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.
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