Results And Observations

RESULTS AND OBSERVATIONS

In our study, total 216 women were enrolled who underwent caesarean section. They wer
followed up to 30 days for detection of surgical site infection. Only 200 women could be
followed up to 30 days and were included in the study analysis.

It was observed that 43(21.5 %) women had surgical site infection detected within 30 days,
either superficial, deep or organ space infection and comprised the study group A. Group B
comprised of 157 (78.5%) women who did not develop SSI. (Table 1)

Table 1: Distribution of women enrolled and grouping

No. of women enrolled n = 216

Followed up to 30 days ( n= 200) Could not be followed up to 30 days
Detected SSI No SSI (n=16)
(group A) (group B) Excluded from study
n=43 n= 157

Figure 1: Grouping of women according to SSI

Group A &B

21.5%
Gr. A

SSI
No SSI
Gr. B
78.5%

26
 Results And Observations

Age wise distribution of women in our study was comparable in both the groups (p value
0.131. Mean age of women in group A was 25.325 4.668 years and in group B was 25.687
3.271. (Table 2)

Table 2: Age wise distribution of women

Age group Group A Group B p value

(years) n % n %
< 25 29 67.4 84 53.5
25-35 13 30.2 72 45.9 0.131*
> 35 1 2.3 1 6
Mean age 25.325 4.668 25.687 3.271 0.561*
Total(200) 43 100 157 100
*not significant
Figure2: Distribution of women according to age

Mean Age
25.69

25.70
25.60
25.50 25.33
Mean Age
25.40
25.30
25.20
25.10
Sepsis No Sepsis

Distribution of women according to parity was comparable in the 2 groups ( p value 0.295).
Mean parity was 1.744 1.002 in group A and 1.73 0.076 in group B(p value 0.976)
(Table3). Table 3: Parity wise distribution of cases

Parity Group A Group B p value

n % n %
1-2 23 53.5 65 41.4
3-4 19 44.2 90 57.3 0.295*
>4 1 2.3 2 1.3
Mean parity 1.744 1.002 1.73 0.076 0.976*
Total(200) 43 100 157 100
*not significant

27
 Results And Observations

Figure 3: Distribution of women according to parity

92
100

90

80 65

70

60 Primi

50 Multi
40
23 20
30

20

10

0
Sepsis No Sepsis

Mean gestation at the time of caesarean section was comparable in both the groups (p value
0.624). Maximum number of women belonged to 37-40 week gestation (Table 4).

Table 4: Distribution of women according to gestational age

Gestational age Group A Group B p value

In weeks n % n %
<37 weeks 10 23.3 26 16.6
37-40 weeks 25 58.1 101 64.3 0.591*

>40 weeks 8 18.6 30 19.1

Mean gestation age 38.365 1.915 38.531 1.980 0.625*

Total(200) 43 100 157 100
*not significant

28
 Results And Observations

Mean BMI was 25.06 9 5.086 in group A and 22.796 2.811 in group B. The difference
was statistically different. (p value 0.001). In group B or control group, no woman had BMI >
30 kg/m2 (Table5).

Table 5: Association of SSI according to BMI

BMI Group A Group B P value

Kg/m2 n % n %

18-25 27 62.8 128 81.53

25.1 30 8 18.6 29 18.47 0.001*

>30 8 18.6 0 0

Mean BMI 25.06 9 5.086 22.796 2.811 0.001*

Total(200) 43 100 157 100

* significant

Figure 4: Mean BMI in both the groups

Mean BMI
Mean BMI

25.07
26.00
25.00
22.80
24.00
23.00
22.00
21.00
Sepsis No Sepsis

29
 Results And Observations

Number of women who were booked (minimum antenatal 3 visits) was comparable in both
the groups (p value 0.966) (Table 6).

Table 6: Association of SSI with booking status

Booking status Group A Group B P value

n % n %
Booked 30 69.8 109 69.4
Unbooked 13 30.2 48 30.6 0.966*
Total(200) 43 100 157 100
* not significant

Number of women with previous LSCS scars was comparable in the two groups (p value
0.335) (Table 7).

Table 7: Association of SSI with number of previous caesarean sections

No of previous Group A Group B P value

caesarean section
n % n %
0 29 67.4 90 57.3
1 11 25.6 59 37.6 0.335*
2 3 7.0 8 5.1
Total(200) 43 100 157 100
*not significant

Mean duration of stay after admission in labor room was 20.535 16.63 hours in group A
and 20.548 16.252 hours in group B (Table 8). The difference was statistically not
significant (p value 0.996). Most of the women had less than 24 hours stay in labor room
which included, women in 1st , 2nd stage of labor (if caesarean was done in 2nd stage) . Stay
in labor room also included women with no labor pains undergoing induction of labor for
various obstetrical and medical indications before undergoing caesarean section.

30
 Results And Observations

Table 8: Association according to duration of stay in labor room

Duration in hours Group A Group B p value

n % n %

< 24 hours 27 62.8 117 74.5

24-48 hours 14 32.6 33 21.0 0.278*

> 48 hours 2 4.7 7 4.5

Mean duration 20.535 16.63 20.548 16.252 0.996*

Total(200) 43 100 157 100

* not significant

In group A one patient had elective LSCS and out of the rest 42 patients mean duration of
labor pains was 6.4525.22285 before undergoing LSCS. In group B 16 patients had elective

Type of caesarean section, emergency or elective was comparable in both the groups (p value
0.101) (Table 9)

Table 9: Association of SSI with type of caesarean section

Type of cesarean Group A Group B P value

section
n % n %
Elective 1 2.3 16 10.2 0.101*

Emergency 42 97.7 141 89.8

Total(200) 43 100 157 100

* Not significant

31
 Results And Observations

Fig 5.Elective &emergency caesarean in both groups

Elective & Emergency CS

10.2%

elective
emergancy

89.8% emergency

In group A 1 patient had elective caesarean and out of the rest 42 women undergoing
emergency caesarean, mean duration of labour pains was 6.4525.222 hours. In group B 141
women had emergency caesarean and mean duration of labor pains was 7.02136.757 The
difference was statistically not significant (p value 0.616). Most of the women delivered
within 12 hours of labor pains in both the groups. (Table 10)

Table 10: Association of SSI with duration of labor pains in emergency caesarean

Duration of labor pains Group A Group B p value

(hours) n % n %

< 6 hours 29 69.0 99 70.2 0.707*

>6-12 10 23.8 28 19.9

>12-24 3 7.1 13 16

>24 0 0 1 .7

Mean 6.4525.222 7.02136.757 0.616*

Total(183) 42 100 141 100

*non significant

32
 Results And Observations

There were 18 women in group A and 64 women in group B who had premature rupture of
membranes either spontaneously (leaking) or as part of surgical induction for severe pre-
eclampsia, eclampsia and accidental haemorrhage (Table 8). In rest of the cases membranes
were ruptured (spontaneous or ARM) in active phase of labor/2nd stage. Mean duration of
premature rupture of membranes (PROM) was 21.55515.786 hours in group A and
7.0786.915 hours in group B. There was statistically significant more number of women
(20.9% versus 1.3%) in group A with PROM > 18 hours (p value 0.001). (Table11)

Table 11: Association of SSI with duration of membrane rupture

Duration of PROM Group A Group B p value

(hours) n % n %
<18 hours 9 20.9 62 39.5 0.001*
>18 hours 9 20.9 2 1.3
No PROM 25 58.1 93 59.2
Mean 21.55515.786 7.0786.915 0.001*
Total 43 100 157 100
* significant

Mean no. of per vaginal examinations were more in group A (5.1392.605) compared to
group B(3.9802.023). The difference was statistically significant (p value 0.002) (Table 12).
The number of PVs included PV done in casualty and pre-induction PV to asses cervix.

Table 12: Association of SSI with number of PV examinations

Number of PV Group A Group B p value

examinations n % n %
0-3 16 37.2 73 46.5
3-6 12 27.9 69 43.9 0.001*
>6 15 34.9 15 9.6
Mean no. PVs 5.1392.605 3.9802.023 0.002*
Total no. of women 43 100 157 100
(200)
*significant

33
 Results And Observations

In our study preoperative anaemia was present comparably in both the groups. There was no
statistical difference in number of women having anaemia (p value 0.524) (Table 13).

Table 13: Association of SSI with pre-op anaemia

Anaemia Group A Group B p value

n % n %

Absent 26 60.5 120 76.4

Present 17 39.5 37 23.6 0.524*

Total(200) 43 100 157 100

* not significant

Women having hyperglycaemia in pregnancy were found to be associated comparably in both

the group (p value 0.806) as most of the diabetics were controlled either on medical
nutritional method or oral hypoglycaemic or on insulin.(Table 14)

Table 14: Association of SSI with Diabetes

Diabetes status Group A Group B P value

n % n %

GDM 1 2.3 4 3.2 0.806*

Diabetes in pregnancy 1

No GDM 42 97.7 152 96.8

Total(200) 43 100 157 100

*not significant

34
 Results And Observations

No significant difference was found with type of skin incision, vertical or transverse in both
the groups (p value 0.809) (Table15).

Table 15: Association of SSI with type of skin incision

Type of incision Group A Group B P value

n % n %
Transverse 41 95.3 151 96.2
Vertical 2 4.7 6 3.8 0.809*
Total(200) 43 100 157 100
* Not significant

There was no statistical difference in number of women having PPH in the two groups (p
value 0.524) (Table 16).

Table 16: Association of SSI with PPH

PPH Group A Group B P value

n % n %
PPH absent 40 93.0 141 89.8
PPH present 3 7.0 16 10.2 0.524*
Total(200) 43 100 157 100
*not significant

Type of skin suturing was not significant (p value 0.144) in women with SSI compared to
control group (Table 17)

Table 17: Association of types of skin suturing

Skin suturing Group A Group B P value

n % n %
Mattress 39 90.7 151 96.1
Subcutaneous 4 9.3 6 3.9 0.144*
Total(200) 43 100 157 100
*not significant

35
 Results And Observations

There was significantly more number of women who had post operative anaemia in group A
compared to group B(p value 0.035) (Table 18)

Table 18: Association with post-operative anaemia

post-operative Group A Group B p value

anaemia n % n %

No 26 60.5 120 76.4 0.035*

Yes 17 39.5 37 23.6

Total(200) 43 100 157 100

*significant

There was significantly more number of women who had post-operative fever in group A
compared to group B (p value 0.001). In group B there was no women who had fever after 5
days of caesarean section. In the control group none of the women had fever after 5 days.
Mean duration of fever in group A was 4.0435 1.988 days while mean duration of fever in
group B was2.8077 0.6939 days and it was significant (p value 0.005)(Table 19)

Table 19: Association of SSI with post-operative fever

Onset of fever Group A Group B P value

In days n % n %

No fever 21 48.8 132 84.1

Fever- Before 5 days 16 37.2 25 15.9

Fever- on or after 5 6 14.0 0 0.00 0.001*

days

Mean duration of 4.0435 1.988 2.8077 0.6939 0.005*

fever in days

Total(200) 43 100 157 100

*significant

36
 Results And Observations

More women had genito-urinary infection in group A compared to group B (11.6% versus
4.5%). But the difference was statistically non significant (p value 0.084) (Table 20).

Table 20: Association of SSI with genito-urinary tract infection

Genito-urinary Group A Group B p value

infection n % n %
Absent 38 88.4 148 93.9
Present 5 11.6 7 4.5 0.084*
Total(200) 43 100 157 100
* Non significant

Number of women with SSI or group A had significantly more hospital stay (p value 0.001).
Mean duration post op stay in ward was 7.3255.48 days in group A compared to
4.8851.377 days in group B (Table 21).

Table 21: Association of SSI with postoperative stay

post-operative stay days Group A Group B p value

n % n %
5 days 23 53.5 122 77.7
6-10 days 15 53.9 35 22.3 0.001*
>10 days 5 11.6 0 0
Mean duration of stay days 7.3255.48 4.8851.377 0.001*
Total(n=200) 43 100 157 100
*significant

Infections (other than genito-urinary tract infections) were significantly found in more
number of women in SSI group compared to control group (p value 0.001) (Table22). These
infections include respiratory infections, skin infections, viral infection, and mastitis.

Table 22: Association of SSI with other infections

Other infections Group A Group B p value

n % n %
Absent 25 58.1 136 86.62
Present 18 41.9 21 13.38 0.001*
Total(200) 43 100 157 100
*significant

37
 Results And Observations

About 46.5% patients among patients having SSI needed readmission whereas no women
needed readmission in the control group. Readmission was done in all women for SSI. No
women in control group required readmission. Hence SSI increases the need for post op
hospital readmission significantly (p value 0.01) (Table 23). In SSI group 11 women
continued to stay after 8 days after stitch removal because of SSI.

Table 23: Readmission in both groups

Readmission Group A Group B P value

n % n %

Readmission done 20 46.5 0 0

Readmission not done 23 63.5 157 100 0.01*

Total(200) 43 100 157 100

* Significant

Most of the women had superficial SSI involving skin and subcutaneous tissue as defined by
CDC. Only 4 women had deep SSI involving fascia/ rectus sheath and only 1 woman had
organ space infection having pyoperitoneum (Table 24).

Table 24: Types of SSI

Types of SSI Group A

n %

Superficial 38 88.4

Deep 4 9.3

Organ space 1 2.3

Total 43 100

38
 Results And Observations

Figure 6: Type of SSI

SSI Type
2.3%
9.3%

Deep

88.4% superficial organ space

Superficial

Most of SSI was detected between 5-15 days. Only 2 women had SSI after 15 days (Table
25).

Table 25: Time period for detection of SSI

SSI detected in (days) Group A

n %

Within 5 days 2 4.65

5-15 days 39 90.7

After 15 days 2 4.65

Mean in days 9.523.51

Total 43 100

39
 Results And Observations

Eleven women with SSI had sterile cultures. Staphylococcus aureus was the commonest
organism grown. Three women were found to have more than one organism in the cultures
and in one women culture report was obtained contaminated (Table 26).

Table 26: Micro-organism cultured

Organism cultured Number=n %
sterile 11 25.6
Staph aureus 8 18.6
Acinetobacter 6 14.0
Ecoli 3 7.0
Enterococcus 3 7.0
Klebsiella 3 7.0
Staph aureus+ Acinetobacter 1 2.3
Klebsiella + E coli 1 2.3
Pseudomonas + Acinetobacter 1 2.3
Candida 1 2,3
Contaminated 1 2,3
NA 4 9.3
Total 43 100.0

Figure 7: Micro-organisms from wound culture

Wound culture
acinetobacter

candida

2.3% Staph
coag negaureus
staph aureus
14%
25.6%
coag neg
staph staph+ acinetobacter
aureus
aureus+acinatobacter
18.6% contaminated growth
2.3%
9.3% Ecoli

enterococcus
7% 7%
7% klebsiella
2.3%
2.3% klebsiella+e coli
2.3%

40
 Results And Observations

Twenty eight women were treated conservatively with antibiotics and dressings. Fifteen
women required resuturing. Women undergoing resuturing were having deep SSI (n=4) and
also superficial SSI (n=11). The woman who had organ space infection was treated with
laparotomy and higher antibiotics. (Table 27)

Table 27: Treatment provided to patients with SSI

Treatment Group A

n %

Conservative 28 65.1

Resuturing 14 32.5

Laprotomy 1 0.3

Total 43 100

Figure 8: Management in women with SSI: Conservative/resuturing

Management of SSI

35%

Conservative
65%
Resuturing

41
 Results And Observations

Independent risk factors for SSI

The significant risk factors associated with SSI in our study were BMI, duration of PROM,
number of PV examinations, post operative fever, post operative stay in ward, other
infections and post operative anaemia (p value 0.001, 0.001, 0.003, 0.001, 0.001, 0.001, 0.035
respectively). These were subjected to multivariate logistic regression to know the association
of independent factors associated with SSI. It was seen that anaemia was an independent risk
factor for SSI with odds ratio of 2.395 (Table 28).

Table 28: Adjusted odds ratios (with various significant parameters in univariate analysis)

Risk factor Case Control Unadjusted Adjusted OR p value

OR (95%CI) (95%CI)

BMI mean 25.06 9 5.086 22.796 2.811 0.842 0.854 0.001

PROM 21.55515.786 7.0786.915 0.936 0.938 0.001

duration
mean

No. of PV 5.1392.605 3.9802.023 0.791 0.782 0.003

examinations

Postoperative 4.0435 1.988 2.8077 0.69 0.725 0.629 0.001

fever mean
days

Post 7.3255.48 4.8851.377 1 0.547 0.001

operative
stay in ward

Other 18/43 21/147 0.214 0.232 0.001

infections

Post 17/43 37/157 0.472 2.395 0.035

operative
anaemia

42