Duke Health Referring Physicians


Quality-Improvement Initiative Reduced Wound Complications After Cesarean Delivery

After implementing a simple bundle of quality-improvement measures in January 2016, the rate of surgical-site infections among women undergoing cesarean delivery decreased by 70% at Duke, according to findings from a new study.

Margaret Villers, MD, a fellow in the Division of Maternal Fetal Medicine in the Department of Obstetrics and Gynecology at Duke University, presented results from the retrospective cohort study at the 37th Annual Pregnancy Meeting of the Society for Maternal Fetal Medicine held January 23 to 28, 2017, in Las Vegas, NV.

“Since implementing the bundle, we are seeing far fewer patients come back with wound infections after cesarean delivery,” Villers said. “Nurses keep saying to me, ‘This is really great.’”

Historically, approximately 10% of women undergoing cesarean delivery at Duke developed wound complications. In addition to increasing patient morbidity, these complications increased the rate of hospital readmissions and increased costs to the health care system.

To address this issue, Duke introduced a new bundle of measures designed to reduce the risk of wound complications in all women undergoing cesarean delivery. The measures were tailored to the obstetric patient population at Duke, which includes a high prevalence of morbidly obese women (body mass index > 40 kg/m2). The bundle includes 3 key components:

  • Preoperative skin preparation with 2% chlorhexidine cloths
  • Preoperative vaginal cleansing with chlorhexidine gluconate
  • Negative pressure wound therapy in women with a body mass index > 40 kg/m2

In the study, Villers compared wound complication rates before and after the bundle was implemented.

Women in the prebundle group (n = 311) underwent cesarean delivery between January and June 2014, and those in the postbundle cohort (n = 514) delivered via cesarean delivery between January and June 2016. All women were evaluated 30 days after delivery for the presence of wound complications (infection, seroma, and hematoma) and specific types of surgical-site infections (superficial wound infections, deep wound infections, and endometritis).

Most baseline and procedural characteristics were similar in the prebundle and postbundle cohorts (Table 1). One exception was the closure rate of subcutaneous tissue, which was higher in the postbundle group than in the prebundle group (93% vs 80%; P < .001).

Table 1. Patient and Procedural Characteristics

Characteristic Prebundle
(n = 311)
(n = 514)
P Value
Patient age, y 31 31 NS
Median BMI at delivery, kg/m² 32.7 33.5 NS
Gestational age at delivery, wk 38 38 NS
Cesarean delivery in labor, % 49 47 NS
Chorioamnionitis, % 9 9 NS
Pfannenstiel skin incision, % 96 96 NS
Subcutaneous closure, % 80 93 < .001
Suture skin closure, % 95 95 NS

BMI = body mass index, NS = nonsignificant.

“Quality improvement can be a challenging process, but everyone has been incredibly supportive, including the residents and nursing staff,” Villers said.

To facilitate compliance, Villers and colleagues produced a short video illustrating the skin preparation and vaginal cleansing procedures. In the postbundle cohort, compliance with all components of the bundle was 78%.

Introducing the care bundle significantly improved surgical outcomes for patients undergoing cesarean delivery (Table 2). The overall rate of wound complications decreased from 10% in the prebundle period to 4% in the postbundle group (P < .001). This included a reduction in the rate of surgical-site infections from 9% to 2% in the prebundle and postbundle periods, respectively (P = .003).

Table 2. Outcomes Before and After Implementing the Bundle

Outcome Prebundle
(n = 311)
(n = 514)
P Value
All wound complications, % 10 4 < .001
Infections 9 2
Seroma 2 1
Hematoma 0 1
All surgical-site infections, % 9 2 .003
Superficial incisional 5 0.3
Deep incisional 2 0.3
Endometritis 0.3 1

In an adjusted analysis that controlled for the difference in rates of subcutaneous closure between the 2 cohorts, the benefit of the care bundle remained statistically significant. Implementing the bundle reduced the risk of surgical-site infections after cesarean delivery by 70% (adjusted odds ratio 0.3; 95% confidence interval, 0.1-0.5).

In a separate study, Villers and colleagues described the specific benefits of negative pressure wound therapy in morbidly obese women undergoing cesarean delivery. Together, these studies highlight the reductions in postoperative wound complications among women undergoing cesarean delivery at Duke.

Source: Villers MS, Thomas CH, Grotegut CA, Geine RP, Swamy GK. Reduction of cesarean delivery surgical site infections using an evidence-based care bundle. Presented at: Society for Maternal-Fetal Medicine 37th Annual Pregnancy Meeting; January 23-28, 2017; Las Vegas, NV. Abstract 702.