Clinical audit gynecology

1. Clinical Audit ON
Lower segment caesarean section procedure
Dr. Kabita Sharma
Department of OBG &
GYN

2. CLINICAL AUDIT
OBJECTIVES :
 To assess the relation of duration of surgery to
postoperative morbidity like duration of stay at
hospital.
 To assess the effects of prophylactic antibiotics with
postoperative SSI, endometritis and urinary tract
infection.

3. Introduction
 Caesarean section (CS) rates have increased globally
during the past three decades.
 The risks associated with cesarean delivery can be
divided into short term, long term, and those that
present risks to future pregnancies.
 Caesarean section -Single most important risk factor
for postpartum maternal infection
.

4. COMPLICATIONS
 The major non-anesthesia-related complications related
to caesarean delivery are
 Surgical site infection
 Endometritis
 Urinary tract infection
 A major cause of prolonged hospital stay

5.  Surgical site infection (SSI) following CS is a common
cause of morbidity with reported rates of 3–15%.
 SSI represents a substantial burden to the health system
including increased length of hospitalisation and costs of
post discharge care.
Incidence of surgical site infection following caesarean section: a systematic
review BMJ Open 2017

6. SURGICAL SITE INFECTION

7. TABLE 1
CRITERIA FOR DEFINING A SURGICAL SITE INFECTION (SSI)
Superficial Incisional SSI
infection occurs within 30 days after the operation
and
infection involves only skin or subcutaneous tissue of the incision
and at least one of the following:
1. Purulent drainage, with or without laboratory confirmation, from the superficial incision.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the
superficial incision.
3. At least one of the following signs or symptoms of infection: pain or tenderness,
localized swelling, redness, or heat and superficial incision is deliberately opened by
surgeon, unless incision is culture-negative.
4. Diagnosis of superficial incisional SSI by the surgeon or attending physician.
Do not report the following conditions as SSI:
1. Stitch abscess (minimal inflammation and discharge confined to the points of suture
penetration).
2. Infection of an episiotomy or newborn circumcision site.
3. Infected burn wound.
4. Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI).
Note: Specific criteria are used for identifying infected episiotomy and circumcision sites and burn
wounds.433

8. Effective interventions to decrease surgical site infection include
 Prophylactic antibiotic use
 Chlorhexidine skin preparation
 Hair removal using clippers instead of razors,
vaginal cleansing by povidone-iodine
 Placental removal by traction of the umbilical cord
instead of by manual removal
 Suture closure of subcutaneous tissue if the wound
thickness is >2 cm
 Skin closure with sutures instead of with staples.

9.  Operative duration is independently associated with
increased infectious complications and length of stay
after adjustment for procedure and patient risk factors.
 Prophylactic antibiotics use of prophylactic antibiotics
in women undergoing cesarean section reduces the
incidence of wound infection, endometritis and serious
infectious complications by 60% to 70%

10. Period of Audit: SEP 2023 to OCT 2023
Study Design: Retrospective study of LSCS cases
Study Area: Patients who have undergone LSCS procedure
at VINAYAKA HOSPITAL

11. Sample design: Patients who have undergone LSCS during
study period
Sample size: 06

12. Following parameters were monitored in LSCS patients:
1. Average operating time
2. Adherence of antibiotic prophylaxis protocol with
respect to
a) Choice of antibiotics
b) Timing of antibiotic administration before surgery

13. Duration of operation /
Operating time
 Formula: Incision Time – Closure
Time

14. DATE INCISION TIME CLOSURE TIME
OPERATING
TIME
HOSPITAL STAY
03.09.2023 2:48 PM 3:25 PM 37 mnts. 4 DAYS
14.09.2023 3:30 PM 4:20 PM 50 mnts. 4 DAYS
19.09.2023 1:30 PM 2:15 PM 45 mnts. 3 DAYS
19.09.2023 6:15 PM 6:45 PM 30 mnts. 3 DAYS
22.09.2023 11:55 AM 12:20 PM 25 mnts. 4 DAYS
23.10.2023 10:05 AM 10:30 AM 25 mnts. 3 DAYS

15. Operating Time:
The Average Operating Time : 35 mins
Range : 25 minutes to 50
minutes

16.  Operative duration is independently associated with increased infectious
complications and length of stay after adjustment for procedure and
patient risk factors
 Increased operative time was linked with an increased blood loss, low
five-minute Apgar scores and umbilical arterial pH < 7.1.

17.  Duration of surgery alone is not a major determinant of
postoperative morbidity and
Important predictors of outcome are
o Type of surgery performed and the
o Patient's general health
o Pre existing conditions such as
Previous surgeries, malpresentations,
lower uterine segment not formed,
prolonged second stage were important

18. Length of hospital stay
 Guidelines published by the ACOG suggest that, when
there have been no complications, the duration of
postpartum hospital stays range from an average of 48
hours for vaginal delivery to an average of 96 hours for
cesarean birth (excluding the day of delivery)

19.  Early discharge means reduced health care cost
 It enables mother to return home sooner with newborn.
 Early discharge should not preclude educating woman on breastfeeding,
family planning and care of new born.
 The complications should also be monitored to accurately determine the
costs and benefits of early postpartum discharge

20.  Preoperative Prophylactic Antibiotic Usage

21. Antibiotic prophylaxis for caesarean
section
 Cefazolin 1-2gm I/V 30-60 min prior to skin incision
OR
 Cefuroxime 1.5 gm 30-60 min prior to skin incision
OR
 Augmentin 1.2 gm I/V 30 -60 min prior to skin incision
OR
 Ceftriaxone 1gm I/V 30-60 min prior to skin incision

22.  Prophylactic Antibiotic given :
In 100 % of cases

23. 100%
Antibiotic prophylaxis before surgery

24. RECOMMENDATIONS
Enhanced recovery after surgery (ERAS)
 A concept that combines various evidence-based aspects of perioperative
care to accelerate patient recovery.

25.  (ERAS) Committee guides on perioperative care for
cesarean delivery.
 Covers practices from the time of decision making to
hospital discharge
 The recommendations are based on a thorough review
of the literature and includes a ‘maternal focused
pathway’ for both scheduled and unscheduled surgeries

26. Components of ERAS :
 Optimize antenatal pathway
 Preoperative pathway
 Intraoperative pathway
 Neonatal pathway
 Optimize and manage maternal comorbidities

28. THANK YOU