Background: Surgical site infections (SSI) are a frequent complication following caesarean section (C-section) and are primarily responsible for increased adverse outcome for mothers, and increased treatment costs. Studies from developing countries regarding SSI post CS are lacking therefore we conducted a study to is to ascertain the incidence of surgical site infections and associated risk factors in women undergoing CS at 4 major hospitals in Nablus, West Bank.
Methods: A prospective cohort study was conducted in four private hospitals in Nablus, West Bank between December 2019 and February 2020. During this period, out 1146 deliveries, 640 underwent CS and only 311 women of them agreed to participate. Sociodemographic and clinical data were gathered on admission, 7 days and 30 days post CS. Association between the incidence of SSI and other variables was analysed using appropriate descriptive and analytical methods and a binary logistic regression was performed. The level of significance was set at a p-value less than 0.05.
Results: Overall, the SSI incidence rate among participants was 10.56%, all of them superficial. The mean age (SD) of participants was 27.92 ± 5.91 years, while the mean (SD) of gestational age and Body Mass Index (BMI) before pregnancy were 37.9 (SD= 2.15) and 24.33 (SD= 3.99) respectively. 12.5% of participants smoked during or before pregnancy, and only 9.24% had a pre-existing medical condition.
Regarding obstetrical and surgical characteristics: CS was programmed in 80.2% of the cases, being previous CS (49.5%) and failure to progress (17.2%) the most frequent indications. 82.5% of deliveries had no complication. Most operations (88.1%) lasted between 30-60 minutes. 74.9% of cases had an intact membrane while only 7.3% (22 cases) had rupture of membrane (ROM) for more than 24 hours. Placental delivery by manual extraction was practiced in 71.6%. General anaesthesia was provided in only 44 cases (14.5%). 99.2% had hair removal by shaving. The mean (SD) of the Estimated Blood Loss (EBL) was 613.76 ml (167.93ml). Sutures were used as a method of skin closure in 92.1% of cases. About two-third of cases (66%) had dressing removal after 48 hours. Half of participants (50.8%) did not have a prophylactic coverage by antibiotics while 90.4% had post-CS antimicrobial therapy. 74.6% of women were discharged on antibiotics. Statistically significant association was found between surgical site infection and BMI (p value < 0.001), length of time of membrane ruptured (p value < 0.001), type of placental delivery (p value= 0.041), type of CS (P value= 0.029) and EBL (P value = 0.000). Once introduced in the binary logistic regression model to assess the risk factors for SSI post CS, only three variables remained significant: BMI: OR=3.299 (CI95%: 1.84-5.92), EBL: OR=1.004 (CI95%:1.002-1.007) and ROM: OR=0.392 (CI95%: 0.230-0.667).
Conclusion: SSI post CS was found to be high in this study (55.85% and 10.56% respectively), reflecting the urgent need of the implementation of a comprehensive preventive and curative care guidelines mentioned (especially for the indication of CS and indication for antibiotic therapy) and taking into consideration the risk factors mentioned. The establishment of a systematic and sustained surveillance system of SSI post CS is also recommended as an important tool for quality improvement and patient safety.
Keywords: pregnancy, CS, surgical site infection, caesarean section, Palestine, prevention, SSI.