Adhesive incisional drapes during cesarean delivery for preventing wound infection: A systematic review and meta-analysis of randomized controlled trials

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Adhesive

incisional

drapes

during

cesarean

delivery

for

preventing

wound

infection:

A

systematic

review

and

meta-analysis

of

randomized

controlled

trials

Rebecca

Eckler

a

,

Johanna

Quist-Nelson

b

,

Gabriele

Saccone

c

,

Harvey

Ward

d

,

Vincenzo

Berghella

b,

*

a

SidneyKimmelCollegeofMedicine,ThomasJeffersonUniversity,Philadelphia,PA,USA

b

DepartmentofObstetricsandGynecology,DivisionofMaternal-FetalMedicine,ThomasJeffersonUniversityHospital,Philadelphia,PA,USA

c

DepartmentofNeuroscience,ReproductiveSciencesandDentistry,SchoolofMedicine,UniversityofNaplesFedericoII,Naples,Italy

d

DepartmentofObstetricsandGynaecology,CoffsHarbourHealthCampus,CoffsHarbour,Australia

ARTICLE INFO Articlehistory: Received12March2019

Receivedinrevisedform16July2019 Accepted28July2019

Availableonline2August2019 Keywords:

Cesareandelivery Adhesivedrapes Plasticdrapes Postoperativeinfection Surgicalsiteinfection

ABSTRACT

Objective:Tocomparetheincidenceofwoundinfectionaftercesareandeliveryinproceduresconducted usingadhesiveincisionaldrapesversesnoadhesiveincisionaldrapes.

Study Design: Searches were performed in electronic databases (MEDLINE, ClinicalTrials.gov, the CochraneCentralRegisterofControlledTrials,Scopus,OVID,EMBASE,andthePROSPEROInternational Prospective Register ofSystematic Reviews). We includedrandomized controlled trialscomparing adhesive incisional drapesto no adhesiveincisional drapesduring cesarean delivery.Theprimary outcomeofthismeta-analysiswaswoundinfection.Meta-analysiswasperformedusingtherandom effectsmodelofDerSimonianandLaird,toproducerelativerisk(RR)with95%confidenceinterval(CI). Results: 52 publications were identifiedthrough initial search of databases and two randomized controlledtrialswereeligibleandincludedinthemeta-analysis.Ourmeta-analysisexaminedatotalof 1943 subjectsand showedastatisticallysignificantincreaseinwoundinfectionsinpatientsinthe adhesiveincisionaldrapegroupwhencomparedtothecontrolgroup(RR:1.29,95%CI:1.02–1.65). Conclusion:Adhesiveincisionaldrapesmayincreasetheincidenceofwoundinfectionsaftercesarean delivery.Furtherstudiesarenecessarytoexplorethisrelationshipinthesettingofcurrentpostoperative infection prophylaxis, including broad-spectrum antibiotic coverage, skin preparation and vaginal cleansing.

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

The incidence of Cesarean delivery (CD) has increased drasticallyin thepastfew decadesmakingup nearlyonethird of all births and affecting an estimated 22.9 million women globally[1].Woundinfectionsareoneofthemostcommoncauses ofmaternalmorbidityafterCDswithanincidenceof3–5%andare associated witha maternalmortality rate of upto3% in some regions[2].GiventhehighincidenceofCDs,post-cesareanwound infectionsplacelargephysicalandﬁnancialcoststothepatientand healthcaresystem[3].

Numeroustrials have investigatedthe impactof variousCD techniquesinthepreventionofwoundinfections[4].Forexample, studies haveexamined theeffectof antiseptic skinpreparation [5,6], perineal hair removal [7], antibiotic prophylaxis [8,9], vaginal irrigation [10], and different skin closure techniques [11]. Studieshave also investigated the useof various surgical apparatuses to reduce wound infection rates including O-ring retractors [12], the Lap-Protector [13], and adhesive incisional drapes[14,15].Adhesiveincisionaldrapesareusedinnumerous typesofsurgeryincludinggeneralorabdominal,orthopedic,and cardiactolimitwoundinfection.However,studiesinvestigating theutilityofadhesiveincisionaldrapesinpreventinginfectionare conﬂicting.ACochranereviewexaminingtheuseofpreoperative skin preparation for CD found that there was no signiﬁcant difference in wound infection rates when comparing adhesive incisionaldrapestonoadhesiveincisionaldrapes(RR1.29;95%CI 0.97–1.71)[6].However,anotherCochranereviewexaminingthe

* Correspondingauthorat:DepartmentofObstetricsandGynecology,Divisionof Maternal-FetalMedicine,ThomasJeffersonUniversity,833ChestnutStreet,First Floor,Philadelphia,PA,19107,USA.

E-mailaddress:vincenzo.berghella@jefferson.edu(V.Berghella).

http://dx.doi.org/10.1016/j.eurox.2019.100090

ContentslistsavailableatScienceDirect

European

Journal

of

Obstetrics

&

Gynecology

and

Reproductive

Biology:

X

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useof adhesive incisional drapes in various types of surgeries found that there was no evidence that they reduced wound infectionsandthatthereissomeevidencethattheymayinstead increaseratesofinfection(RR1.23;95%CI1.02–1.48,P=0.03)[16]. Despitethepotentialincreasedriskofwoundinfectionsassociated withadhesiveincisionaldrapes,someproviderspreferusingthese drapesforothertheoreticalclinicalbenefits.Forexample,adhesive incisionaldrapesmaytheoreticallyincreasetheaccuracyofblood lossmeasurementsduringtheprocedureandthesedrapesmay also reduce the risk of amniotic emboli by minimizing the contaminationofamnioticfluid totheblood streamwithinthe abdomen. Given these preferences as well as the con_flicting existing data, we sought to compare the incidence of wound infection after CD in procedures conducted using adhesive incisionaldrapesversesnoadhesiveincisionaldrapes.

Materialsandmethods

The meta-analysis was conducted following the PRISMA statement and checklist [17]. Searches were performed in electronicdatabases (MEDLINE, ClinicalTrials.gov, the Cochrane CentralRegisterofControlledTrials,Scopus,OVID,EMBASE,and the PROSPERO International Prospective Register of Systematic Reviews)frominceptionofdatabasesuntilApril2018usingthe MeSH terms and text words: “cesarean section”, “cesarean”, “drape”, “drapes”, “adhesive”, “adhesives”, “tissue adhesives”, “plastics”. The “AND” or “OR” operator was used to combine termsindifferentcombinations(SeeSupportingAppendixAfor search strategy). No restrictions for language or geographic locationwereapplied.Thissearchwasperformedbytwohealth sciencesreferencelibrariansandtwoinvestigatorsindependently. Beforedataextraction,theprotocolwasregisteredwithPROSPERO InternationalProspectiveRegisterofSystematicReviews (Regis-trationnumber:CRD4201809489)

We included all randomized controlled trials (RCTs) that compared adhesive incisional drapes to no adhesive incisional drapes during cesarean delivery. Trials were excluded if they examinedtheuseofadhesiveincisionaldrapesinnon-cesarean surgeries.Weexcluded articlesthat wereobservationalstudies, reviews,retrospective studies, or pseudo-RCTs. Trials were not excluded based on maternal age, gestational age, or fetal anomalies.

Theinterventionofadhesiveincisionaldrapeswasdeﬁnedas surgicaldrapeswithadhesivematerialappliedovertheskinofthe surgicalsitesothatthedrapemustbeincisedinordertoincisethe skin(Fig.1).Thecontrolgroupwasnoadhesiveincisionaldrapes (Fig.1).Theprimaryoutcomewaswoundinfection,asdeﬁnedby each trial. Secondary outcomes included wound hematoma,

wound seroma, wound separation, readmission for wound concerns, cellulitis, endometritis, and duration hospital stay in days.

Theriskofbiaswasidentiﬁedaseitherlow,high,orunclear followingthe7categoriesoutlinedintheCochraneHandbookfor Systematic Review of Interventions: (1) Random sequence generation(selectionbias)(2),Allocationconcealment(selection bias)(3),Blindingofparticipantsandpersonnel(performancebias) (4),Blindingofoutcomeassessment(detectionbias)(5), Incom-plete outcome data (attrition bias) (6), Selective reporting (reportingbias)and(7)OtherBias(anybiasthatdidnotﬁtinto categories1_–6)[18].Theoverallriskofbiaswasthengradedbythe level of evidence, using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Groupapproach[19].Allauthorswerecontactedformissingdata. Data abstraction was completed by two independent inves-tigators(JQN,RE).Eachinvestigatorindependentlyabstracteddata fromeachstudyandanalyzeddataseparately.Thedataanalysis was completed independently by authors (GS, JQN, RE) using Review Manager 5.3 (The Nordic Cochrane Centre, Cochrane Collaboration, 2014, Copenhagen, Denmark). The completed analyseswerethencompared,andanydifferenceswereresolved withreviewoftheentiredataandindependentanalysis.

Data from each eligible study were extracted without modiﬁcation of original data. A 2 by 2 tablewas assessed for therelativerisk(RR);forcontinuousoutcomesmeansstandard deviationswereextractedandimportedintoReviewManagerv. 5.3 (TheNordicCochraneCentre,CochraneCollaboration,2014, Copenhagen,Denmark).

Meta-analysiswasperformedusingtherandomeffectsmodel ofDerSimonianandLaird,toproducesummarytreatmenteffects in terms of RR or mean difference (MD) with 95% conﬁdence interval(CI).Thedecisiontousetherandomeffectsmodelversus theﬁxedeffectsmodelwasdeterminedaprioribasedonclinical heterogeneity. Subsequently, statistical heterogeneitywas mea-sured using I-squared (Higgins I2_). _Potential _publication _biases

were assessed statistically by using Begg’sand Egger’s tests if greaterthan10publicationswereanalyzed.Apvalue<0.05was consideredstatisticallysigniﬁcant.

Results

Fig.2showsthestudyselectionflowchart.52publicationswere identifiedthrough initial search of databases. After removalof duplications,35records werecheckedagainstthepre-specified inclusion criteria focusingontitle and abstract.Ultimately two RCTs were included in this meta-analysis consisting of 1943 subjectscollectively (Table1).Cordtz et al. [14] examined two

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interventions,adhesiveincisionaldrapesandskinre-disinfection, whereskinwasdisinfectedwith2.5%iodinein70%ethanolshortly beforeskinclosure[14].Accordingly,the1340subjectsinthistrial wererandomizedintofourarms(1)adhesiveincisionaldrapesand

skinre-disinfection(2)adhesiveincisionaldrapesandnoskin re-disinfection (3) no adhesive incisional drapes and skin re-disinfection (4) no adhesive incisional drapes and no skin re-disinfection (Table 1). Ward et al. [15] investigated the single intervention of adhesiveincisional drapes and randomized603 subjectsintotwoarms(1)adhesiveincisionaldrapesand(2)no adhesiveincisionaldrapes(Table1).

Fig.3summarizesourriskofbiasaccordingtotheCochrane Collaboration’s tools [18]. Both studies have a high risk of performance bias as masking of surgeons to the intervention wasnotpossible.Thetwostudiesalsohaveahighriskofattrition biasaspatientswerenotfollowedbeyond14daysintheCordtz etal.study[14]and5daysintheWardetal.study[15]andthere wasnomentionofintention-to-treatineitherstudy.Therewasan unclearriskofselectionbias,detectionbias,andotherbiasinthe Cordtz et al. [14] study as allocation concealment, outcome assessment,andbaselinecharacteristicswerenotreportedinthe trial.Allotherformsofbiasweredeterminedtobelowrisk.Using theGRADEWorkingGroupapproach,theoverallriskofbiasfor each studywas gradedas1B,a strongrecommendation witha moderatequalityofevidence.Thislevelofgradewasselectedas bothstudieswereRCTswithimportantlimitations(inconsistent results, methodologic flaws, indirect or imprecise). Therefore, furtherresearch(ifperformed)islikelytohaveanimpactonour confidenceintheestimateofbenefitandriskandmaychangethe estimate[19].

Numerouspatientcharacteristicswerenotreportedinoneor both studies including maternal age, gestational age, gravity, parity,indicationforCD,andnumberofscheduled,primaryand emergency CD atrandomization (Table 2).Many intraoperative riskfactorsforwoundinfectionwerealsonotdescribed,suchas BMI,diabetes,typeofskinincision,closureofsubcutaneousfatif 2cm,methodofskinclosure,durationofmembranerupture,and durationofCD(Table3).Theprimaryoutcomeofwoundinfection was reportedbyeach RCTs, but nootherwound complications (hematoma, seroma, or readmission for wound concern) were reportedassecondaryoutcomes(Table3).

NeitherofthetwoRCTsreportedanybenefitofusingadhesive incisionaldrapesduringCDinpreventinginfection.Cordtzetal. [14] showed a significant increase in wound infections in the adhesive incisionaldrapegroupcompared tocontrols (RR1.37; 95%CI:1.03–1.82),whileWardetal.[15]showedthattherewasno significantdifferenceininfectionsbetweengroups(RR1.11;95%

Fig.2.PRISMAﬂowchartforstudyselection.

Table1

Characteristicsoftheincludedtrials.

Cordtz1989 Ward2001

Studylocation CopenhagenS,Denmark Tygerberg,SouthAfrica NumberofPatients 1340(662a_/678b₎ ₆₀₃_(305/298)

Inclusioncriteria Cesareandelivery Cesareandelivery

Exclusioncriteria NR Clinicallysuspectedruptureduterus Primaryoutcomes Woundinfection Woundinfection

Deﬁnitionof primaryoutcome

Totalinfectionrate:totalof“possibleinfected”and“infected”.“Possible infected:localizederythemaand/orseroussecretionwithoutpresence ofpus.Infected:presenceofpusirrespectiveoftheresultsof bacteriologicalexamination.Puscouldbeclassiﬁedassuperﬁciallyor subfasciallylocated.Incisionfordrainagewasalsorecorded.”

“Infectionwasdiagnosediftwoofthreefeatureswerepresent:1. Erythematouscellulitis(erythematousindurationeithersideofthe incisionline).2.Seropurulentdischargefromthewound.3.Positive swabculture(organismsandleucocytes).”

Intervention(s) studied

Adhesiveincisionaldrapesc

Adhesiveincisionaldrapes Control(s) Noadhesiveincisionaldrapesc

Noadhesiveincisionaldrapes Followuptime

period:

14dayspostoperatively 5dayspostoperatively

Abbreviations:NR,notrecorded.

a

The662subjectsinadhesiveincisionaldrapeconsistedof325withskinre-disinfectionand337withnoskinre-disinfection.

b

The678subjectsinthecontrolconsistedof324withskinre-disinfectionand354withnoskinre-disinfection.

c

Twointerventions:adhesiveincisionaldrapesandskinre-disinfection.Twocontrols:noadhesiveincisionaldrapesandnoskinre-disinfection.Thetwointerventionsand twocontrolscombinedtocreatefourarms:(1)adhesiveincisionaldrapesandskinre-disinfection(2)adhesiveincisionaldrapesandnoskinre-disinfection(3)noadhesive incisionaldrapesandskinre-disinfection(4)noadhesiveincisionaldrapesandnoskinre-disinfection.

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CI:0.70–1.76)(Fig.4).Ourmeta-analysisexaminedatotalof1943 subjectsand demonstrated a signiﬁcantly higher proportion of patientsintheadhesiveincisionaldrapegroupdevelopedwound infectionwhencompared tothecontrolgroup(RR1.29;95%CI 1.02–1.65)(Table3,Fig.4).

Comment

Thisstudyshowed thattheuseofadhesiveincisionaldrapes comparedtheuseofnoadhesiveincisionaldrapesduringCDmay increase theincidence of wound infections. A recent Cochrane review evaluated the impact of adhesive incisional drapes on woundinfections[16].Thismeta-analysisincludedRCTs examin-ing the use of adhesive incisional drapes in various types of

surgeries,includinggeneral orabdominalsurgeries[20–22],hip surgeries[23],andcardiacsurgeries[24]inadditiontoCDs[14,15]. The review included seven RCTs [16], two of these RCTs used iodine-impregnatedadhesivedrapes[20,24]andfiveoftheseRCTs usedadhesiveincisionaldrapesthatwerenotiodine-impregnated [14,15,21–23].Thismeta-analysisshowednosignificantdifference in the incidence of wound infection with the use of iodine-impregnatedadhesiveincisionaldrapes(RR1.03;CI0.66–1.6)and increasedincidenceofwoundinfectionwiththeuseofadhesive incisionaldrapesthatwerenotiodine-impregnated (RR1.23;CI 1.02–1.48)[16].Ourfindingsareconsistentwiththeresultsofthis review, as the two RCTs included in our meta-analysis used adhesiveincisionaldrapesthatwerenotiodine-impregnatedand also found increased wound infection rates. Furthermore, the

Fig.3. Assessmentofriskofbias.(A)Summaryofriskbiasforeachtrial;plussign,lowriskofbias;minussign,highriskofbias;questionmark;unclearriskofbias.(B)Riskof biasasagraphabouteachriskofbiasitempresentedaspercentagesacrossallincludedstudies.

Table2

Characteristicsofsubjectsatdelivery.

Cordtz1989 Ward2001

AdhesiveIncisionalDrapes NoadhesiveIncisionalDrapes AdhesiveIncisionalDrapes NoadhesiveIncisionalDrapes Maternalage,y+/ sd NR NR 26.7+/ 6.55 25.39+/ 3.77 Gravity,n(range) NR NR 2(1–9) 2(1–9) Parity,n(range) NR NR 1(0–7) 0.5(0–8) ScheduledCD,% NR NR 89.2 88.6 PrimaryCD,n(%) NR NR 172/305(56.39) 200/298(67.11) CDindication NR NR NR NR Antepartumhemorrhage,% NR NR 2.3 4.2 Breechpresentation,% NR NR 8.5 8.4 Cephalopelvicdisproportion,% NR NR 27.5 27.2 Fetaldistress,% NR NR 24.5 27.5 Malpresentation,% NR NR 2.6 1.7 Placentaprevia,% NR NR 1.1 1.7 Prolapsedcord,% NR NR 0.7 0.7 2previousCD,% NR NR 9.8 10.4 Slowprogress,% NR NR 10.5 7.4 Other,% NR NR 12.1 11.1 Prophylacticantibiotics,n(%) 56/662(8.46) 54/678(7.96) 305/305(100.0) 298/298(100.0) Abbreviations:CD,cesareandelivery;n,number;NR,notrecorded;sd,standarddeviation;y,year.

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Cochranereviewconclusionsareinagreementwithourstudyin ﬁnding that there was some evidence that adhesive incisional drapesmayincreasewoundinfectionrates[16].

Another Cochrane review, which included thesame studies [6,14,15], evaluated the effect of preoperative skin preparation duringcesareandeliveriesonwoundinfectionrates,andadhesive incisionaldrapes wereexaminedas analternativeformof skin preparation[6].Thetworeviewsfoundthesamerelativerisk,yet confidenceintervalsdifferedbetweenourmeta-analysisandthe Cochrane review (RR 1.29; CI 1.02–1.65 while the Cochrane reported RR 1.29; CI 0.97–1.71). This difference highlights the differencebetweenfixedeffectsandrandomeffects.Wechosethe randomeffectsmodelaswedeterminedthetwoRCTsareclinically heterogeneous basedondifferencesin patientpopulation char-acteristicsand treatmenteffects. The studies represented pop-ulationsofdifferentcountries(DenmarkversusSouthAfrica),the usage of prophylactic antibiotic greatly differed in each study (8.21%versus100%),andtheprimaryoutcomeofwoundinfection was measured for different durations (14 days versus 5 days) (Tables1and2).Incontrast,theCochranereviewusedthefixed effects model assumingthat the two RCTsestimated thesame underlyingpopulationcharacteristicsandtreatmenteffectsbased onfindingno substantialstatistical heterogeneity(Tau2 _>_0, _I2

>30%, P<0.10 in Chi2 test for heterogeneity). However, the Cochrane review indicated that future updates should use the randomeffectsmodelifclinicalorsubstantialstatistical hetero-geneityis detected. Statistically heterogeneity testing was also foundtobenon-signiﬁcantinourstudy,yetstatistical heteroge-neitydoesnotprecludeclinicalheterogeneityandthedecisionto

proceed with the random effects model was made a priori as indicatedinourmethods[25].

A strengthof ourstudyis that weadheredtotheCochrane Handbook for Systematic Review of Interventions PRISMA checklist [17] and preregistered our protocol in PROSPERO International Prospective Register of Systematic Reviews. Also, wecontactedandreceivedresponsesfromauthorsofbothRCTs andwewereabletocollectadditionalunpublisheddatafromthe Wardetal.study[15].

Ourstudyislimitedbytheminimalavailableresearchonthis subjectandtheageoftheincludedstudies,whichwerepublished in1989and2001.Becauseofthetimelapsethathasoccurredsince publication, some of the CD techniques for prevention of postoperative wound infectionhave changed and thesestudies maynotberepresentativeofcurrentrisks.Anotherlimitationof ourstudyisthatwewerenotabletosynthesizeotherplanned secondary outcomesas nocommon secondary outcomes were examinedbythetwostudies.Wewerealsounabletoincludeand controlforbaselinecharacteristicandriskfactorsasthisdatawas notpublishedbybothstudies.Lastly,theintervention,control,and primary outcome of wound infection varied between the two trials.

Although each study’s deﬁnition of the adhesive incisional drapes seems to align with our deﬁnition as described in the methods,thereareavarietyofadhesiveincisionaldrapesubtypes. Forexample,differentbrandsofadhesiveincisionaldrapeshave different strength of adhesive properties and some drapes are impregnatedwithantibioticsorantimicrobialagents.Itisunlikely that thetwousedthesame typeof drapes,as Wardet al.[15]

Table3

Intraoperativeriskfactorsforwoundinfectionandprimaryoutcomeforadhesiveincisionaldrapeandcontrol.

Cordtz1989 Ward2001 RR(95%CI)

AdhesiveIncisional Drapes Noadhesive IncisionalDrapes AdhesiveIncisional Drapes NoadhesiveIncisional Drapes

Typeofskinincision

Pfannenstiel,% NR NR 35.1 37.6 Midlinevertical,% NR NR 63.9 62.4 Closureofskin Sutures,% NR NR 5.9 4.4 Staples,% NR NR 38.0 39.9 Both,% NR NR 56.1 55.7 InlabororROM>2hrs,% NR NR 66.5 61.3 DurationofROM,hrs+/ sd NR NR 9.21+/ 18.12 11.51+/ 17.6 Chorioamnionitis,% NR NR 1.3 2.4

Scalpelectrodeused,% NR NR 9.2 8.1

DurationofCD,mins+/ sd NR NR 37.03+/ 11.16 35.87+/ 11.73 Re-disinfectionofskinbefore

closure,n(%)

NR NR 305/305(100) 298/298(100) Primaryoutcome

WoundInfection,n(%) 99/662(15.0) 74/678(10.9) 34/305(11.1) 30/298(10.1) 1.29,(1.02-1.65) Abbreviations:CD,cesareandelivery;CI,conﬁdenceinterval;hrs,hours;mins,minutes;n,number;NR,notrecorded;ROM,ruptureofmembranes;RR,relativerisk;sd, standarddeviation.

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describestheadhesiveincisionaldrapesusedas“newgeneration” andthisstudywaspublishedoveradecadeaftertheCordtzetal. trial[14]. Additionally, neithertrial clearly deﬁnes the control group.

Eachtrialdeﬁnedwoundinfectiondifferently,withonestudy thatfollowedpatientsfor5dayspost-CD[15]andtheotherstudy thatfollowedpatientsfor14dayspost-CD[14](Table1).Thisshort follow-up period for detecting wound infection is inconsistent with the CDC’s deﬁnition of surgical site infection whereby infectionscanoccurwithin30dayspostoperatively[26].Although wound infections can be diagnosed within 30 days of CD, the majority of post-operative wound infections become clinically apparentbetween4–7 days after CD [27]. However,one study foundthatthemediantimeofwoundinfectiondiagnosiswas9.5 days(IQR: 6.5–11.5)whenconductingcomplete30-daypost-CD surveillance[28].Consequently,thereisconcernthatourincluded trialsmayhaveunderreportedwoundinfectionratesandwound infections occurring after the follow-up period may have differentiallyeffectedtheinterventionandcontrolgroups.

In summary, the results of our meta-analysis suggest that adhesiveincisionaldrapesmayincreasetheincidenceofwound infectionsafterCD. Furtherstudiesarenecessarytoexplorethe relationshipofadhesiveincisionaldrapesduringCDinthesetting ofcurrent postoperativeinfectionprophylaxis, including broad-spectrumcoverage,vaginalcleansingandskinpreparation. DeclarationofCompetingInterest

Allauthorsdeclarenoconﬂictsofinterest.Theauthorsaloneare responsibleforthecontentandwritingofthisarticle.

Acknowledgment

Theauthorshavenograntsorfundingtoreport. AppendixA.

Pubmed MEDLINE Database Search Strategy: (("Cesarean Section"[Mesh]ORCesarean))AND ((((drape)OR drapes)) AND (((("TissueAdhesives"[PharmacologicalAction]OR"Tissue Adhe-sives"[Mesh]))OR(adhesivesORadhesive))OR"Plastics"[Mesh])). References

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