Identification and management of women at high risk for pelvic infection following cesarean section

Women undergoing cesarean section for cephalopelvic disproportion 6 or more hours after rupture of the membranes have been identified to be at inordinately high risk for puerperal infection. In the present study, 337 such women were assigned randomly to 2 treatment groups. One group was given antimicrobials beginning preoperatively and continuing for 4 days (early treatment); the second group was given treatment only if infection was apparent during the puerperium (standard treatment). The efficacy of cefamandole was compared to that of penicillin plus gentamicin for women in both groups. Of 209 women assigned to the early treatment group, 25 (12%) developed pelvic infection. Although 12 of these women developed a parametrial phlegmon, this represented only 6% of all women. Only 3 (1%) women receiving early treatment developed a wound abscess. In contrast, of 128 women not given antimicrobials preoperatively, 109 (86%) developed pelvic infection. Moreover, 24 (19%) developed a phlegmon; 14(12%) developed an incisional abscess and one third of these had fascial disruption. When the results of early and standard treatment were compared midway through the study, standard treatment was abandoned. We conclude that identification of the high-risk patient plus timely treatment results in a highly significant reduction in pelvic infections following cesarean section. Cefamandole or penicillin in combination with gentamicin was equally effective as an early treatment regimen. More important, the incidence of associated severe complications was significantly less in women given early treatment.