INFEXIT: Implementing vaginal disinfection prior to cesarean section

Published:September 29, 2022DOI:


      • Implementing vaginal disinfection in a Dutch hospital is feasible and effective.
      • Vaginal disinfection shows a decline in post cesarean endometritis.
      • Vaginal disinfection shows significant decrease in endometritis for patients with ruptured membranes and in second stage of labor.
      • Vaginal disinfection leads to significantly fewer readmissions and lower costs.



      To evaluate the rate of implementation after adding vaginal disinfection to the cesarean section protocol and its effect on post cesarean infections and hospital readmissions.

      Study design

      This is an intervention study where two groups were compared. Women the year before (n = 1384) and one year following (n = 1246) the addition of vaginal disinfection, with povidone-iodine 1% prior to the cesarean section, to the protocol. Primary outcome was the rate of implementation. Secondary outcomes were the rates of endometritis, wound infection and postoperative fever. With the effect expressed in the number of hospital readmissions.


      The implementation rate was 85.6%. Intention-to-treat analysis showed endometritis rates of 2.0% versus 1.1% (p = 0.07). For women with preoperative ruptured membranes there was a significant decrease in endometritis, from 3.4% to 1.3% (p = 0.02). Per-protocol analysis showed endometritis rates of 2.0% to 1.0% (p = 0.05). Women with ruptured membranes, 3.4% versus 1.3% (p = 0.02), and women who were in the second stage of labor, 4.7% versus 0.0% (p = 0.01), had a significant decrease in endometritis. For wound infection and postoperative fever rates were similar.
      The decrease of infections had a significant effect on hospital readmissions, 27 versus 10 (p = 0.04).


      The implementation of this quality improvement measure shows to be adequate as the vast majority of women undergoing a cesarean received vaginal disinfection. Vaginal disinfection showed a declining trend of endometritis and postoperative fever and for women with broken membranes prior to cesarean section the decrease in endometritis was significant. These beneficial effects have led to a statistical and clinically relevant decrease in hospital readmissions and thus cost reduction.


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        • Boushra M.
        • Rahman O.
        Postpartum Infection. Treasure Island (FL).
        StatPearls Publishing. 2021; ([cited 2021 Sep 30] Available from:)
        • Allen V.M.
        • O'Connell C.M.
        • Liston R.M.
        • Baskett T.F.
        Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term.
        Obstet Gynecol. 2003 Sep; 102: 477-482
      1. Perined. [Internet] Utrecht; 2020. Dutch. [cited on 2022 Mar 17] Available from:

        • Haas D.M.
        • Morgan S.
        • Contreras K.
        • Kimball S.
        Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.
        Cochrane Database Syst Rev. 2020; (Apr 26;4(4):CD007892)
        • Zuarez-Easton S.
        • Zafran N.
        • Garmi G.
        • Salim R.
        Postcesarean wound infection: prevalence, impact, prevention, and management challenges.
        Int J Womens Health. 2017 Feb; 17: 81-88
      2. Kasteren MEE van, Gyssens IC, Kullberg BJ, Bruining HA, Stobberingh EE, Goris RJA. Optimaliseren van het antibioticabeleid in Nederland. V. SWAB-richtlijnen voor perioperatieve antibiotische profylaxe. Ned Tijdschr Geneesk. 2000 Oct 21;144(43):2049-55. Dutch.

        • Mayhall C.G.
        Surgical infections including burns.
        in: Wenzel R.P. Prevention and control of nosocomial infections. Williams and Perkins, Baltimore1993
        • Mackeen A.D.
        • Packard R.E.
        • Ota E.
        • Speer L.
        Antibiotic regimens for postpartum endometritis.
        Cochrane Database Syst Rev. 2015; (Feb 2;2015(2):CD001067)
      3. WHO. Recommendation on vaginal preparation with antiseptic agents for women undergoing caesarean section. Geneva: World Health Organization; 2021.

        • Roeckner J.T.
        • Sanchez-Ramos L.
        • Mitta M.
        • Kovacs A.
        • Kaunitz A.M.
        Povidone-iodine 1% is the most effective vaginal antiseptic for preventing post-cesarean endometritis: a systematic review and network meta-analysis.
        Am J Obstet Gynecol. 2019 Sep; 221: 261.e1-261.e20
        • Teisberg E.
        • Wallace S.
        • O'Hara S.
        Defining and Implementing Value-Based Health Care: A Strategic Framework.
        Acad Med. 2020 May; 95: 682-685
        • Felder L.
        • Paternostro A.
        • Quist-Nelson J.
        • Baxter J.
        • Berghella V.
        Implementation of vaginal cleansing prior to cesarean delivery to decrease endometritis rates.
        J Matern Fetal Neonatal Med. 2019 Jun; 32: 1997-2002
      4. Rijksinstituut voor Volksgezondheid en Milieu. PREZIES. Protocollen postoperatieve wondinfecties. Bijlage 2: Definities Postoperatieve wondinfecties. 2019 Mar 28. Dutch.

      5. OLVG. Passantenprijslijst zorgproducten OLVG 2020 [Internet]. Amsterdam: OLVG; 2020. Dutch. [cited 2020 Dec 4] Available from:

        • Charoenviboonphan P.
        Preoperative vaginal painting with 1% povidone-iodine before cesarean delivery to reduce postoperative febrile morbidity: a randomized control trial.
        Region 4–5 Med J. 2011; 30: 117-214
      6. Aref, NK. Vaginal cleansing prior to caesarian section: To do or not to do?: A randomized trial. Journal of Gynecology Obstetrics and Human Reproduction. 2019, Jan;48(1):65-68.

        • Asghania M.
        • Mirblouk F.
        • Shakiba M.
        • Faraji R.
        Preoperative vaginal preparation with povidone-iodine on post caesarean infectious morbidity.
        J Obstet Gynaecol. 2011 Jul; 31: 400-403
        • Kiani S.A.
        • Zafar M.
        • Yasmin S.
        • Mazhar S.B.
        Vaginal cleansing prior to cesarean section and post-operative infectious morbidity.
        J Soc Obstetr Gynaecol Pakistan. 2018; 8: 95-99
        • Yildirim G.
        • Güngördük K.
        • Asicioglu O.
        • Basaran T.
        • Temizkan O.
        • Davas I.
        • et al.
        Does vaginal preparation with povidone-iodine prior to caesarean delivery reduce the risk of endometritis? A randomized controlled trial.
        J Matern-Fetal Neonatal Med. 2012 Nov; 25: 2316-2321
        • Starr R.V.
        • Zurawski J.
        • Ismail M.
        Preoperative vaginal preparation with povidone-iodine and the risk of postcesarean endometritis.
        Am College Obstetric Gynecol. 2005 May; 105: 1024-1029
        • Barat S.
        • Bouzari Z.
        • Ghanbarpour A.
        • Zabihi A.
        Impact of preoperative vaginal preparation with povidone iodine on post cesarean infection.
        Caspian J Reprod Med. 2016 Jan; 2: 2-8
        • Nandi J.K.
        • Saha D.P.
        • Pal S.
        • Barman S.
        • Mitra A.
        Antiseptic vaginal preparation before cesarean delivery to reduce post operative infection: A randomised controlled trial.
        J Med Sci Clin Res. 2015 Feb; 3: 4310-4315
      7. Haas DM, Pazouki F, Smith RR et al. Vaginal cleansing before cesarean delivery to reduce postoperative infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. 2010 Mar;202(3):310.e1-6.