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

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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

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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

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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

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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

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UTI Urinary tract infection

VDRL Venereal Disease Research Laboratory Test

WHO World Health Organization

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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.

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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

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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%,

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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

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(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

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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

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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

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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)

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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

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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

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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

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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)

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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

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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)

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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)

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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

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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)

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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

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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

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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

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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

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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%

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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.

101

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.

102

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

___________________________

104

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

107

S. n

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 Pat

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Age

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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

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nsio

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P/H

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M

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Pre

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Pre

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Rh

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HIV

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AG

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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

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s C

pre-

oper

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Dur

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n of

labo

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)

Indu

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labo

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Typ

e of

inci

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Dur

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n of

surg

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(in

min

ts)

Cae

sare

an

Em

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ncy/

Ele

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esar

ean

h/o

prim

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PPH

Prop

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Surg

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site

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Inci

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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