Open access Quality improvement report BMJ Open Qual: first published as 10.1136/bmjoq-2020-000976 on 11 August 2020. Downloaded from Implementation of vaginal preparation prior to caesarean section Adam D Jakes,1 Annie Bell,1 Lilian Chiwera,2 Jilly Lloyd1 To cite: Jakes AD, ABSTRACT SSIs involve discharging wounds with deep Bell A, Chiwera L, et al. Introduction Surgical site infections following caesarean tissue involvement of the fascial and muscle Implementation of vaginal section are associated with significant morbidity. Vaginal preparation prior to caesarean layers. Organ/space SSIs extend beyond preparation is the cleansing of the vaginal epithelium section. BMJ Open Quality the fascial and muscle layers, for example, with an antibacterial solution to reduce the bacterial load 2020;9:e000976. doi:10.1136/ an abscess or collection. Deep incisional and therefore reduce ascending genital tract infection. bmjoq-2020-000976 and organ/space SSIs following a caesarean It is recommended by the WHO and a Cochrane review ► Additional material is in 2018 concluded that vaginal preparation immediately section are commonly grouped together to published online only. To view before caesarean section probably reduces the rates of include postoperative endometritis and intra- 1 please visit the journal online postoperative endometritis. abdominal collections. (http:// dx. doi. org/ 10. 1136/ Objective To implement vaginal preparation prior to SSIs are associated with a significant bmjoq- 2020- 000976). caesarean section at Guy’s and St Thomas’ Hospital NHS morbidly and mortality. High SSI rates inev- Foundation Trust and reduce rates of deep surgical site itably result in poor patient outcomes and Received 23 March 2020 infections. significant financial burden to healthcare Revised 25 June 2020 Methods The protocol (included within the appendices) organisations. Rates vary nationally between Accepted 9 July 2020 for vaginal preparation prior to caesarean section was hospitals and regions because of variations developed after reviewing the available evidence. Two vaginal preparation champions, a midwife and a scrub in surgical care and different data collection nurse, were selected to help promote and assist in the approaches used to record SSIs at hospital implementation. The first implementation cycle included and community level. elective and category II and III caesarean sections. To Guy’s and St Thomas’ Hospital NHS copyright. ensure acceptability, 20 women were asked to complete Foundation Trust is a large, tertiary hospital a questionnaire following vaginal preparation. Once the in central London. The maternity service intervention was being performed in >85% of eligible delivers roughly 6800 babies each year, women, the inclusion criteria was expanded to include with a caesarean section rate of 35%.2 The category I caesarean sections. Results Twelve months following implementation, vaginal trust implemented SSI surveillance for both http://bmjopenquality.bmj.com/ preparation was still being performed in 89% of eligible elective and emergency caesarean sections women. The deep surgical site infection rate is now the in 2010 in line with Public Health England 3 lowest recorded in the last 6 years. Vaginal preparation recommendations. This consists of surveil- prior to caesarean section was acceptable to pregnant lance forms, postdischarge questionnaires women and no adverse effects were reported. and telephone interviews. Post- discharge Conclusions Vaginal preparation prior to caesarean response rates using postal questionnaires section has been successfully implemented at Guy’s and and telephone surveys for the validated St Thomas’ Hospital NHS Foundation Trust. This simple, quarter in 2019 were 91.5%.4 Superficial cheap intervention, performed with readily available materials, is still being performed in a high number of SSIs have been significantly reduced by the caesarean sections 12 months post-implementa tion. implementation of standardised skin prepa- on September 27, 2021 by guest. Protected It has resulted in a reduction in deep surgical site ration, changing the timing of prophylactic © Author(s) (or their infections. Involvement of key stakeholders and the antibiotic administration from post-cord employer(s)) 2020. Re- use recruitment of vaginal preparation champions were key permitted under CC BY-NC. No clamping to pre-surgical incision, the use of commercial re- use. See rights to success. evidence- based suture material and negative and permissions. Published by pressure dressings for high- risk women.4 BMJ. Unfortunately, deep surgical site (and 1 PROBLEM Women's Services, Guy's and organ/space) infections such as endome- Saint Thomas' NHS Foundation A surgical site infection (SSI) is defined as Trust, London, UK an infection that occurs within 30 days after tritis have remained constant over the past 1 2Infection Control, Guy's and a surgical procedure. It can be divided into 5 years. There were seven deep SSIs in 2017 Saint Thomas' NHS Foundation superficial incisional, deep incisional and and five in 2018. Trust, London, UK organ/space infections. SSIs are considered The aim of the quality improvement project Correspondence to superficial when involving only the skin and was to implement vaginal preparation prior Dr Adam D Jakes; subcutaneous tissue, for example, cellulitis or to caesarean section and reduce rates of deep a. jakes@ nhs. net a superficial wound infection. Deep incisional SSIs. Jakes AD, et al. BMJ Open Quality 2020;9:e000976. doi:10.1136/bmjoq-2020-000976 1 Open access BMJ Open Qual: first published as 10.1136/bmjoq-2020-000976 on 11 August 2020. Downloaded from BACKGROUND that there may not be a significant drop in the number of A caesarean section is the most common obstetric opera- infections following the intervention. However, the infec- tion and rates are increasing worldwide.5 6 The incidence tion rates were not expected to rise, and vaginal prepa- of SSI following caesarean section varies but has been ration is seen as a best practice perioperative strategy for reported in up to 10% of women.6 Obesity appears to preventing caesarean section SSIs. be the biggest risk factor for developing an SSI.6 Conse- To ensure the intervention was acceptable to women, a quences of caesarean section SSIs include chronic pelvic patient questionnaire was designed to inquire about their pain, delay in returning to normal activities, depression, experience following vaginal preparation. Twenty women longer hospital stay and increased hospital costs.7 were approached the following day after their caesarean Superficial SSIs are much more common than deep section and asked to complete a questionnaire. or organ/space SSI following caesarean section. At Guy’s and St Thomas’ Hospital NHS Foundation, superficial SSIs have been significantly reduced through a number of DESIGN improvement strategies, but deep surgical SSI remained Scoping constant. The project team was made up of an obstetric registrar, Vaginal preparation is the cleansing of the vaginal obstetric consultant and labour ward lead, the Infection epithelium with an antibacterial solution to reduce the Control Surveillance Team Leader and obstetric theatre bacterial load and therefore reduce ascending genital midwifery practice lead. Early feedback during scoping of tract infection. A Cochrane review in 2018 concluded the project revealed that the phrase ‘vaginal cleansing’, that vaginal preparation with povidone-iodine or chlor- which is used by the WHO and Cochrane review, may not hexidine solution immediately before caesarean delivery be appropriate. There was concern that it implied that the probably reduces the rates of postoperative endome- vagina was dirty, and therefore the phrase ‘vaginal prepa- tritis.8 It was also recommended in a systematic review ration’ was agreed and used throughout the project. and meta- analysis of best practice perioperative strategies A survey was sent to the labour ward leads within the for preventing caesarean section SSIs published in the UK via the British Intrapartum Society mailing list, labour BJOG.7 Vaginal preparation with povidone- iodine imme- ward lead forums and contacting individual centres in diately before caesarean section is recommended by the December 2018. Each labour ward lead was asked whether WHO.9 Women undergoing caesarean delivery who were they had successfully implemented vaginal preparation copyright. already in labour or who had ruptured membranes bene- prior to caesarean section within their unit. Data were fited the most from this intervention.8 also collected regarding the barriers to implementation. There is no agreed protocol in the literature for vaginal Responses were collected as either fully implemented, preparation prior to caesarean section. in the process of implementation, ongoing consultation A decision was made to implement vaginal prepara- regarding implementation or no current plans for imple- tion prior to caesarean section at Guy’s and St Thomas’ mentation. In those who had successfully implemented http://bmjopenquality.bmj.com/ Hospital NHS Foundation Trust in an attempt to reduce vaginal preparation, data were collected regarding the rates of deep SSIs. date of implementation, the category of caesarean section included and the cleansing solution and technique used. Fifty- two maternity units responded. Five units have MEASUREMENT successfully implemented vaginal preparation prior to All caesarean sections performed in theatre are recorded caesarean section. All