Introduction
Direct maternal infections around the time of childbirth account for about one tenth of the global burden of maternal death. Women who develop peripartum infections are also prone to severe morbidity, long-term disabilities such as chronic pelvic pain, fallopian tube blockage and secondary infertility. Maternal infections before or during childbirth are also associated with an estimated 1 million newborn deaths annually.
Several factors increase the risk of maternal peripartum infections, including pre-existing maternal conditions (e.g. malnutrition, diabetes, obesity, severe anaemia, bacterial vaginosis and group B streptococcus infections), as well as prelabour rupture of membranes, multiple vaginal examinations, manual removal of the placenta, operative vaginal birth and caesarean section. As such, the strategies to reduce maternal peripartum infections and their short- and long-term complications have been directed at improving infection prevention and control practices.
Globally, an effective intervention for preventing morbidity and mortality related to maternal infection is the use of antibiotics and antiseptics. However, the misuse of antibiotics for obstetric conditions and procedures is common in many settings. Inappropriate antibiotic use has implications for the global effort to prevent and reduce antimicrobial resistance. The WHO global strategy for containment of antimicrobial resistance underscores the importance of appropriate use of antimicrobials at different levels of the health system to reduce the impact of antimicrobial resistance, while ensuring access to the best treatment available.
In 2019, the Executive Guideline Steering Group (GSG) for World Health Organization (WHO) maternal and perinatal health recommendations prioritized updating of the existing WHO recommendations on choice of antiseptic agent and method of application for preoperative skin preparation for caesarean section in response to the availability of new evidence. The recommendations in this document thus supersede the previous WHO recommendations for choice of antiseptic agent and method of application for preoperative skin preparation for caesarean section as published in the 2015 guideline WHO recommendations for prevention and treatment of maternal peripartum infections.
Target audience
The primary audience for these recommendations includes health professionals who are responsible for developing national and local health-care guidelines and protocols (particularly those related to the prevention and treatment of peripartum infections) and those involved in the provision of care to women and their newborns during labour and childbirth, including midwives, nurses, general medical practitioners and obstetricians, as well as managers of maternal and child health programmes, and relevant staff in ministries of health and training institutions, in all settings.
Guideline development methods
The updating of these recommendations was guided by standardized operating procedures in accordance with the process described in the WHO handbook for guideline development. The recommendations were initially developed and updated using this process, namely: (i) identification of priority questions and outcomes; (ii) retrieval of evidence; (iii) assessment and synthesis of evidence; (iv) formulation of the recommendations; and (v) planning for the dissemination, implementation, impact evaluation and future updating of the recommendations.
The scientific evidence supporting the recommendations were synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. An updated systematic review was used to prepare the evidence profiles for the prioritized questions. WHO convened a meeting on 19–20 October 2020 where the Guideline Development Group (GDG) members reviewed, deliberated and achieved consensus on the strength and direction of the recommendations presented herein. The recommendations were formulated under one of the following categories: recommended, not recommended, recommended only in specific contexts (the intervention is applicable only to the condition, setting or population specified in the recommendations), recommended only in the context of rigorous research (implementation of the recommendations can still be undertaken provided it takes the form of research that addresses unanswered questions). Through a structured process, the GDG reviewed the balance between the desirable and undesirable effects and the overall certainty of supporting evidence, values and preferences of stakeholders, resource requirements and cost–effectiveness, acceptability, feasibility and equity.
Recommendations
The GDG issued these recommendations on choice of antiseptic agent and method of application for preoperative skin preparation for caesarean section with remarks and implementation considerations. To ensure that these recommendations are correctly understood and applied in practice, guideline users may want to refer to the remarks, as well as to the evidence summary, including the considerations on implementation.
WHO recommendations on choice of antiseptic agent and method of application for preoperative skin preparation for caesarean section
View in own window
Recommendation a: The use of alcohol-based chlorhexidine gluconate for skin preparation prior to elective or emergency caesarean section is recommended.
(Recommended) Recommendation b: The method of application of alcohol-based chlorhexidine gluconate prior to caesarean section should be based primarily on instructions for use, the clinician’s experience and preferences.
(Recommended) |
Remarks:
There was a lack of evidence to recommend a specific concentration of chlorhexidine gluconate; however, most trials included used 2% chlorhexidine gluconate in 70% alcohol. Maternal allergy to alcohol-based chlorhexidine gluconate must be excluded before surgery. In women with no previous history of allergy to alcohol-based chlorhexidine gluconate, it should be noted that chlorhexidine gluconate can cause skin irritation. A standard preoperative skin preparation technique that is appropriate for the intended skin incision must be followed. As alcohol is highly flammable, alcohol-based antiseptic preparations may ignite if used in the presence of diathermy, and they must be allowed to dry by evaporation. It is advisable to ensure that the drapes are not saturated with alcohol or that the alcohol-based solution has not formed a pool underneath the woman before starting surgery. Particular care should be taken at emergency caesarean section. Where chlorhexidine gluconate is not available, other antiseptic agent such as povidone-iodine can be considered a suitable antiseptic agent for preoperative skin preparation, although it is not as effective as alcohol-based chlorhexidine gluconate. The Guideline Development Group noted that the current recommendation is consistent with the 2016 WHO global guidelines on the prevention of surgical site infection, which recommends chlorhexidine gluconate alcohol-based antiseptic solutions for surgical site skin preparation in individuals undergoing surgical procedures. These recommendations supersede Recommendation No. 17 of the 2015 WHO recommendations for prevention and treatment of maternal peripartum infections where this was considered a conditional recommendation based on low-quality evidence.
|