Review of Cesarean Delivery Infection in Nigeria

Adeyinka A; Egagifo O; Igberase GO

Case Report

Review of Cesarean Delivery Infection in Nigeria

Adeyinka A, Egagifo O and Igberase GO^*
Department of Obstetrics and Gynecology, Delta State University Teaching Hospital, Nigeria

^*Corresponding author: Gabriel Igberase, Department of Obstetrics and Gynecology, Delta State University Teaching Hospital, Oghara, Nigeria

Published: 15 Jun, 2018
Cite this article as: Adeyinka A, Egagifo O, Igberase GO. Review of Cesarean Delivery Infection in Nigeria. Ann Clin Case Rep. 2018; 3: 1518.

Abstract

Cesarean delivery complications are common in Nigeria and it is an important contributor to the occurrence of puerperal sepsis and post Cesarean morbidities and mortalities. A review of the literature was carried out using various search engines such as PUBMED, GOOGLE and African Journal online (AJOL).
The conclusion was that the prevalence Cesarean delivery infection remains high in Nigeria. There is therefore the urgent need to prevent and promptly treat these infections in order to prevent the immediate and long term complications of Cesarean wound infections in Nigeria.

Introduction

In the recently conducted African Surgical Outcomes Study, of which Cesarean delivery constituted a third of all the patients studied, postoperative complications occurred in 18.2% of the 10,885 participants. Post-operative infection was the most common complication occurring in 10.2% of the patients, of whom 9.7% died [1]. This brought to the fore the public health importance of postoperative infection in the developing world. Caesarean delivery constitutes an important risk factor for the occurrence of puerperal sepsis. Puerperal sepsis on the other hand is one of the commonest complications of Caesarean delivery, and a major cause of post Cesarean morbidities and mortalities [2-4]. Caesarean surgical infection has the potential not only to cause postoperative sepsis, but also to cause multiple organ failure from systemic inflammatory response syndrome, emotional stress of the women involved, prolonged hospital stay, increased overall cost of care, and long term maternal morbidities (including infertility, chronic pelvic pain, ectopic pregnancy [2-5].
Maternal death is the most unfortunate consequence of post-cesarean infection. Postpartum infection remains an important cause of maternal death and morbidities, despite significant advances in diagnosis, medical management and antimicrobial therapy [2,3]. In developing countries, sepsis is the third most common cause of maternal mortality, next to post partum hemorrhage and hypertension; accounting for 10.7% of maternal deaths [6] Sepsis was the commonest (27.4%) cause of maternal death in Benin, Nigeria; and second commonest(16%) in Enugu [7,8]. Post-cesarean infection accounted for 9%, 9.9% and 24% of maternal mortality in studies conducted by Ugwu et al. in Enugu, Adekanle et al. in Ogbomoso, and Igberase et al. in Eku respectively [9-11]. The prevention of infection of Cesarean surgical sites should be a healthcare priority, especially in developing countries.
Although attention had focused more on surgical site infections which implies infection at or near surgical incisions or any other organ handled or manipulated during surgery within thirty days of an operative procedure [12], post cesarean infection should also include any other bacterial infections occurring after and related to surgery such as urinary tract infections, breast abscesses, pneumonias, and even bed sores resulting from prolonged immobilizations.

Incidence of Cesarean Section Infection in Nigeria

Unlike in advanced countries where post-cesarean wound infections complicates 3.7% to 9.9% of cesarean births, [13-16] post cesarean infection rates in some centers in Africa range between 7.1% and 19% [17-19] and in Nigeria between 9% and 16.2% [11,20-26]. As alarming as these rates are, they may infact have been underestimated to start with, as most of the studies conducted on cesarean infections were limited to the first week after surgery when patients were still on admission whereas the vast majority of surgical site infections occur after patients have left the hospital [5,15,27]. Besides, many cases occurring outside the health institutions may not have been documented at all.

Risk Factors for Post Cesarean Infection in Nigeria

Infection of surgical sites depends on several factors: the amount of bacteria introduced into the wound during surgery, the virulence of the organisms, the microenvironment of the wound, and the patients host defense mechanisms [12,28]. Several demographic, medical, obstetrics and operative situations have been studied and found to favor one or more of these etio-pathogenic mechanisms, although only a few of these have been studied and demonstrated to be of significance in the Nigerian settings.
Demographic risks factors of significance in the causation of caesarean infections include low socio economic status and poor nutritional state of the women. Morhason-Bello et al. [22] in an observational descriptive studies conducted in Ibadan found that women with up to primary school were 20 times more likely than those with secondary education & above to develop wound infection (95% CI OR = 1.8 to 250.0). This is because low educational attainment, a marker for low socio economic status, is a predictor of poor nutrition and hence increased susceptibility to infections. Also, low educational attainment predicts poor health seeking behaviour including utilization of antenatal services. Morharson-Bello found that unbooked patients were more likely to have post caesarean infections (OR-1.28: 0.20-8.33)
Medical risks factors for post caesarean infections includes maternal obesity, diabetes, hypertension, immune suppressive illnesses, prolonged preoperative hospital stay, and coexisting infection at a remote site [12,16,28]. Ezechi et al. [24] in a case-control study conducted in Lagos demonstrated that body mass index >25 doubled the odds for post-operative infections (OR 2.34 CI 1.12 - 4.23). Obesity is a precursor of glucose intolerance, and together with diabetes mellitus, may be associated with impairment of immunity.
Obstetrics events such as prolonged premature rupture of membranes, passage of offensive liquor, frequent vaginal examinations before surgery, emergency category of cesarean delivery have been shown to be risk factors for post caesarean infections [11,12,16,28]. Ezechi et al. showed that prolonged ruptured of membrane increased the odds of post-caesarean infection four times (OR=4.45. 95% CI=2.34-8.51). Similarly, Onyegbule et al. [23] in a cross sectional study in Nnewi showed that Women with rupture of membrane less than 24 hours had 89.0% lower odds compared with those with ruptured membrane >24 hours of developing post caesarean wound. Ruptured membrane exposes the otherwise sterile amniotic cavity to vaginal floral, increasing the odds for infections. It is not uncommon in Nigeria for women to present with prolonged rupture of membrane with frankly offensive liquor. Morhason-Bello [22] showed that offensive liquor had 4.29 times the odds of postcaesarean infection (CI 0.66-28.04).
Morhason-Bello et al. [22] also showed that more than two vaginal examinations before surgery had more than 3 odds of post-caesarean infections (0.51-21.72). This is because digital vaginal examination directly introduces vaginal floral into the cervical canal and uterine cavity. Prolonged labour is a common occurrence in Nigeria, and it is an important risk factor for wound infection. Onyegbule et al. [23] found that women with labour duration less than 12 hours have 93.0% lower odds of developing post caesarean wound infection compared to those who labored for >12 hours. Similarly, Jido et al. in Kano [20] in a case control study demonstrated that labour lasting >6 hours was associated with higher risk for infections.
Operative factors play important role in the pathogenesis of postoperative infections. Factors that had been studied and established as predictors of infections include prolonged duration of operation; vertical skin incision; junior category of surgeon; excessive operative blood loss; poor surgical techniques; inadequate sterilization of surgical equipments; preoperative skin shaving; improper surgical antimicrobial prophylaxis; development of subcutaneous hematomas; and inadequate antiseptic skin preparation [12,16,28]. Ezechi et al. [24] showed that prolonged operating time increases risk of postcesarean infections almost three times (OR 2.87 CI 1.96-5.97). Jido et al. [20] in Kano also showed a significantly higher incidence of post-cesarean infections in those with operating time exceeding 60 minutes. Prolonged exposure of pelvic tissue increases the likelihood of peritoneal contaminations especially in the less than standard hygiene state of the operating theatres in the developing countries. Abdominal incision types have also been implicated. Onyegule et al. [23] demonstrated that the use of sub-umbilical midline incision increases the odds of infection by 79% (OR=0.21: 95% CI 0.05-0.91) when compared with transverse incisions. Meanwhile, a midline incision is the choice emergency incision prevalent in the developing countries.
Jido also showed that increased operative blood loss, postoperative anemia, and hospital stay beyond 8 days are risk factors for infections. In the developing countries where women go into pregnancy with decreased iron stores and where malaria and worm infestation is prevalent, anaemia in pregnancy is a common finding. With dearth of skilled surgeons, increased operative blood loss is not uncommon. The consequence of these is postoperative infection.

Prevention of Post-Cesarean Infections in Nigeria

In Nigeria where only 36% of women deliver in health facilities and only 38% of deliveries are attended by skilled providers, [29] it is not surprising that most patients who have labored elsewhere and arrive at referral centers for cesarean surgeries are already exposed to the settings for postoperative infections. Increased access to and acceptance of antenatal care and institutional deliveries will therefore necessarily reduce infective morbidities after surgeries.
Implementation of infection control measures has the potential to reduce post-operative infections. The institutionalization of infection control policies, practice of standard surgical protocols, and use of adjunctive measures such as antimicrobial prophylaxis are some of the time-tested recommendations for reducing surgical infections [4,5,12,28]. Brisibe et al. in Port-Harcourt and Abubakar et al. in Kano have demonstrated improvement in surgical infection rate following implementation of these infection control measures [21,30] However, the knowledge and implementation of these measures in developing countries remain suboptimal. Brisibe et al. [31] in another study demonstrated poor adherence to infection control policy in tertiary hospitals in Port-Harcourt. In the study, the reasons given by the health professionals for non-adherence to the infection control policy included poor supervision (39.39%), lack of in-service training (21.21%), inadequate supply of consumables (34.29%), and absence of a hospital policy on infection control (22.88%) [31]. Therefore, institutional commitment to infection control policies with clear definition of objectives, development of pragmatic implementable guidelines, creation of awareness among hospital health professionals, enforcement of compliance to the guidelines, and monitoring through regular audits will go a long way to entrench standard infection control practices and ultimately reduce the incidence of post cesarean infections.
Antibiotics play a central role both in the prevention and the treatment of post cesarean infections. Abuse and misuse of antibiotics in Nigeria is indeed alarming, providing the scenarios for the emergence of widespread antibiotic resistance. The sale of substandard antibiotic products has not helped the situation. Even when genuine brands are available, many parturient cannot afford its prohibitive cost. Thus, government regulation of antibiotics sales and use, and government subsidy of cost of antibiotics will go a long way to optimize its benefit to women requiring it. The recent WHO initiatives on antibiotics use is a welcome development, and compliance with the recommended practice should be encouraged in Nigeria.

Conclusion

Studies in many Nigerian institutions show that cesarean birth rate is quiet high, being between 11.8% and 40.1%, and still rising [9,11,32,33] This rising cesarean prevalence, the high incidence of post-caesarean infections, and the dire short and long term consequences of this problem make organized actions on prevention of post-operative infections among women who had caesarean birth a very important and timely initiative.

Case Report