What is the recommended protocol for daily cleansing of the abdomen with chlorhexidine (CHG) prior to cesarean section?

Chlorhexidine Abdominal Cleansing Protocol for Cesarean Delivery

Chlorhexidine-alcohol is the preferred solution for abdominal skin cleansing before cesarean delivery, and should be applied immediately before the procedure rather than as a daily cleansing regimen in the days leading up to surgery. 1

Evidence-Based Recommendations for Skin Preparation

Immediate Pre-Operative Preparation (High Priority)

• Chlorhexidine-alcohol should be used for abdominal skin cleansing immediately before cesarean delivery 1
• This recommendation has high-quality evidence with a strong recommendation grade according to the Enhanced Recovery After Surgery (ERAS) Society guidelines 1
• The application should occur in the operating room as part of the surgical preparation protocol

Daily Pre-Operative Cleansing (Not Recommended)

• Daily application of chlorhexidine gluconate cloths in the days before scheduled cesarean delivery is not effective in reducing surgical site infections 2
• A randomized clinical trial showed no difference in surgical site infection rates by 6 weeks postoperatively between patients using 2% chlorhexidine cloths versus placebo cloths (2.6% vs 3.7%, P=0.24) 2

Comprehensive Infection Prevention Protocol

Additional Recommended Measures

1. Antibiotic Prophylaxis:

   • Administer intravenous antibiotics within 60 minutes before skin incision 1, 3
   • First-generation cephalosporin for all women 1, 3
   • Add azithromycin for women in labor or with ruptured membranes 1, 3

2. Vaginal Preparation:

   • Consider vaginal preparation with povidone-iodine solution 1, 3
   • Some evidence suggests chlorhexidine vaginal preparation may reduce endometritis rates 4, 5
   • A study showed endometritis was significantly reduced from 27.6% to 6.6% with chlorhexidine vaginal preparation 4

Implementation Considerations

• Focus on the immediate pre-operative application rather than daily cleansing regimens
• Ensure proper application technique covering the entire surgical site
• Follow manufacturer's instructions for contact time before incision

Pitfalls and Caveats

• Daily pre-operative chlorhexidine application does not provide additional benefit beyond standard immediate pre-operative preparation 2
• Even with proper skin preparation, other factors like surgical technique and antibiotic prophylaxis remain critical for infection prevention 1
• Combination approaches using both abdominal and vaginal chlorhexidine preparation have not shown significant benefit in reducing surgical site infections in some studies 6
• Be aware of potential allergic reactions to chlorhexidine, though these are rare

Conclusion

For optimal infection prevention in cesarean delivery, chlorhexidine-alcohol should be used for immediate pre-operative abdominal skin preparation rather than as a daily cleansing regimen. This should be combined with appropriate antibiotic prophylaxis and consideration of vaginal preparation to minimize post-cesarean infectious complications.