018;131:e172-89. - PubMed
Betran 2016
    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
Briscoe 2019
    1. Briscoe KE, Haas DM. Developing a core outcome set for cesarean delivery maternal infectious morbidity outcomes. American Journal of Perinatology 2019 Feb 28 [Epub ahead of print]. [DOI: 10.1055/s-0039-1681095] - DOI - PubMed
Caissutti 2017
    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
Carter 2017
    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
Caughey 2018
    1. Caughey AB, Wood SL, Macones GA, Wrench IJ, Huang J, Norman M, et al. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2). American Journal of Obstetrics and Gynecology 2018;219:533-44. - PubMed
Disgupta 1988
    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
Duignan 1975
    1. Duignan NM, Lowe PH. Pre-operative disinfection of the vagina. Journal of Antimicrobial Chemotherapy 1975;1(1):117-20. - PubMed
Gibbs 1982
    1. Gibbs RS, Blanco JD, St Clair PJ, Castanda YS. Vaginal colonization with resistant aerobic bacteria after antibiotic therapy for endometritis. American Journal of Obstetrics and Gynecology 1982;142(2):130-4. - PubMed
GRADEpro GDT 2015 [Computer program]
    1. McMaster University (developed by Evidence Prime) GRADEpro GDT. Version accessed prior to 20 February 2020. Hamilton (ON): McMaster University (developed by Evidence Prime).Available at gradepro.org.
Graham 1993
    1. Graham JM, Blanco JD, Oshiro BT, Magee KP, Monga M, Eriksen N. Single-dose ampicillin prophylaxis does not eradicate enterococcus from the lower genital tract. Obstetrics and Gynecology 1993;81:115-7. - PubMed
Haeri 1976
    1. Haeri AD, Kloppers LL, Forder AA, Baillie P. Effect of different pre-operative vaginal preparations on morbidity of patients undergoing abdominal hysterectomy. South African Medical Journal 1976;50(49):1984-6. - PubMed
Higgins 2011
    1. Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Hsu 2016
    1. Hsu CD, Cohn I, Caban R. Reduction and sustainability of cesarean section surgical site infection: An evidence-based, innovative, and multidisciplinary quality improvement intervention bundle program. American Journal of Infection Control 2016;44(11):1315-20. - PubMed
Mackeen 2014
    1. Mackeen AD, Packard RE, Ota E, Berghella V, Baxter JK. Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. Cochrane Database of Systematic Reviews 2014, Issue 12. [DOI: 10.1002/14651858.CD009516.pub2] - DOI - PMC - PubMed
Mackeen 2015
    1. Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database of Systematic Reviews 2015, Issue 2. [DOI: 10.1002/14651858.CD001067.pub3] - DOI - PMC - PubMed
Martens 1991
    1. Martens MG, Faro S, Maccato M, Riddle G, Hammill HA. Susceptibility of female pelvic pathogens to oral antibiotic agents in patients who develop postpartum endometritis. American Journal of Obstetrics and Gynecology 1991;164(5 Pt 2):1383-6. - PubMed
NICE 2011
    1. National Institute for Health and Care Excellence. NICE Guidance: Caesarean section [CG132]. www.nice.org.uk 2011. - PubMed
Olsen 2010
    1. Olsen MA, Butler AM, Willers DM, Gross GA, Hamilton BH, Fraser VJ. Attributable costs of surgical site infection and endometritis after low transverse cesarean delivery. Infection Control and Hospital Epidemiology 2010;31:276-82. - PMC - PubMed
Osborne 1977
    1. Osborne NG, Wright RC. Effect of preoperative scrub on the bacterial flora of the endocervix and vagina. Obstetrics and Gynecology 1977;50:148-51. - PubMed
Review Manager 2014 [Computer program]
    1. Nordic Cochrane Centre, The Cochrane Collaboration Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Schünemann 2013
    1. Schünemann H, Brożek J, Guyatt G, Oxman A, editor(s). Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach (updated October 2013). GRADE Working Group, 2013. Available from gdt.guidelinedevelopment.org/app/handbook/handbook.html.
Smaill 2014
    1. Smaill FM, Grivell RM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database of Systematic Reviews 2014, Issue 10. [DOI: 10.1002/14651858.CD007482.pub3] - DOI - PMC - PubMed
Stiver 1984
    1. Stiver HG, Forward KR, Tyrrell DL, Krip G, Livingstone RA, Fugere P, et al. Comparative cervical microflora shifts after cefoxitin or cefazolin prophylaxis against infection following cesarean section. American Journal of Obstetrics and Gynecology 1984;149(7):718-21. - PubMed
Watts 1991
    1. Watts DH, Hillier SL, Eschenbach DA. Upper genital tract isolates at delivery as predictors of post-cesarean infections among women receiving antibiotic prophylaxis. Obstetrics and Gynecology 1991;77(2):287-92. - PubMed
Yokoe 2001
    1. Yokoe DS, Christiansen CL, Johnson R, Sands KE, Livingston J, Shtatland ES, et al. Epidemiology of and surveillance for postpartum infections. Emerging Infectious Diseases 2001;7(5):837-41. - PMC - PubMed
Yonekura 1985
    1. Yonekura ML. Risk factors for postcesarean endomyometritis. American Journal of Medicine 1985;78(6 Suppl 2):177-87. - PubMed
Zuarez‐Easton 2017
    1. Zuarez-Easton S, Zafran N, Garmi G, Salim R. Postcesarean wound infection: prevalence, impact, prevention, and management challenges. International Journal of Women's Health 2017;9:81-8. - PMC - PubMed

References to other published versions of this review

Haas 2009
    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
Haas 2010a
    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
Haas 2013
    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
Haas 2014a
    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
Haas 2014b
    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
Haas 2018
    1. Haas DM, Morgan S, Contreras K, Enders S. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2018, Issue 7. [DOI: 10.1002/14651858.CD007892.pub6] - DOI - PMC - PubMed

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