Evidence-Based Project

Complete:

1. Title of the article: infection among women undergoing C section in the hospital.

2. APA reference for the article:

Answer the following questions. Responses for each question should be at least 100 words, but no more than 200 words. Please type your responses using 12-point font and double-spaced.

1. What is the problem that the research is addressing?

1. Why is this problem significant to nursing practice?

1. Summarize the findings from this research article.

1. Describe the recommendation (s) for nursing practice.

o r i g i n a l a r t i c l e

Practices to Reduce Surgical Site Infections Among Women
Undergoing Cesarean Section: A Review

Rebeccah A. McKibben, MPH;1 Samantha I. Pitts, MD;1 Catalina Suarez-Cuervo, MD;2 Trish M. Perl, MD, MSc;1,2

Eric B. Bass, MD1,2

objective. Surgical site infections (SSIs) are a leading cause of morbidity and mortality among women undergoing cesarean section
(C-section), a common procedure in North America. While risk factors for SSI are often modifiable, wide variation in clinical practice exists.
With this review, we provide a comprehensive overview of the results and quality of systematic reviews and meta-analyses on interventions to
reduce surgical site infections among women undergoing C-section.

methods. We searched PubMed and the Cochrane Database of Systematic Reviews for systematic reviews and meta-analyses published
between January 2000 and May 2014 on interventions to reduce the occurrence of SSIs (incisional infections and endometritis), among women
undergoing C-section. We extracted data on the interventions, outcomes, and strength of evidence as determined by the original article authors,
and assessed the quality of each article based on a modified Assessment of Multiple Systematic Reviews tool.

results. A total of 30 review articles met inclusion criteria and were reviewed. Among these articles, 77 distinct interventions were evaluated:
29% were supported with strong evidence as assessed by the original article authors, and 83% of the reviews articles were classified as good
quality based on our assessment. Ten interventions were classified as being effective in reducing SSI with strong evidence in a good-quality
article, including preoperative vaginal cleansing, the use of perioperative antibiotic prophylaxis, and several surgical techniques.

conclusion. Efforts to reduce SSI rates among women undergoing C-section should include interventions such as preoperative vaginal
cleansing and the use of perioperative antibiotics because compelling evidence exists to support their effectiveness.

Infect Control Hosp Epidemiol 2015;36(8):915–921

Almost 30% of births in the developed world are by cesarean
section (C-section), making this an extremely common pro-
cedure performed in almost every hospital.1 Surgical site
infections (SSIs), including both incisional infection and
endometritis, are a leading cause of morbidity following
C-section.2–4 This procedure is associated with increased
mortality, higher rehospitalization rate, longer length of stay,
and greater healthcare costs.5–9 The rate of SSI following
C-section ranges from 3% to 15%, depending on the surveil-
lance method and patient population.10 According to the 2009
National Healthcare Safety Network (NHSN) report, the
pooled risk-adjusted mean rates of SSI after C-section from
2006 to 2008 were 1.5%, 2.4%, and 3.8%, depending on the
presence and number of risk factors.11

Clinical trials have revealed ways to reduce SSI rates after
C-section based on the risk factors for developing an SSI; many
SSIs are preventable with proper perioperative preparation and
surgical technique.12–17 However, wide variation in clinical
practice exists because techniques employed in C-section

often depend on the clinical situation and the surgeon’s
preference.18 A comprehensive synthesis based on evidence-
based techniques will help to increase the consistency and
frequency with which clinicians employ best practices to
reduce SSI after C-section.19

In this analysis, we systematically reviewed the results and
quality of systematic reviews and meta-analyses regarding the
impact of practices designed to reduce SSI rates among
women undergoing C-section. These findings highlight stra-
tegies that provide a strong evidence base for reducing SSIs
after C-section.

methods

The protocol for our systematic review was based on the
Methods Guide for Effectiveness and Comparative Effectiveness
Reviews from the Agency for Healthcare Research and Quality
(AHRQ).20 The analytic framework of this review is shown in
Figure 1.

Affiliations: 1. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; 2. Johns Hopkins Bloomberg School of
Public Health, Baltimore, Maryland.

© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2015/3608-0007. DOI:

10.1017/ice.2015.116

Received March 12, 2015; accepted April 28, 2015; electronically published May 20, 2015

infection control & hospital epidemiology august 2015, vol. 36, no. 8

Data Sources and Selection

Two members of our study team searched PubMed and the
Cochrane Database of Systematic Reviews for systematic
reviews and meta-analyses of interventions to reduce the rate
of SSIs among women undergoing C-section in the United
States, as either a primary or secondary outcome. We used the
Center for Disease Control’s NHSN’s definition of SSI, which
is stratified by superficial incisional SSI, deep incisional SSI,
and organ/space SSI.21 To review the most recent data, the
study search was limited to English-language articles published
between January 1, 2000, and May 1, 2014. Eligible compara-
tors included placebo, no treatment, or standard of care.
We included reviews of women undergoing C-section among
other surgical populations if the data were separately identifi-
able. The reviewers screened articles identified in our search by
title and abstract for subsequent full-text review of eligibility,
and reference lists of pertinent systematic reviews or meta-
analyses were used to identify additional reports. We did not

attempt to identify unpublished articles or contact study
authors. The full PubMed search strategy is shown in Table 1.

Data Extraction and Quality Assessment

Two reviewers independently extracted data from the included
review articles (ie, including the interventions, outcomes, and
strength of evidence) and independently assessed the quality of
the reviews using standardized data collection tools. The
quality of included reviews was determined using a modified
version of the Assessment of Multiple Systematic Reviews
(AMSTAR) tool.22 Modifications to the AMSTAR tool were
made to clarify the quality assessment criteria and standardize
the analysis (Table 2). A third party resolved discrepancies
between the 2 reviewers to reach a decision that all 3 authors
endorsed.
The reviewers classified the strength of evidence as “strong”

or “weak” based on the conclusions by the authors of the
original article, taking into account the original authors’

figure 1. Analytic framework for systematic review.

916 infection control & hospital epidemiology august 2015, vol. 36, no. 8

assessment of the amount of evidence, sample sizes, study
designs, and potential risk of bias in the studies. The quality
assessment criteria from the modified AMSTAR tool
were classified as either “major” or “minor.” The 4 major
quality assessment criteria included duplicate data extraction
(criterion 2b), a literature search performed on at least
2 databases (criterion 3), a list of included studies (criterion 5a),
and the rating and documentation of the scientific quality of
included studies (criterion 7). The other 8 criteria in the
modified AMSTAR tool were classified as minor quality assess-
ment criteria.

To determine whether a review met the minor quality
assessment criteria regarding characteristics of the included
studies (study design [6a], intervention [6c], comparison
group [6d], and outcome [6e]), we used the following system:
“yes” if all included studies in the review satisfied the criterion;
“some” if at least 1, but not all, studies in the review satisfied
the criterion; and “no” if none of the included studies satisfied
the criterion. When determining whether a review met the
minor quality assessment criterion concerning the population
of the included studies (criterion 6b), we used the following
system: “yes” if most included studies reported ≥2 of
3 population variables (eg, age, elective vs emergency
C-section, and primary vs repeat C-section); “some” if at least
1 study, but not all, reported >1 of the population variables;
and “no” if none of the included studies reported >1 of the
population variables. When determining whether a review
met the minor quality assessment criteria regarding grading
the strength of evidence of the included studies (criterion 9),
we used the following system: “yes” if the grading addressed
the risk of bias, consistency, directness, and precision of
evidence; “some” if the grading addressed only 3 of those
4 domains of the evidence; and “no” if the grading addressed
<3 of those 4 domains of evidence. The use of a random- effects model in the analysis was sufficient to satisfy the minor criteria for combining results quantitatively (criterion 10a). The overall quality of the review was determined using the definitions outlined in Table 3.

table 1. PubMed Search Strategy

Search String No. of Results

1 “wound infection”[mh] 37,094
2 “wound infection [tiab] 12,663
3 “surgical wound infection”[mh] 28,241
4 “surgical wound infection”[tiab] 640
5 “obstetric infection”[tiab] 13
6 “surgical site infection”[tiab] 2,625
7 #1 OR #2 OR #3 OR #4 OR #5 OR #6 45,558
8 cesarean delivery[tiab] 6,630
9 cesarean section[mh] 35,066
10 cesarean section[tiab] 19,156
11 #8 OR #9 OR #10 10,960
12 #7 AND #11 908

NOTE. mh, mesh; tiab, title and abstract.

table 2. Modified Version of the Assessment of Multiple Systematic Reviews Quality Assessment Tool

Item No. Criterion

1 Was an ‘a priori’ design involved?
2a Was there duplicate study selection?
2b Was there duplicate data extraction?
3 Was a literature search performed on at least 2 databases including MedLine or PubMed?
4 Was the review limited to publications in peer-reviewed journals?

(If “no”, go to 4a)
4a Was regulatory data used?
4b Were data from clinical trial registries used?
4c Were data from conference papers/abstracts used?
5a Was a list of included studies provided?
5b Was a list of excluded studies provided?
6a Was the study design of included studies provided?
6b Was the population of included studies provided (age; elective vs emergency; repeat vs non-repeat)?
6c Was the intervention in included studies provided?
6d Was the comparison group in included studies provided?
6e Was the outcome of the included studies provided?
7 Was the scientific quality of the included studies rated and documented?
8a Did researchers use assessment of study quality to select and exclude studies?
8b Did researchers report how findings varied according to study quality?
9 Was the strength of overall body of evidence graded using risk of bias, consistency, directness, and precision of evidence?
10a Were results combined quantitatively?
10b Did researchers demonstrate sufficient homogeneity to justify meta-analyses?
11 Was the likelihood of publication bias assessed?
12 Do the authors report on potential conflicts of interest?

surgical site infections in cesarean sections 917

results

The search identified 908 citations, of which 65 full-text
articles were further reviewed after title and abstract screening.
A total of 30 review articles met the inclusion criteria for the
final analysis (Figure 2).23–45

Data Extraction Results

The interventions, outcomes, and strength of evidence
from each article as assessed by its authors are outlined in
Supplementary Table 1. Four articles reviewed preoperative

cleansing techniques to reduce SSIs. A total of 10 articles
reviewed the use, type, and timing of antibiotic prophylaxis to
reduce SSIs, and 23 articles reviewed different intraoperative
surgical techniques to reduce SSIs, including incision type,
skin and uterine incision closure, and placenta removal. Of all
the articles we reviewed, 5 articles reviewed the use of drains to
reduce the occurrence of SSIs, 1 article reviewed SSI outcome
related to venous thromboembolism prevention, and 2 articles
reviewed the use of supplemental oxygen to reduce the
occurrence of SSIs.
Based on our quality assessment, 25 review articles were

graded as good quality (83%) and 5 articles were graded as fair
quality (17%). No articles received a poor quality rating.
The majority of the 30 review articles met our 4 major quality

assessment indicators: (1) duplicate and independent data
extraction (63%), (2) a literature search performed on at least
2 different databases (93%), (3) a list of included studies (93%),
and (4) the rating and documentation of the quality of included
studies (63%). Most articles provided an a priori design (60%),
performed duplicate and independent data selection (60%),
combined results quantitatively (87%), and reported potential
conflicts of interests (60%). Studies published outside of
peer-reviewed journals comprised (63%) of the total reviews,
and most of those (84%) used data from both clinical registries

Literature search performed and
citations screened as described in

“Methods”
N=908 Excluded at title or abstract level

n=843

• Ineligible study design (not
reviews): 309

• No surgical site of interest: 16
• No Cesarean section surgery

group or sub-group: 1
• Non-English study: 7
• Study published before 2000:

510

Full-text articles assessed
n=65

Excluded at full-text article level
n=35

• Ineligible study design: 19
• Lack of relevance: 5
• No surgical site of interest: 9
• No Cesarean section surgery

group or sub-group: 1
• Ineligible comparison group: 1

ARTICLES INCLUDED
n=30

figure 2. Study search flow diagram.

table 3. Grading System for Overall Quality Assessment of
Included Reviewsa

Quality Assessment Definition

Good ≥2 major criteria and ≥4 minor criteria
Fair <2 major criteria and >3 minor criteria

or
>1 major criteria and <4 minor criteria

Poor <2 major criteria and <4 minor criteria

aAny quality assessment major or minor criteria that were classified as
“yes, unknown” or “some” were counted as equivalent to “yes” when
tabulating an overall rating for the review.

918 infection control & hospital epidemiology august 2015, vol. 36, no. 8

and conference papers and/or abstracts. Most articles included
descriptions of the design (93%), intervention (87%), outcomes
(87%), and comparison group (63%) in the included studies.
Half of the articles justified meta-analyses on the basis of an
assessment that included studies were similar enough to merit
combining their results quantitatively.

Fewer than half of the review articles included a list of
excluded studies (47%) or graded the strength of the overall
body of evidence using at least 3 of 4 domains (ie, risk of bias,
consistency, directness, and precision of evidence; 40%). Only
23% of review articles included either some or any important
information about the study populations (eg, age, primary
vs repeat C-section, or elective vs emergent C-section). Articles
rarely reported how findings varied with study quality (13%)
or assessed the likelihood of publication bias (23%). Only
1 article (3%) used study quality as an eligibility criterion.

Strength of Evidence of Intervention and Quality Assessment
Synthesis

Only 22 of the 77 distinct interventions (29%) were classified
as having “strong” strength of evidence by the authors of the
article. Most of the interventions (71%) were classified as
having a “weak” evidence base by the original authors of the
article.

Among the review articles that met our criteria for good
quality, 13 practices were classified as having “strong” strength
of evidence by the authors. Of these, interventions in 10 good-
quality articles were shown to be effective in reducing SSI rates.
These interventions included preoperative vaginal cleansing,
perioperative antibiotic prophylaxis, and several surgical
techniques: (1) Joel-Cohen was superior to Pfannenstiel
incision; (2) suture closure of skin was superior to staple clo-
sure; (3) suture closure of subcutaneous tissue with thickness
>2 cm was superior to nonclosure; and (4) cord traction was
superior to manual removal for placental delivery.

Four interventions with strong evidence in good-quality
articles did not significantly reduce the risk of developing an
SSI relative to their comparator: (1) the use of multiple vs
single doses of perioperative antibiotics; (2) the use of systemic
vs lavage administration of perioperative antibiotics; (3) the
choice of perioperative antibiotics, whether ampicillin or a
cephalosporin; and (4) the use of subcutaneous drains.
A good-quality article with strong evidence also showed that
the disruption of the muscle beds increased the risk of SSI, and
this risk was equivalent to that associated with Pfannenstiel
incision.

Four interventions were shown to be effective in reducing
SSIs rates with strong evidence by the authors of the articles,
but the review articles were rated as having only fair quality in
our quality assessment. These included the use of perioperative
antibiotic prophylaxis (as mentioned above, a good-quality
article also found strong evidence on the effectiveness of this
intervention); antibiotic prophylaxis administration before
surgical incision compared to after cord clamping; delivery of

placenta with cord traction compared to manual removal; and
the use of subcutaneous drains in women with subcutaneous
tissue thickness >2 cm.
Multiple interventions reported in good-quality articles were

equally as effective in reducing the occurrence of SSIs, and
notably had weak strength of evidence: the administration of
prophylactic antibiotics prior to surgical incision compared to
after cord clamping (as mentioned above, a fair quality article
found strong evidence on the effectiveness of this intervention);
the use of extended-spectrum penicillin compared to cepha-
losporin antibiotics; the use of third-generation cephalosporin
compared to aminopenicillin antibiotics; the use of extended-
spectrum antibiotics compared with narrow-spectrum anti-
biotics; the use of suture closure of the skin compared with
staple closure (as mentioned above, a good-quality article found
strong evidence on the greater effectiveness of suture closure
compared to staple closure); nonclosure of the visceral perito-
neum compared with closure of the visceral and parietal peri-
toneum; and use of subsheath drains compared with
subcutaneous drains.

discussion

We used a structured process and systematic methods to
identify evidence-based practices that have been shown to
reduce the occurrence of SSIs among women undergoing
C-section. In summary, this overview demonstrates a robust
evidence base for the effectiveness of the following practices to
reduce SSIs: preoperative vaginal cleansing, perioperative
antibiotic prophylaxis, the Joel-Cohen surgical incision, suture
closure for both the skin and subcutaneous tissue >2 cm, and
cord traction for placenta delivery. Surprisingly, no systematic
reviews among women undergoing C-section have addressed
the effectiveness of hair removal or skin preparation in redu-
cing SSIs, although these interventions have been assessed in
other surgical populations.46,47 While the majority of review
articles included in this analysis were of good quality, only
~50% of the interventions from good-quality articles had
strong strength of evidence of effectiveness as assessed by the
original authors of the article, suggesting the need for robust
studies on the safety and effectiveness of pre-, intra- and
postoperative interventions to reduce SSIs.
Our review has important strengths and limitations.

Given the variation in practice and opinions, importantly,
2 independent reviewers identified reviews for inclusion,
extracted data, and performed quality assessment analyses,
which minimized the risk of bias. Our protocol was based on
the Methods Guide published by AHRQ, and we used a
modified AMSTAR tool for quality assessment, both of which
are well-validated tools for analysis.20,22 Our study was limited
by the fact that all included reviews were published in
English, and we only included interventions that had been
assessed in North America, so our findings may not be
generalizable to the global community. However, this decision
was based on the desire to assess interventions that have

surgical site infections in cesarean sections 919

been implemented in North American populations and to
formulate recommendations that are relevant to these
populations. We limited our study search to PubMed and the
Cochrane Database for Systematic Reviews because those are
the best sources for identifying systematic reviews. Although
we did not search other databases or look for nonpublished
literature, it is unlikely that we missed a high-quality sys-
tematic review of the topic. Lastly, we did not assess the clinical
heterogeneity of the studies included in the reviews, or the
impact that varying study designs may have had on the
outcomes measured.

Efforts to reduce SSI rates among women undergoing
C-section should use interventions supported by compelling
evidence of their effectiveness in high-quality studies, includ-
ing preoperative vaginal cleansing and the use of perioperative
prophylactic antibiotics. This study also highlights the need for
further research on the effectiveness of other techniques to
reduce SSI rates among women undergoing C-section, parti-
cularly on the timing of prophylactic antibiotic administration,
intraoperative surgical techniques, and postoperative wound
care. Cesarean deliveries are among the most common surgical
procedures in the United States, with more than 1 million
procedures performed each year.48 These procedures offer a
unique surgical challenge, as obstetricians must strive to
reduce the risks for both mother and child. Because of the
desire to choose the physician and time of delivery, the
frequency of C-section births is increasing in this otherwise
healthy population. Hence, there is an obligation to balance
patient desires with evidence-based techniques to reduce SSI
rates in this population of women and for physicians to
employ best practices to protect the safety of mothers and
neonates.

acknowledgment

Financial support. No financial support was provided relevant

to this article.

Potential conflict of interest. All authors report no conflict of interest relevant

to this article.

Address correspondence to Rebeccah A. McKibben, MPH, 624 North
Broadway, Room 680A, Baltimore, MD, 21205 (rmckibb2@jhmi.edu).

supplementary material

To view supplementary material for this article, please visit http://dx.doi.org/

10.1017/ice.2015.116

references

1. Osterman MJ, Martin JA. Trends in low-risk cesarean delivery
in the United States, 1990–2013. National Vital Statistics Report
Atlanta, GA: Centers for Disease Control and Prevention, National
Center for Health Statistics, National Vital Statistics System
2014;63:1–16.

2. Brown HL. Informing the patient and the community about the
implications of primary cesarean. Semin Perinatol 2012;36:
403–406.

3. Liu S, Liston RM, Joseph KS, et al. Maternal mortality and severe
morbidity associated with low-risk planned cesarean delivery
versus planned vaginal delivery at term. CMAJ 2007;176:455–460.

4. Hillan EM. Postoperative morbidity following Caesarean
delivery. J Adv Nurs 1995;22:1035–1042.

5. Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G.
Postpartum maternal mortality and cesarean delivery. Obstet
Gynecol 2006;108:541–548.

6. Herwaldt LA, Cullen JJ, Scholz D, et al. A prospective study of
outcomes, healthcare resource utilization, and costs associated
with postoperative nosocomial infections. Infect Control Hosp
Epidemiol 2006;27:1291–1298.

7. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ.
The impact of surgical-site infections in the 1990s: attributable
mortality, excess length of hospitalization, and extra costs. Infect
Control Hosp Epidemiol 1999;20:725–730.

8. Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR.
Association between method of delivery and maternal rehospi-
talization. JAMA 2000;283:2411–2416.

9. Olsen MA, Butler AM, Willers DM, Gross GA, Hamilton BH,
Fraser VJ. Attributable costs of surgical site infection and endo-
metritis after low transverse cesarean delivery. Infect Control Hosp
Epidemiol 2010;31:276–282.

10. Olsen MA, Butler AM, Willers DM, Devkota P, Gross GA,
Fraser VJ. Risk factors for surgical site infection after low trans-
verse cesarean section. Infect Control Hosp Epidemiol 2008;29:
477–484; discussion 485–476.

11. Edwards JR, Peterson KD, Mu Y, et al. National Healthcare
Safety Network (NHSN) report: data summary for 2006 through
2008, issued December 2009. Am J Infect Control 2009;37:
783–805.

12. Alanis MC, Villers MS, Law TL, Steadman EM, Robinson CJ.
Complications of cesarean delivery in the massively obese
parturient. Am J Obstet Gynecol 2010;203(271):e271–e277.

13. Dempsey JC, Ashiny Z, Qiu CF, Miller RS, Sorensen TK,
Williams MA. Maternal pre-pregnancy overweight status and
obesity as risk factors for cesarean delivery. J Maternal Fetal
Neonat Med 2005;17:179–185.

14. Killian CA, Graffunder EM, Vinciguerra TJ, Venezia RA. Risk
factors for surgical-site infections following cesarean section.
Infect Control Hosp Epidemiol 2001;22:613–617.

15. Myles TD, Gooch J, Santolaya J. Obesity as an independent risk
factor for infectious morbidity in patients who undergo cesarean
delivery. Obstet Gynecol 2002;100:959–964.

16. Schneid-Kofman N, Sheiner E, Levy A, Holcberg G. Risk factors
for wound infection following cesarean deliveries. Int J Gynecol
Obstet 2005;90:10–15.

17. Tran TS, Jamulitrat S, Chongsuvivatwong V, Geater A. Risk
factors for postcesarean surgical site infection. Obstet Gynecol
2000;95:367–371.

18. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter
JK, Chauhan SP. Evidence-based surgery for cesarean delivery:
an updated systematic review. Am J Obstet Gynecol 2013;209:
294–306.

19. Hofmeyr JG, Novikova N, Mathai M, Shah A. Techniques for
cesarean section. Am J Obstet Gynecol 2009;201(5):431–444.

20. Agency for Healthcare Research and Quality. Methods Guide for
Effectiveness and Comparative Effectiveness Reviews. Rockville,
MD: Agency for Healthcare Research and Quality (US), 2008.

920 infection control & hospital epidemiology august 2015, vol. 36, no. 8

http://dx.doi.org/10.1017/ice.2015.116

http://dx.doi.org/10.1017/ice.2015.116

21. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance
definition of health care–associated infection and criteria for
specific types of infections in the acute care setting. Am J Infect
Control 2008;36:309–332.

22. White CM, Ip S, McPheeters M, et al. Using existing systematic
reviews to replace de novo processes in conducting comparative
effectiveness reviews. Methods Guide for Effectiveness and Com-
parative Effectiveness Reviews. Rockville, MD: Agency for
Healthcare Research and Quality (US), 2008.

23. Haas DM, Morgan Al Darei S, Contreras K. Vaginal preparation
with antiseptic solution before cesarean section for preventing
postoperative infections. Cochrane Database Syst Revs 2010;3:
CD007892.

24. Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophy-
laxis for preventing infection after cesarean section. Cochrane
Database Syst Revs 2010;1:CD007482.

25. Alfirevic Z, Gyte GM, Dou L. Different classes of antibiotics given
to women routinely for preventing infection at caesarean section.
Cochrane Database Syst Revs 2010;10:CD008726.

26. Tita AT, Rouse DJ, Blackwell S, Saade GR, Spong CY, Andrews WW.
Emerging concepts in antibiotic prophylaxis for cesarean
delivery: a systematic review. Obstet Gynecol 2009;113:675–682.

27. Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of
perioperative antibiotics for cesarean delivery: a metaanalysis.
Am J Obstet Gynecol 2008;199(301):e301–e306.

28. Tooher R, Gates S, Dowswell T, Davis LJ. Prophylaxis for venous
thromboembolic disease in pregnancy and the early
postnatal period. Cochrane Database Syst Revs 2010;5:CD001689.

29. Mathai M, Hofmeyr GJ. Abdominal surgical incisions for
caesarean section. Cochrane Database Syst Revs 2007;1:
CD004453.

30. Altman AD, Allen VM, McNeil SA, Dempster J. Pfannenstiel
incision closure: a review of current skin closure techniques.
JOGC 2009;31:514–520.

31. Tuuli MG, Rampersad RM, Carbone JF, Stamilio D, Macones GA,
Odibo AO. Staples compared with subcuticular suture for skin
closure after cesarean delivery: a systematic review and meta-
analysis. Obstet Gynecol 2011;117:682–690.

32. Dodd JM, Anderson ER, Gates S. Surgical techniques for uterine
incision and uterine closure at the time of caesarean section.
Cochrane Database Syst Revs 2008;3:CD004732.

33. Jacobs-Jokhan D, Hofmeyr G. Extra-abdominal versus intra-
abdominal repair of the uterine incision at caesarean section.
Cochrane Database Syst Revs 2004;4:CD000085.

34. Anderson ER, Gates S. Techniques and materials for closure of
the abdominal wall in caesarean section. Cochrane Database Syst
Revs 2004;4:CD004663.

35. Chelmow D, Rodriguez EJ, Sabatini MM. Suture closure of sub-
cutaneous fat and wound disruption after cesarean delivery:
a meta-analysis. Obstet Gynecol 2004;103:974–980.

36. Hellums EK, Lin MG, Ramsey PS. Prophylactic subcutaneous
drainage for prevention of wound complications after cesarean
delivery—a metaanalysis. Am J Obstet Gynecol 2007;197(3):229–235.

37. Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the
placenta at caesarean section. Cochrane Database Syst Revs 2008;3:
CD004737.

38. Bamigboye AA, Hofmeyr GJ. Non-closure of peritoneal surfaces
at caesarean section—a systematic review. S Afr Med J 2005;
95(2):123–126.

39. Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for
cesarean delivery. Am J Obstet Gynecol 2005;193(5):1607–1617.

40. Gates S, Anderson ER. Wound drainage for caesarean section.
Cochrane Database Syst Revs 2013;12:CD004549.

41. Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation for pre-
venting infection following caesarean section. Cochrane Database
Syst Revs 2012;9:CD007462.

42. Liabsuetrakul T, Peeyananjarassri K. Mechanical dilatation of the
cervix at non-labour caesarean section for reducing postoperative
morbidity. Cochrane Database Syst Revs 2011;11:CD008019.

43. Chelmow D, Ruehli MS, Huang E. Prophylactic use of antibiotics
for nonlaboring patients undergoing cesarean delivery with
intact membranes: a meta-analysis. Am J Obstet Gynecol 2001;
184:656–661.

44. Clay FS, Walsh CA, Walsh SR. Staples vs subcuticular sutures for
skin closure at cesarean delivery: a metaanalysis of randomized
controlled trials. Am J Obstet Gynecol Am J 2011;204:378–383.

45. Mackeen AD, Berghella V, Larsen ML. Techniques and materials
for skin closure in caesarean section. Cochrane Database Syst Revs
2012;11:CD003577.

46. Webster J, Osborne S. Preoperative bathing or showering with
skin antiseptics to prevent surgical site infection. Cochrane
Database Syst Revs 2012;9:CD004985.

47. Tanner J, Woodings D, Moncaster K. Preoperative hair removal
to reduce surgical site infection. Cochrane Database Syst Revs
2006:CD004122.

48. Hall MJ, DeFrances CJ, Williams SN, Golosinskiy A, Schwartzman A.
National Hospital Discharge Survey: 2007 summary. Nat Health
Stat Repts 2010:1–20; 24.

surgical site infections in cesarean sections 921

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Methods
Data Sources and Selection
Data Extraction and Quality Assessment
Figure 1Analytic framework for systematic review.
Table 1PubMed Search Strategy
Table 2Modified Version of the Assessment of Multiple Systematic Reviews Quality Assessment�Tool
Results
Data Extraction Results
Figure 2Study search flow diagram.
Table 3Grading System for Overall Quality Assessment of Included Reviewsa
Strength of Evidence of Intervention and Quality Assessment Synthesis
Discussion
Acknowledgment
ACKNOWLEDGEMENTS