Demographic profile, unplanned status and intraoperative situations increase surgical site infection in cesarean delivery: conclusions from a prospective study in central India

Abstract

Background

Surgical site infection continues to be a significant source of morbidity and mortality especially in developing countries. Data pertaining to incidence and risk factors following obstetric surgeries are scarce. This study aims to identify risk factors and microbiological etiology of SSI in patients undergoing cesarean section in a teaching tertiary care hospital in Central India.

Methods

450 in-patient women who underwent cesarean for various indications were enrolled for the study and followed up for 30 days. Patients who reported between July 2022 to June 2023 were included in study and analyzed as per CDC definition and methodology. Incidence, risk factors like rural location, patients who are referred, duration of rupture of membrane, timing of prophylactic antibiotic, duration of surgery and microbiological etiology for SSI were noted from data collected.

Results

The incidence of SSI is 13.7%. Rural location (OR 2.08), low socioeconomic status (OR 3.1), multiparity (OR 3.0), obesity (OR 4.05), emergency status (OR 4.63), increased duration of rupture of membrane (OR 8.3), prolonged labor (OR 11.7) and increased preoperative stay (OR 4.24) due to associated morbidities are the risk factors for SSI identified by univariate logistic regression model. Increase in each hour duration of surgery and inappropriate timing of antibiotic prophylaxis increased the risk of SSI by nearly double.

Conclusion

Rate of SSI in cesarean is 13.7%. Low socioeconomic status, rural locations, emergency status of surgery, long intra-operative period and time of prophylactic antibiotic are major risk factors for SSI in cesarean delivery.

Clinical trial

Not Applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-025-11217-6.

Background

Surgical site infection (SSI) represents a prevalent form of healthcare associated infections (HAI). SSI account for significant morbidity, increased healthcare costs, and prolonged hospital stays of affected patients [1]. The onset of SSI typically hinges upon the interaction of four primary factors: bacterial inoculums, bacterial virulence, micro-environment of the surgical site, and host defense.

Cesarean section (CS) is a critical surgical intervention that saves the lives of both the mother and the child. It has its own place in emergency obstetrics. However, CS itself is not without risk. Complications after CS are hemorrhage, amniotic fluid embolism, accidental injury to bladder and bowel and anesthetic adverse conditions. SSI with wound gaping or burst abdomen is one of important complications. In this study we are mainly addressing SSI as it is a major delayed hazard of cesarean delivery.

SSI following cesarean delivery can result in complications such as wound dehiscence, endometritis and sepsis, contributing to a high rate of maternal morbidity and, in severe cases mortality [2]. Incidence of SSI following CS depends on many risk factors such as maternal age, hypertensive disorders, prolonged labor, premature rupture of membrane, time of cesarean section and pre-existing maternal comorbidities [3, 4]. Rates of SSI after cesarean section vary approximately between 6 and 27.2% worldwide, with lower rates observed in high-income countries and substantially higher rates reported in low-middle-income countries (LMIC) [5, 6]. This variance can be attributed to differences in infection prevention protocols, healthcare infrastructure, and resource availability [7]. The occurrence of SSI not only extends the duration of hospitalization but also escalates associated healthcare costs.

In numerous instances of SSI, the causative pathogens stem from the patient’s endogenous microbiota. Staphylococcus aureus stands out as a commonly isolated organism in SSI, constituting approximately 15–20% of hospital-acquired cases. Its prevalence poses significant challenges in treatment due to its resistance to multiple antibiotics [8, 9]. This study addresses this critical issue in the context of cesarean delivery whose rising rates are of immense concern.

We aim to identify the risk factors and microbiological etiology of SSI. As there are few reports on this theme from settings in Teaching Hospitals in Central India, relevance of study is high. Socio-economic background here is peculiar pertaining to literacy, attitude, callous behavior towards parturient, money saving mindset and poor communication and transport facilities; and is the mainstay behind unsatisfactory outcomes of cesarean delivery. Use of ANC checkup services are only 55.6%, use of Iron and Folic acid are only 30.3%, BMI is less than 18.5 in 25% women as per a National survey in India [10]. These are indirect etiological causes of SSI in cesarean delivery in India. By identifying modifiable risk factors this study will contribute to reduce morbidity and healthcare costs associated with SSI.

Materials and methods

This prospective observational study was conducted on 450 women at the Department of Obstetrics and Gynecology and includes CS procedures performed in tertiary care teaching hospital situated in a rural area of Central India. The study was conducted from July 2022 to June 2023 (12 months). This teaching Medical College and tertiary care hospital within the private, not-for-profit health care sector serves the rural population of nearby areas. (Total population of this district is 19.8 lac out of which 12 lac rural and 7.8 lac urban population contribution). This is the only tertiary care centre in this area.

According to the Center for Disease Control and Prevention (CDC), SSI are defined as infections occurring within 30 days post-surgery at the surgical site, and they can manifest as superficial, deep incisional, or organ/space infections. Inclusion criteria consists all patients who underwent CS in study duration and gave written consent. Each woman was explained that we are observing her wound periodically for development of any signs of infection. She was also appraised that these observations are part of our routine post operative management protocols. Exclusion criteria comprises patients who refused for being a part of the study, not willing to give written informed consent and who were lost to follow-up. 450 patients in the age range of 18 to 40 years, satisfying inclusion criteria were enrolled (Flow chart– Fig. 1). The surgical wound was examined during the initial check dressing on the fifth post-operative day or on the day of discharge. Subsequently, all patients were monitored in the postnatal clinic on an outpatient basis until the 30th day following the surgery. After satisfactorily treating SSI by standard protocols i.e. two antibiotics, anti-inflammatory drugs and vitamin B complex; patient was discharged from hospital. Criteria to be satisfied for making patient fit for discharge was signs like no redness, no swelling, no discharge from wound and no gaping. Each woman was reviewed every week for signs of SSI as mentioned before to declare no recurrence or complete cure. If the woman did not report after one week of discharge, she was given a telephonic call. Four to five women did not report in spite of call and in this situation a paramedical worker was sent to the house of woman. This was possible because our van is going daily to villages under “Vital statistics programme”. The questionnaire was closed after being satisfied. Discharge from wound site, pain or tenderness, localized swelling and induration, redness (erythema) or heat around wound, seroma and hematoma were criteria to identify signs of SSI. Data was collected from all patients encompassing age, gestational age, obstetric history, demographic particulars, and various risk factors (occurrence of premature rupture of membranes, frequency of vaginal examinations, duration of surgery) through a comprehensive questionnaire created following a review of the literature to determine SSI risk factors and following consultation with local expert’s group of consultants. Face validity of data collection form was checked on 20 patients, these patients were not included in final study.

Fig. 1.

Recruitment of study subjects (July 2022-Jume 2023) for 450 women who underwent cesarean

All the collected information was filled in a proforma and findings were tabulated in Microsoft excel Worksheet and computer-based analysis was performed using the SPSS (Statistical product and service solutions) software. In the present pregnancy details of patient as age, residential location, socioeconomic class, body mass index, antenatal visits, parity, previous cesarean section, preterm delivery, ante partum hemorrhage, or pregnancy induced hypertension, severe anemia and other significant illness were noted. Hemoglobin 7gm% or less than 7gm% was considered severe anemia. Those patients who had attended antenatal clinic at least thrice before delivery were considered booked cases. Pus samples were collected from surgical wound sites using sterile cotton swabs. The sample was sent to a microbiological laboratory for culture, sensitivity testing and identification of microorganisms. The laboratory used standard procedures including disc diffusion to test antibiotic susceptibility. The results helped determine the effectiveness of antibiotic treatment.

Statistical analysis

Statistical analysis was done by statistical software SPSS version-23.0. All categorical variables were represented by frequency and percentage. Chi-square test was used to compare two groups in one category. Univariate logistic regression was used to calculate odds ratio and confidence interval for indicating association between dependent variable SSI and independent variables (demographic variables, emergency status of surgery, intra operative period, prophylactic antibiotic, obstetric co-morbidity and other intra partum features). P value less than 0.05 was considered as significant.

Ethical consideration

The Institutional Ethics Committee of R.D. Gardi Medical College approved the study (Approval No. PG/Obstetrics and Gynaecology/37/2021). A written informed consent was obtained from all participants in local language; Hindi, after explaining purpose of the study and study procedure orally and textually in Hindi. The participants could withdraw from study at any point. The study was carried out according to ethical principles outlined in the Declaration of Helsinki.

Result

Total 450 women participated in study, in which 62 women had SSI, 13.7% rate of SSI. The study variables were age, socioeconomic status, demographic location, BMI, antenatal visits, parity, gestational age, type and indication of CS, associated co-morbidities (anemia, diabetes), duration of labor and rupture of membrane, number of vaginal examinations, timing of prophylactic antibiotics, type of incision, type and time of onset of SSI and various pathogens.

In the univariate analysis of demographic characteristics (Table 1), certain variables were significantly associated with the occurrence of surgical site infections (SSI) following cesarean delivery. Patients from rural areas were significantly more likely to develop SSI compared to those from urban areas (16.7% vs. 8.6%; OR: 2.08, 95% CI: 1.11–3.92; p = 0.022). Similarly, socioeconomic status (SES) was an important determinant, with patients from lower SES backgrounds having a higher risk of SSI compared to those from middle SES (18.6% vs. 8.8%; OR: 3.11, 95% CI: 1.07–9.03; p = 0.003). Parity showed a notable association, particularly among women with three previous pregnancies (Gravida 4), who were at significantly higher risk of infection compared to primigravida women (25.5% vs. 10.7%; OR: 3.00, 95% CI: 1.38–6.51; p = 0.009). Body Mass Index (BMI) was also associated with SSI risk. Women with a BMI between 25 and 29.9 (overweight) were more likely to develop SSI than those with a normal BMI (25.7% vs. 8.2%; OR: 4.05, 95% CI: 2.26–7.28; p < 0.001).No statistically significant associations were observed for age group (< 25 vs. >25 years), antenatal visit status (booked vs. referral), or for other BMI categories (< 18.5 and > 30). SES category “upper,” as well as parity levels Gravida 2 and 3, also did not show significant associations.

Table 1.

Univariate analysis of demographic characteristics in patients undergoing Cesarean delivery (n = 450), with and without surgical site infection (SSI)

Categorical Variable	Total n = 450 (%)	SSI n = 62 (%)	Non-SSI n = 388 (%)	OR	95% CI	p-value
Age Group
< 25 years	240(100.0%)	34 (14.2%)	206 (85.8%)	R	R	-
> 25 years	210 (100.0%)	28 (13.3%)	182 (86.7%)	0.86	0.50–1.48	0.596
Location
Urban	163 (100.0%)	14 (8.6%)	149 (91.4%)	R	R	-
Rural	287 (100.0%)	48 (16.7%)	239 (83.3%)	2.08	1.11–3.92	0.022
Socioeconomic Status (SES)
Middle	148(100.0%)	13 (8.8%)	135 (91.2%)	R	R	-
Lower	242(100.0%)	45 (18.6%)	197 (81.4%)	3.11	1.07–9.03	0.003
Upper	60(100.0%)	4 (6.7%)	56 (93.3%)	1.35	0.42–4.31	0.783
Parity
Gravida 1	205(100.0%)	22 (10.7%)	183 (89.3%)	R	R	-
Gravida 2	107(100.0%)	12 (11.2%)	95 (88.8%)	1.11	0.52–2.35	0.847
Gravida 3	87(100.0%)	15 (17.2%)	72 (82.8%)	1.83	0.89–3.74	0.119
Gravida 4	51(100.0%)	13 (25.5%)	38 (74.5%)	3	1.38–6.51	0.009
BMI Group
18.5–24.9	267(100.0%)	22 (8.2%)	245 (91.8%)	R	R	-
< 18.5	26(100.0%)	2 (7.7%)	24 (92.3%)	0.98	0.22–4.42	1
25–29.9	140(100.0%)	36 (25.7%)	104 (74.3%)	4.05	2.26–7.28	< 0.001
> 30	17(100.0%)	2 (11.8%)	15 (88.2%)	1.56	0.33–7.29	0.637
Antenatal Visit
Booked	123 (100.0%)	13 (10.6%)	110 (89.4%)	R	R	-
Referral	327(100.0%)	49 (15.0%)	278 (85.0%)	1.63	0.84–3.18	0.166

Note: Values represent row-wise percentages. Statistically significant variables with p < 0.05 are indicated. “R” denotes the reference category for odds ratio (OR) calculations

Univariate analysis of obstetric risk factors (Table 2) identified several significant associations with surgical site infection (SSI) following cesarean delivery. Among fetal and labor-related variables, malpresentation was significantly associated with decreased risk of SSI compared to normal fetal presentation (11.1% vs. 14.1%; OR: 3.42, 95% CI: 1.06–11.02; p = 0.039). Similarly, obstructed labor showed a borderline significant association with SSI (17.2% vs. 13.5%; OR: 1.56, 95% CI: 0.52–4.68; p = 0.043), although the wide confidence interval suggests caution in interpretation. The presence of anemia was a strong predictor of SSI, with affected patients showing a substantially higher risk (20.9% vs. 10.8%; OR: 15.3, 95% CI: 8.19–28.59; p < 0.001). Likewise, patients with hypertension (HTN) (18.6% vs. 12.4%; OR: 26.2, 95% CI: 10.81–63.47; p < 0.001) and diabetes mellitus (DM) (14.3% vs. 13.8%; OR: 22.34, 95% CI: 5.17–96.48; p < 0.001) had significantly increased odds of developing SSI. The absence of Medical comorbid conditions was associated with a significantly lower risk of SSI. Patients with no comorbidities had an 18.8% infection rate compared to 6.1% in those with comorbidities (OR: 2.35, 95% CI: 1.31–4.23; p = 0.004), indicating a protective effect. Other obstetric factors such as gestational age, fetal distress, non-progress of labor, cephalopelvic disproportion, previous cesarean section, antepartum hemorrhage, immunodeficiency, and chronic illness did not show statistically significant associations with SSI in this cohort.

Table 2.

Univariate analysis of obstetric risk factors in patients undergoing Cesarean delivery (n = 450), with and without surgical site infection (SSI)

Categorical Variable	Total (n)	SSI (Row %)	Non-SSI (Row %)	OR	95% CI	p-value
Gestational Age Group
37–40 weeks	280(100.0%)	42 (15.0%)	238 (85.0%)	R	R	-
< 37 weeks	121(100.0%)	15 (12.4%)	106 (87.6%)	0.75	0.39–1.43	0.378
> 40 weeks	49(100.0%)	5 (10.2%)	44 (89.8%)	0.66	0.23–1.85	0.435
Fetal Distress (FD)
No	352(100.0%)	49 (13.9%)	303 (86.1%)	R	R	-
Yes	98(100.0%)	13 (13.3%)	85 (86.7%)	1.83	0.84–3.98	0.123
Non-Progress of Labor (NPOL)
No	381(100.0%)	51 (13.4%)	330 (86.6%)	R	R	-
Yes	69(100.0%)	11 (15.9%)	58 (84.1%)	1.52	0.69–3.34	0.296
Cephalopelvic Disproportion (CPD)
No	427(100.0%)	60 (14.0%)	367 (86.0%)	R	R	-
Yes	23(100.0%)	2 (8.7%)	21 (91.3%)	0.94	0.19–4.64	0.942
Malpresentation
No	396(100.0%)	56 (14.1%)	340 (85.9%)	R	R	-
Yes	54(100.0%)	6 (11.1%)	48 (88.9%)	3.42	1.06–11.02	0.039
Previous Cesarean
No	329(100.0%)	45 (13.7%)	284 (86.3%)	R	R	-
Yes	121(100.0%)	17 (14.0%)	104 (86.0%)	1.05	0.59–1.86	0.871
Antepartum Hemorrhage (APH)
No	394(100.0%)	54 (13.7%)	340 (86.3%)	R	R	-
Yes	56(100.0%)	8 (14.3%)	48 (85.7%)	1.07	0.46–2.48	0.873
Obstructed Labor
No	421(100.0%)	57 (13.5%)	364 (86.5%)	R	R	-
Yes	29(100.0%)	5 (17.2%)	24 (82.8%)	1.56	0.52–4.68	0.043
Anemia
No	316(100.0%)	34 (10.8%)	282 (89.2%)	R	R	-
Yes	134(100.0%)	28 (20.9%)	106 (79.1%)	15.3	8.19–28.59	< 0.001
Hypertension (HTN)
No	348(100.0%)	43 (12.4%)	305 (87.6%)	R	R	-
Yes	102(100.0%)	19 (18.6%)	83 (81.4%)	26.2	10.81–63.47	< 0.001
Diabetes Mellitus (DM)
No	429(100.0%)	59 (13.8%)	370 (86.2%)	R	R	-
Yes	21(100.0%)	3 (14.3%)	18 (85.7%)	22.34	5.17–96.48	< 0.001
Immunodeficiency
No	441(100.0%)	61 (13.8%)	380 (86.2%)	R	R	-
Yes	9(100.0%)	1 (11.1%)	8 (88.9%)	7.53	0.69–82.45	0.098
Chronic Illness
No	445(100.0%)	62 (13.9%)	383 (86.1%)	R	R	-
Yes	5(100.0%)	0 (0.0%)	5 (100%)	6.11	0.69–53.98	0.102
Medical co-morbidities
No	271(100.0%)	51 (18.8%)	220 (81.2%)	R	R	-
Yes	179(100.0%)	11 (6.1%)	168 (93.9%)	2.35	1.31–4.23	0.004

Note: Values represent row-wise percentages. Statistically significant variables with p < 0.05 are indicated. “R” denotes the reference category for odds ratio (OR) calculations

Table 3 presents the univariate analysis of clinical and procedural risk factors associated with surgical site infection (SSI) among cesarean delivery patients. Emergency cesarean deliveries were significantly associated with a higher risk of SSI compared to elective procedures (16.6% vs. 4.0%; OR: 4.63, 95% CI: 1.61–13.29; p = 0.004). Similarly, a duration of premature rupture of membranes (PROM) > 12 h significantly increased the risk of SSI (25.8% vs. 7.7%; OR: 8.34, 95% CI: 4.19–16.63; p < 0.001), as did a labor duration > 12 h (25.6% vs. 7.0%; OR: 11.72, 95% CI: 5.79–23.74; p < 0.001).The timing of prophylactic antibiotics also influenced infection rates; patients who received antibiotics during surgery were at higher risk than those who received them preoperatively (20.7% vs. 10.3% OR: 0.48, 95% CI: 0.25–0.92; p = 0.002). A strong association was observed between frequent vaginal examinations (> 3) and SSI (36.6% vs. 5.2%; OR: 9.85, 95% CI: 4.91–19.74; p < 0.001), as well as prolonged anesthesia duration (> 1 h) (28.6% vs. 7.1%; OR: 5.47, 95% CI: 2.92–10.26; p < 0.001). Suggesting prolonged anesthesia poses more risk than short duration anesthesia. Use of natural suture material was associated with a significantly increased risk of SSI compared to synthetic material (25.7% vs. 7.9%; OR: 4.27, 95% CI: 2.24–8.13; p < 0.001). Additionally, a longer preoperative hospital stay (> 7 days) was significantly associated with higher infection risk. Patients hospitalized for 7–14 days had an OR of 4.24 (27.0%, 95% CI: 2.10–8.55; p < 0.001), and those hospitalized for > 14 days had an OR of 2.98 (20.0%, 95% CI: 1.15–7.72; p = 0.024), compared to those with shorter stays. No statistically significant associations were found for blood transfusion, type of incision, or vertical vs. transverse incision (p > 0.005).

Table 3.

Univariate analysis of clinical and procedural risk factors in patients undergoing Cesarean delivery (n = 450), with and without surgical site infection (SSI)

Categorical Variable	Total (n)	SSI (Row %)	Non-SSI (Row %)	OR	95% CI	p-value
Time of Cesarean
Elective	100(100.0%)	4 (4.0%)	96 (96.0%)	R	R	-
Emergency	350(100.0%)	58 (16.6%)	292 (83.4%)	4.63	1.61–13.29	0.004
Duration of PROM
< 12 h	299(100.0%)	23 (7.7%)	276 (92.3%)	R	R	-
> 12 h	151(100.0%)	39 (25.8%)	112 (74.2%)	8.34	4.19–16.63	< 0.001
No. of Vaginal Exams
< 3	327(100.0%)	17 (5.2%)	310 (94.8%)	R	R	-
> 3	123(100.0%)	45 (36.6%)	78 (63.4%)	9.85	4.91–19.74	< 0.001
Duration of Labor
< 12 h	286(100.0%)	20 (7.0%)	266 (93.0%)	R	R	-
> 12 h	164(100.0%)	42 (25.6%)	122 (74.4%)	11.72	5.79–23.74	< 0.001
Pre-op Stay Duration
1–7 Days	290(100.0%)	22 (7.6%)	268 (92.4%)	R	R	-
7–14 Days	115(100.0%)	31 (27.0%)	84 (73.0%)	4.24	2.10–8.55	< 0.001
> 14 Days	45(100.0%)	9 (20.0%)	36 (80.0%)	2.98	1.15–7.72	0.024
Duration of Anesthesia
< 1 h	310(100.0%)	22 (7.1%)	288 (92.9%)	R	R	-
> 1 h	140(100.0%)	40 (28.6%)	100 (71.4%)	5.47	2.92–10.26	< 0.001
Prophylactic Antibiotics Timing
Half hour prior	300(100.0%)	31 (10.3%)	269 (89.7%)	R	R	-
During surgery	150(100.0%)	31 (20.7%)	119 (79.3%)	0.48	0.25–0.92	0.002
Blood Transfusion
Not received	339(100.0%)	43 (12.7%)	296 (87.3%)	R	R	-
Received	111(100.0%)	19 (17.1%)	92 (82.9%)	1.33	0.72–2.45	0.357
Type of Incision
Transverse	423(100.0%)	54 (12.8%)	369 (87.2%)	R	R	-
Vertical	27(100.0%)	8 (29.6%)	19 (70.4%)	2.4	0.92–6.27	0.072
Suture Material
Synthetic	302(100.0%)	24 (7.9%)	278 (92.1%)	R	R	-
Natural	148(100.0%)	38 (25.7%)	110 (74.3%)	4.27	2.24–8.13	< 0.001

Note: Values represent row-wise percentages. Statistically significant variables with p < 0.05 are indicated. “R” denotes the reference category for odds ratio (OR) calculations

Discussion

World Health Organization declares that in developing countries SSI is most frequently reported type of hospital associated infection with a pooled incidence of 11.8 episodes of SSI per 100 surgical procedures [11]. The complications arising from a cesarean procedure not only pose risk to the mother and baby but also lead to increased healthcare costs. SSI significantly contributes to increased maternal mortality and morbidity, reduced patient satisfaction, prolonged hospital stays, and elevated treatment costs [12]. SSIs are the second most common complication after urinary tract infections as HAI in cesarean delivery with reported rates between 3 and 15% in United States of America (USA).

In this study incidence is notably higher compared to previous Indian studies. For instance, findings with incidence of 4.1% and 7.84% reported in Kerala (2016) and Madhya Pradesh (2017) are lower than our result of 11.8% [2, 13]. Kerala is a highly literate state. The literacy level has impact on lower rates of SSI. Previous reports on SSI rates in Ujjain are lower than the present findings, indicating declining standards of socio economic and procedural factors. Also the referral rate has increased due to JSY (Janani Suraksha Yojna) policy of Institutional births. Major contributors of SSI are those women who are referred from other center and who have not primarily visited this medical facility. The development of SSI is multi-factorial and various risk factors have been found to predict post cesarean SSI.

In this study age does not show a significant impact on SSI, the majority of women who developed SSI were aged below 25 years (Table 1). This distribution aligns with the general age range of pregnant women. These findings are consistent with previous studies, which reported that 92% of infections occurred in women under 30 years of age [13], while some authors report rate of SSI in women aged more than 35 [14].

The present study found that the majority of women developed SSI were from rural areas. A significant portion of the participants belonged to the lower SES group. These findings are consistent with the previous studies, which reported majority of participants being from rural areas and low SES [13, 15] (Table 1). A systematic review in 2024 of literature in Ethiopia has reported a strong co-relation between occurrence of SSI and rural location of women [16].

Parity also affects SSI risk. Compared to first-time mothers (gravid 1), second-time mothers (gravida 2) have almost no difference in risk. Third-time mothers (gravida 3) show a slight increase in risk. However, women with four or more pregnancies (gravida 4) have three times higher risk. Our findings are also consistent to a previous study which suggests that with increasing parity, the risk for developing SSI increases by nearly more than 3 times. These findings were compared to some other previous studies which observed that first-time mothers who underwent primary cesarean had a significant association with developing SSI [4] (Table 1).

Maternal BMI was a significant contributing factor in the development of SSI. Similar findings are quoted in other studies which demonstrated a linear relationship between high maternal BMI and occurrence of SSI [2, 17, 18]. In our study 38.7% of the women had a BMI of less than 24.9, while 61.2% had a BMI of 25 or higher. This distribution indicates that approximately half of the study population had a higher BMI. Women with a BMI greater than 25 (obese) had high incidence of SSI (p = < 0.001). As women having BMI more than 30 had SSI rate of 11.8% which is peculiar and is less than finding of 25.7% SSI rate in obese (BMI 25-29.9) women. We too found this result odd.

Of the total SSI analyzed, a substantial majority 93.5% underwent emergency cesarean section, while only 6.4% had elective cesarean section (Table 3). This distribution aligns with findings from other studies [19, 20]. The predominance of emergency procedures could be attributed to factors such as unplanned surgical intervention and associated risk factors, including prolonged rupture of membrane, multiple vaginal examinations, and extended labor duration increasing the risk of SSI. Similar findings are also reported in other study [20].

In this study, the distribution of co-morbidities among women who underwent CS reveals that the majority did not have any co-morbid conditions. However, some proportion of women did present with various co-morbidities. Patients with anemia are more susceptible to SSI. Anemia weakens resistance to infection and is often linked with puerperal sepsis. In the current study, 32.47% of the patients had anemia, consistent with previously reported study’s findings [15, 21]. Additionally, poor glucose control during surgery and the perioperative period increases infection risk and worsens sepsis outcomes, aligning with the results of previous study [3]. This is further supported by another previous study where women with diabetes mellitus were more likely to develop post-operative SSI than non-diabetic women [17]. Hypertensive disorders were observed in 26.80% of the women in our study, correlating with the incidence reported by previous study [15, 18]. Conversely, a study in Cuba identified anemia as the primary co-morbidity followed by obesity and hypertension [20] (Table 2).

In this study out of all SSI, 20.9% were booked cases, while majority 79.03%, were referrals. This finding is consistent with a previous recent study where the majority of cases were unbooked [13, 20]. Additionally, antenatal care offers crucial opportunities for health education and the early detection and management of maternal issues [13] (Table 1).

Frequent vaginal examinations exacerbate this risk by potentially introducing pathogens into the uterine environment. These factors were also prevalent in the present study. Notably, 62.9% (n = 39/62) of the cases had a duration of PROM exceeding 12 h. Similarly, prolonged labor lasting for more than 12 h was observed in 25.6% of the women studied. Prolonged rupture of membrane (PROM) exceeding eight hours, extended labor durations, and multiple per vaginal examinations (more than three) are well-documented risk factors for SSI, as reported in previous studies [18–22]. The loss of the protective cervical mucus plug and the barrier effect of fetal membranes and amniotic fluid after rupture of membrane are believed to contribute to the increased risk of infection. Similar findings are present in other previous studies which are comparable to results of our study [23] (Table 3).

The duration of preoperative hospital stay was significantly associated with SSI (p < 0.001). The risk of infection after cesarean section increased with the length of hospital stay. This is in agreement with another study [24]. The increased risk of SSI after CS can be attributed to several factors. Hospital spaces are often contaminated due to the presence of patients, attendants, and health professionals. Cross contamination can occur between patients, health professionals, equipment, the environment, and air. Moreover, patients with longer post-operative stays have more exposure to colonization and contamination with pathogenic microorganisms, potentially lowering the host’s resistance to infections. Consequently, these factors contribute to an elevated risk of SSI following CS (Table 3). An Indian study in 2024 also documents association of long hospital stay and SSI [25].

More than one hour duration of anesthesia was significantly associated with occurrence of SSI in this study (p < 0.001) (Table 3). Prolonged operating time leading to more exposure to microorganisms and increased chances of hypoxic injury has found to be associated with SSI. Duration of regional anesthesia which necessarily results in hypotension is a reciprocation of hypoxia. Many other studies are comparable to our findings of increased rate of SSI association with anesthesia duration of more than one hour [14,21 ]. Excellent surgical techniques with good tissue handling, adequate hemostasis while preserving tissue blood and oxygen supply, obliteration of dead spaces and standard post-operative wound care are associated with good tissue healing and less infection [26, 27] (Table 3).

Timing of antibiotic prophylaxis plays a crucial role in reducing SSI following cesarean delivery. While its administration time remains a topic of debate, it is universally recommended for all such procedures. Inappropriate timing of antibiotic prophylaxis was identified as a significant risk factor for SSI in our study. Our results show that antibiotic administration half hour prior to surgery is more effective in reducing SSI rates than antibiotic given during surgery (p = 0.002). Additionally, the risk of SSI has been linked to the volume of blood loss during cesarean section, with a 30% increase in infection risk for every 100 ml of blood loss. In this study 30.6% SSI patient received blood transfusion, while 12.6% did not receive transfusion during surgery. Our results show no co-relation of blood transfusion and SSI (Table 3) while some researchers have documented positive relationship of SSI and more blood transfusion [28]. The type of incision made in CS was transverse in 12.7% of women and vertical in 29.6% of cases, and do not have statistical co-relation with SSI, while few authors report more SSI in vertical incision [19].

In our study, Coagulase-negative Staphylococcus (CONS) was identified in majority of patients 35.4%, in which Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequent and dominant isolated microorganisms found in 72.7% out of all CONS. Klebsiella species accounted for 21.1% of isolates, while Escherichia coli (E. coli) was present in 17.7% of cases. A single patient (1.6%) had both E. coli and MRSA. Pseudomonas aeruginosa was identified in 5.5% of patients. 17.1% did not yield any microorganism. These findings are consistent with a study from Indonesia at Cipto Mangunkusumo Hospital and Kosovo [29]. Distribution of organisms is also consistent with a report from National Nasocomial Infections Surveillance Service (1997–2001), which mentions that Staphylococcus aureus (47%), including MRSA, and Staphylococcus epidermidis (CONS) were the most common organisms causing SSI [30]. A report from same setting also shows that S. aureus comprising 36% of isolates, followed by gram-negative rods including Klebsiella species 21.1% and E. coli 17.7% are responsible for SSI in CS. They also noted that 44% of S. aureus strains were resistant to penicillin [13]. The microbial etiology of post cesarean wound infection is diverse, as it is associated with vaginal, nasopharyngeal and skin micro-organisms.

The rate of 13.7% in CS in this setting is higher than a recent literature published in 2023. A systematic review and meta-analysis which analyzed 180 eligible studies have concluded a pooled global incidence of SSI in CS being 5.63%. Rate was highest for Africa, 11.91% and lowest for North America was 3.87%. They attribute it to low income and low human development index level [31].

A recent literature has documented negative economic impact, increased morbidity, extended postoperative hospital stay, readmission, sepsis, and death in colorectal surgery where the causative organisms are almost same due to anatomical location of vagina and rectum [32, 33]. Few authors have now also published results of an enzyme Butyrylcholinesterase levels as predictors of SSI [34].

Implications

In spite of all prophylactic precautions and preventive measures, rate of SSI is still on higher side. Major pre-operative factors highlight the need to improve preoperative management. Identifying anemia and hypertension as major predisposing risk factors suggest that better management of these conditions could reduce SSI rates. Considering SSI prevention guideline documents, available evidence, and our personal experience, we authors have categorized SSI prevention strategies into 3 categories. Best practices should be followed by all acute care hospitals. Additional intervention like prophylactic antibiotics along with strict aseptic practices will be rewarding. Controversial interventions like unnecessary per vaginal examination, prolonged hypotension and hypoxemia should be avoided. We strongly recommend to follow progress of labor by per abdominal examination and descent of presenting part. This will minimize number of per vaginal examinations. Anesthesiologist should take care to maintain optimum saturation percentage of oxygen (SpO2) and blood pressure during surgery. There are reports which recommend avoiding general anesthesia to reduce rate of SSI [35].

Limitations

As this study is single centered, generalization is not applicable. The limited sample size can affect statistical power of study. Broader conclusions and statistical associations are not possible with this sample size. As an observational study it might not establish causal relationship between risk factors and surgical site infection. Inaccuracy and recall bias is possible with self reported and medical history data. If the follow up study is short, late onset SSIs might not have been captured, resulting in under estimating infection rates. The number of hospitals attended by the patient before visiting us and the variable time of reporting to tertiary care hospital may be an important deciding factor for occurrence of SSI.

Conclusion

Our study showed rate of SSI in cesarean is 13.7% in Central India, which is comparable to other studies from same setting. Risk factors for SSI in cesarean delivery are low socioeconomic status, rural location and emergency status of surgery, long intra-operative period and timing of prophylactic antibiotic. There is a need for standardization of timing for prophylactic antibiotic. Duration of anesthesia in cesarean delivery may be reduced by appointing experienced consultants for patients having risk factors. This may help to reduce modifiable risk factors.

Electronic supplementary material

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Abbreviations

SSI

Surgical Site Infection

CS

Cesarean Section

LMIC

Low Middle Income Countries

MRSA

Methycillin resistant staphylococcus aureus

AMR

Antimicrobial resistance

IPC

Infection prevention and control

CDC

Centre for disease control

BMI

Body mass index

SPSS

Statistical product and service solutions

SES

Socioeconomic status

PROM

Premature rupture of membrane

OR

Odds Ratio

CI

Confidence interval

USA

United States of America

HAI

Healthcare associated infection

CONS

Coagulase negative Staphylococcus

Author contributions

RS conceived the idea of this study. She is responsible for study design, analysis and conclusion. MS and RM has carried out data collection and personal interaction with patients. The clinical observance was also conducted by them. KM has written the manuscript, edited and finalized the text. All authors read and approved the final manuscript.

Funding

We declare that we have not received any funding.

Data availability

The data is available with the Corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The Institutional Ethics Committee of R. D. Gardi Medical College, Ujjain approved the study (Approval Number - PG/ OBSTETRICS & GYNECOLOGY/37/2021). A written informed consent was obtained from all participants in the local language, Hindi; adhering to Declaration of Helsinki.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.