الفهرس 
CESAREAN SECTION (CS)Only 14 pages are availabe for public view
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Abstract
Caesarean section is one of the most commonly performed abdominal operations on women in most countries of the world. Its rate has increased markedly in recent years, and is about 20-25% of all child births in most developed countries (Menacher et al., 2009).
In contemporary Obstetrics the cesarean section rate is increasing and has become a common procedure (Bergella et al., 2005).
The rate of cesarean section has risen to a level near to 46% in China, Europe, Latin America and United States. Surgical site infection (SSI) after a cesarean section increases maternal morbidity and medical costs (Alderice et al., 2005).
The rates in other parts of the world vary widely from 1.6% of all child births in Haiti to 59% in Chilean private hospitals (Belizan et al., 2009).
A surgical site infection is an infection that occurs after surgery in the part of the body where the surgery took place. SSI can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material (CDC HAI, 2008) SSI has a great impact on the economy aid health care resources. Infection has always been a feature of modern surgery and continues to be a significant problem for health care practitioners across the world (Gala and El-Hindawy, 2011).
Risk factors that are associated with wound complication in cesarean section include maternal medical disease, pre-eclampsia, obesity, infection, frequent vaginl examinations, internal monitors, and a need for emergent cesarean delivery (Owen et al., 1994).
Obesity is a well-known risk factor for surgical site, possible biological explanations for this association include the relative avascularity of adipose tissue, the increase in wound area and the poor penetration of prophylactic antibiotics m adipose tissue (Olsen et al., 2008).
As with most surgical procedures, there is no standard technique for cesarean section (Bergella at al., 2005; Mackeen et al., 2012).
A variety of techniques exist for nearly every step of the procedure, many of which have been studied (Coronis et al., 2013; Cromi et al., 2010).
To date there is insufficient evidence to favor one method of subcutaneous tissue closure (Mackeen et al., 2012). Several studies have investigated the effect of closure of s.c. fat on wound complication rates, however there is insufficient data regarding the influence of s.c. tissue closure on wound cosmoses (Anderson et al., 2004; Chelmow et al., 2004).
The aim of this study is to determine the surgical site infection rate and patient satisfaction in obese women undergoing cesarean section using subcutaneous tissue closure compared to non-closure of the subcutaneous tissue with subcuticular skin closure of all included women.
One meta-analysis review and 3 randomized controlled studies have been identified comparing different ways of subcutaneous tissue closure in cesarean section (Chelmow et al., 2004), (Islam et al., 2011), (Husslein et al., 2014), (Gaertner et al., 2007).
Primary outcomes were rates of wound dehiscence and wound complication rate. Secondary outcomes were patients’ satisfaction, operating time, and postoperative pain.
This is a randomized controlled comparative study conducted in Ain-Shams University Maternity Hospital during the period from November 2013 to September 2014. It included (143) pregnant women who underwent elective cesarean section.
The patients included were any female in childbearing period, planned for elective cesarean section and obese (BMI > 30) (Haslan et al., 2005).
Excluding patients who had concurrent overt infection (e.g. chorioamenitis, pyelonephritis or chest infection). Women who had intraoperative events that may themselves predispose to perioperative infection [e.g. Bowel injury, operative time more than 90 minutes]. Women who had hemoglobin less than 10g/dl, pre-eclampsia, rupture of membranes more than 12 hours. Pregnant females with >1 previous cesarean section. Women who had immunodeficiency, D.M., on steroids or on anti-coagulants drugs.
The included women were randomized into one of the following two groups: group 1 includes 72 patients and had their subcutaneous tissue suture closed and group 2 includes 71 patients who had their subcutaneous tissue left unclosed.
In this study all Cesarean section procedures were performed by surgeons who at least had a 2-year experience in practicing cesarean sections.
A prophylactic antibiotic was given, as advised by the local protocols of Ain Shams University Maternity Hospital, as two intravenous doses of one of first-generation cephalosporin or broad-spectrum penicillin [after clamping of the umbilical cord and 6 hours postoperatively]. Oral prophylactic antibiotics of the same group were then started for3-5days.
After closure of the fascial layer,Subcutaneous tissue was closed or not closed according to the allocated group i.e. closure of the subcutaneous tissue by simple interrupted sutures using absorbable 2-0 sutures in group 1 and non-closure of the subcutaneous tissue in group 2. Subcutaneous drains were not to be left in any of the included women.
Closure of the skin by subcuticular stitches using non-absorbable polypropylene 2-0 in all cases. Postoperative1y, wound was uncovered 24 hours postoperatively, was dressed, while uncovered, with alcohol 70% antiseptic solution for 7 days. The wound was inspected 48 hours, 7 days and one month after the Cesarean section.
Results of this study demonstrated that no statistically difference between the two groups regarding demographic data, wound inflammation, wound dehiscence or wound collection at 2,7 and 30 days postoperatively.
As regard closure time: the mean closure time was higher in group 1 (subcutaneous tissue closure) in comparison to group 2(subcutaneous tissue non closure) and was statistically significant.
As regard patient’s satisfaction, the rate of patient’s satisfaction was significantly higher in women of group 1 (subcutaneous tissue closure) in comparison with women in group 2 (subcutaneous tissue non-closure)
There was no statistically significant difference between two groups as regard scar appearance with p-value: 0.235.
The closure of the subcutaneous tissue was not associated with lower rate of SSI comparing to non-closure of subcutaneous tissue, but associated with better cosmetic outcome and patients’ satisfaction.