Gupta AS
Cesarean delivery rates are rising globally. WHO
recommends the optimal incidence to remain between 10 to 15% or
extended to 20% for adequate prevention of the mother and the child
and to prevent severe maternal morbidity and improve neonatal
outcome. However, facts
indicate a much higher incidence of cesarean births. In private
sectors incidence has touched almost
70% and in some hospitals in Brazil the incidence has touched 100%.
On an average 1 out of 3 or 1 out of 2 women give birth by cesarean
section.
Current pregnancy cesarean births are associated with post operative
postpartum hemorrhage, hollow organ injuries, anesthesia
complications, infectious morbidity that includes superficial and
deep wound infections, thromboembolic phenomena and even mortality.
Post cesarean section wound infection can cause severe morbidity and
even mortality. Obese women, women in prolonged labor, PROM, poor
aseptic techniques, uncontrolled diabetes, increased operative time
and excessive blood loss, are all factors that predispose to cesarean
section infectious morbidity. Nosocomial infections, cross infections
lead to serious infections. E. Coli and staphylococcus aureus are the
commonest organisms isolated. Reported incidence of post operative
sepsis after cesarean section that includes major causes like pelvic
infections, deep incision sepsis, or minor like superficial wound
sepsis, febrile morbidity or catheter associated urinary tract
infection ranges from 3.15% to 35.7%.
Superficial wound infections are commonly seen.
Deep incision sepsis is not a common feature. However, if the uterine
incision gets infected and breaks down then it can lead to pelvic or
generalized peritonitis and severe abdominal signs. Many times these
patients come back after discharge from the hospital with signs of
peritonitis and fever. These patients are morbidly sick and an
optimal treatment plan is required. Evaluation with ultrasonography
(3D), CT scan and MRI usually indicate the extent of the infection
and soft tissue injuries like uterine incision dehiscence or
breakdown. Broad spectrum parenteral antibiotics after sample
collection for cultures are started. Fluid electrolyte imbalances are
corrected. Blood gas analysis and their correction is required.
Correction of anemia by transfusion of packed red blood cellss
may also be needed. Large abdominal
generalized collections usually require drainage. In a very moribund
patient ultrasonography guided drains may be inserted. However, it is
more prudent to perform an exploratory laparotomy, drain the
collection, perform peritoneal lavage, insert drains. If the uterine
incision has broken down it may not be possible to repair it in the
presence of overwhelming infection. Loose hanging, broken sutures
should be excised and the edges freshened. It may be a difficult
decision to defer closure of the uterine wound. However, if the
tissue is not friable which it usually is then uterine incision may
be closed with interrupted sutures as continuous sutures may cut
through the friable tissue. Choice of suture material should be a non
reactive, mono-filament, delayed absorbable suture like PDS. However,
if the tissue is very friable then a decision for closure of the
abdomen without suturing the uterus with placement of
intra-peritoneal drains or a hysterectomy may have to be considered
(a preoperative counseling and consent should be obtained).
Hysterectomy would further add to the morbidity as it would open up
tissue planes and provide a path for the spread of the infection.
Once the patient stabilizes then the uterine incision may be seen to
have healed by secondary intention by imaging techniques. In these
cases of deep wound infection the integrity of the scar is suspect
and the patient should be warned against future pregnancies or
counseled regarding the grave but a real risk of scar rupture or
dehiscence and its associated consequences for self and for her baby.
Such advise and counseling should be properly documented in her case
record for future reference.
Overuse of cesarean deliveries, lifestyle changes resulting in
obesity, diabetes, casual attitude towards aseptic precautions, poor
infection control surveillance all form a perfect recipe for
postoperative cesarean sepsis.
We bring the eagerly awaited November issue with a collection of
interesting cases for our discerning readers.