Hindawi

International Journal of Reproductive Medicine

Volume 2022, Article ID 4442453, 11 pages
https://doi.org/10.1155/2022/4442453

Research Article
Risk Factors Associated with Surgical Site Infection following
Cesarean Section in Tertiary Care Hospital, Nepal

Astha Regmi ,1 Neebha Ojha,2 Meeta Singh,3 Asmita Ghimire,4 and Nisha Kharel 2

1
Department of Obstetrics and Gynecology, Damauli Hospital, Tanahun, Nepal
2
Department of Obstetrics and Gynecology, TUTH, IOM, Nepal
3
Department of Obstetrics and Gynecology, NGMCTH, Nepal
4
Department of Obstetrics and Gynecology, Grande International Hospital, Kathmandu, Nepal

Correspondence should be addressed to Astha Regmi; astharegmi123@gmail.com

Received 31 August 2021; Accepted 8 April 2022; Published 16 May 2022

Academic Editor: Vikas Roy

Copyright © 2022 Astha Regmi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Cesarean section (CS) is one of the most performed surgeries in obstetrics. Surgical site infection is the major cause of
morbidity and mortality causing an increase in the duration of hospitalization as well as the cost of admission for the patient.
Objective. To determine incidence of surgical site infection following cesarean section, classify them according to CDC criteria,
and identify the different risk factors. Methodology. This is a case-control study conducted at the Department of Obstetrics and
Gynecology at Tribhuvan University Teaching Hospital (TUTH), main campus of Institute of Medicine (IOM), Kathmandu,
Nepal. Surgical site infections (SSI) in patients who underwent cesarean sections from February 2019 to August 2019 were
taken as cases, while the patients who underwent cesarean section before or after the procedure and did not develop SSI
comprised the controls. Visual inspection during ward rounds, reports from laboratory, and postprocedure follow-ups for up
to 30 days formed the basis of identifying infections on the patients. Risk factors were identified by bivariate and multivariate
logistic regression. Results. Out of 1135 cases of cesarean sections, 97 of them developed SSI with incidence rate of 8.54%.
Among them, 94.85% were superficial incisional and 5.15% were deep incisional type of SSI with no organ space type. Cases
had higher mean age 26:88 ± 4:38 years compared to 24:81 ± 5:08 years in controls. Host-related risk factors which led to
higher odds of developing surgical site infection (SSI) were obesity with adjusted odds ratio (AOR) 15.72 (confidence interval
(CI): 4.60-53.67), diabetes/hypertension in pregnancy with AOR 4.75(CI 1.69-13.32), and other medical diseases with AOR
9.38 (CI 2.89-30.46). Duration of the rupture of membrane for more than 18 hours with AOR 8.38 (CI 1.48-47.35), more than
five per vaginal (PV) examination with AOR 1.93 (95% CI 1.03-3.64), and in labor status with AOR 6.52 (CI 1.17-36.38) were
some procedure-related factors resulting into higher odds of infection. Conclusion. Multiple risk factors like age, obesity,
medical complications during pregnancy, occurrence of labor status during cesarean section, prolonged duration of rupture of
membrane for more than 18 hours, and more than five vaginal examinations before the procedure increases the chance of
surgical site infection (SSI) following cesarean section.

1. Introduction maternal mortality and morbidity that comes with it paral-

lelly. Major complications associated with cesarean delivery
Cesarean section (CS) is one of the most performed major include postpartum endometritis, hemorrhage, injury to pel-
surgical procedures in obstetrics. When adequately indi- vic organs, thromboembolic disorders, anesthesia-related
cated, it can prevent poor obstetric outcomes and can be a complications, and wound complications [1, 2].
life-saving procedure for both the mother and the fetus. Surgical site infection (SSI) is an infection that occurs
Nevertheless, at a time when the cesarean delivery rate has within 30 days after the operation and involves the skin
been rising globally, concern is growing about the risk of and subcutaneous tissue of the incision (superficial inci-
2 International Journal of Reproductive Medicine

sional) and/or the deep soft tissue (for example, fascia and Thus, total sample size = 144 with 10% nonresponse rate,
muscle) of the incision (deep incisional) and/or any part of and the total sample size would be 160 (80 cases and 80
the anatomy (for example, organs and spaces) other than control)
the incision that was opened or manipulated during an oper-
ation (organ/space) [3]. It is the most common infection in 2.3. Operational Definitions
surgical patients and a major cause of maternal morbidity
and mortality too [4]. (I) Surgical site infection (SSI): the Centers for Disease
The recent incidence rates of SSI following cesarean Control and Prevention (CDC) defines surgical site
section in different countries are India 13% [1], Nepal infection (SSI) as an infection following surgery at
12.6% [5], Nigeria 9.1% [6], Tanzania 10.9% [7], and Austra- the part of the body where the surgery was
lia 17% [8]. In a systematic review of the maternal intrinsic conducted
risk factors associated with SSI following cesarean section, (II) Superficial SSI: infection occurs within 30 days after
obesity and chorioamnionitis were concluded to be common the operation and only involves skin and subcuta-
risk factors for the overall SSI [8]. Other factors are duration neous tissue at the region of incision and at least
of rupture of membranes, emergency CS [9], lack or improper one of the following conditions occurs:
use of preoperative prophylaxis antibiotics [9–11], and onset
of labor [12]. Cesarean section in the Tribhuvan University (a) Purulent drainage with or without laboratory
Teaching Hospital (TUTH) has escalated from 30.3% to confirmation, from the superficial incision
46.7% in the last ten years. As a result, higher numbers of SSIs (b) Organisms isolated from an aseptically
can be expected. Readmission of postpartum women in the obtained culture of fluid or tissue from the
hospital not only adds burden to the hospital and healthcare superficial incision
staff but also causes the huge impact on psychosocial health
of a mother. Therefore, identifying risk factors for SSI in a (c) At least one of the following signs or symptoms
hospital setting might be of importance to reduce maternal of infection: pain or tenderness, localized swell-
morbidity and mortality. However, there are very few studies ing, redness, or heat and superficial incision is
about SSI following CS in Nepal. This had led the healthcare deliberately opened by surgeon, unless incision
system to be unaware of many risk factors which might be is culture negative
more prevalent in our setting. (d) Diagnosis of superficial incisional SSI made by
The main objective of this study is to determine the inci-
a surgeon or attending physician
dence of SSI following CS in TUTH, classify them, and ana-
lyze different host, pregnancy, and procedure-related risk (III) Deep incisional SSI: infection occurs within 30 days
factors. after the operation if no implant is left in place or
within one year if implant is in place and the infec-
2. Methodology tion appears to be related to the operation and
infection involves deep soft tissue (e.g., fascia and
2.1. Study Setting and Design. This is a case-control study muscle) of the incision and at least one of the
conducted in the Department of Obstetrics and Gynecology, following:
Institute of Medicine, Tribhuvan University Teaching Hos-
pital, Kathmandu, for duration of 7 months from February (a) Purulent drainage from the deep incision but
2019 to October 2019. TUTH is in capital city of Nepal not from the organ/space component of the
and is one the tertiary care centers for obstetric patients’ surgical site
referral causing a huge patient flow.
(b) A deep incision spontaneously dehisces or is
2.2. Sample Size Determination and Sampling Technique. deliberately opened by a surgeon when the
The sample size was calculated using STATA 14.1 based patient has at least one of the following signs
on previous study by Dagshinjav et al. (2016) in Mongolia or symptoms: fever (>38°C), localized pain, or
[13]. Based on their methodology, the sample size in this tenderness, unless incision is culture negative
study was calculated. The sample size was determined in
(c) An abscess or other evidence of infection
the following manner.
involving the deep incision is found on direct
Two-sided confidence level = 95%
Power ð1 − βÞ = 90% examination, during reoperation, or by histo-
Ratio of control to cases = 1 : 1 pathologic or radiologic examination
Percent of controls exposed = 52:6% (d) Diagnosis of deep incisional SSI made by a sur-
Expected odds ratio: 2.7 geon or attending physician
According to Dagshinjya et al. (2016), odds ratio of post-
cesarean surgical site infection was 2.7 and percent of con- (IV) Organ space SSI: infection occurs within 30 days
trol exposed was 52.6% after the operation if no implant is left in place or
Sample size for case = 72 within one year if implant is in place and the infec-
Sample size for control = 72 tion appears to be related to the operation and
International Journal of Reproductive Medicine 3

infection involves any part of the anatomy (e.g., (iii) Patients with SSI diagnosed on hospital stay or on
organs) operation and at least one of the following: follow-up after discharge

(a) Purulent drainage from a drain that is placed 2.5.2. Inclusion Criteria (Control)
through a stab wound into the organ/space
(i) The immediate (before or after) cesarean section
(b) Organisms isolated from an aseptically done in same day or a day before and after, in which
obtained culture of fluid or tissue in the the cesarean section of the case was done
organ/space
(ii) Women meeting above criteria and who do not
(c) An abscess or other evidence of infection develop SSI till 30th POD (as per CDC)
involving the organ/space that is found on
direct examination, during reoperation, or by 2.5.3. Exclusion Criteria (Case and Control)
histopathologic or radiologic examination
(i) Women who did not response to follow-up or who
(d) Diagnosis of organ/space SSI made by a sur- did not show up for follow-up notification
geon or attending physician
(ii) Patient who had undergone cesarean hysterectomy
related to delivery
2.4. Study Variables and Data Collection Tools. Data were
collected through face-to-face interviews and revision of (iii) Abdominal delivery after uterine rupture
hospital record charts. Proforma with structured question- (iv) Women who had follow-up after 30 days
naire including the following variables was used for data
collection. (v) Women following cesarean section in hospitals
other than TUTH
(i) Age of the patient (vi) Women who do not want to take part in the study
(ii) Age at marriage
2.6. Study Population and Framework. This is a hospital-
(iii) Education status based case-control type of study conducted for seven
(iv) Body mass index (during wound examination) months from February 2019 to October 2019. The SSI cases
among cesarean sections of 6 months from 27 February 2019
(v) Parity to 31 August 2019 participated in the study. There were total
of 2446 deliveries in these six months out which 1135
(vi) ANC visits
(46.4%) had cesarean delivery (CD). All the women who
(vii) Primary/previous cesarean developed surgical site infection as per CDC criteria and
out of cesarean sections from February 2019 to August
(viii) Medical disorders in pregnancy (diabetes/hyper- 2019 in department of obstetrics and gynecology in TUTH
tensive disorder/others) were included in the study as cases. Controls were selected
(ix) Emergency or elective cesarean as per inclusion criteria in 1 : 1 ratio.
All the women who had cesarean section in first 6
(x) Duration of surgery (from anesthesia to closure of months of study duration were counselled regarding surgical
the skin) site infections and its signs/symptoms. Counseling was done
(xi) Rupture of membrane (ARM/PROM) and its presurgery, during postpartum period in wards, and at time
duration in hours of discharge.
Surgical site infection was defined as per the CDC defini-
(xii) Number of PV examinations tion by CDC (1992). Those patients following cesarean sec-
tion who developed SSI in ward or visited obstetric
(xiii) Labor status
Outpatient Department (OPD) or emergency or got admit-
(xiv) Indication of cesarean section ted in the ward for management were enrolled in the study
as cases. Women who had undergone cesarean section on
(xv) Blood loss during surgery in ml same day or one day before or after the cesarean section of
SSI case and who did not develop SSI up to 30th postopera-
2.5. Inclusion and Exclusion Criteria tive day were taken as control in the ratio 1 : 1. Among the
possible controls, the first one who came to follow up was
2.5.1. Inclusion Criteria (Case)
included in the study, and cases who did not follow up till
(i) Any surgical site infection following cesarean sec- 30th postop day were excluded.
tion in TUTH in study duration Consent was taken and detail history was recorded.
Patients were examined, necessary investigations (as per
(ii) Surgical site infection defined according to CDC hospital protocol) were sent, and proforma was filled. Both
criteria cases and controls were followed up till 30th postoperative
4 International Journal of Reproductive Medicine

day and managed as per hospital protocol and all required with significant p value of 0.008. Obesity and overweight
information was collected. Detailed study design is shown were more prevalent in women with SSI than in the non-
in Figure 1. SSI group. In the SSI group, 17% (n = 14), 50% (n = 40),
and 33% (n = 26) were found to have normal weight, over-
2.7. Data Analysis. The data were properly coded, catego- weight, and obesity, respectively, at the time of wound exam-
rized, and checked for completeness, accuracy, clarity, and ination. Similarly, in controls, 51% (n = 41), 43% (n = 34),
consistency by the principal investigator and supervisors and 6% (n = 5) were found to have normal weight, over-
before being entered into software for final analysis. Data weight, and obesity, respectively, with statistically significant
was analyzed into SPSS 22. Predictor variables were recoded p value at <0.001.
and dichotomized to perform analysis. Descriptive analysis Most of the women in both SSI group and non-SSI
was performed for each variable. Frequency and percentage group were primipara. There were with 74% (n = 59) of pri-
were computed for categorical variable. Independent T-test mipara women in the SSI group and 60% (n = 48) in the
was applied to compare the mean values of two groups. In non-SSI group with statistically not significant p value of
bivariate analysis, binary logistic regression was employed 0.065.
to identify the one-to-one relationship between predictors Majority of women in both cases and controls had
and outcome variables. Before conducting multivariate anal- undergone primary CS. In the SSI group, 90% (n = 72) cases
ysis, multicollinearity was tested between the predictor’s var- were primary CS and 10% (n = 8) were cases of repeat cesar-
iables. All statistically significant variable levels of p < 0:05 in ean section. In the non-SSI group, 80% (n = 64) cases were
unadjusted analysis were included into the multivariate primary CS, whereas 20% (n = 16) cases were repeat cesar-
regression model. Finally, multivariate logistic regression ean, i.e., previous CS cases. The result was not statistically
was used to identify the relationship between host- and significant at p value of 0.048.
procedure-related risk factors with SSI after adjusting con- There were more women with medical complications
founding variables. p value < 0.05 was considered as statisti- like diabetes (GDM/DM), HTN (pregnancy induced or
cally significant. chronic), and other disorders like hypothyroidism, anemia,
fever, autoimmune disease like SLE, scleroderma in the SSI
2.8. Data Quality and Ethical Assurance. Data was collected group, i.e., 53% (n = 42) out of total SSI cases. On contrary,
by means of face-to-face interview as well as reviewing hos- 85% (n = 68) of women of the non-SSI group had no compli-
pital record charts to get necessary information. To get cation implying more the medical complications, more was
informed consent and reliable data, a clear explanation of the chance of developing SSI. The result was statistically sig-
the purpose of the study was explained. Also, subjects were nificant at p value of <0.001 as depicted in the table below.
positive as their treatment was going together with the Table 2 shows procedure-related characteristics of
research. patients with SSI following cesarean section compared with
The Tribhuvan University Teaching Hospital is an insti- the control group. Emergency indication of cesarean section
tution with ongoing multidisciplinary academic research. It was more common in the SSI group with 95% occurrence
has an institutional research board (IRB), which provided (n = 76) compared to 81% (n = 56) in the non-SSI group,
ethical clearance for this study before data collection after and elective cesarean section was more common in the
reviewing the proposal. non-SSI group, i.e., 19% (n = 15) as compared to the SSI
group, i.e., 5% (n = 4). The result was statistically significant
3. Results at p value of 0.013 as shown in Table 2.
Artificial rupture of membrane was done more fre-
There were 2446 deliveries in obstetric unit of TUTH in six quently in the SSI group, i.e., 57% (n = 39) as compared to
months of study, out which 1135 (46.4%) had cesarean the non-SSI group, i.e., 48% (n = 27). However, the result
delivery (CD). Ninety-seven cases of surgical site infections was not statistically significant with p value of 0.310. The
were identified. The incidence rate of surgical site infection mean duration of rupture of membrane was longer in the
among cesarean section was calculated to be 8.54%. As SSI group, i.e., 9:5 ± 2:3 hours compared to 3:99 ± 1:9 hours
shown in Figure 2, majority of SSI, i.e., 94.85% (n = 92), were in the non-SSI group implying longer the duration of mem-
superficial type and remaining 5.15% (n = 5) were deep brane rupture more the chance of SSI.
without any deep incisional type of SSI. Among them, 80 Mean duration of membrane rupture was being more
cases and controls were taken as per inclusion criteria. common in the SSI group than non-SSI, and duration was
Seventeen cases were not included as follow-ups were not categorized as more than 18 hours and less than 18 hours,
continued by the patients. Sixty-nine percent of the SSI respectively. In the SSI group, there were a greater number
(n = 55) were diagnosed within 10th postoperative days. of cases with membrane rupture duration longer than 18
Remaining 31% (n = 25) SSI were diagnosed after 10th day. hours, i.e., 13 (20%) as compared to the non-SSI group,
Maximum day of diagnosis was 26th postoperative day. i.e., 2 (4%), and it was statistically significant at p value of
Table 1 shows the host-related characteristics of patients 0.005.
with SSI following cesarean section compared with the con- Total numbers of PV examinations, i.e., from admission
trol group. Majority of cases and controls were under the age to cesarean section, were categorized in two groups, i.e., up
of 26-29 years with mean age of case higher than controls, to 5 and more than 5. In the SSI group, there were more
i.e., 26:88 ± 4:38 years and 24:93 ± 4:80 years, respectively, women who had PV examinations of more than 5 times,
International Journal of Reproductive Medicine 5

Total deliveries in 6 months

2446

Vaginal delivery Cesarean section

1311 1135

The cesarean section cases were followed up in ward/OPD/ER till 30th post-operative
day. Purpose of follow up was explained before surgery, during ward admission and at
time of discharge. Principal Investigator was informed whenever SSI was diagnosed,
and questionnaires were filled by the principal investigator with face-to-face interview
and hospital chart.

Total 97 cases of surgical site infections were identified (N = 97)

17 cases excluded because of missed follow-up or lack of response

80 controls were taken as per inclusion criteria

Proforma with pretested questionnaires were filled up in each case and control. Necessary reports were
collected. Data was entered in SPSS 22 each day of case identification. Data analysis into SPSS 22.
Descriptive analysis, T test, bivariate analysis was done. Finally those variables with significant odds were
analyzed by multivariate analysis and adjusted odd ratio was derived.

Figure 1: Study design/framework.

SSI
i.e., 54% (n = 43) as compared to the non-SSI group, i.e., 38%
5
(5.15%)
(n = 30). The result was significant at p value of 0.039.
Duration of surgery (i.e., from the time of anesthesia spi-
nal/induction of anesthesia up to skin closure) was also
found to be positively associated with occurrence of SSI.
62% (n = 50) of the SSI group and 45% (n = 36) of the
non-SSI group had duration of surgery > 60 minutes at sta-
tistically significant p value of 0.026. And 38% (n = 30) of
women in the SSI group and 55% (n = 44) of women in
the non-SSI group had surgery duration of up to 60 minutes.
Hence, the longer the surgery duration, the more the chance
of SSI was expected in the study.
Most of the women were already in labor during cesar-
92 ean section, i.e., 90% (n = 72) of the SSI group and 70%
(94.85%) (n = 56) of the non-SSI group. Similarly, 10% (n = 8) of
women in the SSI group and 30% (n = 24) in the non-SSI
group had not gone into labor. This result was statistically
significant p value of 0.002.
Total blood loss was up to 200 ml in 83% (n = 61) for SSI
Superficial
and 89% (n = 71) for the non-SSI group. It was found that
Deep
the blood loss was in the range of 200-400 ml in 23%
Figure 2: Types of SSI in the study. (n = 19) SSI as compared to 11% (n = 9) non-SSI group with
statistically significant p value of <0.037.
6 International Journal of Reproductive Medicine

Table 1: Host-related characteristics of patients with SSI following DM/HTN with adjusted 4.56 (1.60-12.99) and p value of
cesarean section compared with control group. 0.024 and other medical complications with adjusted OR
8.78 (2.68-28.80) and p value of <0.001 were significantly
Respondent’s Case (SSI) Control (non-SSI)
p value associated with SSI compared to those with no medical
characteristics n (%) n (%)
disorder.
Age 0.128 In multivariate analysis, women who were already in
15-20 5 (6) 11 (14) labor had 6.52 times higher chance of developing SSI with
21-25 22 (28) 29 (36) adjusted OR 6.52 (1.17-36.38) at p value 0.032. Similarly,
26-30 40 (50) 33 (41) prolonged duration of membrane rupture, i.e., >18 hours,
>30 13 (16) 7 (9) and a higher number of PV examination had higher chances
of developing SSI with adjusted OR 8.38 (1.48-47.35) at p
Education level 0.664
value 0.016 and 2.52 (1.01-6.30) at p value 0.046, respectively.
Lower primary 30 (38) 25 (31) However, few of the significant variables in bivariate
Secondary 21 (26) 25 (31) analysis like emergency CS, previous CS, prolonged duration
Graduate or above 29 (36) 30 (38) of surgery, i.e., more than 60 minutes, labor dystocia cases,
BMI <0.001∗ and those with more blood loss, i.e., more than 200 ml, did
Normal 14 (17) 41 (51) not show higher odds of SSI after multivariate analysis.
Overweight 40 (50) 34 (43)
Obesity 26 (33) 5 (6) 4. Discussion
Parity 0.065 Wound-related complication like surgical site infection fol-
Primipara 59 (74) 48 (60) lowing cesarean section is a major cause of morbidity and
Multipara 21 (26) 32 (40) mortality, increasing both the duration of patient hospital-
Site of ANC visits 1.00 ization and hospital costs [4]. It is the most common
TUTH 67 (84) 67 (84) infection in surgical patients and constitutes 15% nosocomial
Outside TUTH 13 (16) 13 (16) infection [14]. With the rising trend in the cesarean deliveries
worldwide, SSI is also increasing. Also, it is one of the fre-
ANC visits 0.074
quently observed postoperative complications in the institute
≤4 times 15 (19) 25 (32) where the study was carried out. Most surgical site infections
>4 times 63 (81) 54 (68) are caused by contamination of an incision with microorgan-
Previous vs primary CS 0.048 isms present in patient’s own body during surgery [15].
Previous CS 7 (9) 16 (20) Infection caused by microorganisms from a source other
Primary CS 73 (91) 64 (80) than the patient’s body following the surgery is less common
Complication during [16]. Most surgical site infections are preventable [8]. Mea-
<0.001∗ sures can be taken in the pre-, intra-, and postoperative
ANC
None 38 (47) 68 (85)
phases of care to reduce the risk of infection [17, 18]. Proper
postoperative surveillance of the cases with risk factors
DM/HTN 22 (28) 7 (9)
reduces the incidence and complications of wound infec-
Others 20 (25) 5 (6) tion [19].
∗
Denotes statistically significant at p < 0:05.
4.1. Classification of SSI. CDC has classified surgical site
infection into three categories, i.e., superficial incisional,
deep incisional, and organ/space SSI. Different literatures
Tables 3 and 4 show the bivariate and multivariate logis- mention superficial incisional type as the most common
tic regression model for host-, pregnancy-, and procedure- of all. In this study, out of 97 cases of SSI, 92, i.e.,
related risk factors among patients with SSI following cesar- 94.8%, cases were superficial incisional and 5 cases, i.e.,
ean section compared with the control groups. 5.2%, were deep incisional with no case of organ space
After initial analysis, all statistically significant variable infection.
levels of p < 0:05 in unadjusted analysis were included into
the multivariate regression model. Hence, in the multivariate 4.2. Incidence of SSI. SSI rate after CS ranges from 3% to 15%,
logistic regression model, only few factors were seen to be varying based on the population being studied, the methods
positively associated with development of SSI in the host- used to monitor and identify the cases, and the use of appro-
and pregnancy-related risk factor. priate antibiotic prophylaxis [1, 3, 20]. In this study, incidence
In the multivariate regression model, women who were rate of SSI was 8.54%. In study done in Nigeria, Jido et al. [6]
overweight with adjusted OR 4.11 (1.74-9.71) and p value reported the SSI rate of 9.1% following cesarean section. Previ-
of 0.001 and were in obese nutritional status with adjusted ous study by Shrestha S et al. [5] in Nepal reported 12.6% inci-
OR 15.72 (95% CI 4.60-53.67) and p value of <0.001 had dence rate of SSI in 2014. Opøien et al. [21] in 2007 found that
higher chances of developing SSI than normal and under- the total rate of SSI was 8.9%, with an observation period of 30
weight ones. Women having medical complication such as days postoperatively, compared to 1.8% registered at hospital
International Journal of Reproductive Medicine 7

Table 2: Procedure-related characteristics of patients with SSI following cesarean section compared with control group.

Case (SSI) Control (non-SSI)

Procedure-related characteristics p value1
n (%) n (%)
Type of CS 0.013∗
Emergency 76 (95) 65 (81)
Elective 4 (5) 15 (19)
Membrane rupture 0.310
Artificial 39 (57) 27 (48)
Spontaneous 29 (43) 29 (52)
Duration of membrane rupture
≤18 hours 50 (80) 54 (96) 0.005
18 hours 13 (20) 2 (4)
Number of PV examination
≤5 times 37 (46) 50 (62) 0.039∗
>5 times 43 (54) 30 (38)
Duration of surgery 0.026∗
≤60 minutes 30 (38) 44 (55)
>60 minutes 50 (62) 36 (45)
Status of labor 0.002∗
NIL 8 (10) 24 (30)
ESOL/ASOL/SSOL 72 (90) 56 (70)
Blood loss during surgery (ml) <0.037∗
100-200 61 (83) 71 (89)
250-400 19 (23) 9 (11)
1
Chi-square test and Fisher exact test. ∗ Denotes statistically significant at p < 0:05.

discharge. In Patan Hospital, Pandit et al. [22] reported a rate than or 4 ANC visits. However, result was not statistically
of 2.76% as the incidence of wound infection among the cases significant with p value 0.074.
of cesarean section from March 2002 to January 2003. This It was seen that primipara women were at higher risk of
lower incidence rate might have been because of them con- developing SSI with OR 1.87 (0.96-3.66) as compared to
sidering only those SSI which developed during the hospital multipara women; however, the result was not statistically
stay. Follow-ups of the cases were not conducted till 30th significant with p value 0.066.
POD as per CDC directives which might have resulted into It is assumed that women with previous CS have increased
lower rate. risk of surgical site infection due to poor healing of previous
scarred tissue in which incision is repeated, relative avascular-
ity, more blood loss during surgery, and longer surgery dura-
4.3. Host-Related Risk factors. In the present study, mean age tion [23]. But in this study, previous CS had 0.38 (0.14-0.99)
of SSI group was 26:88 ± 4:38 years compared to 24:81 ± odds of having SSI as compared to primary CS. Even though
5:08 years. This means that women with SSI were rela- the result was not statistically significant at p value of 0.337
tively older than the non-SSI groups. With increasing age on multivariate analysis, previous CS seems to have lower
during pregnancy, risk of medical complications also odds of developing SSI in comparison to primary CS. Also in
increases [23]. a study of SSI following cesarean, by Jido and Garba [6],
Obesity has previously been reported to predict SSI via forty-one (93.1%) of the cases were primary CSs compared
various possible factors, including the relative avascularity to 327 (74.1%) of the controls, i.e., SSI was more frequent in
of adipose tissue [24]. Another factor may be technical diffi- primary CS than previous CS.
culties of handling adipose tissue which can result into more In this study, women having medical complication such
trauma to the anterior abdominal wall, or difficulty in oblit- as DM/HTN with AOR 4.75(1.69-13.32) and p value of
erating dead space in the fat-tissue of the abdominal wall 0.003 and other medical complications with AOR 9.38
[13]. This study also identified that women with obesity have (95% CI 2.89-30.46) and p value of 0.001 were significantly
higher risk of developing SSI than those with normal weight associated with SSI compared to those having no medical
and underweight with adjusted OR 15.72 (4.60-53.67) at p disorder. Other medical complications included hypothy-
value of <0.001. roidism, anemia, heart disease, respiratory tract infections
Antenatal checkup visit > 4 had higher odds, i.e., 1.94 with fever, and immune-mediated disorder like scleroderma.
(0.93-4.05), of developing SSI compared to those with less There were 8 cases of hypothyroidism, 6 cases of anemia, 3
8 International Journal of Reproductive Medicine

Table 3: Bivariate and multivariate logistic regression model for host- and pregnancy-related risk factor.

Host- and pregnancy-related Bivariate analysis Multivariate analysis

characteristics Unadjusted OR (95% CI) p value Adjusted OR (95% CI) p value
Age
≤30 Ref
>30 2.02 (0.76-5.37) 0.157
Education level
Up to lower primary 1.24 (0.59-2.59) 0.565
Secondary 0.86 (0.40-1.88) 0.722
Graduate or above Ref
BMI
Normal Ref
Overweight 3.44 (1.61-7.36) 0.001∗ 4.11 (1.74-9.71) 0.001∗
Obesity 15.22 (4.90-47.29) <0.001∗ 15.72 (4.60-53.67) <0.001
Parity
Primi Ref
Multi 0.53 (0.27-1.04) 0.066
ANC visits
≤4 times Ref
>4 times 1.94 (0.93-4.05) 0.074
Previous CS
Yes 0.38 (0.14-0.99) 0.048∗ 0.599 (0.21-1.70) 0.337
No Ref
Medical complication
None Ref Ref
DM/HTN 5.62 (2.19-14.37) <0.001∗ 4.75 (1.69-13.32) 0.003∗
Others 7.15 (2.48-20.60) <0.001∗ 9.38 (2.89-30.46) 0.001∗
∗
Denotes statistically significant at p < 0:05.

cases of respiratory tract infections with fever, 2 cases of This study showed that subject with more than five PV
heart disease, and 1 case of scleroderma. examination before the procedure had higher risk of develop-
ing SSI with AOR 2.52 (1.01-6.30), p value of 0.046 com-
4.4. Procedure-Related Risk factors. Emergency CS had 4.38 pared to that of less than 5 times. With increased number
times higher odds of SSI than elective surgery, i.e., OR 4.38 of PV examination, there are chances of more contamina-
(CI 1.38-13.86, p value 0.012). However, on multivariate tion from vagina to endometrium and hence uterine wall,
analysis, the adjusted odds ratio was omitted due to multi- which will ultimately traverse to incision site during cesar-
collinearity effect of multiple variables. ean delivery. Similarly, Saeed and et al. [25] concluded that
The mean duration of rupture of membrane in cases was there was increased risk of SSI for women who had ≥5 vag-
9:5 ± 19:11 hours, whereas for controls, it was 3:98 ± 13:54 inal examinations (AOR, 3.24; 95% CI, 0.92-11.41). In a
hours implying that mean duration was higher for cases. study by Mpogoro et al. [7], they concluded that multiple
Hence, duration was categorized as 18 hours or less and vaginal examinations (HR: 2.5; 95% CI, 1.2-5.1; p = 0:011)
more than 18 hours. The duration of rupture for more than was one of the causes for SSI.
18 hours was predictive of SSI on both bivariate and multi- Surgery duration for more than 60 minutes was associ-
variate analysis with AOR 8.38 (1.48-47.35) at p value ated with higher risk of surgical site infection with adjusted
0.016. However, there was no significant difference between OR of 2.12 (95% CI 0.91-4.90); however, the result was not
spontaneous and artificial rupture of the membrane among statistically significant on multivariate analysis with p value
the cases and control with p value of 0.311. Also, no study 0.080.
has compared between artificial and spontaneous rupture. Compared to those who were not in labor, women who
In cesarean section, nonsterile amniotic fluid may act as a were already in labor during cesarean section (including all
transport medium by which bacteria get to the uterine and stages of labor) had higher odds of developing SSI, i.e.,
skin incisions leading to chorioamnionitis and its sequelae AOR 6.52 (1.17-36.38), at significant p value 0.032 on multi-
like SSI. variate analysis. Labor status increases the chance of multiple
International Journal of Reproductive Medicine 9

Table 4: Bivariate and multivariate logistic regression model for procedure-related risk factor.

Bivariate analysis Multivariate analysis

Procedure-related characteristics
Unadjusted OR (95% CI) p value Adjusted OR (95% CI) p value
Type of CS
Emergency 4.38 (1.38-13.86) 0.012∗
Elective Ref
Membrane rupture
Artificial 1.44 (0.70-2.94) 0.311
Spontaneous Ref
Duration of rupture
≤18 hours Ref Ref 0.016∗
>18 hours 7.02 (1.50-32.66) 0.013∗ 8.38 (1.48-47.35)
Number of PV examination
≤5 times Ref Ref
∗
>5 times 1.93 (1.03-3.64) 0.040 2.52 (1.01-6.30) 0.046∗
Duration of CS
≤60 minutes Ref Ref
∗
>60 minutes 2.03 (1.08-3.83) 0.027 2.12 (0.91-4.90) 0.080
Stage of labor
NIL Ref Ref
ESOL/ASOL/SSOL 3.85 (1.61-9.23) 0.002∗ 6.52 (1.17-36.38) 0.032∗
Meconium
Yes 1.92 (0.93-3.95) 0.075
No Ref
Labor dystocia
Yes 1.39 (1.12-1.78) 0.013∗ 1.45 (0.45-4.62) 0.531
No Ref Ref
Blood loss (ml)
100-200 Ref Ref
250-400 2.45 (1.03-5.82) 0.041∗ 2.32 (0.71-7.45) 0.159
∗
Denotes statistically significant at p < 0:05.

PV examinations, rupture of membrane, prolonged rupture, Blood loss had higher odds of developing SSI, i.e., 2.45
prolonged latent phase, and other labor dystocia, which indi- (1.03-5.82), with significant p value of 0.013, but the result
rectly increases the chance of SSI. was not significant on multivariate analysis.
Meconium-stained liquor was the most common indica-
tion in both the SSI and non-SSI groups. Hence, cases were
divided in terms of indication as meconium stained and 5. Conclusion
nonmeconium stained. Indication as meconium was more
common in the SSI group as compared to non-SSI; however, Surgical site infection following cesarean section is a com-
the result was not statistically significant with p value of mon complication with incidence of 8.54% in TUTH,IOM,
0.072. On bivariate analysis, meconium stained had higher Nepal. Multiple risk factors like increasing age, obesity, med-
odds of developing SSI with OR 1.92 (0.93-3.95) compared ical complications during pregnancy, initiation of labor dur-
to nonmeconium-stained indications. ing cesarean section, prolonged duration of rupture of
Also in this study, labor dystocia including prolonged membrane for more than 18 hours, and more than five PV
latent phase of labor, nondescent of head, and nonprogress examination increase the chance of surgical site infection
of labor was another common indication of CS in the SSI after cesarean section. Hence, obstetrician should consider
group. On multivariate analysis, there was higher odds of earlier or more frequent postoperative follow-up in patients
developing SSI among labor dystocia group, i.e., AOR 1.45 with these risk factors. Obstetrician should try to avoid pre-
(0.45-4.62); however, the result was not statistically signifi- ventable risk factors to reduce incidence of surgical site
cant with p value 0.531. infection following cesarean section.
10 International Journal of Reproductive Medicine

Acronyms wound infections,” American Journal of Infection Control,

vol. 20, no. 5, pp. 271–274, 1992.
ANC: Antenatal care [4] “Protocol for surgical site infection surveillance with a focus on
AOR: Adjusted odds ratio settings with limited resources [Internet],” May 2022, https://
ARM: Artificial rupture of membrane www.who.int/publications/i/item/protocol-for-surgical-site-
ASOL: Active stage of labor infection-surveillance-with-a-focus-on-settings-with-limited-
CD: Cesarean delivery resources.
CDC: Centers for Disease Control and Prevention [5] S. Shrestha, R. Shrestha, B. Shrestha, and A. Dongol, “Inci-
CS: Cesarean section dence and risk factors of surgical site infection following cesar-
DM: Diabetes mellitus ean section at Dhulikhel Hospital,” Kathmandu University
GDM: Gestational diabetes mellitus Medical Journal, vol. 12, no. 46, pp. 114–117, 2014.
HAI: Healthcare-associated infection [6] T. Jido and I. Garba, “Surgical-site infection following cesarean
HTN: Hypertension section in Kano, Nigeria,” Annals of Medical and Health Sci-
IOM: Institute of Medicine ences Research, vol. 2, no. 1, pp. 33–36, 2012.
LMI: Low- and middle-income countries [7] F. J. Mpogoro, S. E. Mshana, M. M. Mirambo, B. R. Kidenya,
LPOL: Latent phase of labor B. Gumodoka, and C. Imirzalioglu, “Incidence and predictors
NDOH: Nondescent of head of surgical site infections following caesarean sections at
NIL: Not in labor Bugando Medical Centre, Mwanza, Tanzania,” Antimicrobial
NPOL: Nonprogress of labor Resistance and Infection Control, vol. 3, no. 1, 2014.
OR: Odds ratio [8] P. Lakhan, J. Doherty, M. Jones, and A. Clements, “A sys-
PIH: Pregnancy-induced hypertension tematic review of maternal intrinsic risk factors associated
with surgical site infection following caesarean sections,”
PROM: Premature rupture of membrane
Healthcare Infection, vol. 15, no. 2, pp. 35–41, 2010.
PV: Per vaginal
SROM: Spontaneous rupture of membrane [9] T. C. F. Farret, J. Dallé, M. V. da Silva, C. V. W. Riche, and V. S.
Antonello, “Risk factors for surgical site infection following
SSI: Surgical site infection
cesarean section in a Brazilian Women’s Hospital: a case-
SSOL: Second stage of labor control study,” Brazilian Journal of Infectious Diseases,
TUTH: Tribhuvan University Teaching Hospital vol. 19, no. 2, pp. 113–117, 2015.
WHO: World Health Organization. [10] C. A. Killian, E. M. Graffunder, T. J. Vinciguerra, and R. A.
Venezia, “Risk factors for surgical-site infections following
Data Availability cesarean section,” Infection Control & Hospital Epidemiology,
vol. 22, no. 10, pp. 613–617, 2001.
Data is available upon request from the corresponding [11] S. P. Gong, H. X. Guo, H. Z. Zhou, L. Chen, and Y. H. Yu,
author. “Morbidity and risk factors for surgical site infection following
cesarean section in Guangdong Province, China,” Journal of
Obstetrics and Gynaecology Research, vol. 38, no. 3, pp. 509–
Conflicts of Interest 515, 2012.
The authors declare that they have no conflicts of interest. [12] R. Shree, S. Y. Park, R. H. Beigi, S. L. Dunn, and E. E. Krans,
“Surgical site infection following cesarean delivery: patient,
provider, and procedure-specific risk factors,” American Jour-
Acknowledgments nal of Perinatology, vol. 33, no. 2, pp. 157–164, 2016.
[13] N. Dagshinjav, E. Tudevdorj, M. Davaasuren, and N. Gurjav,
I sincerely thank Mr. Dev Ram Sunuwar for his help in sta- “Risk factors for sepsis following cesarean section in Ulaanbaa-
tistical analysis and all the participants of the study who tar: a case-control study,” Central Asian Journal of Medical Sci-
made this work successful. Also, I would like to thank Er. ences, vol. 3, no. 1, pp. 81–87, 2017.
Bhushan Lohani (PhD candidate at UTEP, Texas, USA) for [14] L. McKibben, T. Horan, J. I. Tokars et al., “Guidance on public
reviewing language part of the article. reporting of healthcare-associated infections: recommenda-
tions of the Healthcare Infection Control Practices Advisory
Committee,” American Journal of Infection Control, vol. 33,
References no. 4, pp. 217–226, 2005.
[1] S. Zuarez-Easton, N. Zafran, G. Garmi, and R. Salim, “Postce- [15] N. M. Kaplan, A. A. Smadi, M. I. Al-Taani, and M. A. El-
sarean wound infection: prevalence, impact, prevention, and Qudah, “Microbiology of wound infection after caesarean sec-
management challenges,” International Journal of Women's tion in a Jordanian hospital,” Eastern Mediterranean Health
Health, vol. 9, pp. 81–88, 2017. Journal, vol. 9, no. 5-6, pp. 1068–1074, 2003.
[2] E. Declercq, M. Barger, H. J. Cabral et al., “Maternal outcomes [16] C. Wloch, J. Wilson, T. Lamagni, P. Harrington, A. Charlett,
associated with planned primary cesarean births compared and E. Sheridan, “Risk factors for surgical site infection follow-
with planned vaginal births,” Obstetrics & Gynecology, ing caesarean section in England: results from a multicentre
vol. 109, no. 3, pp. 669–677, 2007. cohort study,” BJOG: An International Journal of Obstetrics
[3] T. C. Horan, R. P. Gaynes, W. J. Martone, W. R. Jarvis, and & Gynaecology, vol. 119, no. 11, pp. 1324–1333, 2012.
E. T. Grace, “CDC definitions of nosocomial surgical site infec- [17] P. J. Jenks, M. Laurent, S. McQuarry, and R. Watkins, “Clinical
tions, 1992: a modification of CDC definitions of surgical and economic burden of surgical site infection (SSI) and
International Journal of Reproductive Medicine 11

predicted financial consequences of elimination of SSI from an

English hospital,” Journal of Hospital Infection, vol. 86, no. 1,
pp. 24–33, 2014.
[18] D. L. Stevens, A. L. Bisno, H. F. Chambers et al., “Practice
guidelines for the diagnosis and management of skin and
soft-tissue infections,” Clinical Infectious Diseases, vol. 41,
no. 10, pp. 1373–1406, 2005.
[19] S. Bärwolff, D. Sohr, C. Geffers et al., “Reduction of surgical site
infections after Caesarean delivery using surveillance,” Journal
of Hospital Infection, vol. 64, no. 2, pp. 156–161, 2006.
[20] N. Schneid-Kofman, E. Sheiner, A. Levy, and G. Holcberg,
“Risk factors for wound infection following cesarean deliver-
ies,” International Journal of Gynecology & Obstetrics, vol. 90,
no. 1, pp. 10–15, 2005.
[21] H. K. Opøien, A. Valbø, A. Grinde-Andersen, and M. Walberg,
“Post-cesarean surgical site infections according to CDC stan-
dards: rates and risk factors. A prospective cohort study,” Acta
Obstetricia et Gynecologica Scandinavica, vol. 86, no. 9,
pp. 1097–1102, 2007.
[22] A. Pandit, P. Sharma, and K. Yangzom, “Incidence of caesar-
ean wound infection in Patan Hospital, Nepal,” Journal of
Nepal Medical Association, vol. 42, no. 149, pp. 280–283, 2013.
[23] E. S. Miller, K. Hahn, and W. A. Grobman, “Consequences of a
primary elective cesarean delivery across the reproductive life,”
Obstetrics & Gynecology, vol. 121, no. 4, pp. 789–797, 2013.
[24] V. St, C. Lamoutte, S. De, and A. Verdeja, “Wound infection
after cesarean: effect of subcutaneous tissue thickness,” Obstet-
rics and Gynecology, vol. 95, 6, Part 1, pp. 923–926, 2000.
[25] K. B. Saeed, P. Corcoran, M. O’Riordan, and R. A. Greene,
“Risk factors for surgical site infection after cesarean delivery:
a case-control study,” American Journal of Infection Control,
vol. 47, no. 2, pp. 164–169, 2019.