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SURGICAL WOUND SITE OUTCOME IN ELECTIVE AND EMERGENCY CAESAREAN SECTION - A PROSPECTIVE
OBSERVATIONAL COMPARATIVE STUDY.
1
S. No Table of Content Page No
1 INTRODUCTION 9
2 REVIEW OF LITERATURE 13
3 AIMS & OBJECTIVES 15
4 MATERIALS & METHODS 48
5 RESULTS 54
6 DISCUSSION 85
7 CONSULATION 93
8 LIMITATIONS 95
9 BIBLIOGRAPHY 97
2
List of Tables
S. No Table Description Page
No1 Descriptive analysis of study group 552 Comparison of study group with post-operative wound complications of
study population 553 Comparison of mean patient age (in years) between study groups 564 Comparison of study group with socioeconomic status of study
population 575 Comparison of study group with history of study population 586 Comparison of study group with history of leaking PV of study
population 59
7 Comparison of study group with regular antenatal care of study population 60
8 Comparison of study group with obstetric parameters of study population 61
9 Comparison of study group with previous LSCS of study population 6210 Comparison of median value in period of gestation (in weeks) between
study groups 6211 Comparison of study group with h/o hypertension of study population 6312 Comparison of study group with PHM diabetic Miletus/GDM of study
population 6413 Comparison of mean BMI between study groups 6514 Comparison of median value in PALPATION fundal ht (weeks)
between study group in the study population 6715 Comparison of study group with a presentation of fetus study population 6716 Comparison of median value in hemoglobin (g/dl) between study group 6817 Comparison of study group with blood group of study population 7018 Comparison of study group with viral marker status of study population 7019 Comparison of study group with pre-operative UTI of study population 7120 Comparison of median value duration of labor between study group in
the study population 7221 Comparison of study group with induction of labour of study population 7222 Comparison of study group with type of incision of study population 7223 Comparison of median value in duration of surgery (in mints) between
study group73
3
24 Comparison of study group with h/o primary PPH of study population 7425 Comparison of study group with prophylactic antibiotics pre op intra op
of study population 7526 Comparison of study group with febrile morbidity of study population 7627 Comparison of study group with operative wound discharge of study
population 7728 Comparison of study group with wound gaping of study population 7829 Comparison of study group with wound hematoma of study population 7930 Comparison of study group with surgical site infection of study
population 80
31 Comparison of study group with incisional site induration of study population 81
32 : Comparison of study group with burst abdomen of study population 8233 Descriptive analysis of culture report in the study population 8234 Comparison of median value in Suture removal time in days between
study group in the study population 83
35 Comparison of study group with 3rd week wound healthy of study population 83
36 Descriptive analysis of wound complications in the study population 84
4
List of Figure
S. No Figure Description Page
No1 Clustered bar chart of Comparison of study group with post-operative
wound complications of study population 56
2 Error bar chart of comparison of mean patient age (in years) between study groups 57
3 Clustered bar chart of comparison of study group with socio economic status of study population 58
4 Clustered bar chart of comparison of study group with history of study population 59
5 Box plots of comparison of median value in period of gestation (in weeks) between study groups 63
6 Clustered bar chart of comparison of study group with h/o hypertension of study population 64
7 Clustered bar chart of comparison of study group with P/H/M diabetic Miletus/GDM of study population 65
8 Error bar chart of comparison of mean pre pregnancy BMI between study groups 66
9 Error bar chart of comparison of mean current BMI between study groups 66
10 Box plot of comparison of median value in haemoglobin (g/dl) between study group 69
11Box plot of comparison of median value in post-operative haemoglobin (g/dl) between study group 69
12 clustered bar chart of comparison of study group with pre-operative UTI of study population 71
13 clustered bar chart of comparison of study group with type of incision of study population 73
14 Box plot of comparison of median value in duration of surgery (in mints) between study group 74
15 Clustered bar chart of comparison of study group with h/o primary PPH of study population 75
16 Clustered bar chart of comparison of study group with prophylactic antibiotics pre op intra op of study population 76
17 Clustered bar chart of comparison of study group with febrile morbidity of study population 77
18 Clustered bar chart of comparison of study group with operative wound discharge of study population 78
19 Clustered bar chart of comparison of study group with wound gaping of study population 79
20 Clustered bar chart of comparison of study group with wound hematoma 80
5
of study population
21 Clustered bar chart of study group with surgical site infection in the study population 81
22 Clustered bar chart of comparison of study group with incisional site induration of study population 81
23 Clustered bar chart of comparison of study group with burst abdomen of study population 82
24 Bar chart of culture report in the study population 8325 Bar chart of wound complications in the study population 84
6
Glossary Abbreviations
ANC Antenatal care
ASC Active Surveillance Culture
AST Active Surveillance Testing
BMI Body mass index
CBGB Country Bluegrass Blues.
CDC Centers for Disease Control and Prevention
CS Caesarean section
ECS Emergency Caesarean section
GBS Group B streptococcus
GDM Gestational diabetes mellitus
HBS AG hepatitis B Antigen
HIV Human immunodeficiency virus
LOS length of stay
LSCS lower segment Caesarean sectio
NFHS National Family Health Survey
NHS National Health Service trust
NHSN National Healthcare Safety Network
NICE National Institute for Health and Clinical Excellence
NIOS National institute of open school
PCS Planned Caesarean Section
PLICS Patient Level Information and Costing System
PPH postpartum hemorrhage
PROM Premature Rupture of Membranes
SIP Superficial Incisional Primary
SIS Superficial Incisional Secondary
SSI surgical site infection
UIO University of Oslo
UK United Kingdom
7
UTI Urinary tract infection
VDRL Venereal Disease Research Laboratory Test
WHO World Health Organization
8
INTRODUCTION
9
INTRODUCTION
Caesarean section (CS) is one of the most common surgical procedures performed globally. The
incidence of caesarean deliveries, both repeat and primary, has risen dramatically over the last
few decades, with an estimated global number of 22.9 million caesarean deliveries in 2012.1, 2 In
developed countries, the proportion of caesarean births was 21.1%, whereas in least developed
countries only 2% of deliveries were by CS according to 2007 estimates.3 The postpartum period
is a challenging time for women. Psychologically, it is the period she starts experiencing
motherhood. Physiologically, she starts adapting to new demands of the newborn and her own.
However, pathology or complications at any stage in peripartum period may jeopardize the
whole process. Women experiencing delivery through Caesarean section are at higher risk of
complications than those through vaginal delivery. Surgical site infections are a major
contributor to morbidity and mortality in postsurgical care. The risk for surgical site infection is
multifactorial and includes a host of microbial, patient-related, and procedure-related factors.4
Caesarean wound infections represent a significant health and economic burden. Several
modifiable risk factors have been identified for their development. Understanding these risks and
techniques to manage caesarean wounds is essential.5 In all the caesarean section patients,
depending on the definitions used and the period of observation, surgical site infection (SSI)
occur in about 1.8%–9.8% of these subjects which results in increased duration of hospitalization
and increased rates of morbidity with increased hospital readmissions.6-13 The rates of SSI are not
only multifactorial but also highly dependent on the detection rates and the definition of what an
SSI is. Post-caesarean SSI extends hospitalization by about 4 days, and also generates huge
additional costs in treating patients.13 Women undergoing Caesarean delivery have a 5 to 20 fold
greater risk of complication compared with Vaginal delivery.14 Wound complications in the
caesarean section include Surgical site infection (stitch abscess, cellulitis), seroma, hematoma,
10
wound separation, wound dehiscence and rarely burst abdomen.15-18 Surgical site Infection
predominates the picture. Infections are commonly polymicrobial (caused by many organisms).
Pathogens isolated from infected wounds and the endometrium include Escherichia coli, group B
streptococcus, Enterococcus faecalis, Staphylococcus aureus and coagulase-negative
staphylococci, anaerobes (including Peptostreptococcus species and Bacteroides species),
Gardnerella vaginalis and genital mycoplasmas.19 Antimicrobial prophylaxis at the time of
surgery has reduced the rate of postpartum endometritis and wound infection after both
nonelective and elective caesarean delivery.20
Wound complications delay the recovery, prolong the hospitalization, necessitate the
readmission or prolong outpatient treatment. Wound infection is the commonest and most
troublesome disorder of wound healing and despite modern surgical techniques and the use of
antibiotics prophylaxis, surgical site infections (SSI) remains a major contributory factor of
maternal morbidity and mortality. It is therefore important to identify and treat the comorbid and
risk factors along with predisposing factors which contribute to wound complications and bring
back the mother to optimal condition and hence decreasing the incidence of wound
complications. The risk factors for surgical site infections (SSI) after caesarean section are many;
these include intrinsic and extrinsic risk factors that predispose patients to SSI. Intrinsic factors
are patient-related while extrinsic factors are related to patient care and management, although
the intrinsic factors cannot be changed, the risk they present in terms of infection is identifiable
and manageable.
Factors6, 10, 14, 21, 22 that have been associated with an increased risk of wound complications among
women who have a cesarean delivery include emergency caesarean section21, labor and its
duration, ruptured membranes and the duration of rupture, the socioeconomic status of the
11
woman, number of prenatal visits, vaginal examinations during labor, urinary tract infection,
anemia, blood loss, obesity, diabetes, the skill of the operator and the operative technique.7, 14, 21-24
Schneid-Kofman N et al12 and Farret TC et al25 observed that Emergency caesarean section is an
independent risk factor for the development of Surgical site infection. Farret TC et al25 observed
that patients who had an emergency cesarean had a 3.3-fold greater risk of SSI. The need of the
study arises because the literature comparing the incidence of surgical site infection in
emergency versus elective caesarean section is very limited, especially in developing countries
like india. There is also a need to determine the factors, which may result in different surgical
wound site complications between emergency and elective caesarean section so that appropriate
interventions can be planned to prevent morbidity resulting from surgical wound site
complications. Also, the incidence of surgical site infection in cases of emergency LSCS is high,
increasing the maternal morbidity.26 Also the variation in the spectrum of causative organisms
means that prophylactic antibiotic though effective , may fail when used inappropriately or
wrongly used.
So we carried out our study with the objective of estimate the incidence of various surgical
wound site complications in elective and emergency caesarean section and to determine the
factors affecting various wound site complications in cesarean section so that the obtained data
can be utilized to design strategies helpful in minimizing the extrinsic risk factors and hence
decreasing the morbidity.
12
AIMS & OBJECTIVES
13
AIMS AND OBJECTIVES:
Aim: To study surgical wound site outcome in elective and emergency caesarean section
Objectives:
To study the incidence of various surgical wound site complications in elective and
emergency caesarean section.
To compare the profile of surgical wound site complications between emergency and
elective caesarean section
14
REVIEW OF LITERATURE
15
REVIEW OF LITERATURE
Delivery of the baby by an abdominal and uterine incision is known as caesarean section. Lower
segment Caesarean section is the one of most common surgical procedure done in Obstetrics.
Women undergoing Caesarean delivery have a 5 to 20 fold greater risk of complication
compared with Vaginal delivery.14 Wound complications from caesarean delivery are a
significant emotional and economic burden. Caesarean section is one of the most common
surgical procedures performed globally. The incidence of caesarean deliveries, both repeat and
primary, has risen dramatically over the last few decades, with an estimated global number of
22.9 million cesarean deliveries in 2012.1, 2 In developed countries, the proportion of caesarean
births was 21.1%, whereas at least developed countries only 2% of deliveries were by CS
according to 2007 estimates.3
The rates of caesarean section are on the rise in the last few decades. There continues to be an
unprecedented rise in the Caesarean Section rates. Caesarean section (CS) rates continue to
evoke worldwide concern because of their steady increase, lack of consensus on the appropriate
CS rate and the associated additional short- and long-term risks and costs.
According to Global, Regional and National Estimates: 1990-2014 from 150 countries, Betran
AP et al.27 reported that 18.6% of all births occur by CS, ranging from 6% to 27.2% in the least
and most developed regions, respectively. Latin America and the Caribbean region has the
highest CS rates (40.5%), followed by Northern America (32.3%), Oceania (31.1%), Europe
(25%), Asia (19.2%) and Africa (7.3%). Based on the data from 121 countries, the trend analysis
showed that between 1990 and 2014, the global average CS rate increased 12.4% (from 6.7% to
19.1%) with an average annual rate of increase of 4.4%. The largest absolute increases occurred
in Latin America and the Caribbean (19.4%, from 22.8% to 42.2%), followed by Asia (15.1%,
16
from 4.4% to 19.5%), Oceania (14.1%, from 18.5% to 32.6%), Europe (13.8%, from 11.2% to
25%), Northern America (10%, from 22.3% to 32.3%) and Africa (4.5%, from 2.9% to 7.4%).
Asia and Northern America were the regions with the highest and lowest average annual rate of
increase (6.4% and 1.6%, respectively).
Mylonas et al28 in their study reported that in Germany, the rate of Caesarean Sections doubled
from 15.3% in 1991 to 31.7% in 2012. The increase in Caesarean Sections has been partly
explained by increasing clinical indications for Caesarean Section such as breech presentation,
multiple pregnancies, fetal macrosomia, a history of previous Caesarean Section, increasing
maternal medical indications such as preeclampsia, maternal cardiac conditions and the maternal
request for elective Caesarean Section.
The World Health Organization (WHO) earlier predicted 5–15% rate of caesarean section in any
population to be acceptable.29 Later in 2014, in their report, they concluded that CS should be
undertaken when medically necessary, and rather than striving to achieve a specific rate, efforts
should focus on providing caesarean section to all women in need. How to define the woman ‘in
need’ can only be ascertained by the health care providers caring for the woman on a case‐by‐case basis.30, 31
The incidences of caesarean section are on a rise in India. The overall rate of caesarean section
delivery in 2015–16 is around 17.2% in India according to NFHS-4 (National Family Health
Survey) data32. It has increased from 8.5% in 2005–06 reported in NFHS-3. However, the
caesarean section rate is estimated to be low in rural areas (12.9%) according to NFHS-4 data.
Lack of availability of emergency obstetric services, knowledge and financial constraints are
some of the important factors for low caesarean section rate among rural women. The incidence
17
of caesarean section in was reported as 26% in the civil hospital, Aizawal during the period of
our study from 2016 to 2017.
COMPLICATIONS OF LSCS:
The most common complications after caesarean section in the mother are33-35:
1. Infection.
2. Heavy blood loss.
3. Deep Vein Thrombosis, Amniotic fluid embolism, Pulmonary embolism.
4. Nausea, vomiting, and severe headache after the delivery (related to anesthesia and the
abdominal procedure).
5. Bowel problems, such as constipation or when the intestines stop moving waste material
normally (ileus).
6. Injury to another organ (such as the bladder). This can occur during surgery.
7. Maternal death (very rare).
In their study on the incidence of surgical complications associated with caesarean section (CS),
Nielsen TF et al34 reported the overall complication rate was 11.6% (9.5% patients with minor
complications and 2.1% with major complications). The complication rate for emergency
operations was 18.9% and for elective CS, 4.2%--a highly significant difference. (p less than
0.001).
18
Six risk factors were associated with the occurrence of surgical complications in emergency
cases:
1. Station of the presenting part of the fetus in relation to the spinal plane (p less than
0.001),
2. Labor prior to surgery (p less than 0.001),
3. Low gestational age (less than 32 weeks) (p less than 0.001),
4. Rupture of fetal membranes (with labor) prior to surgery (p less than 0.01),
5. Previous CS (p less than 0.01), and
6. Skill of the operator (p less than 0.05).
However, no such risk factors were found in the elective group. They concluded that emergency
CS requires great skill on the part of the surgeon, and should therefore not be entrusted to young,
inexperienced obstetricians.
The postpartum period is a challenging period where women start experiencing motherhood and
start adapting to new demands of the newborn and her own. However, pathology or
complications at any stage in peripartum period may jeopardize the whole process. Women
experiencing delivery through Caesarean section are at higher risk of complications than those
through vaginal delivery.
As reported by Dimitrova V et al35, in 574 Planned or Elective Caesarean Section, the frequency
of postoperative complications was 1.4% while in 292 Emergency Caesarean section it was
2.05% (p>0.05). There was no significant difference in the distribution of the different types of
postoperative complications in 34 cases with PCS (Planned or Elective Caesarean Section) and
33 cases with ECS (Emergency Caesarean section). The percentage of patients with previous CS
was significantly higher in the complicated cases with PCS compared to that with ECS. The two
19
studied groups do not differ significantly regarding the type of skin incision, operator's
qualification, blood loss, drainage of the subfascial space, accompanying diseases.
SURGICAL SITE INFECTION:
DEFINITION36-38:
The Centers for Disease Control and Prevention defines SSI as an infection occurring within 30
days from the operative procedure in the part of the body where the surgery took place.
The definition of a surgical site infection has been standardized by the Center for Disease
Control and Prevention. It can be grouped in incision, deep and organ infections.
Surgical site infections (SSI) are divided into two main groups:
(1) Incisional surgical site infections, which are further subdivided into
(1a) Superficial incisional (skin and subcutaneous tissues)
(1b) Deep incisional (deep soft tissue such as fascia and muscle layers)
(2) Organ/space surgical site infections (any part of anatomy other than the incision opened or
manipulated during an operative procedure)
According to the NHSN / CDC definition, Procedure associated Module, released on January
2018, the criteria are:
Superficial incisional surgical site infection criteria:
(1) Infection occurs at incision site within 30 days after surgery, where day 1 is the procedure
date, and
(2) Infection involves only skin and subcutaneous tissue of the incision, and
(3) Patient has at least one of the following:
(3a) Purulent drainage from the superficial incision
20
(3b) Organism isolated from a culture of fluid or tissue from the superficial incision,
which is aseptically obtained
(3c) Surgeon deliberately opens wound and there is at least one sign or symptom (pain,
tenderness, localized swelling, redness, heat) unless the wound culture is negative
(3d) Diagnosis of infection by the surgeon or attending physician
(4) None of the following:
(4a) Stitch abscess with minimal inflammation and discharge confined to the points of
suture penetration
(4b) Infection of an episiotomy site
(4c) Infection of a neonatal circumcision site
(4d) Infected burn wound
Deep incisional surgical site infection criteria:
(1) Infection occurs at operative site
(1a) Within 30 days after surgery if no implant (the nonhuman-derived foreign body that
is permanently placed in the patient during surgery) is left in place,
(1b) Within 1 year after surgery, if an implant is left in place
(2) Infection appears related to surgery, and
(3) Infection involves deep soft tissue (muscle and fascial layers), and
(4) At least one of the following:
(4a) Purulent drainage from the deep incision but not from the organ/space component of
the surgical site
(4b) Wound dehisces or is deliberately opened by the surgeon when the patient has fever
(> 38°C) and/or localized pain and/or tenderness unless the wound culture is negative
21
(4c) An abscess or other evidence of infection involving the deep incision seen on direct
examination, during surgery, by histopathologic examination or by radiologic
examination
(4d) Diagnosis of deep incisional surgical site infection by the surageon or attending
physician
Organ/Space surgical site infection criteria:
(1) Infection occurs
(1a) within 30 days after surgery if no implant (nonhuman-derived foreign body that is
permanently placed in the patient during surgery) is left in place,
(1b) within 1 year after surgery if an implant is left in place
(2) Infection appears related to surgery, and
(3) Infection involves any part of anatomy other than the incision opened or manipulated during
an operative procedure, and
(4) At least one of the following:
(4a) Purulent drainage from a drain that is placed through a stab wound into the
organ/space
(4b) Organisms isolated from an aseptically obtained culture of fluid or tissue in the
organ or space
(4c) An abscess or other evidence of infection involving organ or space seen on direct
examination, during surgery, by histopathologic examination, or on radiologic
examination
(4d) Diagnosis of an organ/space surgical site infection by surgeon or attending physician
22
Specific sites of organ or space surgical site infection:
(1) Arterial Or Venous Infection
(2) Breast Abscess Or Mastitis
(3) Intervertebral Disc Space
(4) Ear, Mastoid
(5) Endometritis
(6) Endocarditis
(7) Eye, Other Than Conjunctiva
(8) Gastrointestinal Tract
(9) Intra-Abdominal, Not Specified Elsewhere
(10) Intracranial, Brain, Or Dural Infection or Abscess
(11) Joint or Bursa
(12) Mediastinitis
(13) Meningitis or Ventriculitis
(14) Myocarditis or Pericarditis
(15) Oral Cavity (Mouth, Tongue or Gums)
(16) Osteomyelitis
(17) Other Infections 0f The Lower Respiratory Tract
(18) Other Infections of The Urinary Tract
(19) other male or female reproductive tract
(20) spinal abscess without meningitis
(21) sinusitis
(22) upper respiratory tract, pharyngitis
23
(23) vaginal cuff
Classification when more than one site involved:
(1) Infection involving both superficial and deep surgical incisions is classified as a deep
incisional surgical site infection
(2) If an organ or space infection drains through the incision, then it is classified as a deep
incisional surgical site infection
There are two specific types of superficial incisional SSIs:
1. Superficial Incisional Primary (SIP) – a superficial incisional SSI that is identified in
the primary incision in a patient that has had an operation with one or more incisions (for
example, C-section incision or chest incision for CBGB)
2. Superficial Incisional Secondary (SIS) – a superficial incisional SSI that is identified in
the secondary incision in a patient that has had an operation with more than one incision
(for example, donor site incision for CBGB)
Postoperative infection at the surgical sites in the obstetrics and gynecological procedures are
very common in developing countries as the state of health of many women is below the
optimum level, i.e hemoglobin, nutritional status, and multiparity. Wound infection is the
commonest and most troublesome disorder of wound healing18, 39 and despite modern surgical
techniques and the use of antibiotics prophylaxis, surgical site infections (SSI) remains a major
contributory factor of maternal morbidity and mortality.
SSI is the second most common infectious complication after UTI following caesarean
delivery39. For the majority of obstetric patients, it rarely represents a threat to life. However,
there are few reaching morbidity and socioeconomic consequences for the health care services.
24
Women undergoing Caesarean delivery have a 5 to 20 fold greater risk of complication
compared with Vaginal delivery.14
Wound complications in caesarean section include Surgical site infection (stitch abscess,
cellulitis), seroma, hematoma, wound separation, wound dehiscence and rarely burst abdomen.15-
18 Surgical site Infection predominates the picture. Infections are commonly polymicrobial
(caused by many organisms). Pathogens isolated from infected wounds and the endometrium
include Escherichia coli, group B streptococcus, Enterococcus faecalis, Staphylo- coccus aureus
and coagulase-negative staphylococci, anaerobes (including Peptostreptococcus species and
Bacteroides species), Gardnerella vaginalis and genital mycoplasmas.19 Antimicrobial
prophylaxis at the time of surgery has reduced the rate of postpartum endometritis and wound
infection after both nonelective and elective cesarean delivery.20
Wound complications delay the recovery, prolong the hospitalization, necessitate the
readmission or prolong outpatient treatment. Wound infection is the commonest and most
troublesome disorder of wound healing and despite modern surgical techniques and the use of
antibiotics prophylaxis. Surgical site infections are a major contributor to morbidity and
mortality in postsurgical care. The risk for surgical site infection is multifactorial and includes a
host of microbial, patient-related, and procedure-related factors4. Caesarean wound infections
represent a significant health and economic burden.
25
WOUNDS AND SURGICAL SITE INFECTION:
The term wound has been defined as a disruption of normal anatomical structure and, more
importantly, function.
Wound healing is divided into four sequential, yet overlapping phases:
(1) Hemostasis
(2) Inflammation,
(3) Proliferation And
(4) Remodeling.40
Complications in wound healing can arise from abnormalities in any of the basic components of
the repair process. Deficient scar formation, Hypertrophic scar, Keloid, Exuberant granulation,
Desmoids, Contractures, Avoidable scarring41
The factors that influence repair can be categorized into local and systemic.
The classification system was developed initially by the American College of Surgeons and
adapted in 1985 by the Centers for Disease Control and Prevention.
Four classes of surgical wound types are described based on the wound’s level of contamination:
I. Clean,
II. Clean- contaminated,
III. Contaminated and
IV. Dirty - infected
A biofilm42, 43 can be described as a microbial colony encased in a polysaccharide matrix which
can become attached to a wound surface. This can affect the healing potential of chronic wounds
due to the production of destructive enzymes and toxins which can promote a chronic
inflammatory state within the wound. Biofilms can be polymicrobial and can result in delayed
26
wound healing and chronic wound infection resistant to antibiotics, leading to prolonged
hospitalization for some patients. There appears to be a correlation between biofilms and non-
healing in chronic wounds. It is suggested that biofilms are a major player in the chronicity of
wounds. They are a complex concept to diagnose and management needs to be multifactorial. In
many instances, wound colonizing-bacteria are thought to be capable of forming biofilms, a
significant factor contributing to delays or failure in wound healing.42 Antimicrobial prophylaxis
has been shown to be effective at reducing the risk of surgical site infection. Next, to SSI,
Hematoma represents the second-most common Cesarean wound complication. In the short term,
multiple layers of closure serve as a barrier against infection. Wound hematomas develop when
bleeding occurs after the wound has been closed. Blood becomes trapped and exerts pressure on
the surrounding tissue, squeezing out nutrients and oxygen. If the pressure becomes great
enough, it can compromise the sutures, creating a portal for bacteria to enter the body, while the
blood itself provides a nutrient-rich growth medium for those bacteria. As with infection,
treatment requires exploration and drainage of the wound with a scalpel, and sometimes
antibiotics
INCIDENCE OF POST CAESAREAN SSI:
In all the caesarean section patients, depending on the definitions used and the period of
observation, surgical site infection (SSI) occur in about 1.8%–9.8% of these subjects.6-13 The rate
of SSI has been reported to be from 5.7–9.0% 44 from studies around the world and many other
studies in various centers reported infection rates ranging from 6.09–38.7%.6, 45 The total number
of Post CS SSI was 2.66% in the study by Dhar H et al (2014).22
27
In England, 9.6% (394/4107) of women in the study developed a post-surgical infection
following caesarean section with 0.6% (23/4107) readmitted for treatment of the infection7. The
rate of SSI was 9.8% by Wilson J et al (2013).8 Furthermore, the mortality rate associated with
surgical site infection is 3% and 75% of SSI associated deaths are directly caused by SSI.46
The variation in incidence may reflect differences in population characteristics and risk factors,
perioperative practices, and the duration from the procedure until ascertainment. The risk for
developing SSI has significantly decreased in the last three decades, mainly owing to
improvements in hygiene conditions, antibiotic prophylaxis, sterile procedures, and other
practices. Despite this decrease, the occurrence of SSI is expected to increase given the
continuous rise in the incidence of cesarean deliveries. Post caesarean SSI may increase maternal
morbidity and mortality. In addition, SSI can be frustrating for the mother trying to recover from
the procedure and at the same time take care of the newborn. It may prolong maternal
hospitalization, increase health care costs, and lead to other socioeconomic implications.
Satyanarayan et al.47 in their study reported rates of wound infections as high as 25.2% in
emergency CS compared to 7.6% in elective cases.
Staphylococcus aureus is the most commonly isolated bacteria in wound infections following
Caesarean Section.48 Other workers isolated more gram-negative organisms like E. coli, Proteus
mirabilis, Pseudomonas, and Klebsiella in CS wound infections. SSI in relation to cesarean
delivery has a distinctive microbial source of pathogens composed of both skin and vaginal
origin.49 Accordingly, it is usually a polymicrobial infection consisting of both aerobic bacteria
and anaerobic organisms.49 The variation in the spectrum of causative organisms means that
prophylactic antibiotic though effective may fail when the wrong agent is used or used
inappropriately
28
RISK FACTORS FOR POST CAESAREAN SSI:
Developing SSI is a traumatic experience. The multiple risk factors for postcesarean wound and
other infections include patient characteristics and intrapartum management.
The risk factors for surgical site infections (SSI) after caesarean section are many; these include
intrinsic and extrinsic risk factors that predispose patients to SSI.
Intrinsic factors are patient-related while extrinsic factors are related to patient care and
management, although the intrinsic factors cannot be changed, the risk they present in terms of
infection is identifiable and manageable.
Risk factors6, 10, 14, 21, 22,7, 14, 21-24 can be divided into three categories50:
1) Host-related factors,
2) Pregnancy and Intrapartum-related factors, and
3) Procedure-related factors.
Host-related risk factors include maternal older or younger age, obesity, residence in rural
(compared to urban) area, pregestational diabetes mellitus, previous cesarean delivery, recurrent
pregnancy loss, and maternal preoperative condition (American Society of Anesthesiologists
score >3).
Pregnancy-related factors include hypertensive disorder, gestational diabetes mellitus, twin
pregnancy, preterm rupture of membranes, a greater number of vaginal examinations, the
prolonged trial of labor prior to surgery, epidural use, use of internal fetal monitoring, and
chorioamnionitis.
In regard to the procedure itself, SSI was more common among cesarean sections performed in
an emergency setting, non use of prophylactic antibiotics, and in cases accompanied by uterine
29
rupture, caesarean hysterectomy, need for blood transfusion and in surgeries of longer duration.
Surgery duration of more than 1 hour had been reported to increase the risk for SSI more than
two fold.
SSI can be attributed to a perioperative bacterial load in the tissue at the site of surgery and the
diminished integrity of the host’s defenses. Some of the risk factors observed for CS wound
infections are obesity, diabetes, immunosuppressive disorders, chorioamnionitis, a previous
Caesarean delivery, certain medications like steroids, the lack of pre-incision antimicrobial care,
lengthy labour and surgery.51 Any infection of the abdominal wound complicating CS should be
minimized through strict preventative measures, such as antisepsis, preoperative preparation, a
reduction in the duration of surgery, a reduction in blood loss, the use of absorbable sutures and
avoiding cross-infection.
Overall, factors6, 10, 14, 21, 22,7, 14, 21-24that have been associated with an increased risk of wound
complications among women who have a cesarean delivery include
1. Emergency cesarean section21,
2. Labor and its duration,
3. Ruptured membranes and the duration of rupture,
4. The socioeconomic status of the woman,
5. Number of prenatal visits,
6. Vaginal examinations during labor,
7. Urinary tract infection,
8. Anemia,
9. Blood loss,
10. Obesity,
30
11. Diabetes,
12. The skill of the operator and
13. The operative technique.
Schneid-Kofman N et al12 and Farret TC et al25 observed that Emergency caesarean section is an
independent risk factor for the development of Surgical site infection. Farret TC et al25 observed
that patients who had an emergency caesarean had a 3.3-fold greater risk of SSI.
Optimization of maternal comorbidities, appropriate antibiotic prophylaxis, and good surgical
technique may ameliorate the risk of subsequent wound infection. Clinical suspicion for wound
infection should be raised by fever, wound erythema, incisional drainage, and expanding
induration. Approaches to wound management combine administration of topical/systemic
antibiotics, debridement of necrotic tissue, and application of dressings for a balanced moist
environment.20, 23 Necrotizing fasciitis represents a severe, rapidly expanding wound infection,
which presents an immediate threat to the life of the patient. Early identification and debridement
are critical for survival.
The variation in Surgical Site Infections is not only influenced by the use of antibiotic
prophylaxis but also importantly by specific obstetric risk factors. Zerr et al.52 have shown that
the risk of surgical site infection is increased in patients with medical conditions such as diabetes
mellitus and obesity.
Additionally, obesity is a recognized and well-established health risk factor and has an influence
on wound healing and the risk of SSI.12
Intrapartum factors can also increase the risk of surgical site infection such as in Caesarean
Sections that are performed in labor or as an emergency and also where there is suspected
chorioamnionitis.12
31
Not only are the patient-dependent risk factors significant but also the surgical specific factors
may play a role in the risk of surgical site infection.
MOST RELEVANT STUDIES
1. SSI IN ELECTIVE Vs EMERGENCY CS
2. SSI INCIDENCE, RISK FACTORS:
SSI IN ELECTIVE Vs EMERGENCY CS
Vijaya K et al (2015)26 studied the incidence of wound infection in emergency and elective
lower segment caesarean section (LSCS) and factors predisposing to wound infection. The
differences in incidences of wound infection in emergency and elective LSCS was studied. This
Hospital based prospective and comparative study was conducted in Modern Government
Maternity Hospital, Petlaburj, Osmania Medical College, Hyderabad, from October 2012 to
September 2013. Total number of LSCS performed from November 2012 to October 2013 was
5864 (32.16% of the total deliveries - 18236). Total number of surgical site infections (SSI) in
254cases (4.33% of total LSCS performed) SSI in elective LSCS = 36 (1.03% of elective LSCS
performed) SSI in emergency LSCS = 218 (9.18% of emergency LSCS performed). Cases of SSI
with caesarean section performed elsewhere and referred to our hospital are excluded. The mean
age among cases of elective LSCS is 25 years. The mean age among cases of emergency LSCS
is 24 years. Anemia (26.77%) and preeclampsia (25.19%) are the most commonly associated risk
factors for SSI. The incidence of surgical site infection in cases of emergency LSCS is high,
increasing the maternal morbidity. The recognition and correction of associated medical
complications in the antenatal period are vital. Early decision making in cases of emergency
LSCS reduces the infection rate in cases of emergency LSCS. Gram-negative E.coli and
32
Klebsiella are the most commonly isolated organisms and are sensitive to aminoglycosides and
quinolone. Empirical treatment may be started against these organisms in case of delay in culture
and sensitivity report
Kishwar N et al (2016)53 in their study determined the risk factors for surgical site infection in
women undergoing lower segment caesarean section and compared the frequency of identified
risk factors for surgical site infection among women undergoing elective and emergency
caesarean section. They did a cross-sectional comparative study, conducted at Hayatabad
Medical Complex Peshawar from August 2014 to August 2015. Consecutive 195 postoperative
cases of emergency and elective caesarean section with surgical site infection were enrolled into
the study. The patients were followed on the 3rd to 5th postoperative day and on 28th day
thereafter. Final outcome i.e. surgical site infections (SSI) was measured on 28th day by
researcher and SSI were labeled as positive, as per operational definition. A total of 195 post-
operative cases diagnosed with surgical site infection, were studied during the specified period.
Of these 164(84.1%) were delivered with emergency caesarean section whereas 31(15.9%) by
elective caesarean section. The average age of the patients was recorded 27.8 ± 7.7 (ranging from
21 to 40) years, average parity of the women was recorded 4.4±1.6 (range 0-9), the average
gestational age of the women was recorded 38±1.3 (ranging from 37 to 40) weeks. Average BMI
of the patients was recorded 29.3±4.6 (ranging from 20 to 45). In this study, BMI of more than
35kg/m2 was associated with higher rate of SSI. Obesity, gestational age, educational and
economic status were risk factors for surgical site infections; more so following emergency vs
elective caesarean sections.
33
Dimitrova V et al (2005)35 analyzed the frequency of complications after elective/planned [PCS]
and emergency Cesarean section [ECS]; and compared the types of complications in the two
evaluated groups and the possible risk factors for complications after elective and emergency
procedures. The study was retrospective, hospital-based one. Data regarding complications
following Cesarean section [CS] that demanded transfer of the patients to The Clinic of High
Infectious Risk, State University Hospital "Maichin Dom", Sofia and prolonged hospital stay
(more than 7 days after the operation) were analyzed. The incidence of complications in 574
consecutive PCS and in 292 ECS was calculated. The type of the following complications was
compared in the two groups: uterine infections (endo/mio/ metrophlebitis), wound infection,
subfascial hematoma, residua, sepsis, pelvic thrombophlebitis. Statistical evaluation of the results
was performed by Student's t-test with p<0.05 considered statistically significant. In 574 PCS the
frequency of postoperative complications was 1,4% while in 292 ECS it was 2,05% (p>0.05).
There was no significant difference in the distribution of the different types of postoperative
complications in 34 cases with PCS and 33 cases with ECS. The percentage of patients with
previous CS was significantly higher in the complicated cases with PCS compared to that with
ECS. The two studied groups did not differ significantly regarding the type of skin incision,
operator's qualification, blood loss, drainage of the subfascial space, accompanying diseases.
They concluded that Caesarean section constitutes a major surgical procedure characterized with
morbidity even if performed as a planned procedure. The risk of complications seems to be
higher in cases of repeated CS.
SSI INCIDENCE, RISK FACTORS:
Farret TC et al (2015)25 evaluated patients with diagnosis of surgical site infection (SSI)
following caesarean section and their controls to determinate risk factors and impact of antibiotic
34
prophylaxis on this condition. All cesareans performed from January 2009 to December 2012
were evaluated for SSI, based on criteria established by CDC/NHSN. Control patients were
determined after inclusion of case-patients. Medical records of case and control patients were
reviewed and compared regarding sociodemographic and clinical characteristics. Their study
demonstrated an association following univariate analysis between post-cesarean SSI and
number of internal vaginal examinations, time of membrane rupture, emergency caesarean and
improper use of antibiotic prophylaxis. This same situation did not repeat itself in multivariate
analysis with adjustment for risk factors, especially with regard to antibiotic prophylaxis,
considering the emergency caesarean factor only. They not only questioned surgical
antimicrobial prophylaxis use based on data presented here and in literature but suggested that
the prophylaxis is perhaps indicated primarily in selected groups of patients undergoing
caesarean section. Further research with a greater number of patients and evaluated risk factors
are fundamental for the better understanding of the causes and evolution of surgical site infection
after caesarean delivery.
Nuthalapaty FS et al (2013)54 compared wound complications after Caesarean section in the
obese patient, following early versus delayed skin staple removal. They conducted a single-
center, non-inferiority, randomized controlled trial. Following Caesarean section, obese women
(BMI ≥ 30 kg/m(2)) with subcutaneous wound depth ≥ 2.0 cm and skin staple closure of a
transverse incision were randomized to staple removal on postoperative day 3 (early) or between
postoperative day 7 and postoperative day 10 (delayed). The primary outcome was superficial
wound dehiscence; a rate of 8% or higher in the early group was defined as inferior. Secondary
outcomes were seroma/hematoma, surgical site infection, and visual Analogue pain score. The
planned sample size was 250 patients per group. The study was halted after 295 patients were
35
randomized because of slow enrolment and exhaustion of funding. The rate of superficial wound
dehiscence was 15.2% in the early group (n = 145) versus 11.5% in the delayed group (n = 148).
The point estimate for this difference (3.7 %; 95% CI -4.4 to 12.4) favours delayed removal.
However, because the 95% CI includes zero and the upper CI exceeds the predefined limit for
non-inferiority (8%), non-inferiority was not demonstrated. The rates of all secondary outcomes
were similar in the early group and the delayed group: seroma/hematoma (6.9% vs. 4.7%; RR
1.4, 95% CI 0.6 to 3.7, P = 0.4); surgical site infection (9.7% vs. 4.8%; RR 2.0, 95% CI 0.8 to
4.9, P = 0.1); and composite (superficial wound dehiscence, seroma/hematoma, and surgical site
infection) wound complication (17.2% vs. 12.8%; RR 1.3, 95% CI 0.8 to 2.3, P = 0.3). They
concluded that the non-inferiority of early skin staple removal was not demonstrated. Delayed
removal of staples should remain the accepted standard in the obese patient following Caesarean
section.
Moreira CM et al (2014)55 evaluated the safety of electrocautery for coagulation during
Caesarean sections. A randomized, controlled, clinical pilot study was performed at a university
maternity hospital. After admission for delivery and decision to perform a C-section, volunteers
were randomized to either the intervention group (use of electrocautery for coagulation) or
nonintervention group. The women were examined at the time of postpartum discharge (day 3),
at days 7 to 10, and again at days 30 to 40 for signs of infection, hematoma, seroma, or
dehiscence. Data were analyzed using an intention-to-treat analysis, and risk ratios were
calculated. No significant differences were found between the two groups. Only 2.8% of patients
in the intervention group developed surgical wound complications during hospitalization.
However, 7 to 10 days following discharge, these rates reached 23.0% and 15.4% in the
intervention and nonintervention groups, respectively (RR = 1.50, 95% CI = 0.84-2.60). They
36
concluded that further studies should confirm whether the use of electrocautery for coagulation
does not increase the risk of surgical wound complications in patients undergoing Caesarean
sections.
Corcoran S et al (2013)56 undertook a baseline assessment to determine SSI rates, and
subsequently, a quality improvement program was introduced, followed by repeat surveillance.
Data were collected during in-hospital stays and for up to 30 days after CS during both periods.
Interventions in the quality improvement program included the use of nonabsorbable sutures for
skin closure, use of clippers instead of razors, and use of 2% ChloraPrep for skin disinfection
before incision. A total of 710 patients were surveyed before the interventions, and 824 patients
were surveyed after the interventions. Of these, 114 (16%) had an SSI before the interventions,
and 40 (4.9%) had an SSI after the interventions (P <.001; odds ratio, 0.27), with 90% and 83%,
respectively, detected after hospital discharge. In multivariate analysis, obesity (P =.002) and the
use of absorbable suture materials for skin closure (P =.008) were significantly associated with a
higher SSI rate before the interventions; however, only obesity was associated with a higher SSI
rate after the quality program. They concluded that surveillance of SSI rates after CS followed by
3 interventions contributed to a significant reduction in SSI rate and improved patient care.
Gong SP et al (2012)51 estimated the incidence and identified the risk factors for a surgical site
infection after a cesarean section. A survey of women who underwent a caesarean section was
conducted in eight hospitals in Guangdong Province, China. The rate of surgical site infection
was estimated and a nested case control study was then carried out to identify the risk factors.
Among 13 798 women surveyed, 96 (0.7%) developed a surgical site infection after a cesarean
section. Multivariate logistic regression analysis identified six factors independently associated
with an increased risk of surgical site infection, which included obesity, premature rupture of
37
membranes, lower preoperative hemoglobin, prolonged surgery, lack of prophylactic antibiotics
and excessive anal examinations performed during hospitalization. They concluded that Surgical
site infection occurs in approximately 0.7% of cesarean section cases in the general obstetric
population in China. Obesity, premature rupture of membranes, lower preoperative hemoglobin,
prolonged surgery, lack of prophylactic antibiotics and excessive anal examinations during
hospitalization are considered to be independent risk factors.
Dhar H et al (2014)22 determined the incidence of surgical site infections (SSI) in patients
undergoing a Caesarean section (CS) and identified risk factors, common bacterial pathogens
and antibiotic sensitivity. SSI significantly affect the patient's quality of life by increasing
morbidity and extending hospital stays. A retrospective cross-sectional study was conducted in
Nizwa Hospital, Oman, to determine the incidence of post-Caesarean (PCS) SSI from 2001 to
2012. This was followed by a case-control study of 211 PCS cases with SSI. Controls (220) were
randomly selected cases, at the same hospital in the same time period, who had undergone CS
without any SSI. Data was collected on CS type, risk factors, demographic profile, type of
organism, drug sensitivity, and date of infection. The total number of PCS wound infections was
211 (2.66%). There was a four-fold higher incidence of premature rupture of the membranes (37,
17.53%) and a three-fold higher incidence of diabetes (32, 15.16%) in the PCS cases compared
with controls. The most common organisms responsible for SSI were Staphylococcus aureus (66,
31.27%) and the Gram-negative Escherichia coli group (40, 18.95%). The most sensitive
antibiotics were aminoglycoside and cephalosporin. Polymicrobial infections were noted in 42
(19.90%), while 47 (22.27%) yielded no growth. A high incidence of associated risk factors like
obesity, hypertension, anemia and wound hematoma was noted. They concluded Measures are
38
needed to reduce the incidence of SSI, including the implementation of infection prevention
practices and the administration of antibiotic prophylaxis with rigorous surgical techniques.
Jenks PJ et al (2014)13 determined the clinical and economic burden of SSI over a two-year
period and predicted the financial consequences of their elimination. SSI surveillance and Patient
Level Information and Costing System (PLICS) datasets for patients who underwent major
surgical procedures at Plymouth Hospitals NHS Trust between April 2010 and March 2012 were
consolidated. The main outcome measures were the attributable postoperative length of stay
(LOS), cost, and impact on the margin differential (profitability) of SSI. A secondary outcome
was the predicted financial consequence of eliminating all SSIs. The median additional LOS
attributable to SSI was 10 days [95% confidence interval (CI): 7-13 days] and a total of 4694
bed-days were lost over the two-year period. The median additional cost attributable to SSI was
5,239 pounds (95% CI: 4,622-6,719) and the aggregate extra cost over the study period was
2,491,424 pounds. After calculating the opportunity cost of eliminating all SSIs that had
occurred in the two-year period, the combined overall predicted financial benefit of doing so
would have been only 694,007 pounds. For seven surgical categories, the hospital would have
been financially worse off if it had successfully eliminated all SSIs. They concluded that SSI
causes significant clinical and economic burden. Nevertheless the current system of
reimbursement provided a financial disincentive to their reduction.
Dyrkorn OA et al (2012)45 did their interventional study to reduce the caesarean section surgical
wound infection incidence to below the Norwegian national level of 8 %. The intervention (a
quality improvement project) was implemented in September 2008. A bundle of measures were
introduced. Staff from all aspects of patient flow was recruited. Cochrane literature was used as
gold standard. Data registration was based upon CDC criteria. Results were based on data
39
collected through the Norwegian national surveillance system for infections in healthcare, NOIS.
Study setting This Maternity clinic has about 2500 births annually and a caesarean section rate
pushing 15 %. The study was conducted on caesarean section patients registered in NOIS (2008-
2010). From September 2009 data were harvested continuously. Data were monitored as
cumulative incidence rate and by statistical process control as g chart (number of surgeries
between infections including a delayed moving average). Infection control staff reported results
to Head of Maternity Clinic monthly. The overall rate of caesarean section surgical wound
infections was significantly reduced to 3,1 % (2008-2010 about 1 % in 2010). This result was
demonstrated elegantly as a marked shift in the processing chart. We found the g-chart was
efficient, sensitive and simple to handle.
Gregson H (2011)44 did their study to set up a surgical site infection (SSI) benchmark rate for
caesarean sections and improve infection rates by monitoring and implementing compliance with
the guidelines produced by the National Institute for Health and Clinical Excellence (NICE). A
total of 2382 patients who had undergone caesarean section at Maidstone and Tunbridge Wells
NHS Trust were monitored at two obstetric sites over a two-year period. A proactive infection
surveillance system was used during the patients' hospital stay. Community midwives collected
and returned post-discharge data on wound status. Patients were asked to return post-operative
questionnaires 30 days after surgery, providing details of any wound problems. Compliance with
NICE guidance on reducing SSIs was measured at both sites and changes were implemented
accordingly. Infection rates before compliance with NICE guidance from July 2008 to June 2009
ranged from 5.7% to 9.0%. After introducing the guidelines, rates of SSI at site A and site B
were reduced by 3.3% and 3.8% respectively. Rates of SSI at site A were reduced further to
40
1.3% on introduction of the Hydrofiber and hydrocolloid dressing. Results suggest that the
Hydrofiber and hydrocolloid combination dressing assists in the reduction of SSI rates following
caesarean section when used in combination with the NICE guidance.
Wilson J et al (2013)8 evaluated the efficacy of case-finding methods for SSI following
caesarean delivery and their utility in establishing benchmark rates of SSI. Hospitals conducted
surveillance over one or two 13-week periods. Patients were reviewed during their inpatient stay,
postpartum by community midwives and via patient questionnaire at 30 days post delivery. To
estimate the reliability of case-finding methods, case-note reviews were undertaken in a random
sample of four hospitals. A total of 404 SSIs were detected in 4107 caesarean deliveries from 14
hospitals. The median time to SSI was 10 days, 66% were detected in-hospital or by community
midwives, and an additional 34% were patient-reported. The rate of SSI was 9.8% but the
proportion of patients followed up varied significantly between centres. The estimated sensitivity
and specificity of case-finding was 91.4% [95% confidence interval (CI): 53.4-98.4] and 98.6%
(95% CI: 98.4-98.8), the positive predictive value 91.0% (95% CI: 82.4-96.1) and negative
predictive value 98.6% (95% CI: 93.9-99.5). Combined case ascertainment methods are a
feasible way to achieve active post-discharge surveillance and had high negative and positive
predictive values. Additional SSIs can be detected by patient questionnaires but rates of SSI were
strongly influenced by variation in the intensity of both health care worker- and patient-based
case-finding. This factor must be taken into account when comparing or benchmarking rates of
SSI.
Wloch C et al (2012)7 assessed the frequency and risk factors for surgical site infection
following caesarean section. In their Prospective multicentre cohort study, data from fourteen
NHS hospitals in England, April to September 2009 were studied. Women who underwent
41
caesarean section at participating hospitals during designated study periods.: Infections that met
standard case definitions were identified through active follow up by healthcare staff during the
hospital stay, on return to hospital, during midwife home visits and through self-completed
patient questionnaires. The main outcome measure was Surgical site infection within 30 days of
operation. Altogether, 9.6% (394/4107) of women in the study developed a post-surgical
infection following caesarean section with 0.6% (23/4107) readmitted for treatment of the
infection. Being overweight (body mass index [BMI] 25-30 kg/m(2) odds ratio [OR] 1.6, 95%
confidence interval [95% CI] 1.2-2.2) or obese (BMI 30-35 kg/m(2) OR 2.4, 95% CI 1.7-3.4;
BMI > 35 kg/m(2) OR 3.7, 95% CI 2.6-5.2) were major independent risk factors for infection
(compared with BMI 18.5-25 kg/m(2)). There was a suggestion that younger women and
operations performed by associate specialist and staff grade surgeons had a greater odds of
developing surgical site infection with OR 1.9, 95% CI 1.1-3.4 (<20 years versus 25-30 years),
and OR 1.6, 95% CI 1.0-2.4 (versus consultants), respectively. This study identified high rates of
postsurgical infection following caesarean section. Given the number of women delivering by
caesarean section in the UK, substantial costs will be incurred as a result of these infections.
Prevention of these infections should be a clinical and public health priority.
Hadar E et al (2011)10 investigated the timing and risk factors of maternal complications of
cesarean section (CS). Review of the files of all women who underwent CS at a tertiary medical
center between September 2007 and December 2008 yielded 100 patients with postpartum
complications was done. Their clinical and surgery-related characteristics were compared with
100 women with uncomplicated CS operated in January 2009. Complications were analyzed by
prevalence and time of occurrence. The only between-group difference in background factors
42
was a higher rate of obesity (BMI > 30) in the controls. The complication rate was 5.7%. The
most common complication was endomyometritis (3.6%), followed by wound infection (1.8%)
and wound hematoma (1.2%). In most cases, endomyometritis was diagnosed on postoperative
days 2-3 and wound complications on days 2-5; 7 of the 9 readmissions occurred on
postoperative days 5-6. On multivariate analysis, significant independent predictors of
postoperative complications were surgeon experience (OR = 2.4, 95% CI 1.2-4.8) and
intrapartum CS (OR = 2.1, 95% CI 1.1-4.3). Caesarean section performed by a resident or during
active labor is associated with an increased risk of postpartum complications. Medical teams
should be alert to morbidity in women at risk, particularly during the first 4 days after CS.
Alanis MC et al (2010)9 in their study determined predictors of cesarean delivery morbidity
associated with massive obesity. This was an institutional review board-approved retrospective
study of massively obese women (body mass index, > or = 50 kg/m(2)) undergoing cesarean
delivery. Bivariable and multivariable analyses were used to assess the strength of association
between wound complication and various predictors. Fifty-eight of 194 patients (30%) had a
wound complication. Most (90%) were wound disruptions, and 86% were diagnosed after
hospital discharge (median postoperative day, 8.5; interquartile range, 6-12). Subcutaneous
drains and smoking, but not labor or ruptured membranes, were independently associated with
wound complication after controlling for various confounders. Vertical abdominal incisions were
associated with increased operative time, blood loss, and vertical hysterotomy. Women with a
body mass index > or = 50 kg/m(2) have a much greater risk for caesarean wound complications
than previously reported. Avoidance of subcutaneous drains and increased use of transverse
43
abdominal wall incisions should be considered in massively obese parturients to reduce operative
morbidity.
Olsen MA et al (2008)6 determined independent risk factors for SSI after low transverse
caesarean section. They did their Retrospective case-control study in Barnes-Jewish Hospital, a
1,250-bed tertiary care hospital. A total of 1,605 women who underwent low transverse
caesarean section during the period from July 1999 to June 2001. Using the International
Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI or
wound complication and/or data on antibiotic use during the surgical hospitalization or at
readmission to the hospital or emergency department, we identified potential cases of SSI in a
cohort of patients who underwent a low transverse cesarean section. Cases of SSI were verified
by chart review using the definitions from the Centers for Disease Control and Prevention's
National Nosocomial Infections Surveillance System. Control patients without SSI or
endomyometritis were randomly selected from the population of patients who underwent a
caesarean section. Independent risk factors for SSI were determined by logistic regression. SSIs
were identified in 81 (5.0%) of 1,605 women who underwent low transverse caesarean section.
Independent risk factors for SSI included development of subcutaneous hematoma after the
procedure (adjusted odds ratio [aOR], 11.6 [95% confidence interval [CI], 4.1-33.2]), operation
performed by the university teaching service (aOR, 2.7 [95% CI, 1.4-5.2]), and a higher body
mass index at admission (aOR, 1.1 [95% CI, 1.0-1.1]). Cephalosporin therapy before or after the
operation was associated with a significantly lower risk of SSI (aOR, 0.2 [95% CI, 0.1-0.5]). Use
of staples for skin closure was associated with a marginally increased risk of SSI. They
44
concluded that these independent risk factors should be incorporated into approaches for the
prevention and surveillance of SSI after surgery.
Opoien HK et al (2007)11, in their study documented the true incidence of post-cesarean surgical
site infections (SSI), according to the definition of the US Centers for Disease Control and
Prevention (CDC), and to identify independent risk factors for infection. They did a Prospective
population-based cohort study in Norway in Sykehuset Asker og Baerum HF, a secondary
community hospital, associated with the University of Oslo (UiO), Norway, accounting for 2,000
deliveries per year. All cesarean deliveries during a 12-month period from September 2003 were
participants. Their main outcome measures were rate and risk factors for SSI. The total rate of
SSI was 8.9%, with an observation period of 30 days postoperatively, compared to 1.8%
registered at hospital discharge. The total response rate was 100%. There was no significant
difference in SSI rate in elective or emergency cesarean section (CS), respectively. All SSI were
superficial. We found 2 significant independent risk factors: operating time > or =38 min and
body mass index (BMI) >30. They concluded that the rate of SSI is underestimated if the
observation time is limited to the hospital stay. Operating time exceeding 38 min substantially
increases the risk of SSI. The finding of no significant difference in SSI rate between elective
and emergency CS should lead to a different approach concerning the use of antibiotics:
subgroup at risk (operating time > or =38 min and BMI >30) may benefit from antibiotics in
relation to the operation, whether the CS is an emergency or elective operation.
Schneid-Kofman N et al (2005)12 in their study identified risk factors for early wound infection
(diagnosed prior to discharge) following cesarean delivery. They did a population-based study
comparing women who have and have not developed a wound infection prior to discharge from
45
Soroka University Medical Center, Ben Gurion University of the Negev, between 1988 and
2002. Of the 19,416 cesarean deliveries performed during the study period, 726 (3.7%) were
followed by wound infection. Using a multivariable logistic regression model, the following risk
factors were identified: obesity (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.6-3.1);
hypertensive disorders (OR = 1.7; 95% CI, 1.4-2.1); premature rupture of membranes (OR = 1.5;
95% CI, 1.2-1.9); diabetes mellitus (OR = 1.4; 95% CI, 1.1-1.7); emergency cesarean delivery
(OR = 1.3; 95% CI, 1.1-1.5); and twin delivery (OR = 1.6; 95% CI, 1.3-2.0). Combined obesity
and diabetes (gestational and pregestational) increased the risk for wound infection 9.3-fold
(95% CI, 4.5-19.2; P <.001). They concluded that independent risk factors for an early wound
infection were obesity, diabetes, hypertension, premature rupture of membranes, emergency
cesarean delivery, and twin delivery. Information regarding higher rates of wound infection
should be provided to obese women undergoing cesarean delivery, especially when diabetes
coexists.
Nielsen TF et al (1984)34 studied the incidence of surgical complications associated with
cesarean section (CS) prospectively in 1319 patients undergoing CS during the years 1978, 1979
and 1980 (18% of all deliveries). The overall complication rate was 11.6% (9.5% of patients with
minor complications and 2.1% with major complications). The complication rate for emergency
operations was 18.9% and for elective CS, 4.2%--a highly significant difference. (p less than
0.001). Six risk factors were associated with the occurrence of surgical complications in
emergency cases: Station of the presenting part of the fetus in relation to the spinal plane (p less
than 0.001), labor prior to surgery (p less than 0.001), low gestational age (less than 32 weeks) (p
less than 0.001), rupture of fetal membranes (with labor) prior to surgery (p less than 0.01),
46
previous CS (p less than 0.01), and skill of the operator (p less than 0.05). However, no such risk
factors were found in the elective group. The clinical relevance of these findings is summarized
in two conclusions. Firstly, the proportion of emergency operations needs to be reduced, either in
favor of elective procedures or by allowing more patients to give birth by the vaginal route.
Secondly, emergency CS requires great skill on the part of the surgeon, and should therefore not
be entrusted to young, inexperienced obstetricians.
LACUNAE IN LITERATURE:
The literature with regards to rate of caesarean section in india is very limited. There is
no scientifically sound data on a large scale other than from NFHS-4 survey. Also caesarean
sections done in private hospitals in india are always not accounted for. There are also some gaps
in the literature with regards to incidence of Surgical site infection in caesarean section per se.
Published Studies focusing on frequency of wound complications on a large scale with adequate
sample size are very rare. Various factors affecting wound site complications include Host-
related, Pregnancy and Intrapartum-related, and Procedure-related factors. There is a definite lacunae in
literature with regards to pregnancy and intra-partum related factors in india which can be acted upon
with apparent benefits. So, we took steps towards addressing these issues in our study.
47
MATERIALS & METHODS
48
Study design: A prospective observational comparative study.
Study duration: The data collection for the study was conducted for a 1 year period from 1 st
October 2016 to 30th September 2017
Study area: The study was conducted in the department of obstetrics and gynecology, Civil
Hospital, Aizwal, Mizoram
Study population: All the mothers admitted in the Civil Hospital, Aizwal, Mizoram after
cesarean section with wound complications.
Sample size: (justification)
Based on the analysis of pilot data from the same setting from the previous hospital records, the
expected prevalence of Wound complications after cesarean section to be around 20 per 1000
Hospital admission in Civil hospital, Aizawl, Mizoram. For a confidence level of 95% with a
margin of error of around 5 %, sample size taken for the study was calculated using following
formula:
n = (Z2 × P (1- P)) / e 2
P is proportion
Z is Value from standard normal distribution corresponding to desired confidence level
e is desired precision
By applying following values,
P = 0.02
Z = 1.96 (for Confidence Interval of 95 %)
e = 0.05
We have arrived at a sample size of 31 each Elective and Emergency cesarean section
49
Inclusion Criteria:
Women undergoing Elective or emergency Lower segment Cesarean section in Civil Hospital,
Aizwal.
Exclusion Criteria:
Women with Other systemic complications of respiratory system, cardiovascular system,
gastrointestinal tract and central nervous system.
Methodology:
All the mothers operated for lscs (emergency or elective) admitted in maternity ward was
followed up from the post op day 0(day of operation) up to 3 weeks. Patients were observed for
any operative wound discharge, soakage of dressing along with vitals and clinical examinations.
on the post op day2 dressing is removed and kept open after proper cleaning of incisional site
with spirit swabs followed by daily dressing of wound with fusidic acid spray. On the post op
day6,7 or 10 according to patient profile and surgeons judgement, suture removal is done.
Patients, who developed wound site complications undertook valid consent. Detailed history,
clinical examinations and investigations profile was collected. Patient was look for any
discharge, wound gaping, surgical site infection , hematoma, seroma , abscess , induration ,
wound gaping and burst abdomen from day of operation. All the findings were noted according
to proforma. All the patients with wound discharge wound gaping and surgical site infection
sample was collected for culture and sensitivity. Patients were followed up up to 3 weeks after
operation for wound site outcome. Patient was treated conservatively or by secondary resuturing
of wound after treating active infections accordingly.
50
After valid consent and information regarding test culture and sensitivity sample is taken by no
touch technique. After proper hand washing with soap and water clean gloves were put. Soiled
dressing were removed if present. Gloves were removed and after proper hand hygiene sterile
gloves were put. Wound was cleansed thoroughly with at least 80 ml of normal saline and peri-
wound skin cleansing was ensured. Then at least 2 swabs were taken from viable tissue and were
put in clean sterile test tubes by no touch technique. For the patient with wound discharge,
discharge or pus was aspirated by synringe under strict aspetic precautions and were transferred
in sterile test tubes or container. Specimen was sent to microbiology department for culture and
sensitivity testing. Reports were followed up and antibiotics were administered according to
susceptibility test results.
Method of assessment of outcome of interest:
The key outcome variables i.e. Surgical Site Infection (SSI) was assessed by CDC Criterion for
Superficial incisional SSI37, as follows
Infection occurs within 30 days AND involves only skin and subcutaneous tissue of the incision
AND patient has at least one of the following:
a. purulent drainage from the superficial incision.
b. organisms identified from an aseptically-obtained specimen from the superficial incision or
subcutaneous tissue by a culture or non-culture based microbiologic testing method which is
performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance
Culture/Testing (ASC/AST).
c. superficial incision that is deliberately opened by a surgeon, attending physician or other
designee and culture or non-culture based testing is not performed.
AND
patient has at least one of the following signs or symptoms: pain or tenderness; localized
swelling; erythema; or heat. A culture or non-culture based test that has a negative finding does
not meet this criterion. d. diagnosis of a superficial incisional SSI by the surgeon or attending
physician or another designee.
51
Deep incision SSI
Infection occurs within 30 days AND involves deep soft tissues of the incision (e.g., fascial and
muscle layers) AND patient has at least one of the following:
a. purulent drainage from the deep incision.
b. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a
surgeon, attending physician or other designee and organism is identified by a culture or non-
culture based microbiologic testing method which is performed for purposes of clinical diagnosis
or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST) or culture or non-culture
based microbiologic testing method is not performed
AND
Patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or
tenderness. A culture or non-culture based test that has a negative finding does not meet this
criterion. c. an abscess or other evidence of infection involving the deep incision that is detected
on gross anatomical or histopathologic exam, or imaging test.
STATISTICAL METHODS:
Occurrence of wound site complications was considered as the primary outcome variable:
Type of cesarean section was considered as primary explanatory variable
Descriptive analysis was carried out by mean and standard deviation for quantitative variables,
frequency, and proportion for categorical variables. Data was also represented using appropriate
diagrams like bar diagram, pie diagram, and box plots.
A shapiro- Wilk's test (p>0.05) 57, 58 and a visual inspection of their histograms, normal Q-Q plots
and box plots showed that the study group and palpation fundal ht (weeks), haemoglobin (g/dl),
duration of labour (in mints), duration of surgery (in mints), suture removal time in days,
postoperative haemoglobin parameters were non-normally distributed for study group.59-61
The comparison study group and palpation fundal ht (weeks), hemoglobin (g/dl), duration of
labour (in mints), duration of surgery (in mints), suture removal time in days, postoperative
hemoglobin were assessed by comparing the median values. Mann Whitney U test was used to
assess statistical significance.
52
The association between SSI and type of cesarian section was assessed by cross-tabulation and
comparison of percentages. Chi-square test was used to test statistical significance.
P value < 0.05 was considered statistically significant. IBM SPSS version 22 was used for
statistical analysis.6
53
RESULTS
54
RESULTS:
A total of 1523 women who underwent caesarean section during the study period, satisfying the
inclusion and exclusion criteria were assessed for development of wound site complications. The
overall incidence of wound site infection was 4.59% ( 95% CI 3.54 %to 5.64%).
Table 1: Descriptive analysis of study group
Study group Number of cases Number of cases with complications Percetage
Incidence of complications (95%
CI)Elective CS 970 31 3.19 2.2 to 4.5
Emergency CS 553 39 7.31 5.1 to 9.5
Out of 970 women, who underwent elective caesarean section, 31 (3.19%, 95% CI 2.2 % 4.5%)
women developed wound site complications. Among 553 women undergoing emergency
caesarean section 39 women (7.31%, 95% CI 5.1%to 9.5%). (Table 1)
Table 2: Comparison of study group with post-operative wound complications of study population
Post-operative wound complications
Study groupChi-square P-valueElective CS
(N=970)Emergency CS
(N=553)Complications 31 (3.19%) 39 (7.05%)
11.946 0.001No complications 939 (96.80%) 514(92.94%)
The difference in the proportion of post-operative wound complications between study group
was statistically significant (P value 0.001). (Table 2 & Figure 1)
Figure 1: Clustered bar chart of Comparison of study group with post-operative wound complications of study population (N=1523)
55
Elective CS Emergency CS0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
3.19% 7.05%
96.80% 92.94%
Complications No complications
Study group
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Table 3: Comparison of mean patient age (in years) between study groups (N=70)
Study group Patient Age (in years)Mean± SD
Mean difference
95% CIP value
Lower Upper
Elective CS 28.81 ± 7.172.29 -0.90 5.49 0.157
Emergency CS 26.51 ± 6.23
The mean age of elective group was 28.81 ± 7.17 years and the emergency group was 26.51 ±
6.23 years, and the mean difference (2.29 years) between two groups was statistically not
significant (P value 0.157). (Table 3 & Figure 2)
56
Figure 2: Error bar chart of comparison of mean patient age (in years) between study groups (N=70)
Table 4: Comparison of study group with socioeconomic status of study population (N=70)
Socioeconomic StatusStudy group
Chi-square P-valueElective CS Emergency CS
Low 23 (74.2%) 30 (76.9%)1.102 0.577Middle 7 (22.6%) 6 (15.4%)
High 1 (3.2%) 3 (7.7%)
In elective CS group, 23 (74.2%) were in low class, 7 (22.6%) were in middle class, and 1
(3.2%) were in high class. In emergency CS group, 30 (76.9%) were in low class, 6 (15.4%)were
in middle class, and 3 (7.7%) were in high class. The difference in the proportion of
socioeconomic status between study group was statistically not significant (P value 0.557).
(Table 4 & Figure 3)
57
Figure 3: Clustered bar chart of comparison of study group with socioeconomic status of study population (N=70)
Elective CS Emergency CS0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
74.20% 76.90%
22.60%15.40%
3.20%7.70%
Low Middle High
Study group
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Table 5: Comparison of study group with history of study population (N=70)
HistoryStudy group
Chi-square P-valueElective CS Emergency CS
Referred 7 (22.6%) 17 (43.6%)3.384 0.066
Booked case 24 (77.4%) 22 (56.4%)
In elective CS group, 7 (22.6%) were in referred, and 24 (77.4%) were in booked case. In
emergency CS group, 17 (43.6%) were in referred, and 22 (56.4%) were in booked case. The
difference in the proportion of socioeconomic status between study group was statistically not
significant (P value 0.066). (Table 5 & Figure 4)
58
Figure 4: Clustered bar chart of comparison of study group with history of study population (N=70)
Elective CS Emergency CS0.00%
10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
22.60%
43.60%
77.40%
56.40%
Referred Booked case
Study group
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Table 6: Comparison of study group with history of leaking PV/ PROM of study population (N=70)
History of leaking PV/PROM
Study group
Elective CS Emergency CS
Yes 0 (0%) 27 (69.2%)
No 31 (100%) 12 (30.8%)*No statistical test was applied- due to 0 subjects in the cells.
PROM – Premature Rupture of Membranes
In emergency CS group, 27 (69.2%) had history of leaking PV/ PROM. (Table 6)
59
Table 7: Comparison of study group with regular antenatal care of study population (N=70)
Regular antenatal care
Study groupChi square P-value
Elective CS Emergency CS
Regular ANC visits
1 9 (29%) 15 (38.5%)
2.428 0.4882 3 (9.7%) 6 (15.4%)
3 3 (9.7%) 5 (12.8%)
4 16 (51.6%) 13 (33.3%)
Immunized
Yes 31 (100%) 38 (97.4%)* *
No 0 (0%) 1 (2.6%)*No statistical test was applied- due to 0 subjects in the cells.
In elective CS group, 9 (29%) were visited in one time, 3 (9.7%) were visited in second time and
a third time for each, and 16 (51.6%) were visited in the fourth time. In emergency CS group, 15
(38.5%) were visited in one time, 6 (15.4%) were visited in second time, 5 (12.8%) were visited
in a third time, and 13 (33.3%) were visited in the fourth time. (Table 7)
60
Table 8: Comparison of study group with obstetric parameters of study population (N=70)
Obstetric parametersStudy group
Chi square P-valueElective CS Emergency CS
Gravida1 13 (41.9%) 13 (33.3%)
2.916 0.5722 5 (16.1%) 8 (20.5%)3 5 (16.1%) 3 (7.7%)4 2 (6.5%) 6 (15.4%)5 and above 6 (19.4%) 9 (23.1%)ParityPrimi 14 (45.2%) 17 (43.6%)
2.389 0.4961 6 (19.4%) 7 (17.9%)2 7 (22.6%) 5 (12.8%)3 and above 4 (12.9%) 10 (25.6%)Abortion groupNo abortion 24 (77.4%) 31 (79.5%)
0.068 0.9661 abortion 2 (6.5%) 2 (5.1%)More than 2 abortion 5 (16.1%) 6 (15.4%)Number of live births0 15 (48.4%) 21 (53.8%)
6.043 0.1101 8 (25.8%) 4 (10.3%)2 6 (19.4%) 5 (12.8%)3 and above 2 (6.5%) 9 (23.1%)Number of death of child0 27 (87.1%) 32 (82.1%)
0.347 0.8411 3 (9.7%) 5 (12.8%)2 1 (3.2%) 2 (5.1%)
The difference in gravida between study group found to be insignificant with a P- value of 0.572.
The difference in parity between study group found to be insignificant with a P- value of 0.496.
The difference in abortion between study group found to be insignificant with a P- value of
0.966. The difference in number of live births between study group found to be insignificant with
a P- value of 0.110. The difference in number of death of child between study group found to be
insignificant with a P- value of 0.841. (Table 8)
61
Table 9: Comparison of study group with previous LSCS of study population (N=70)
LSCSStudy group
Chi square P-valueElective CS Emergency CS
Previous LSCS
0 18 (58.1%) 25 (64.1%)
0.566 0.7541 5 (16.1%) 4 (10.3%)
2 and above 8 (25.8%) 10 (25.6%)
Caesarean
Primary 19 (61.3%) 26 (66.7%)0.217 0.641
Repeat 12 (38.7%) 13 (33.3%)
The difference in previous LSCS between study group found to be insignificant with a P- value
of 0.754. The difference in cesarean between study group found to be insignificant with a P-
value of 0.641. (Table 9)
Table 10: Comparison of median value in period of gestation (in weeks) between study groups (N=70)
Study group Period of gestation (in weeks)Median (IQR)
Mann Whitney U test (P value)
Elective CS 38.14 (37 to 39.71) 0.071Emergency CS 39.43 (37.29 to 40.14)
Among the people with, elective CS group, the median period of gestation (in weeks) was 38.14
weeks (IQR 37 to 39.71) and it was 39.43 (IQR 37.29 to 40.14) in people with emergency CS
group. The difference in the period of gestation (in weeks) between study groups was statistically
not significant (P Value 0.071). (Table 10 & Figure 5)
Figure 5: Box plots of comparison of median value in period of gestation (in weeks) between study groups (N=70)
62
Table 11: Comparison of study group with h/o hypertension of study population (N=70)
H/o HypertensionStudy group
Chi-square P-valueElective CS Emergency CS
Yes 9 (29%) 14 (35.9%)0.369 0.544
No 22 (71%) 25 (64.1%)
The difference in history of hypertension between study group found to be insignificant with a P-
value of 0.544. (Table 11 & Figure 6)
Figure 6: Clustered bar chart of comparison of study group with h/o hypertension of study population (N=70)
63
Elective CS Emergency CS0%
10%
20%
30%
40%
50%
60%
70%
80%
H/o Hypertension Yes H/o Hypertension No
Study group
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Table 12: Comparison of study group with PHM diabetic Miletus/GDM of study population (N=70)
P/H/M Diabetic Miletus/GDM
Study group Chi-square P-valueElective CS Emergency CS
Yes 6 (19.4%) 8 (20.5%)0.014 0.904
No 25 (80.6%) 31 (79.5%)
The difference in P/H/M diabetic Miletus/GDM between study group found to be insignificant
with a P- value of 0.904. (Table 12 & Figure 7)
64
Figure 7: Clustered bar chart of comparison of study group with P/H/M diabetic Miletus/GDM of study population (N=70)
Elective CS Emergency CS0.00%
10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
19.40% 20.50%
80.60% 79.50%
P/H/M Diabetic Miletus/GDM Yes P/H/M Diabetic Miletus/GDM No
Study group
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Table 13: Comparison of mean BMI between study groups (N=70)
Study group BMIMean± STD
Mean difference
95% CIP value
Lower Upper
Pre-pregnancy BMI
Elective CS 23.35 ± 3.751.37 -0.36 3.10 0.118
Emergency CS 21.98 ± 3.49
Current BMI
Elective CS 29.31 ± 4.411.34 -0.68 3.36 0.189
Emergency CS 27.97 ± 4.04
The mean pre-pregnancy BMI of elective CS group was 23.35 ± 3.75 and emergency CS group
was 21.98 ± 3.49, and the mean difference (1.37) between two groups was statistically not
significant (P value 0.118). The mean current BMI of elective CS group was 29.31 ± 4.41 and
emergency CS group was 27.97 ± 4.04, and the mean difference (1.34) between two groups was
statistically not significant (P value 0.189). (Table 13 & Figure 8,9)
65
Figure 8: Error bar chart of comparison of mean pre-pregnancy BMI between study groups (N=70)
Figure 9: Error bar chart of comparison of mean current BMI between study groups (N=70)
66
Table 14: Comparison of median value in palpation fundal ht (weeks) between study group in the study population
Study group Palpation fundal ht (weeks)Median (IQR)
Mann Whitney U test (P value)
Elective CS 40 (40 to 40) 0.088Emergency CS 40 (40 to 40)
Among the people with, elective CS group, the median palpation fundal ht (weeks) was 40 (IQR
40 to 40) and it was 40 (IQR 40 to 40) in people with emergency CS group. The difference in
palpation fundal ht (weeks) between study groups was statistically not significant (P Value
0.088). (Table 14)
Table 15: Comparison of study group with presentation of fetus study population (N=70)
Presentation of fetus
Study groupChi-square P-value
Elective CS Emergency CS
Presentation
Cephalic 22 (71%) 26 (66.7%)0.148 0.701
Others 9 (29%) 13 (33.3%)
Presenting part
Mobile 9 (29%) 14 (35.9%)
3.636 0.162Engaged 5 (16.1%) 12 (30.8%)
Unengaged 17 (54.8%) 13 (33.3%)
The difference in presentation of the foetus between study group was found to be insignificant
with a P- value of 0.701. The difference in presenting part between study group was found to be
insignificant with a P- value of 0.162. (Table 15)
Table 16: Comparison of median value in hemoglobin (g/dl) between study group
67
Study group Hemoglobin (g/dl)Median (IQR)
Mann Whitney U test (P value)
Elective CS 10 (9 to 12) 0.024Emergency CS 9.5 (8.4 to 10.50)
Post-operative hemoglobin
Elective CS 7.95 (7.65 to 8.25) 0.616Emergency CS 8 (7.3 to 8.25)
Among the people with, elective CS group, the median hemoglobin (g/dl) was 10 (IQR 9 to 12)
and it was 9.50 (IQR 8.4 to 10.50) in people with emergency CS. The difference in hemoglobin
between study groups was statistically significant (P Value 0.024). Among the people with,
elective CS group, the median postoperative hemoglobin was 7.95 (IQR 7.65 to 8.25) and it was
8 (IQR 7.3 to 8.25) in people with emergency CS group. The difference in the period of post-
operative hemoglobin between study groups was statistically not significant (P Value 0.616).
(Table 16 & Figure 10,11)
68
Figure 10: Box plot of comparison of median value in hemoglobin (g/dl) between study group
Figure 11: Box plot of comparison of median value in postoperative haemoglobin (g/dl) between study group
69
Table 17: Comparison of study group with blood group of study population (N=70)
Blood group Study group Chi-square P-valueElective CS Emergency CSBlood group
O 11 (35.5%) 19 (48.7%)
4.105 0.250A 1 (3.2%) 4 (10.3%)AB 3 (9.7%) 1 (2.6%)B 16 (51.6%) 15 (38.5%)
Rh typingPositive 30 (96.8%) 35 (89.7%)
1.287 0.257Negative 1 (3.2%) 4 (10.3%)
The difference in blood group between study group found to be insignificant with a P- value of
0.250. The difference in Rh typing between study group found to be insignificant with a P- value
of 0.257. (Table 17)
Table 18: Comparison of study group with viral marker status of study population (N=70)
Viral marker status
Study groupChi square P-value
Elective CS Emergency CSHIVPositive 6 (19.4%) 6 (15.4%)
0.192 0.662Negative 25 (80.6%) 33 (84.6%)Hbs AGPositive 3 (9.7%) 5 (12.8%)
0.169 0.681Negative 28 (90.3%) 34 (87.2%)VDRLReactive 3 (9.7%) 2 (5.1%)
0.539 0.463Non-reactive 28 (90.3%) 37 (94.9%)Hepatitis CReactive 3 (9.7%) 2 (5.1%)
0.539 0.463Non-reactive 28 (90.3%) 37 (94.9%)
The difference in HIV between study group found to be insignificant with a P- value of 0.662.
The difference in Hbs AG between study group found to be insignificant with a P- value of
70
0.681. The difference in VDRL between study group found to be insignificant with a P- value of
0.463. The difference in hepatitis C between study group found to be insignificant with a P-
value of 0.463. (Table 18)
Table 19: Comparison of study group with pre-operative UTI of study population (N=70)
pre-operative UTIStudy group
Chi square P-valueElective CS Emergency CS
Yes 16 (51.6%) 31 (79.5%)6.083 0.014
No 15 (48.4%) 8 (20.5%)
The difference in pre-operative UTI between study group found to be significant with a P- value
of 0.014. (Table 19 & Figure 12)
Figure 12: clustered bar chart of comparison of study group with pre-operative UTI of study population (N=70)
Elective CS Emergency CS0.00%
10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
51.60%
79.50%
48.40%
20.50%
pre-operative UTI Yes pre-operative UTI No
Study group
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71
Table 20: Comparison of median value duration of labour between study group in the study population
Study group Duration of labour (in mints)Median (IQR)
Mann Whitney U test (P value)
Elective CS 0 (0 to 0) <0.001Emergency CS 8 (2 to 11)
Among the people with, elective CS group, the median duration of labour (in mints) was 0 (IQR
0 to 0) and it was 8 mints (IQR 2 to 22) in people with emergency CS group. The difference in
duration of labour (in mints) between study groups was statistically significant (P Value <0.001).
(Table 20)
Table 21: Comparison of study group with induction of labour of study population (N=70)
Induction of labourStudy group
Elective CS Emergency CS
Yes 0 (0%) 10 (25.6%)
No 31 (100%) 29 (74.4%)*No statistical test was applied- due to 0 subjects in the cells.
In emergency CS group, 10 (25.6%) had induction of labour. (Table 21)
Table 22: Comparison of study group with type of incision of study population (N=70)
Type of incisionStudy group
Chi-square P-valueElective CS Emergency CS
Pffanensteil 10 (32.3%) 19 (48.7%)1.928 0.165
Infraumbilical vertical 21 (67.7%) 20 (51.3%)
The difference in type of incision between study group found to be insignificant with a P- value
of 0.165. (Table 22 & Figure 13)
72
Figure 13: clustered bar chart of comparison of study group with type of incision of study population (N=70)
Elective CS Emergency CS0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
32.30%
48.70%
67.70%
51.30%
Pffanensteil Infra umbilical vertival
Study group
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Table 23: Comparison of median value in duration of surgery (in mints) between study group
Study group Duration of surgery (in mints)Median (IQR)
Mann Whitney U test (P value)
Elective CS 33 (26 to 40) 0.934Emergency CS 35 (25 to 40)
Among the people with, elective CS group, the median duration of surgery (in mints) was 33
(IQR 26 to 40) and it was 35 mints (IQR 25 to 40) in people with emergency CS group. The
difference in duration of surgery (in mints) between study groups was statistically not significant
(P Value 0.934). (Table 23 & Figure 14)
73
Figure 14: Box plot of comparison of median value in duration of surgery (in mints) between study group
Table 24: Comparison of study group with h/o primary PPH of study population (N=70)
h/o primary PPH
Study groupChi square P-value
Elective CS Emergency CS
Yes 10 (32.3%) 16 (41%)0.569 0.451
No 21 (67.7%) 23 (59%)
The difference in history of primary PPH between study group found to be insignificant with a P-
value of 0.451. (Table 24 & Figure 15)
74
Figure 15: Clustered bar chart of comparison of study group with h/o primary PPH of study population (N=70)
Elective CS Emergency CS0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
32%41%
68%59%
h/o primary PPH Yes h/o primary PPH No
Study group
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Table 25: Comparison of study group with prophylactic antibiotics pre op intra op of study population (N=70)
Prophylactic antibiotics pre op intra opStudy group
Elective CS Emergency CS
Yes 31 (100%) 38 (97.4%)
No 0 (0%) 1 (2.6%)*No statistical test was applied- due to 0 subjects in the cells.
In elective CS group, all of them 31 (100%) had prophylactic antibiotics pre-operative intra op.
In an emergency group, 38 (97.4%) had prophylactic antibiotics pre-operative intra op. (Table 25
& Figure 16)
75
Figure 16: Clustered bar chart of comparison of study group with prophylactic antibiotics pre op intra op of study population (N=70)
Elective CS Emergency CS0%
20%
40%
60%
80%
100%
120%100.00% 97.40%
0.00% 2.60%
Yes NoStudy group
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Table 26: Comparison of study group with febrile morbidity of study population (N=70)
Febrile morbidity
Study groupChi-square P-value
Elective CS Emergency CS
Yes 8 (25.8%) 21 (53.8%)5.596 0.018
No 23 (74.2%) 18 (46.2%)
The difference in febrile morbidity between study group found to be significant with a P- value
of 0.018. (Table 26 & Figure 17)
76
Figure 17: Clustered bar chart of comparison of study group with febrile morbidity of study population (N=70)
Elective CS Emergency CS0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
25.80%
53.80%
74.20%
46.20%
Febrile morbidity Yes Febrile morbidity No
Study group
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Table 27: Comparison of study group with operative wound discharge of study population (N=70)
operative wound discharge
Study groupChi square P-value
Elective CS Emergency CS
Purulent 21 (67.7%) 33 (84.6%)2.789 0.095
Serous 10 (32.3%) 6 (15.4%)
The difference in any operative wound discharge between study group found to be insignificant
with a P- value of 0.095. (Table 27 & Figure 18)
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Figure 18: Clustered bar chart of comparison of study group with operative wound discharge of study population (N=70)
Elective CS Emergency CS0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
67.70%
84.60%
32.30%
15.40%
Purulent Serous
Study group
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Table 28: Comparison of study group with wound gaping of study population (N=70)
Wound GapingStudy group
Elective CS Emergency CSYes 29 (93.5%) 39 (100%)No 2 (6.5%) 0 (0%)
*No statistical test was applied- due to 0 subjects in the cells.
In elective CS, 29 (93.5%) had wound gaping. In emergency CS group, 39 (100%) had wound
gaping. (Table 28 & Figure 19)
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Figure 19: Clustered bar chart of comparison of study group with wound gaping of study population (N=70)
Elective CS Emergency CS0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
94%100%
7%0%
Wound Gaping Yes Wound Gaping No
Study group
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Table 29: Comparison of study group with wound hematoma of study population (N=70)
Wound hematoma
Study groupChi square P-value
Elective CS Emergency CS
Yes 15 (48.4%) 9 (23.1%)4.911 0.027
No 16 (51.6%) 30 (76.9%)
The difference in wound hematoma between study group found to be significant with a P- value
of 0.027. (Table 29 & Figure 20)
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Figure 20: Clustered bar chart of comparison of study group with wound hematoma of study population (N=70)
Elective CS Emergency CS0.00%
10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
48.40%
23.10%
51.60%
76.90%
Wound hematoma Yes Wound hematoma No
Study group
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Table 30: Comparison of study group with surgical site infection of study population
(N=70)
Surgical site infection
Study groupChi-square P-value
Elective CS Emergency CS
Yes 23 (74.2%) 34 (87.2%)1.926 0.165
No 8 (25.8%) 5 (12.8%)
The difference in surgical site infection between study group found to be insignificant with a P-
value of 0.165. (Table 30 & Figure 21)
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Figure 21: Clustered bar chart of study group with surgical site infection in the study population (N=70)
Elective CS Emergency CS0.00%
10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
100.00%
74.20%
87.20%
25.80%
12.80%
Surgical site infection Yes Surgical site infection No
Study group
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Table 31: Comparison of study group with incisional site induration of study population (N=70)
Incisional site induration Study groupElective CS Emergency CS
Yes 0 (0%) 2 (5.1%)No 31 (100%) 37 (94.9%)
*No statistical test was applied- due to 0 subjects in the cells.
In emergency CS group, 2 (5.1%) had incisional site induration. (Table 31 & Figure 22)
Figure 22: Clustered bar chart of comparison of study group with incisional site induration of study population (N=70)
Elective CS Emergency CS0%
20%
40%
60%
80%
100%
120%
0.00% 5.10%
100.00% 94.90%
Incisional site induration Yes Incisional site induration No
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Table 32: Comparison of study group with burst abdomen of study population (N=70)
Burst abdomen Study group Chi-square P-valueElective CS Emergency CSYes 2 (6.5%) 1 (2.6%) 0.636 0.425No 29 (93.5%) 38 (97.4%)
The difference in burst abdomen between study group found to be insignificant with a P- value
of 0.425. (Table 32 & Figure 23)
Figure 23: Clustered bar chart of comparison of study group with burst abdomen of study population (N=70)
Elective CS Emergency CS0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
6.50% 2.60%
93.50% 97.40%
Burst abdomen Yes Burst abdomen No
Study group
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Table 33: Descriptive analysis of culture report in the study population (N=70)
Culture report Frequency PercentE.coli 23 32.90%Sterile 22 31.40%Staphylococcus aureus 11 15.70%Streptococcus 8 11.40%Enterococcus 4 5.70%Coagulase negative staphylococcus 2 2.90%
The most common isolated E coli was 32.90%. The proportion of, sterile, Staphylococcus
aureus, streptococcus was 31.40%, 15.70%, and 11.40% respectively. (Table 33 & Figure 24)
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Figure 24: Bar chart of culture report in the study population (N=70)
0.00%
10.00%
20.00%
30.00%32.90% 31.40%
15.70%11.40%
5.70% 2.90%
Culture report
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Table 34: Comparison of median value in Suture removal time in days between study group in the study population
Study group Suture removal time in daysMedian (IQR)
Mann Whitney U test (P value)
Elective CS 7 (7 to 7) 0.347Emergency CS 7 (7 to 7)
Among the people with, elective CS group, the median suture removal time was 7 days (IQR 7 to
7) and it was 7days (IQR 7 to 7) in people with emergency CS group. The difference in suture
removal time in days between study groups was statistically not significant (P Value 0.347).
(Table 34)
Table 35: Comparison of study group with 3rd week wound healthy of study population
(N=70)
3rd week wound HealthyStudy group
Elective CS Emergency CSYes 31 (100%) 37 (94.9%)No 0 (0%) 2 (5.1%)
*No statistical test was applied- due to 0 subjects in the cells.
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In elective CS, all of them 31(100%) were reported in 3rd week wound healthy. In emergency CS
group, 37 (94.9%) were reported 3rd week wound healthy. (Table 35)
Table 36: Descriptive analysis of wound complications in the study population (N=70)
Wound Complications Frequency Percent
Wound gaping 68 97.10%
Surgical site infection 57 81.40%
Wound hematoma 24 34.30%
Burst abdomen 3 4.30%
Incisional site induration 2 2.90%
The most common complication, wound gaping is 68 (97.10%). The proportion of surgical site
infection, wound hematoma, was 81.40%, and 34.30 respectively. (Table 36 & Figure 25)
Figure 25: Bar chart of wound complications in the study population (N=70)
Wound gaping Surgical site infection Wound hematoma Burst abdomen Incisional site induration0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
97.10%
81.40%
34.30%
4.30% 2.90%
Wound complications
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DISCUSSION
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DISCUSSION:
Wound complications delay the recovery, prolong hospitalization, necessitate the readmission or
prolong outpatient treatment. Wound infection is the commonest and most troublesome disorder
of wound healing and despite modern surgical techniques and the use of antibiotics prophylaxis,
surgical site infections (SSI) remains a major contributory factor of maternal morbidity and
mortality. Emergency cesarean section12,25 has been identified as an independent risk factor for
the development of Surgical site infection. So we carried out our study with the objective of
estimating the incidence of various surgical wound site complications in elective and emergency
cesarean section and to compare the profile of women developing surgical site infections
between elective and emergency cesarean sections.
SOCIODEMOGRAPHIC CHARACTERISTICS OF THE STUDY POPULATION:
We conducted a prospective observational comparative study on mothers admitted in the
Maternity ward of Civil Hospital, Aizwal, Mizoram after cesarean section with wound
complications from 1st October 2016 to 30th September 2017 for a period of 1 year after getting
clearance from the ethical committee. During our study period, out of 970 admitted women
undergoing elective CS, 31(3.19%) had complications while 39 (7.05%) out of 553 women
admitted for Emergency LSCS had complications. Hence, our main study population included 31
women undergoing Elective cesarean section and 39 women undergoing Emergency cesarean
section.
The sociodemographic characteristics of our study population was comparable with that of
Vijaya K et al.26 In our study, the mean age of subjects in elective group was 28.81 ± 7.17 years
while in the emergency group, it was 26.51 ± 6.23 years. This mean difference (2.29) between
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two groups was statistically not significant (P value 0.157). Vijaya K et al26 observed that the
mean age among cases of elective LSCS was 25 years and the mean age among cases of
emergency LSCS was 24 years. This increase in age could have been due to the increase in the
age of marriage and childbirth in recent years and differences in parity between the studies.
Similarly, Kishwar N et al53 in their study reported the average age of the subjects as 27.8 ± 7.7
years (ranging from 21 to 40) with average parity of the women being 4.4 ± 1.6.
In our study, the difference in the proportion of socioeconomic status between study groups was
statistically not significant (P value 0.557) which was in contrast to that observed by Kishwar N
et al53, Vijaya K et al26 in their study observed that about 75.5% (192) cases with surgical site
wound infection belonged to upper lower and lower middle socioeconomic class similar to our
study. In our study more than 90% of subjects in both Elective and Emergency CS groups
belonged to lower and middle class. The difference in cases taken for CS being referred or
booked was also not statistically significant between the groups in our study.
INCIDENCE OF COMPLICATIONS:
Women undergoing Cesarean delivery have a 5 to 20 fold greater risk of complication compared
with Vaginal delivery.14 In the current study, the overall incidence of wound site infection was
4.59% ( 95% CI 3.54 %to 5.64%). The incidence of wound site complications was 3.19% in
elective caesarean section (95% CI 2.2 % 4.5%) and 7.31% (95% CI 5.1%to 9.5%) in emergency
caesarean section, which was statistically significant ( P value <0.001) Dimitrova V et al35 in
their study also observed higher incidence of complications in Emergency CS. They observed
that out of 574 Elective CS, the frequency of postoperative complications was 1.4% while in 292
Emergency CS, it was 2.05% (p>0.05). They observed that this difference was not statistically
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significant. Nielsen TF et al34 observed a higher complication rates in their study compared to
our study. The complication rate for emergency operations was 18.9% and for elective CS was
4.2%--a highly significant difference. (p less than 0.001). Similar to our study, they also
observed a higher complication rate in Emergency CS compared to Elective CS.
Wound complications in caesarean section include Surgical site infection (stitch abscess,
cellulitis), seroma, haematoma, wound separation, wound dehiscence and rarely burst
abdomen.15-18 Surgical site Infection predominates the picture.
In our study, the most common complication was wound gaping, which was present in 68 out of
the total 70 subjects with complications (97.10%). The proportion of subjects with wound
haematoma was 34.3% in our study. Hadar E et al10 observed that the most common
complication after caesarean section was endomyometritis (3.6%), followed by wound infection
(1.8%) and wound hematoma (1.2%) in their study. Alanis MC et al9 observed that 30% of their
study subjects had a wound complication and most (90%) were wound disruptions.
The rate of surgical site infection was 81.40% in our study population with complications.
Generally, the rate of SSI ranges from 3% to 15% worldwide6, 11, 12 in caesarean section. The rate
of SSI was high in Emergency CS group (87.2%) compared to Elective CS group (74.2%) in our
study. In Emergency CS, the rate of SSI was 87.2% while in Elective CS, the rate of SSI was
74.2% in our study. Vijaya K et al26 observed that in Elective CS subjects, the prevalence of SSI
was 4.33% (254 subjects) while in emergency CS subjects, the prevalence was 9.18% (218
subjects). Opoien HK et al11 observed that there is no significant difference in SSI rate between
elective and emergency CS. Schneid-Kofman N et al12 observed that emergency cesarean
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delivery is an independent risk factors for an early wound infection even though the rates of SSI
separately are not available from their study.
Vijaya K et al26 in their study observed that wound gaping (82% vs 36%), discharge from
wounds (95% vs 81%), burst abdomen (4.5% vs 0%), erythema (16% vs 6%), induration (44%
vs 36%) was higher in Emergency CS group compared to Elective CS group. Similarly in our
study, purulent discharge from the wounds (84.6% vs 67.7%), wound gaping (100% vs 93.5%),
induration (5.1% vs 0%), Surgical site infection (87.2% Vs 74.2%), Incisional site induration
(5.1% Vs 0%) was higher in Emergency CS group compared to Elective CS group. But
statistically the difference in purulent discharge and Surgical site infection between study groups
was found to be insignificant in our study. But proportion of burst abdomen was higher in
Elective CS group compared to Emergency CS group in our study. But this may be co incidental
and this difference between study groups was statistically insignificant. In our study, 53.8% of
subjects in Emergency CS group had febrile morbidity compared to only 25.8% in the Elective
CS group. This difference in febrile morbidity between study groups was found to be significant
with a P- value of 0.018. There was no difference in suture removal time between the 2 groups as
it was only 7 days in both the groups. In our study, in elective CS group, 100% wounds were
reported healthy in 3rd week but in emergency CS group, only 94.9% were reported 3rd week
healthy. With regards to wound hematoma, 23.1% had hematoma in Emergency CS group while
48.4% had hematoma in Elective CS group and this difference was found to be statistically
significant with a P- value of 0.027 in our study.
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OBSTETRIC VARIABLES:
The risk factors for surgical site infections (SSI) after caesarean section are many; these include
intrinsic and extrinsic risk factors that predispose patients to SSI. Intrinsic factors are patient
related while extrinsic factors are related to patient care and management, although the intrinsic
factors cannot be changed, the risk they present in terms of infection is identifiable and man-
ageable. Factors6, 10, 14, 21, 22 that have been associated with an increased risk of wound
complications among women who have a cesarean delivery include emergency cesarean
section21, labor and its duration, ruptured membranes and the duration of rupture, the
socioeconomic status of the woman, number of prenatal visits, vaginal examinations during
labor, urinary tract infection, anemia, blood loss, obesity, diabetes, the skill of the operator and
the operative technique7, 14, 21-24.
Of all the factors, the differences of only the following factors between the Emergency and
Elective CS group were only statistically significant in our study – Pre mature rupture of
membranes (PROM), Pre-operative UTI, Median Haemoglobin levels, Median duration of
labour (in minutes).
About 69.2% of our study subjects had history of leaking PV in Emergency CS group compared
to nil in the Elective CS group. Schneid-Kofman N et al12 in their study had identified premature
rupture of membranes (Odds ratio = 1.5; 95% CI of 1.2-1.9) as a risk factor for wound infection
following caesarean section. Similarly Dhar H et al22 in their case control study observed that
Post caesarean cases with SSI had four-fold higher incidence of premature rupture of the
membranes on comparison with those without SSI.
Among the subjects in elective group, the median haemoglobin (g/dl) was 10 g/dl (IQR 9 to 12)
and it was 9.50 g/dl (IQR 8.4 to 10.50) in emergency CS group. The difference in haemoglobin
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between study groups was statistically significant (P Value 0.024). Similar to our study, Gong SP
et al51 identified lower preoperative hemoglobin as a factor independently associated with an
increased risk of surgical site infection. The difference in pre-operative UTI between study
groups was also found to be significant with a P- value of 0.014. (51.6% in Elective CS Vs
79.5% in Emergency CS). Antimicrobial prophylaxis is used routinely for pre-, intra- and post-
operative caesarean section.62 One of the most important risk factors for postpartum infection is
caesarean delivery. Since most authors used antibiotic prophylaxis, Pre-op urinary tract infection
was not identified as a major risk factor for SSI in Caesarean section. In contrast to our study
results, Nielsen TF et al34 observed that Station of the presenting part of the fetus in relation to
the spinal plane (p less than 0.001), low gestational age (less than 32 weeks) (p less than 0.001),
previous CS (p less than 0.01), and skill of the operator (p less than 0.05) were associated with
the occurrence of surgical complications in emergency cases. However, no such risk factors were
found in the elective group. Weissman C et al39 in their study observed that Emergency patients,
as compared with elective group 2 (n= 1883) patients, experienced more severe preexisting
illnesses, underwent different and shorter operations, required prolonged postoperative
mechanical ventilation, required longer ICU stays, and had higher mortality.
The microbial etiology of post CS SSIs has been shown to be diverse63, being associated with
both vaginal microorganisms such as Escherichia coli, group B streptococcus (GBS) and
Enterococcus spp, or with nasopharyngeal flora such as Staphylococcus aureus or skin flora such
Staphylococcus epidermidis. In our study, E.coli was the most commonly isolated organism
reported in about 32.9% of the study population followed by staphylococcus and streptococcus.
Dhar H et al22 also in their study observed that the most common organisms responsible for SSI
was Staphylococcus aureus seen in 31.27% of the isolates followed by Gram-negative
Escherichia coli group (18.95%). Similar to our study, Vijaya K et al26 in their study also
observed that E.coli (41.7% of the total cases with SSI) was the most commonly isolated
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organism from wound swab for culture followed by Klebsiella species (22.83% of the total cases
with SSI).In their study, 18 cases of SSI in elective LSCS (50%) cases did not show growth of
any organism while in our study nearly 31.4% of the cultures were negative. The sterile nature of
cultures in our study may be due to nil growth on culture medium as a result of absence of
infection. In infected cases use of pre op / intra op / post op antibiotics could have resulted in
negative cultures. Antibiotic prophylaxis has been found to be the most significant protective
factor (p = 0.0007) in the reduction of postoperative wound infection in literature.21 In our study
97.4% of subjects in the emergency group and 100% of subjects in the elective group received
pre op and intra op antibiotics which could have resulted in sterile reports in about 31.4% of our
cultures.
In our study, we observed that differences in Regular ANC visits, Gravida, Parity, obstetric
scoring (live births, death, abortions) were not statistically significant between the groups. We
also observed that differences in frequency of GDM, H/o Hypertension, Previous LSCS, h/o
primary PPH, Pre BMI, Post BMI, median Post-operative haemoglobin, blood groups, Rh typing,
HIV, HbsAg, VDRL, Hepatitis C status was not statistically significant between the groups.
Similar to our study, Dimitrova V et al35 in their study also observed that there was no significant
differences regarding the type of skin incision, operator's qualification, blood loss, drainage of
the subfascial space, accompanying diseases between the two groups. The differences in Fundal
height in weeks on palpation, type of presentation, status of presenting part, type of incision,
median duration of surgery, median period of gestation was also not statistically significant
between the groups in our study. But Schneid-Kofman N et al12 observed that obesity,
hypertensive disorders (OR = 1.7; 95% CI, 1.4-2.1); premature rupture of membranes, diabetes
mellitus (OR = 1.4; 95% CI, 1.1-1.7) were significant risk factors.
With Caesarean section being performed with increased frequency, there’s the perception to
regard it as an uncomplicated and straight forward procedure but complications do occur causing
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significant morbidity and mortality. Success of operation depends upon a proper preoperative
care. Risk reduction is the goal of well designed plan for preoperative management and care of
patient undergoing obstetric surgery. To be most effective, the planning begins with an
appropriate preoperative evaluation and continues with optimal intra-operative decision making
and technique and care during post operative periods. These care plans are particularly important
for patients with repeat caesarean section. Post partum period is a challenging time for women.
Complications at any stage in peri partum period may affect it. Women experiencing delivery
through Caesarean section are at higher risk of complications than those through vaginal
delivery. The incidence of surgical site infection in cases of emergency LSCS is high, increasing
the maternal morbidity. The recognition and correction of associated medical complications in
the antenatal period is vital. Early decision making in cases of emergency LSCS reduces the
infection rate in cases of emergency LSCS.
CONCLUSIONS:
1. Wound infection is the commonest and most troublesome disorder of wound healing
2. Surgical site infections (SSI) remains a major contributory factor of maternal morbidity
and mortality.
3. The incidence of complications in the elective group was 31.9 (95% CI - 22 to 45) per
1000 women while in emergency group, it was 70.5 (95% CI - 51 to 95) per 1000
women. This difference in the proportion of complications between study group was
statistically significant (P value 0.001).
4. The most common complication in our study was wound gaping (97.10%).
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5. The proportion of subjects with surgical site infection (SSI), wound hematoma was
81.4%, and 34.3% respectively. In Elective CS group, 74.2% had SSI while 87.2% of
subjects in Emergency CS group had SSI.
6. The difference in age, socio economic status between study groups was statistically not
significant
7. Purulent Discharge from the wounds (84.6% vs 67.7%), Wound gaping (100% vs
93.5%), incisional site induration (5.1% vs 0%) was higher in Emergency CS group
compared to Elective CS group but was statistically not significant.
8. 23.1% had hematoma in Emergency CS group while 48.4% had hematoma in Elective
CS group and this difference was found to be statistically significant with a P- value of
0.027.
9. The difference in febrile morbidity between study groups was found to be significant
with a P- value of 0.018.
10. There was no difference in suture removal time in days between study groups as it was 7
in both the groups.
11. In elective CS group, 100% wounds were reported healthy in 3rd week but in emergency
CS group, only 94.9% were reported 3rd week healthy but this difference was
insignificant.
12. Of all the obstetric factors, the differences of only the following factors between the
Emergency and Elective CS group were only statistically significant in our study –
Pre-operative UTI, Median Haemoglobin levels (Pre-op), Premature Rupture of
membranes, Median duration of labour (in minutes).
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13. Differences in Regular ANC visits, Gravida, Parity, obstetric scoring (live births, death,
abortions) were not statistically significant between the groups.
14. Differences in frequency of GDM, H/o Hypertension, Previous LSCS, h/o primary PPH,
Pre surgery BMI, Post surgery BMI, Median Post-operative haemoglobin, blood groups,
Rh typing, HIV, HbsAg, VDRL, Hepatitis C status was not statistically significant
between the groups.
15. The differences in Fundal height in weeks on palpation, type of presentation, status of
presenting part, type of incision, median duration of surgery, median period of gestation
was also not statistically significant between the groups.
16. In our study, E.coli was the most commonly isolated organism reported in about 32.9%
of the study population followed by staphylococcus and streptococcus. Nearly 31.4% of
the cultures were sterile.
17. Post partum period is a challenging time for women. Complications at any stage in peri
partum period may affect it.
18. The incidence of surgical site infection in cases of emergency LSCS is high, increasing
the maternal morbidity. The recognition and correction of associated medical
complications in the antenatal period is vital. Early decision making in cases of
emergency LSCS reduces the infection rate in cases of emergency LSCS.
LIMITATIONS:
The limitations of the study are that it was a hospital based study. Being a tertiary referral
hospital, cases with associated medical and obstetric complications are referred here and some
cases are referred late. Thus, the rate of complications in such cases is more.
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RECOMMENDATIONS:
The incidence of surgical site infection in cases of emergency LSCS is high, increasing the
maternal morbidity. So, the recognition and correction of associated medical complications in the
antenatal period is vital which needs early decision making in cases of emergency LSCS so as to
reduce the infection rate in cases of emergency LSCS.
A large multicenter study with population frame taken from the general community is the need
of the hour with rapid increase in the number of caesarean sections being performed.
There is a need to proceed to the next step in this research question by incorporating RCT’s for
strengthening the evidence
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1. Miller ES, Hahn K, Grobman WA. Consequences of a primary elective cesarean delivery across the reproductive life. Obstet Gynecol. 2013;121(4):789-97.2. Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. Jama. 2015;314(21):2263-70.3. Betran AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, et al. Rates of caesarean section: analysis of global, regional and national estimates. Paediatr Perinat Epidemiol. 2007;21(2):98-113.4. Young PY, Khadaroo RG. Surgical site infections. Surg Clin North Am. 2014;94(6):1245-64.5. Fitzwater JL, Tita AT. Prevention and management of cesarean wound infection. Obstet Gynecol Clin North Am. 2014;41(4):671-89.6. Olsen MA, Butler AM, Willers DM, Devkota P, Gross GA, Fraser VJ. Risk factors for surgical site infection after low transverse cesarean section. Infect Control Hosp Epidemiol. 2008;29(6):477-84; discussion 85-6.7. Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk factors for surgical site infection following caesarean section in England: results from a multicentre cohort study. Bjog. 2012;119(11):1324-33.8. Wilson J, Wloch C, Saei A, McDougall C, Harrington P, Charlett A, et al. Inter-hospital comparison of rates of surgical site infection following caesarean section delivery: evaluation of a multicentre surveillance study. J Hosp Infect. 2013;84(1):44-51.9. 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(3):271.e1-7.10. Hadar E, Melamed N, Tzadikevitch-Geffen K, Yogev Y. Timing and risk factors of maternal complications of cesarean section. Arch Gynecol Obstet. 2011;283(4):735-41.11. Opoien HK, Valbo A, Grinde-Andersen A, Walberg M. Post-cesarean surgical site infections according to CDC standards: rates and risk factors. A prospective cohort study. Acta Obstet Gynecol Scand. 2007;86(9):1097-102.12. Schneid-Kofman N, Sheiner E, Levy A, Holcberg G. Risk factors for wound infection following cesarean deliveries. Int J Gynaecol Obstet. 2005;90(1):10-5.13. Jenks PJ, Laurent M, McQuarry S, Watkins R. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. J Hosp Infect. 2014;86(1):24-33.14. Gibbs RS. Clinical risk factors for puerperal infection. Obstet Gynecol. 1980;55(5 Suppl):178s-84s.15. Chandrasiri M, Fernandopullae R. Comparison of surgical site infections and patients’ comfort level with caesarean section wounds following early exposure versus delayed exposure. Sri Lanka J Obstet Gynaecol. 2016;38(1).16. Parrott T, Evans AJ, Lowes A, Dennis KJ. Infection following caesarean section. J Hosp Infect. 1989;13(4):349-54.17. Owen J, Andrews WW. Wound complications after cesarean sections. Clin Obstet Gynecol. 1994;37(4):842-55.18. Sarsam SE, Elliott JP, Lam GK. Management of wound complications from cesarean delivery. Obstet Gynecol Surv. 2005;60(7):462-73.19. Martens MG, Kolrud BL, Faro S, Maccato M, Hammill H. Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases. J Reprod Med. 1995;40(3):171-5.
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20. Hopkins L, Smaill F. Antibiotic prophylaxis regimens and drugs for cesarean section. Cochrane Database Syst Rev. 2000(2):Cd001136.21. Beattie PG, Rings TR, Hunter MF, Lake Y. Risk factors for wound infection following caesarean section. Aust N Z J Obstet Gynaecol. 1994;34(4):398-402.22. Dhar H, Al-Busaidi I, Rathi B, Nimre EA, Sachdeva V, Hamdi I. A study of post-caesarean section wound infections in a regional referral hospital, oman. Sultan Qaboos Univ Med J. 2014;14(2):e211-7.23. Zuarez-Easton S, Zafran N, Garmi G, Salim R. Postcesarean wound infection: prevalence, impact, prevention, and management challenges. Int J Women's Health. 2017;9:81-8.24. Jido TA, Garba ID. Surgical-site Infection Following Cesarean Section in Kano, Nigeria. Ann Med Health Sci Res. 2012;2(1):33-6.25. Farret TC, Dalle J, Monteiro Vda S, Riche CV, Antonello VS. Risk factors for surgical site infection following cesarean section in a Brazilian Women's Hospital: a case-control study. Braz J Infect Dis. 2015;19(2):113-7.26. Vijaya K, Padmaja A, Poreddy A, Vivekanand N. Surgical Site Wound Infection in Emergency and Elective LSCS–A Comparative Study. Sch J App Med Sci. 2015;3(9D):3412-7.27. Betran AP, Ye J, Moller AB, 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):e0148343.28. Mylonas I, Friese K. Indications for and Risks of Elective Cesarean Section. Dtsch Arztebl Int. 2015;112(29-30):489-95.29. Appropriate technology for birth. Lancet. 1985;2(8452):436-7.30. Betran AP, Torloni MR, Zhang JJ, Gulmezoglu AM. WHO Statement on Caesarean Section Rates. Bjog. 2016;123(5):667-70.31. Betran AP, Torloni MR, Zhang J, Ye J, Mikolajczyk R, Deneux-Tharaux C, et al. What is the optimal rate of caesarean section at population level? A systematic review of ecologic studies. Reprod Health. 2015;12:57.32. Sheet IF. NFHS-4 (National Family Health Survey-4). International Institute for Population Studies. 2017.33. Fawzy M, Zalata K. Late post-cesarean surgical complication. J Obstet Gynaecol Res. 2010;36(3):544-9.34. Nielsen TF, Hokegard KH. Cesarean section and intraoperative surgical complications. Acta Obstet Gynecol Scand. 1984;63(2):103-8.35. Dimitrova V, Pandeva I, Tsankova M, Pranchev N. [Post-operative complications following elective and emergency caesarean delivery]. Akush Ginekol (Sofiia). 2005;44(7):15-21.36. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988;16(3):128-40.37. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol. 1992;13(10):606-8.38. 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(5):309-32.39. Weissman C, Klein N. The importance of differentiating between elective and emergency postoperative critical care patients. J Crit Care. 2008;23(3):308-16.40. Stadelmann WK, Digenis AG, Tobin GR. Physiology and healing dynamics of chronic cutaneous wounds. Am J Surg. 1998;176(2A Suppl):26s-38s.41. Kumar V, Abbas AK, Fausto N, Aster JC. Robbins and Cotran pathologic basis of disease, professional edition e-book: elsevier health sciences; 2014.
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42. Alavi MR, Stojadinovic A, Izadjoo MJ. An overview of biofilm and its detection in clinical samples. J Wound Care. 2012;21(8):376-83.43. Rajpaul K. Biofilm in wound care. Br J Community Nurs. 2015;Suppl Wound Care:S6, s8, s10-1.44. Gregson H. Reducing surgical site infection following caesarean section. Nurs Stand. 2011;25(50):35-40.45. Dyrkorn OA, Kristoffersen M, Walberg M. Reducing post-caesarean surgical wound infection rate: an improvement project in a Norwegian maternity clinic. BMJ Qual Saf. 2012;21(3):206-10.46. Awad SS. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surg Infect (Larchmt). 2012;13(4):234-7.47. Satyanarayana V, Prashanth H, Basavaraj B, Kavyashree A. Study of surgical site infections in abdominal surgeries. J Clin Diagn Res. 2011;5(October (5)):935-9.48. Ako-Nai AK, Adejuyigbe O, Adewumi TO, Lawal OO. Sources of intra-operative bacterial colonization of clean surgical wounds and subsequent post-operative wound infection in a Nigerian hospital. East Afr Med J. 1992;69(9):500-7.49. Gilstrap LC, 3rd, Cunningham FG. The bacterial pathogenesis of infection following cesarean section. Obstet Gynecol. 1979;53(5):545-9.50. Rubin RH. Surgical wound infection: epidemiology, pathogenesis, diagnosis and management. BMC Infect Dis. 2006;6:171.51. Gong SP, Guo HX, Zhou HZ, Chen L, Yu YH. Morbidity and risk factors for surgical site infection following cesarean section in Guangdong Province, China. J Obstet Gynaecol Res. 2012;38(3):509-15.52. Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63(2):356-61.53. Kishwar N, Hayat N, Ayoub S, Ali S. Surgical site infections among patients undergoing elective versus emergency caesarean section. J Postgrad Med Inst. 2016;30(4).54. Nuthalapaty FS, Lee CM, Lee JH, Kuper SG, Higdon HL, 3rd. A randomized controlled trial of early versus delayed skin staple removal following caesarean section in the obese patient. J Obstet Gynaecol Can. 2013;35(5):426-33.55. Moreira CM, Amaral E. Use of electrocautery for coagulation and wound complications in Caesarean sections. ScientificWorldJournal. 2014;2014:602375.56. Corcoran S, Jackson V, Coulter-Smith S, Loughrey J, McKenna P, Cafferkey M. Surgical site infection after cesarean section: implementing 3 changes to improve the quality of patient care. Am J Infect Control. 2013;41(12):1258-63.57. Shapiro SS, Wilk MB. An analysis of variance test for normality (complete samples). Biometrika. 1965;52(3/4):591-611.58. Razali NM, Wah YB. Power comparisons of shapiro-wilk, kolmogorov-smirnov, lilliefors and anderson-darling tests. J stat modeling analytics. 2011;2(1):21-33.59. Cramer D. Fundamental statistics for social research: step-by-step calculations and computer techniques using SPSS for Windows: Psychology Press; 1998.60. Cramer D, Howitt DL. The Sage dictionary of statistics: a practical resource for students in the social sciences: Sage; 2004.61. Doane DP, Seward LE. Measuring skewness: a forgotten statistic? J Stat Educ. 2011;19(2).62. Liu R, Lin L, Wang D. Antimicrobial prophylaxis in caesarean section delivery. Exp Ther Med. 2016;12(2):961-4.63. Kaplan NM, Smadi AA, Al-Taani MI, El-Qudah MA. Microbiology of wound infection after caesarean section in a Jordanian hospital. East Mediterr Health J. 2003;9(5-6):1068-74.
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ANNEXURES
PATIENT INFORMATION SHEET
THUPUI : “Nu nau nei zai chhuahte an zaina hnu hliam zir chianna”.
SAWMNA : He zir chianna neihna ah hian tel ve tura sawm i ni e – Nu nau nei zai chhuahte an zaina hnu hliam zir chianna.
A ZIRNA BUATSAIHTU:
Dr. Priyank Joshi , DNB Resident ,
Department of Obstetrics and Gynaecology,
Civil Hospital, Aizawl, Mizoram.
A KAIHRUAITU:
Dr. Lalbiakdiki
Consultant,
Department of Obstetrics and Gynaecology,
Civil Hospital , Aizawl.
Mizoram.
He zirchiannaa tel tura thu tlukna i siam hmain, he zirchianna pawimawh zia leh a tulzia i hriat hmasak a ngai a ni. Khawngaihtakin a hnuaia zawhna-te hi ngun takin chhiar phawt la, tha i tih chuan midang te nen pawh inrawn hmasa ang che.
1. ‘Enge he zirchianna in a tum?’
He zir chianna in a tum chu Nu nau nei zai chhuah reng reng te hi ege Nu ah effect aneih tih hriat ani.
2. ‘Engvanga he zirchiannaa sawm nge ka nih?’
He zirchiannaah hian tel tura thlante nih tur ang I tlin avangin sawm i ni.
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3. ‘He zirchiannaah hian tel duh lo ta ila, emaw tel hnuah inhnukdawk leh ta ila enge
ka dinhmun tur ni ang?’
He zirchianna hi tlawmngaihna thil a ni a, tel leh tel loh hi nangma duhthlanna a ni. I tel duh loh pawh in, nangmah enkawlnaah hian tunah leh nakin hnu zelah pawh engmah nghawng a neilo ang. I thu tlukna chu engpawh ni se, nangmah enkawltute nen in inkar a tichhe hek lo ang. An enkawl chhung che in thil thar hriat tur pawimawh an hmuh belh mai thei a, thil thar hmuhchhuah a lo awm a nih pawhin i zir zawm zelna turah hriattir i ni ang.
Inhnuhdawh leh i tum a nih pawhin a chhan leh vang sawi ngai lovin englaipawhin theih reng a ni.
4. ‘He zirchiannaah hian engte nge tel?’
He zirchiannaah i tel duh a nih chuan Consent Form-ah hian i hming i ziah a ngai. He zirchianna hi thla 12 chhung tur a ni. He zir chianna ah hian I in zaina chungchanga hriat tur leh thil tangtai tam tak I hriat belh bawk ang.
5. ‘He zirchianna a tel hi ka tan hlauhawmna a awm em?’He zirchianna hi en thlithlaina a nih avangin hlauhawm hranpa engmah a awm lo.
6. ‘He zirchianna ka zir chhung hian harsatna/tawrhna lo thleng se engtia tih tur nge?’
He zirchianna I tih lai mekin na emaw, awm dan danglam emaw I lo tuar palh a nih chuan zirchiangtu Doctor hnenah I hrilh vat tur a ni. A ni chuan a tul angin damdawi a chawh mai ang che. He zirchianna neih laia a kaihhnawih te(entir nan: A zir chiangtu, damdawi In emaw, mawhphurtu Doctor) inthlahdah vang emaw ,ngaihthah avanga natna emaw, damdawi leh a hmanrua engvang pawhin tawrhna a lo awmin zangnadawmna hi pek theih a ni bawk ang. Heng zangnadawmna hi I lo hmu a nih chuan damdawi a i senso te, enkawlna i senso te a rulhna tur atan hman theih a ni.He kaihhruaina hi Secretary, Human Research Ethics Committee hnen atangin hmuh theih a ni bawk.
7. ‘He zirchiannaah hian hlawkpuina enge ka neih ang?’He zir chhianna hian nu nau zaichhuah chungchanga hriat tur leh a hnu leh a in enkawl dan bak hamthatna direct a hmuh tur a awm lo.
8. ‘He zirchianna hian senso ngai emaw ka tan pek ve ngai a awm em?’He zirchiannaah hian senso ngai emaw, i pek ngai engmah a awm lo.
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9. ‘Engtinnge ka thuruk hi thup a nih theih dan tur?’Nangmah enkawltu, entirnan: Nursing staff emaw midang tupawh he zirchianna a tel te hian he zirchianna ah hian nangmah i tel tih an hre tur a ni lo. He zirchianna a an thil hmuhte reng reng thuruk anga thup tlat tur a ni a, i phalna emaw dan in a phalna emaw a nih loh chuan pho lan a thiang lo ang. Nangmah zirchiangtute a chunga tarlan chauhin result kimchang an hria ang a, chu chu him taka vawn tur a ni bawk.
10. ‘A zirchianna result chuan enge a thlen ang?’
Consent Document-a i phalna nei a i hming min sign sak tawh chuan a result chungchangah sawi hona neih te/ lehkhabu a chhutchhuah te kan ti ang. Heng thil kan tihnaah hian i hming tih lan a ni lo ang a, a copy pawh i duh chuan pek i ni bawk ang.
11. ‘Thu tlukna ka siam hmain he zirna chungchang hi sawiho hmasa duh ta ila engtinnge ni ang?’
He information hi i chhiar zawh chuan, a research beitute nen in sawiho thei ang a, zawhna chi hrang hrang pawh i zawt thei ang. Kim chang zawk a i hriat duh chuan inthlahrung hauh loin he number 9429235582 ah hian min rawn be dawn nia.
He zirchianna atana hun min pek avangin kan lawm e.
He zirchiannaah hian i tel duh anih chuan Consent Form kan thil telah hian i hming
i sign dawn nia.
He Information sheet hi i kawl atan pek i ni.
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INFORMED CONSENT FORM
Subject identification number for this trial __________________________________
Title of the Project: SURGICAL WOUND SITE OUTCOME IN ELECTIVE AND EMERGENCY CAESAREAN SECTION - A PROSPECTIVE OBSERVATIONAL
COMPARATIVE STUDY.
Name of the Principal Investigator: __________________________ Tel.
No.________________
I have received the information sheet on the above study and have read and / or understood the
written information.
I have been given the chance to discuss the study and ask questions.
I consent to take part in the study and I am aware that my participation is voluntary.
I understand that I may withdraw at any time without this affecting my future care.
I understand that the information collected about me from my participation in this research and
sections of any of my medical notes may be looked at by responsible persons (ethics committee
members / regulatory authorities). I give access to these individuals to have access to my records.
I understand I will receive a copy of the patient information sheet and the informed consent
form.
___________________________
__________________
Signature / Thumb Impression of subject Date of signature
______________________________
Printed name of the subject in capitals
___________________________
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Signature / Thumb Impression of legally Date of signature
accepted representative
<<The legally acceptable representative signature should be added if the subject is a minor or is
unable to sign for themselves. The relationship between the subject and the legally acceptable
representative should be stated. The impartial witness signature should be added if the subject /
legally acceptable representative is unable to read or write and consent should be obtained in his
presence. >>
_______________________________________________
Printed name of legally acceptable representative in capitals
______________________________________________________
Relationship of legally accepted representative to subject in capitals
________________________________________________________
Signature of the person conducting the Date of Signature
informed consent discussion
_________________________________________
Printed name of the person conducting the
Informed consent discussion in capitals
__________________________________________________________
Signature of impartial witness Date of signature
________________________________________
Printed name of the impartial witness in capitals
105
INFORMED CONSENT FORM
(MIZO language)
Damlo Identification Number: _________________________________
Project Hming: SURGICAL WOUND SITE OUTCOME IN ELECTIVE AND EMERGENCY CAESAREAN SECTION - A PROSPECTIVE OBSERVATIONAL COMPARATIVE
STUDY.
Principal Investigator Hming: _______________________________
Tel. No: __________________________________
He Project in a thil tumte tarlanna Information Sheet hi ka dawnga, chiang taka ka chhiar hnuah
a tum te ka hrethiam.
A Project sawi zauna te neiin zawhna zawh te min phal sak.
He zir zauna ah hian keima duhthlanna ngeia tel ka ni.
Ka duh hun hunah ka inhnuk dawk theiin, ka inhnuh dawkna hian hun lo la kal tura enkawlna ka
dawn tur a khawih buailo tih ka chiang.
Hetih rual hian he project a ka tel chhunga ka medical records an neih ang te hi hemi lam a mi
thiam bik (ethics committee members/ regulatory authorities) ten an duh leh tha an tih anga an
hman rem ka ti e.
Patient Information Sheet leh Informed Consent Form hi ka kawl atan a copy pek ve ka ni.
_____________________________________________
Damlo Signature Date of signature
106
______________________________________________
Damlo hming Hawrawppuiin
__________________________________________________
Aiawhtu Signature Date of Signature
___________________________________________________
Aiawhtu Hming Hawrawppuiin
___________________________________________________
Damlo nen an in laichinna
____________________________________________________
Informed Consent la tu Signature Date of Signature
____________________________________________________
Informed Consent la tu hming hawrawppuiin
_____________________________________________________
Hriatpuitu Signature Date of Signature
______________________________________________________
Hriatpuitu Hming Hawrawpuiin
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S. n
o
Cas
e nu
mbe
r
Stud
y gr
oup
Pat
ient
Age
(in
year
s)
Soci
o ec
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ic S
tatu
s
His
tory
his
tory
of l
eaki
ng P
V
Reg
ular
AN
C v
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Imm
uniz
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Gra
vida
Pari
ty
Abo
rtio
n
Num
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of li
ve b
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s
Num
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of D
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of
Prev
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LSC
S
LM
P
ED
D
Peri
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f ges
tatio
n (in
w
eeks
)
1 10-16/136 Emergency CS 26 LowFollow up case
Present 4
Yes 1 0 0 0 0 0 04-Feb-2016 11-Nov-2016
39.71
2 10-16/841 Elective CS 40Middle
Follow up case Absent 4
Yes 1 0 0 0 0 0 08-Feb-2016 15-Nov-2016
40.14
3 11-16/48 Emergency CS 18 Low ReferedPresent 2
Yes 1 0 0 0 0 0 30-Apr-2016 07-Dec-2016
41.00
4 11--16/562 Emergency CS 27 Low Refered Absent 1Yes 7 3 3 2 1 3 15-Feb-2016 22-Nov-2016
40.29
5 11-16/789 Elective CS 30 LowFollow up case Absent 2
Yes 2 1 0 1 0 1 07-Feb-2016 14-Nov-2016
37.00
611-16/1236 Emergency CS 22 Low Refered
Present 1
Yes 3 2 0 2 0 2 20-Feb-2016 27-Nov-2016
39.86
7 12-16/789 Emergency CS 33 Low ReferedPresent 2
Yes 5 2 2 2 0 2 01-Mar-2016 08-Dec-2016
39.00
812-16/4563 Elective CS 17 Low
Follow up case Absent 1
Yes 1 0 0 0 0 0 04-May-2016 11-Feb-2017
33.14
912-16/4325 Emergency CS 29 Low Refered
Present 4
Yes 2 1 0 1 0 0 12-Mar-2016 19-Dec-2016
38.00
1012/16-5632 Emergency CS 34 Low Refered
Present 1
Yes 8 7 0 7 0 0 21-Mar-2016 28-Dec-2016
36.71
1112-16/4963 Elective CS 36 Low
Follow up case Absent 3
Yes 4 3 0 2 1 3 28-Mar-2016 04-Jan-2017
37.14
12 1-17/45 Elective CS 40 LowFollow up case Absent 4
Yes 1 0 0 0 0 0 02-Apr-2016 09-Jan-2017
38.29
13 1-17/89 Emergency CS 20Middle
Follow up case
Present 4
Yes 2 1 0 1 0 1 09-Apr-2016 16-Jan-2017
40.00
14 1-17/456 Emergency CS 23 LowFollow up case
Present 3
Yes 5 2 2 0 2 2 11-Apr-2016 18-Jan-2017
41.14
15 1-17/789 Emergency CS 31 LowFollow up case Absent 1
Yes 5 4 0 4 0 4 15-Apr-2016 22-Jan-2017
41.71
16 1-17/4563 Emergency CS 39 Low ReferedPresent 1 No 9 8 0 7 1 0 20-Apr-2016 27-Jan-2017
42.00
17 1-17/3256 Emergency CS 17 Middl Follow up Presen 1 Ye 1 0 0 0 0 0 25-Apr-2016 01-Feb-2017 39.4
108
e case t s 3
18 1-17/6933 Elective CS 27 LowFollow up case Absent 4
Yes 5 2 2 0 2 2 30-Apr-2016 06-Feb-2017
39.14
19 2-17/78 Elective CS 33Middle
Follow up case Absent 4
Yes 1 0 0 0 0 0 01-May-2016 08-Feb-2017
37.57
20 2-17/745 Emergency CS 24 LowFollow up case
Present 2
Yes 2 1 0 1 1 1 04-May-2016 11-Feb-2017
37.00
21 2-17/893 Emergency CS 26 Low ReferedPresent 1
Yes 4 3 0 3 0 0 05-May-2016 12-Feb-2017
36.86
22 2-17/1400 Elective CS 27 LowFollow up case Absent 1
Yes 1 0 0 0 0 0 20-Jul-2016 27-Apr-2017
32.86
23 2-17/1562 Elective CS 20 LowFollow up case Absent 4
Yes 1 0 0 0 0 0 13-Jul-2016 20-Apr-2017
34.29
24 2-17/2001 Emergency CS 30 LowFollow up case
Present 3
Yes 3 2 0 2 0 0 20-May-2016 27-Feb-2017
40.00
25 2-17/2500 Elective CS 31 LowFollow up case Absent 4
Yes 7 6 4 2 0 2 21-May-2016 28-Feb-2017
40.86
26 2-17/3002 Elective CS 39Middle
Follow up case Absent 4
Yes 1 0 0 0 0 0 20-May-2016 27-Feb-2017
40.14
27 2-17/3569 Emergency CS 25 Low ReferedPresent 1
Yes 2 0 1 0 0 0 14-May-2016 21-Feb-2017
40.71
28 2-17/4563 Emergency CS 24 Low Refered Absent 2Yes 4 0 3 0 0 0 07-May-2016 14-Feb-2017
39.86
29 2-17/6233 Emergency CS 25 LowFollow up case Absent 4
Yes 1 0 0 0 0 0 25-May-2016 04-Mar-2017
38.00
30 3-17/14 Elective CS 18 LowFollow up case Absent 1
Yes 2 1 0 1 0 1 02-Jun-2016 09-Mar-2017
37.43
31 3-17/456 Emergency CS 25Middle
Follow up case
Present 2
Yes 4 0 3 0 0 0 05-Jun-2016 12-Mar-2017
37.14
32 3-17/896 Elective CS 26 LowFollow up case Absent 4
Yes 3 2 0 2 0 2 11-Jun-2016 18-Mar-2017
40.14
33 3-17/789 Elective CS 32 HighFollow up case Absent 4
Yes 5 4 0 4 0 4 17-Jun-2016 24-Mar-2017
37.00
34 3-17/1456 Emergency CS 44 Low ReferedPresent 1
Yes 12 11 0 9 2 0 10-Jun-2016 17-Mar-2017
37.00
35 3-17/8569 Emergency CS 26 LowFollow up case
Present 3
Yes 2 1 0 0 1 1 21-Jun-2016 28-Mar-2017
37.14
36 4-17/45 Emergency CS 19 LowFollow up case
Present 4
Yes 1 0 0 0 0 0 01-Jul-2016 08-Apr-2017
38.00
37 4-17/789 Elective CS 24 Low Refered Absent 4Yes 3 2 0 2 0 2 01-Jul-2016 08-Apr-2017
39.00
38 4-17/1500 Elective CS 29 LowFollow up case Absent 1
Yes 6 2 3 1 1 2 05-Jul-2016 13-Apr-2017
36.86
109
39 4-17/1600 Elective CS 28 LowFollow up case Absent 4
Yes 3 1 1 1 0 0 20-Jul-2016 27-Apr-2017
37.57
40 5-17/89 Elective CS 20 LowFollow up case Absent 4
Yes 2 1 0 1 0 0
04-Aug-2016
11-May-2017
38.14
41 5-17/86 Elective CS 17 LowFollow up case Absent 1
Yes 1 0 0 0 0 0
07-Aug-2016
14-May-2017
39.29
42 5-17/1269 Emergency CS 28 LowFollow up case
Present 1
Yes 4 3 0 3 0 3
21-Aug-2016
28-May-2017
40.00
43 6-17/789 Elective CS 39Middle Refered Absent 1
Yes 9 8 0 8 0 0
30-Aug-2016 07-Jun-2017
39.43
44 6-17/1633 Emergency CS 20 HighFollow up case Absent 4
Yes 1 0 0 0 0 0 01-Sep-2016 08-Jun-2017
38.29
45 7-17/896 Elective CS 25 LowFollow up case Absent 4
Yes 2 1 0 1 0 0 21-Sep-2016 28-Jun-2017
38.14
46 7-17/1006 Elective CS 35 Low Refered Absent 1Yes 1 0 0 0 0 0 04-Oct-2016 11-Jul-2017
37.57
47 7-17/1652 Elective CS 26 LowFollow up case Absent 2
Yes 1 0 0 0 0 0 20-Jan-2017 27-Oct-2017
30.14
48 8-17/1900 Elective CS 40 LowFollow up case Absent 1
Yes 4 2 1 2 0 2 22-Oct-2016 29-Jul-2017
36.71
49 8-17/1894 Emergency CS 20 HighFollow up case
Present 4
Yes 1 0 0 0 0 0
02-Nov-2016 09-Aug-2017
37.57
50 8-17/1639 Elective CS 29 Low Refered Absent 2Yes 5 2 2 1 1 1
22-Nov-2016 29-Aug-2017
38.57
51 8-17/4555 Emergency CS 32 LowFollow up case
Present 4
Yes 2 1 0 1 0 0
04-Nov-2016 11-Aug-2017
39.00
52 9-17/140 Elective CS 25Middle
Follow up case Absent 3
Yes 1 0 0 0 0 0 02-Dec-2016 11-Sep-2017
40.00
53 9-17/1551 Emergency CS 16 Low ReferedPresent 1
Yes 1 0 0 0 0 0 11-Dec-2016 18-Sep-2017
41.29
54 9-17/2003 Elective CS 25 LowFollow up case Absent 3
Yes 3 2 0 2 0 1 14-Dec-2016 21-Sep-2017
41.71
55 9-17/5001 Elective CS 29Middle Refered Absent 4
Yes 3 0 2 0 0 0 21-Dec-2016 28-Sep-2017
37.00
56 10-17/145 Elective CS 40 Low Refered Absent 1Yes 1 0 0 0 0 0 04-Jan-2017 11-Oct-2017
37.14
57 10-17/789 Emergency CS 22 HighFollow up case
Present 4
Yes 1 0 0 0 0 0 11-Jan-2017 18-Oct-2017
38.14
58 10-17/745 Emergency CS 30 Low Refered Absent 4Yes 2 1 0 0 0 1 22-Jan-2017 29-Oct-2017
39.00
5910-17/1456 Emergency CS 38
Middle Refered Absent 4
Yes 1 0 0 0 0 0 16-Jan-2017 23-Oct-2017
36.86
6010-17/5221 Emergency CS 25 Low
Follow up case
Present 2
Yes 1 0 0 0 0 0 10-Jan-2017 17-Oct-2017
37.29
110
61 4-17/8996 Emergency CS 31 LowFollow up case
Present 4
Yes 5 1 3 0 1 0 04-Sep-2016 11-Apr-2017
37.29
62 5-17/7412 Emergency CS 25Middle Refered Absent 1
Yes 2 0 1 0 0 0 12-Oct-2016
19-May-2017
40.00
63 8-17/1332 Emergency CS 30 LowFollow up case Absent 1
Yes 4 3 0 3 0 3 04-Jan-2017 11-Oct-2017
40.71
64 8-17/456 Elective CS 22Middle Refered Absent 4
Yes 2 1 0 1 0 1 06-Jan-2017 13-Oct-2017
41.14
6512-16/1487 Elective CS 24 Low
Follow up case Absent 4
Yes 1 0 0 0 0 0 01-Mar-2016 08-Dec-2016
39.71
66 1-17/3223 Emergency CS 30 LowFollow up case
Present 1
Yes 5 4 0 4 0 3 04-Apr-2016 11-Jan-2017
39.57
67 3-17/7856 Emergency CS 19 LowFollow up case
Present 3
Yes 1 0 0 0 0 0 12-Jun-2016 19-Mar-2017
40.14
68 3-17/4523 Emergency CS 33Middle Refered Absent 4
Yes 4 3 0 3 0 2 10-Jun-2016 17-Mar-2017
40.71
69 5-17/78 Emergency CS 22 Low Refered Absent 1Yes 3 2 0 2 0 2
14-Aug-2016
21-May-2017
39.57
70 4-17/789 Emergency CS 26 LowFollow up case
Present 3
Yes 1 0 0 0 0 0 22-Jul-2016 29-Apr-2017
37.00
111
S. N
o
H/o
Hyp
erte
nsio
n
P/H
/M D
iabe
tic
Mile
tus/
GD
M
Hei
ght i
n cm
Pre
preg
nanc
y w
eigh
t
Pre
preg
nanc
y B
MI
curr
ent W
eigh
t (in
kg)
Cur
rent
BM
I
PAL
PAT
ION
fund
al h
t (w
eeks
)
Pres
enta
tion
Pres
entin
g pa
rt
PRO
M
Hae
mog
lobi
n (g
/dl)
Post
-ope
rativ
e ha
emog
lobi
n
Blo
od g
roup
Rh
typi
ng
HIV
Hbs
AG
VD
RL
1Yes No
164 52 19.33 66
24.54 40 Cephalic Mobile
Yes 7.9 NA O Positive Positive Negative Non-reactive
112
2 No No158 56 22.43 70
28.04 40 Cephalic Engaged No 8.4 7.0 B Positive Negative Negative Non-reactive
3Yes No
148 40 18.26 49
22.37 36 Others Mobile
Yes 7.8 NA O Positive Negative Negative Non-reactive
4 No No152 52 22.51 64
27.70 40 Cephalic Engaged No 7.9 NA A Positive Negative Negative Non-reactive
5 No No154 70 29.52 83
35.00 40 Cephalic Engaged No 8.6 6.8 B Positive Negative Positive Non-reactive
6 No Yes149 50 22.52 67
30.18 40 Cephalic Unengaged
Yes 8.4 NA O Positive Negative Negative Non-reactive
7Yes No
172 64 21.63 75
25.35 40 Cephalic Unengaged
Yes 8.9 7.1 B Positive Negative Negative Non-reactive
8Yes No
157 50 20.28 60
24.34 34 Cephalic Unengaged No 8.4 7.9 B Positive Negative Negative Non-reactive
9 No No155 60 24.97 71
29.55 40 Cephalic Engaged
Yes 9.0 NA O Positive Negative Negative Non-reactive
10 No Yes153 64 27.34 80
34.17 40 Others Mobile
Yes 7.9 7.0 O Positive Negative Negative Non-reactive
11Yes Yes
164 75 27.89 89
33.09 40 Cephalic Unengaged No 9.4 7.9 B Positive Negative Negative Non-reactive
12 No No148 55 25.11 65
29.67 40 Cephalic Unengaged No 9.4 8.6 O Positive Negative Negative Reactive
13 No No155 49 20.40 60
24.97 40 Cephalic Engaged
Yes 12.0 10.0 O Positive Positive Negative Non-reactive
14 No No149 45 20.27 58
26.12 40 Cephalic Engaged
Yes 9.3 NA O Positive Negative Negative Non-reactive
15Yes Yes
160 72 28.13 90
35.16 40 Others Mobile No 9.5 NA A Positive Negative Negative Non-reactive
16 No No153 60 25.63 75
32.04 40 Cephalic Unengaged
Yes 8.1 8.0 O Negative Negative Negative Non-reactive
17Yes No
160 44 17.19 60
23.44 40 Cephalic Engaged
Yes 9.5 NA B Positive Negative Negative Non-reactive
18 No Yes176 80 25.83 104
33.57 40 Others Mobile No 14.0 NA B Positive Negative Negative Non-reactive
19 No No169 68 23.81 81
28.36 40 Cephalic Engaged No 11.0 NA O Positive Negative Negative Non-reactive
20Yes No
159 54 21.36 69
27.29 40 Others Mobile
Yes 8.8 NA O Positive Negative Negative Non-reactive
21 No No156 49 20.13 62
25.48 40 Cephalic Unengaged
Yes 7.4 6.7 O Positive Negative Negative Non-reactive
22 No No153 40 17.09 51
21.79 34 Others Mobile No 11.0 NA B Positive Positive Negative Non-reactive
23Yes No
153 38 16.23 50
21.36 34 Cephalic Unengaged No 9.9 7.8 B Positive Negative Negative Non-reactive
113
24 No Yes159 52 20.57 69
27.29 40 Cephalic Engaged
Yes 10.5 8.0 B Positive Negative Negative Non-reactive
25Yes No
158 59 23.63 70
28.04 40 Others Mobile No 12.0 NA B Positive Negative Negative Non-reactive
26 No No152 64 27.70 77
33.33 40 Cephalic Unengaged No 11.0 NA B Positive Negative Negative Non-reactive
27 No No148 42 19.17 53
24.20 40 Cephalic Engaged
Yes 8.2 NA
AB Positive Positive Positive Reactive
28Yes No
156 52 21.37 65
26.71 40 Cephalic Engaged No 12.0 8.4 O Positive Negative Negative Non-reactive
29 No No150 50 22.22 66
29.33 40 Cephalic Engaged No 14.0 NA O Negative Negative Negative Non-reactive
30 No No149 51 22.97 65
29.28 40 Cephalic Engaged No 8.9 NA O Positive Positive Negative Non-reactive
31 No No154 59 24.88 73
30.78 40 Cephalic Engaged
Yes 11.0 NA B Positive Negative Positive Non-reactive
32 No No164 70 26.03 86
31.98 40 Cephalic Unengaged No 10.0 8.3
AB Positive Negative Negative Non-reactive
33 No Yes168 79 27.99 96
34.01 40 Others Mobile No 15.2 NA B Positive Negative Negative Non-reactive
34 No No156 68 27.94 84
34.52 40 Others Mobile
Yes 8.4 NA O Positive Negative Negative Non-reactive
35Yes No
154 49 20.66 62
26.14 40 Cephalic Unengaged
Yes 9.2 7.5 B Positive Negative Negative Non-reactive
36 No No144 40 19.29 51
24.59 40 Cephalic Unengaged
Yes 9.6 8.1 B Positive Negative Negative Non-reactive
37Yes Yes
156 44 18.08 65
26.71 40 Others Mobile No 14.6 11.2 O Positive Negative Negative Non-reactive
38 No Yes161 70 27.01 94
36.26 40 Cephalic Unengaged No 12.0 NA O Positive Negative Negative Non-reactive
39Yes No
160 55 21.48 65
25.39 40 Cephalic Engaged No 9.0 8.0 B Positive Negative Negative Non-reactive
40 No No149 53 23.87 65
29.28 40 Cephalic Unengaged No 15.2 12.0
AB Positive Positive Negative Non-reactive
41 No No159 42 16.61 54
21.36 40 Cephalic Unengaged No 9.0 NA B Positive Positive Positive Non-reactive
42 No Yes165 49 18.00 68
24.98 40 Cephalic Unengaged
Yes 8.6 NA O Negative Negative Negative Non-reactive
43Yes No
174 84 27.74 104
34.35 40 Others Mobile No 14.0 NA B Positive Negative Negative Non-reactive
44 No No156 48 19.72 62
25.48 40 Cephalic Engaged No 14.5 NA B Positive Negative Negative Non-reactive
45 No No155 49 20.40 64
26.64 40 Others Mobile No 13.0 NA B Positive Negative Negative Non-reactive
114
46 No No149 59 26.58 74
33.33 40 Cephalic Unengaged No 10.0 NA O Positive Negative Negative Non-reactive
47Yes No
152 64 27.70 82
35.49 32 Others Mobile No 11.0 NA
AB Positive Negative Negative Non-reactive
48 No Yes160 60 23.44 85
33.20 40 Cephalic Unengaged No 9.5 NA A Positive Negative Negative Non-reactive
49Yes No
156 48 19.72 65
26.71 40 Cephalic Unengaged
Yes 9.4 7.5 O Positive Negative Negative Non reactive
50 No No155 50 20.81 66
27.47 40 Cephalic Unengaged No 8.6 NA B Positive Positive Negative Reactive
51 No No156 56 23.01 69
28.35 40 Cephalic Engaged
Yes 9.6 8.0 B Positive Negative Negative Non-reactive
52Yes No
149 59 26.58 74
33.33 40 Others Mobile No 8.9 NA O Negative Positive Negative Non-reactive
53Yes No
156 45 18.49 55
22.60 40 Cephalic Unengaged
Yes 8.4 NA O Positive Negative Negative Non-reactive
54 No No168 56 19.84 72
25.51 40 Cephalic Unengaged No 10.0 NA O Positive Negative Negative Non-reactive
55 No No166 56 20.32 66
23.95 40 Cephalic Unengaged No 9.5 8.1 B Positive Negative Positive Reactive
56 No No157 62 25.15 78
31.64 40 Cephalic Unengaged No 15.0 NA O Positive Negative Negative Non-reactive
57 No No161 54 20.83 70
27.01 40 Others Mobile
Yes 11.8 NA A Positive Negative Negative Non-reactive
58 No No149 55 24.77 69
31.08 40 Cephalic Unengaged No 9.7 8.0 B Positive Negative Negative Non-reactive
59 No No158 50 20.03 65
26.04 40 Others Mobile No 10.0 NA B Positive Positive Negative Non-reactive
60 No Yes166 73 26.49 92
33.39 40 Cephalic Unengaged
Yes 11.0 NA O Positive Negative Negative Non-reactive
61Yes No
156 44 18.08 65
26.71 40 Others Mobile No 9.1 7.5 B Positive Negative Positive Non-reactive
62Yes Yes
160 40 15.63 54
21.09 40 Others Mobile No 9.5 7.0 B Positive Positive Negative Reactive
63 No No156 62 25.48 80
32.87 40 Others Mobile No 12.0 9.0 A Negative Negative Positive Non-reactive
64 No No160 50 19.53 64
25.00 40 Cephalic Unengaged No 10.0 NA O Positive Negative Negative Non-reactive
65 No No156 54 22.19 68
27.94 40 Cephalic Unengaged No 11.0 7.6 O Positive Negative Negative Non-reactive
66Yes Yes
163 80 30.11 102
38.39 40 Others Mobile
Yes 13.6 10.0 B Positive Negative Positive Non-reactive
67 No No148 40 18.26 51
23.28 40 Cephalic Unengaged
Yes 9.5 NA O Positive Negative Negative Non-reactive
115
68 No No150 52 23.11 70
31.11 40 Others Mobile No 10.0 NA B Positive Negative Negative Non-reactive
69 No No166 60 21.77 73
26.49 40 Cephalic Unengaged No 9.6 NA O Positive Negative Negative Non-reactive
70Yes No
154 66 27.83 79
33.31 40 Others Mobile
Yes 9.6 8.0 B Positive Positive Negative Non-reactive
116
S.no
Hep
atiti
s C
pre-
oper
ativ
e U
TI
Dur
atio
n of
labo
ur (i
n m
ints
)
Indu
ctio
n of
labo
ur
Typ
e of
inci
sion
Dur
atio
n of
surg
ery
(in
min
ts)
Cae
sare
an
Em
erge
ncy/
Ele
ctiv
e ca
esar
ean
h/o
prim
ary
PPH
Prop
hyla
ctic
ant
ibio
tics
pre
op/ i
ntra
op
Febr
ile m
orbi
dity
oper
ativ
e w
ound
di
scha
rge
Wou
nd G
apin
g
Wou
nd h
emat
oma
Surg
ical
site
infe
ctio
n
Inci
sion
al si
te in
dura
tion
1 Non-reactive Yes 8.0 No Pffanensteil 42.0 Primary Emergency No Yes Yes PurulentYes No Yes No
2 Non-reactive No 0.0 No Pffanensteil 35.0 Primary Elective caesareanYes Yes No Purulent
Yes
Yes Yes No
3 Non-reactive Yes 12.0 No Pffanensteil 40.0 Primary Emergency No No No PurulentYes No Yes No
4 Non-reactive Yes 4.0 No infraumbilical vertical 48.0 Repeat Emergency No Yes Yes PurulentYes No Yes No
5 Reactive No 0.0 No infraumbilical vertical 40.0 Repeat Elective caesareanYes Yes No Purulent
Yes No Yes No
6 Non-reactive Yes 8.0 No infraumbilical vertical 45.0 Repeat Emergency No Yes No PurulentYes No Yes No
7 Non-reactive Yes 6.0 No infraumbilical vertical 35.0 Repeat EmergencyYes Yes Yes Purulent
Yes No Yes No
8 Non-reactive Yes 0.0 No Pffanensteil 36.0 Primary Elective caesarean No Yes No serousYes
Yes No No
9 Non-reactive Yes 14.0 Yes Pffanensteil 25.0 Primary Emergency No Yes Yes PurulentYes No Yes No
10 Non-reactive Yes 16.0 No infraumbilical vertical 48.0 Primary EmergencyYes Yes Yes Purulent
Yes No Yes No
11 Non-reactive Yes 0.0 No infraumbilical vertical 40.0 Repeat Elective caesarean No Yes No PurulentYes
Yes Yes No
12 Non-reactive No 2.0 No Pffanensteil 30.0 Primary Elective caesareanYes Yes No Purulent No No Yes No
13 Non-reactive Yes 4.0 No infraumbilical vertical 38.0 Repeat EmergencyYes Yes Yes Purulent
Yes No Yes No
14 Non-reactive Yes 6.0 No infraumbilical vertical 40.0 Repeat Emergency No Yes No PurulentYes No Yes No
15 Non-reactive Yes 0.0 No infraumbilical vertical 40.0 Repeat Emergency No Yes Yes PurulentYes
Yes Yes No
16 Non-reactive Yes 8.0 No Pffanensteil 18.0 Primary EmergencyYes Yes No serous
Yes
Yes Yes No
117
17 Non-reactive Yes 12.0 Yes Pffanensteil 22.0 Primary Emergency No Yes No PurulentYes No Yes No
18 Reactive Yes 0.0 No infraumbilical vertical 45.0 Repeat Elective caesarean No Yes Yes Purulent No No Yes No
19 Non-reactive No 0.0 No Pffanensteil 30.0 Primary Elective caesarean No Yes No serousYes
Yes No No
20 Non-reactive No 2.0 No Pffanensteil 25.0 Repeat Emergency No Yes No serousYes
Yes No No
21 Non-reactive Yes 16.0 No Pffanensteil 35.0 Primary Emergency No Yes No PurulentYes No Yes No
22 Non-reactive Yes 0.0 No infraumbilical vertical 26.0 Primary Elective caesarean No Yes Yes PurulentYes No Yes No
23 Non-reactive No 0.0 No infraumbilical vertical 40.0 Primary Elective caesareanYes Yes No serous
Yes
Yes No No
24 Non-reactive Yes 10.0 No Pffanensteil 35.0 Primary EmergencyYes Yes No Purulent
Yes No Yes No
25 Non-reactive Yes 0.0 No infraumbilical vertical 30.0 Repeat Elective caesarean No Yes No serousYes
Yes No No
26 Reactive No 0.0 No Pffanensteil 32.0 Primary Elective caesarean No Yes No PurulentYes No Yes No
27 Reactive Yes 14.0 Yes infraumbilical vertical 40.0 Primary Emergency No Yes Yes PurulentYes No Yes Yes
28 Non-reactive Yes 12.0 Yes infraumbilical vertical 40.0 Primary EmergencyYes Yes No Purulent
Yes No Yes No
29 Non-reactive No 12.0 Yes Pffanensteil 18.0 Primary Emergency No Yes Yes PurulentYes No Yes No
30 Non-reactive Yes 0.0 No infraumbilical vertical 30.0 Repeat Elective caesarean No Yes No serousYes
Yes Yes No
31 Reactive Yes 10.0 Yes infraumbilical vertical 32.0 Primary Emergency No Yes No serousYes
Yes No No
32 Non-reactive No 0.0 No infraumbilical vertical 45.0 Repeat Elective caesareanYes Yes No Purulent
Yes No
Yes No
33 Non-reactive Yes 0.0 No infraumbilical vertical 48.0 Repeat Elective caesarean No Yes No Purulent
Yes No
Yes No
34 Non-reactive Yes 5.0 No Pffanensteil 20.0 Primary Emergency No Yes Yes Purulent
Yes No
Yes No
35 Non-reactive Yes 4.0 No infraumbilical vertical 28.0 Repeat Emergency
Yes Yes Yes Purulent
Yes No
Yes No
36 Non-reactive No18.
0 Yes Pffanensteil 20.0 Primary EmergencyYes Yes No Purulent
Yes No
Yes No
37 Non-reactive Yes 0.0 No infraumbilical vertical 36.0 Primary Elective caesarean
Yes Yes Yes serous
Yes
Yes
Yes No
38 Non-reactive Yes 0.0 No infraumbilical vertical 38.0 Repeat Elective caesarean No Yes No Purulent
Yes No
Yes No
118
39 Non-reactive Yes 0.0 No infraumbilical vertical 35.0 Primary Elective caesarean
Yes Yes No serous
Yes
Yes No No
40 Non-reactive Yes 0.0 No infraumbilical vertical 35.0 Primary Elective caesarean
Yes Yes Yes Purulent
Yes No
Yes No
41 Non-reactive No 0.0 No infraumbilical vertical 33.0 Primary Elective caesarean No Yes No PurulentYes No
Yes No
42 Non-reactive Yes 2.0 No infraumbilical vertical 45.0 Repeat Emergency No Yes No Purulent
Yes No
Yes No
43 Non-reactive No 0.0 No Pffanensteil 26.0 Primary Elective caesarean No Yes Yes PurulentYes No
Yes No
44 Non-reactive No 8.0 Yes Pffanensteil 18.0 Primary Emergency No Yes No PurulentYes No
Yes No
45 Non-reactive No 0.0 No Pffanensteil 20.0 Primary Elective caesarean No Yes No serousYes
Yes No No
46 Non-reactive Yes 0.0 No Pffanensteil 20.0 Primary Elective caesarean No Yes No Purulent
Yes No
Yes No
47 Non-reactive Yes 0.0 No infraumbilical vertical 40.0 Primary Elective caesarean No Yes No Purulent
Yes
Yes
Yes No
48 Non-reactive No 0.0 No infraumbilical vertical 40.0 Repeat Elective caesarean No Yes No PurulentYes
Yes
Yes No
49 Non-reactive No 4.0 Yes Pffanensteil 18.0 Primary EmergencyYes Yes Yes serous
Yes
Yes No No
50 Non-reactive No 0.0 No infraumbilical vertical 25.0 Repeat Elective caesarean No Yes Yes PurulentYes
Yes
Yes No
51 Non-reactive Yes
11.0 Yes Pffanensteil 25.0 Primary Emergency
Yes Yes Yes Purulent
Yes
Yes
Yes No
52 Non-reactive Yes 0.0 No infraumbilical vertical 29.0 Primary Elective caesarean No Yes Yes Purulent
Yes No
Yes No
53 Non-reactive Yes
10.0 No Pffanensteil 20.0 Primary Emergency No Yes No Purulent
Yes No
Yes No
54 Non-reactive No 0.0 No infraumbilical vertical 30.0 Repeat Elective caesarean No Yes Yes PurulentYes No
Yes No
55 Non-reactive Yes 0.0 No infraumbilical vertical 25.0 Primary Elective caesarean
Yes Yes No serous
Yes
Yes No No
56 Non-reactive No 0.0 No Pffanensteil 20.0 Primary Elective caesarean No Yes No PurulentYes No
Yes No
57 Non-reactive Yes 8.0 No Pffanensteil 25.0 Primary Emergency No Yes Yes Purulent
Yes No
Yes No
58 Non-reactive No 0.0 No infraumbilical vertical 35.0 Repeat EmergencyYes Yes No Purulent
Yes
Yes
Yes No
59 Non-reactive Yes 0.0 No infraumbilical vertical 35.0 Primary Emergency No Yes Yes Purulent
Yes No
Yes No
60 Non-reactive Yes 4.0 No infraumbilical vertical 38.0 Primary Emergency No Yes Yes Purulent
Yes No
Yes No
119
61 Non-reactive Yes 0.0 No Pffanensteil 25.0 Primary Emergency
Yes Yes Yes Purulent
Yes No
Yes No
62 Non-reactive Yes 0.0 No infraumbilical vertical 30.0 Primary Emergency
Yes Yes Yes Purulent
Yes No
Yes Yes
63 Non-reactive No 0.0 No infraumbilical vertical 40.0 Repeat EmergencyYes Yes No serous
Yes
Yes No No
64 Non-reactive Yes 0.0 No infraumbilical vertical 40.0 Repeat Elective caesarean No Yes No Purulent
Yes No
Yes No
65 Non-reactive No 0.0 No Pffanensteil 15.0 Primary Elective caesareanYes Yes No serous
Yes
Yes No No
66 Non-reactive Yes 2.0 No infraumbilical vertical 45.0 Repeat Emergency
Yes Yes Yes Purulent
Yes No
Yes No
67 Non-reactive Yes
10.0 No Pffanensteil 25.0 Primary Emergency No Yes Yes Purulent
Yes No
Yes No
68 Non-reactive No 0.0 No infraumbilical vertical 30.0 Primary Emergency No Yes No serousYes
Yes No No
69 Non-reactive Yes 2.0 No infraumbilical vertical 40.0 Repeat Emergency No Yes No Purulent
Yes No
Yes No
70 Non-reactive Yes 8.0 No Pffanensteil 40.0 Primary Emergency
Yes Yes Yes Purulent
Yes No
Yes No
120
S.no
Bur
st a
bdom
en
Cul
ture
re
port
Sutu
re re
mov
al
time
in d
ays
3rd
wee
k w
ound
Hea
lthy
1 No E.coli 7 Yes2 No Staphylococcus aureus 6 Yes3 No E.coli 6 Yes4 No Sterile 7 Yes5 No E.coli 7 Yes6 No E.coli 7 Yes7 No Staphylococcus aureus 7 Yes8 No Sterile 7 Yes9 No Streptocoocus 7 Yes
10 No E.coli 7 Yes11 Yes Staphylococcus aureus 7 Yes12 No E.coli 7 Yes13 No Enterococcus 7 Yes14 No E.coli 7 Yes15 No Staphylococcus aureus 7 Yes16 No E.coli 7 Yes17 No Streptocoocus 7 Yes18 No E.coli 7 Yes19 No Sterile 6 Yes20 No Sterile 7 Yes21 No E.coli 7 Yes22 No Staphylococcus aureus 7 Yes23 No Sterile 7 Yes24 No E.coli 7 Yes25 No Sterile 7 Yes26 No E.coli 7 Yes27 No Enterococcus 10 No28 Yes E.coli 7 Yes
121
29 No E.coli 7 Yes30 No Staphylococcus aureus 7 Yes31 No Sterile 7 Yes32 No Sterile 7 Yes33 No Staphylococcus aureus 7 Yes34 No Sterile 7 Yes35 No Streptocoocus 7 Yes36 No E.coli 7 Yes37 No E.coli 7 Yes38 No Sterile 7 Yes39 No Sterile 7 Yes40 No Sterile 7 Yes41 No Staphylococcus aureus 7 Yes42 No Streptocoocus 7 Yes43 No Enterococcus 6 Yes44 No Streptocoocus 6 Yes45 No Sterile 6 Yes46 No Staphylococcus aureus 6 Yes47 Yes Sterile 7 Yes48 No Sterile 7 Yes49 No Sterile 6 Yes50 No E.coli 7 Yes51 No Staphylococcus aureus 6 Yes52 No Enterococcus 7 Yes53 No Sterile 7 Yes54 No Staphylococcus aureus 7 Yes55 No Sterile 7 Yes56 No E.coli 7 Yes57 No Sterile 7 Yes58 No Coagulase negative staphylococcus 7 Yes59 No Streptocoocus 7 Yes60 No E.coli 7 Yes61 No Coagulase negative staphylococcus 7 Yes62 No E.coli 7 No
122
63 No Sterile 7 Yes64 No Streptocoocus 7 Yes65 No Sterile 6 Yes66 No Streptocoocus 7 Yes67 No E.coli 6 Yes68 No Sterile 7 Yes69 No E.coli 7 Yes70 No E.coli 7 Yes
123
124