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Am J Perinatol
DOI: 10.1055/a-2620-7831
Original Article

Surgical Bundle to Reduce Infectious Morbidity after Cesarean Delivery in Individuals with Morbid Obesity

Martina Benuzzi 
1   EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
2   Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
,
Misa Hayasaka
1   EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Alyssa Savelli 
1   EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
George Saade
1   EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Emily Peters
1   EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
,
Tetsuya Kawakita 
1   EVMS Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
› Author Affiliations
Funding This study was supported by the Eastern Virginia Medical School Junior Clinical Investigator Program (grant no.: VHS 241231).
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Abstract

Objective

This study aimed to evaluate whether the implementation of a surgical bundle reduces surgical site infections (SSI), hospital readmission rates, and emergency department (ED) visits within 6 weeks in individuals with a body mass index (BMI) of 40 kg/m2 or greater after cesarean delivery.

Study Design

This was a retrospective study including individuals with morbid obesity undergoing cesarean delivery at 23 weeks of gestation or greater. The preintervention period spanned from January 2017 to December 2020. The postintervention period extended from January 2021 to April 2023. The surgical bundle included standard preprocedure prophylactic antibiotics and a 48-hour course of oral cephalexin and metronidazole. The primary outcome was SSIs while secondary outcomes included hospital readmission or ED visits within 6 weeks postpartum or wound complications (dehiscence, seroma, or hematoma). Adjusted relative risks (aRR) with 95% confidence intervals (95% CI) were calculated using modified Poisson regression, adjusting for potential confounders.

Results

Of 2,105 pregnancies, 1,308 (62.1%) underwent cesarean in the preintervention period and 797 (37.9%) in the postintervention period. Compared to the preintervention period, the postintervention period had increased use of azithromycin (30.6 vs. 35.9%; p = 0.012), cephalexin (1.8 vs. 52.8%; p < 0.001), and metronidazole (3.1 vs. 60.4%; p < 0.001). However, compared to the preintervention period, the postintervention period had a similar risk of SSIs (6.6 vs. 5.9%; aRR: 0.92; 95% CI: 0.66–1.28), readmission or ED visits (19.8 vs. 19.8%; aRR: 0.94; 95% CI: 0.80–1.11), and wound complications (4.7 vs. 6.4%; aRR: 1.37; 95% CI: 0.96–1.96). In individuals with labor or ruptured membranes, the postintervention period had increased use of azithromycin (74.9 vs. 82.3%; p = 0.022), cephalexin (2.5 vs. 56.1%; p < 0.001), and metronidazole (4.3 vs. 63.8%; p < 0.001). In this subgroup, outcomes remained insignificant.

Conclusion

A morbid obesity surgical bundle increased antibiotic use but did not reduce SSIs, hospital readmission, ED department visits, and wound complications.

Key Points

  • A surgical bundle for individuals with morbid obesity increased the use of postoperative antibiotics.

  • The surgical bundle did not significantly reduce SSIs.

  • The surgical bundle did not significantly reduce hospital readmissions and ED visits.

Keywords

surgical bundle - morbid obesity - infection - readmission - emergency department

Note

This paper was presented at the 45th annual meeting—the pregnancy meeting of the Society for Maternal–Fetal Medicine, from January 27 to February 1, 2025.


Supplementary Material



Publication History

Received: 30 April 2025

Accepted: 23 May 2025

Accepted Manuscript online:
26 May 2025

Article published online:
10 June 2025

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