Technical maneuvers done to alter the postpartum infection rate have been studied with cesarean delivery. For example, allowing the placenta to separate spontaneously compared with removing it manually lowers the infection risk. However, changing gloves by the surgical team after placental delivery does not (Atkinson, 1996). Exteriorizing the uterus to close the hysterotomy may decrease febrile morbidity (Jacobs-Jokhan, 2004). Postdelivery mechanical lower segment and cervical dilatation has not been shown to be efective (Liabsuetrakul, 2011). No diferences were found in postoperative infection rates when single-and two-layer uterine closures were compared (Hauth, 1992). Similarly, infection rates are not appreciatively afected by closure versus nonclosure of the peritoneum (Bamigboye, 2014; Tulandi, 2003). Importantly, although closure of subcutaneous tissue in obese women does not lower the wound infection rate, it does decrease the wound separation incidence (Chelmow, 2004). Similarly, skin closure with staples versus suture has a higher incidence of noninfectious skin separation (Mackeen, 2012; Tuuli, 2011).
• Complications of Uterine and Pelvic Infections
In more than 90 percent of women, metritis responds to antimicrobial treatment within 48 to 72 hours. In some of the remainder, any of several complications may arise. These include wound infections, complex pelvic infections such as phlegmons or abscesses, and septic pelvic thrombophlebitis (Jaiyeoba, 2012). As with other aspects of puerperal infections, the incidence and severity of these complications are remarkably decreased by perioperative antimicrobial prophylaxis.
Wound infection is a common cause of persistent fever in women treated for metritis. Incisional infection risk factors include obesity, diabetes, corticosteroid therapy, immunosuppression, anemia, hypertension, and inadequate hemostasis with hematoma formation. If prophylactic antimicrobials are given, the incidence of abdominal wound infection following cesarean delivery ranges from 2 to 10 percent depending on risk factors (Andrews, 2003; Chaim, 2000). From our experiences at Parkland Hospital, the incidence is closer to 2 percent.
Incisional abscesses that develop following cesarean delivery usually cause persistent fever or fever that begins on about the fourth day. In many cases, antimicrobials had been given to treat pelvic infection, yet fever persisted. The wound is
FIGURE 37-1 Secondary abdominal wound closure technique. (Reproduced with permission from Worley KC: Postoperative complications. In Yeomans ER, Hoffman BL, Gilstrap LC III, et al (eds):
Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw Hill Education, 201o7.) erythematous and drains pus. Although organisms that cause wound infections are generally the same as those isolated from amnionic luid at cesarean delivery, hospital-acquired pathogens may also be causative (Owen, 1994).