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Widmer AF, Atkinson A, Kuster SP, Wolfensberger A, Klimke S, Sommerstein R, Eckstein FS, Schoenhoff F, Beldi G, Gutschow CA, Marschall J, Schweiger A, Jent P. Povidone Iodine vs Chlorhexidine Gluconate in Alcohol for Preoperative Skin Antisepsis: A Randomized Clinical Trial. JAMA 2024; 332:541-549. [PMID: 38884982 PMCID: PMC11184497 DOI: 10.1001/jama.2024.8531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/22/2024] [Indexed: 06/18/2024]
Abstract
Importance Preoperative skin antisepsis is an established procedure to prevent surgical site infections (SSIs). The choice of antiseptic agent, povidone iodine or chlorhexidine gluconate, remains debated. Objective To determine whether povidone iodine in alcohol is noninferior to chlorhexidine gluconate in alcohol to prevent SSIs after cardiac or abdominal surgery. Design, Setting, and Participants Multicenter, cluster-randomized, investigator-masked, crossover, noninferiority trial; 4403 patients undergoing cardiac or abdominal surgery in 3 tertiary care hospitals in Switzerland between September 2018 and March 2020 were assessed and 3360 patients were enrolled (cardiac, n = 2187 [65%]; abdominal, n = 1173 [35%]). The last follow-up was on July 1, 2020. Interventions Over 18 consecutive months, study sites were randomly assigned each month to either use povidone iodine or chlorhexidine gluconate, each formulated in alcohol. Disinfectants and skin application processes were standardized and followed published protocols. Main Outcomes and Measures Primary outcome was SSI within 30 days after abdominal surgery and within 1 year after cardiac surgery, using definitions from the US Centers for Disease Control and Prevention's National Healthcare Safety Network. A noninferiority margin of 2.5% was used. Secondary outcomes included SSIs stratified by depth of infection and type of surgery. Results A total of 1598 patients (26 cluster periods) were randomly assigned to receive povidone iodine vs 1762 patients (26 cluster periods) to chlorhexidine gluconate. Mean (SD) age of patients was 65.0 years (39.0-79.0) in the povidone iodine group and 65.0 years (41.0-78.0) in the chlorhexidine gluconate group. Patients were 32.7% and 33.9% female in the povidone iodine and chlorhexidine gluconate groups, respectively. SSIs were identified in 80 patients (5.1%) in the povidone iodine group vs 97 (5.5%) in the chlorhexidine gluconate group, a difference of 0.4% (95% CI, -1.1% to 2.0%) with the lower limit of the CI not exceeding the predefined noninferiority margin of -2.5%; results were similar when corrected for clustering. The unadjusted relative risk for povidone iodine vs chlorhexidine gluconate was 0.92 (95% CI, 0.69-1.23). Nonsignificant differences were observed following stratification by type of surgical procedure. In cardiac surgery, SSIs were present in 4.2% of patients with povidone iodine vs 3.3% with chlorhexidine gluconate (relative risk, 1.26 [95% CI, 0.82-1.94]); in abdominal surgery, SSIs were present in 6.8% with povidone iodine vs 9.9% with chlorhexidine gluconate (relative risk, 0.69 [95% CI, 0.46-1.02]). Conclusions and Relevance Povidone iodine in alcohol as preoperative skin antisepsis was noninferior to chlorhexidine gluconate in alcohol in preventing SSIs after cardiac or abdominal surgery. Trial Registration ClinicalTrials.gov Identifier: NCT03685604.
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Affiliation(s)
- Andreas F. Widmer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Pediatric Research Centre, University Children’s Hospital Basel, Basel, Switzerland
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St Louis, Missouri
| | - Stefan P. Kuster
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Aline Wolfensberger
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Steffi Klimke
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Rami Sommerstein
- Department of Infectious Diseases, Inselspital Bern University Hospital and University of Bern, Bern, Switzerland
- Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Friedrich S. Eckstein
- Department of Cardiac Surgery, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Florian Schoenhoff
- Department of Cardiac Surgery, Inselspital Bern University Hospital and University of Bern, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christian A. Gutschow
- Department of Visceral and Transplantation Surgery, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jonas Marschall
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St Louis, Missouri
- Department of Infectious Diseases, Inselspital Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Philipp Jent
- Department of Infectious Diseases, Inselspital Bern University Hospital and University of Bern, Bern, Switzerland
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Kim N, Joo EH, Kim S, Kim T, Ahn EH, Jung SH, Ryu HM, Lee JY. Comparative analysis of obstetric, perinatal, and neurodevelopmental outcomes following chorionic villus sampling and amniocentesis. Front Med (Lausanne) 2024; 11:1407710. [PMID: 39005648 PMCID: PMC11239381 DOI: 10.3389/fmed.2024.1407710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/18/2024] [Indexed: 07/16/2024] Open
Abstract
Background The risks of invasive prenatal tests are reported in previous studies such as miscarriage, fetal anomalies, and bleeding. However, few compare short-term and long-term outcomes between invasive tests. This study aims to investigate obstetric, perinatal, and children's neurodevelopmental outcomes following chorionic villus sampling (CVS) or amniocentesis in singleton pregnancy. Methods This retrospective cohort study included healthy singleton pregnancies underwent transabdominal CVS (gestational age [GA] at 10-13 weeks) or amniocentesis (GA at 15-21 weeks) at a single medical center between 2012 and 2022. Only cases with normal genetic results were eligible. Short-term and long-term neurodevelopmental outcomes were evaluated. Results The study included 200 CVS cases and 498 amniocentesis cases. No significant differences were found in body mass index, parities, previous preterm birth, conception method, and cervical length (CL) before an invasive test between the groups. Rates of preterm labor, preterm premature rupture of the membranes, preterm birth, neonatal survival, neonatal short-term morbidities, and long-term neurodevelopmental delay were similar. However, the CVS group had a higher rate of cervical cerclage due to short CL before 24 weeks (7.0%) compared to the amniocentesis group (2.4%). CVS markedly increased the risk of cervical cerclage due to short CL (adjusted odd ratio [aOR] = 3.17, 95%CI [1.23-8.12], p = 0.016), after considering maternal characteristics. Conclusion Performing CVS resulted in a higher incidence of cerclage due to short cervix or cervical dilatation compared to amniocentesis in singleton pregnancies. This highlights the importance of cautious selection for CVS and the necessity of informing women about the associated risks beforehand.
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Affiliation(s)
| | | | | | | | | | | | | | - Ji Yeon Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
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Gialdini C, Chamillard M, Diaz V, Pasquale J, Thangaratinam S, Abalos E, Torloni MR, Betran AP. Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. EClinicalMedicine 2024; 72:102632. [PMID: 38812964 PMCID: PMC11134562 DOI: 10.1016/j.eclinm.2024.102632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/29/2024] [Accepted: 04/19/2024] [Indexed: 05/31/2024] Open
Abstract
Background Caesarean section (CS) is the most performed major surgery worldwide. Surgical techniques used for CS vary widely and there is no internationally accepted standardization. We conducted an overview of systematic reviews (SR) of randomized controlled trials (RCT) to summarize the evidence on surgical techniques or procedures related to CS. Methods Searches were conducted from database inception to 31 January 2024 in Cochrane Database of Systematic Reviews, PubMed, EMBASE, Lilacs and CINAHL without date or language restrictions. AMSTAR 2 and GRADE were used to assess the methodological quality of the SRs and the certainty of evidence at outcome level, respectively. We classified each procedure-outcome pair into one of eight categories according to effect estimates and certainty of evidence. The overview was registered at PROSPERO (CRD 42023208306). Findings The analysis included 38 SRs (16 Cochrane and 22 non-Cochrane) published between 2004-2024 involving 628 RCT with a total of 190,349 participants. Most reviews were of low or critically low quality (AMSTAR 2). The SRs presented 345 procedure-outcome comparisons (237 procedure versus procedure, 108 procedure versus no treatment/placebo). There was insufficient or inconclusive evidence for 256 comparisons, clear evidence of benefit for 40, possible benefit for 17, no difference of effect for 13, clear evidence of harm for 14, and possible harm for 5. We found no SRs for 7 pre-defined procedures. Skin cleansing with chlorhexidine, Joel-Cohen-based abdominal incision, uterine incision with blunt dissection and cephalad-caudal expansion, cord traction for placental extraction, manual cervical dilatation in pre-labour CS, changing gloves, chromic catgut suture for uterine closure, non-closure of the peritoneum, closure of subcutaneous tissue, and negative pressure wound therapy are procedures associated with benefits for relevant outcomes. Interpretation Current evidence suggests that several CS surgical procedures improve outcomes but also reveals a lack of or inconclusive evidence for many commonly used procedures. There is an urgent need for evidence-based guidelines standardizing techniques for CS, and trials to fill existing knowledge gaps. Funding UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).
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Affiliation(s)
- Celina Gialdini
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
- Facultat de Ciències de la Salut Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | | | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Julia Pasquale
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
| | - Maria Regina Torloni
- Evidence Based Healthcare Post-Graduate Program, Department of Medicine, São Paulo Federal University, São Paulo, Brazil
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Jung YM, Lee SM, Kim SY, Chung JH, Won HS, Lee KA, Park MH, Cho GJ, Oh MJ, Choi ES, Ahn KH, Hong SC, Sung JH, Roh CR, Kim SM, Kim BJ, Kim HJ, Oh KJ, Hong S, Park IY, Park JS. The Skin Antiseptic agents at Vaginal dElivery (SAVE) trial: study protocol for a randomized controlled trial. Trials 2023; 24:130. [PMID: 36810189 PMCID: PMC9942633 DOI: 10.1186/s13063-023-07101-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/18/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Cleansing of the vulva and perineum is recommended during preparation for vaginal delivery, and special attention is paid to cleansing before episiotomy because episiotomy is known to increase the risk of perineal wound infection and/or dehiscence. However, the optimal method of perineal cleansing has not been established, including the choice of antiseptic agent. To address this issue, we designed a randomized controlled trial to examine whether skin preparation with chlorhexidine-alcohol is superior to povidone-iodine for the prevention of perineal wound infection after vaginal delivery. METHODS In this multicenter randomized controlled trial, term pregnant women who plan to deliver vaginally after episiotomy will be enrolled. The participants will be randomly assigned to use antiseptic agents for perineal cleansing (povidone-iodine or chlorhexidine-alcohol). The primary outcome is superficial or deep perineal wound infection within 30 days after vaginal delivery. The secondary outcomes are the length of hospital stay, physician office visits, or hospital readmission for infection-related complications, endometritis, skin irritations, and allergic reactions. DISCUSSION This study will be the first randomized controlled trial aiming to determine the optimal antiseptic agent for the prevention of perineal wound infections after vaginal delivery. TRIAL REGISTRATION ClinicalTrials.gov NCT05122169. First submitted date on 8 November 2021. First posted date on 16 November 2021.
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Affiliation(s)
- Young Mi Jung
- grid.31501.360000 0004 0470 5905Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - Seung Mi Lee
- grid.31501.360000 0004 0470 5905Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea
| | - So Yeon Kim
- grid.413967.e0000 0001 0842 2126Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jin Hoon Chung
- grid.413967.e0000 0001 0842 2126Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Hye-Sung Won
- grid.413967.e0000 0001 0842 2126Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Kyung A Lee
- grid.255649.90000 0001 2171 7754Department of Obstetrics and Gynecology, Ewha Womans University Seoul Hospital, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Mi Hye Park
- grid.255649.90000 0001 2171 7754Department of Obstetrics and Gynecology, Ewha Womans University Seoul Hospital, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Geum Joon Cho
- grid.222754.40000 0001 0840 2678Department of Obstetrics and Gynecology, Guro Hospital, College of Medicine, Korea University, Seoul, South Korea ,grid.222754.40000 0001 0840 2678Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, South Korea
| | - Min-Jeong Oh
- grid.222754.40000 0001 0840 2678Department of Obstetrics and Gynecology, Guro Hospital, College of Medicine, Korea University, Seoul, South Korea ,grid.222754.40000 0001 0840 2678Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, South Korea
| | - Eun Saem Choi
- grid.222754.40000 0001 0840 2678Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, South Korea ,grid.411134.20000 0004 0474 0479Department of Obstetrics and Gynecology, Korea University Anam Hospital, Seoul, South Korea
| | - Ki Hoon Ahn
- grid.222754.40000 0001 0840 2678Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, South Korea ,grid.411134.20000 0004 0474 0479Department of Obstetrics and Gynecology, Korea University Anam Hospital, Seoul, South Korea
| | - Soon-Cheol Hong
- grid.222754.40000 0001 0840 2678Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, South Korea ,grid.411134.20000 0004 0474 0479Department of Obstetrics and Gynecology, Korea University Anam Hospital, Seoul, South Korea
| | - Ji-Hee Sung
- grid.264381.a0000 0001 2181 989XDepartment of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Cheong-Rae Roh
- grid.264381.a0000 0001 2181 989XDepartment of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sun Min Kim
- grid.412479.dDepartment of Obstetrics and Gynecology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Byoung Jae Kim
- grid.412479.dDepartment of Obstetrics and Gynecology, Seoul Metropolitan Government, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Hyeon Ji Kim
- grid.412480.b0000 0004 0647 3378Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do South Korea
| | - Kyung Joon Oh
- grid.31501.360000 0004 0470 5905Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080 South Korea ,grid.412480.b0000 0004 0647 3378Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do South Korea
| | - Subeen Hong
- grid.411947.e0000 0004 0470 4224Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - In Yang Park
- grid.411947.e0000 0004 0470 4224Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Abstract
IMPORTANCE Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer. OBSERVATIONS Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis. CONCLUSIONS AND RELEVANCE Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.
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Affiliation(s)
- Jessica L Seidelman
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Christopher R Mantyh
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
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Trivedi M, Robinson AM, Islam MR. Effect of vaginal antiseptic prior to caesarean section on the rate of post-caesarean complications: a blinded randomised controlled trial. Trials 2022; 23:231. [PMID: 35331307 PMCID: PMC8943976 DOI: 10.1186/s13063-021-05857-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 11/22/2021] [Indexed: 11/11/2022] Open
Abstract
Background Rates of caesarean section (CS) delivery are increasing worldwide. CS delivery is often complicated by post-surgical infection, estimated to have ten times higher risk of infections than that of vaginal delivery. While widespread use of prophylactic antibiotics with CS has reduced post-CS infection, incidence may be reduced further by cleansing the vagina with betadine antiseptic wash prior to CS. However, reports are not consistent, and different antiseptics have been practised variably. Therefore, in order to ensure that the risks to the mother are as minimal as possible, it is important to determine whether vaginal irrigation with antiseptic wash reduces post-CS infection rate, and if so, which antiseptic is paramount. Methods Women giving birth by elective or emergency CS will be assigned into either the intervention (1% povidone iodine (n = 125) or chlorhexidine (n = 125)) or the control (no-irrigation (n = 125)) group by using a block randomisation technique. Participants will receive vaginal cleansing with an intervention or no vaginal cleansing prior to CS. Follow-up will occur at day 14 and day 28 post-CS. A predeveloped questionnaire will be completed with patients’ socio-demographic characteristics and required clinical and pregnancy-related information. All the fever, infection and readmission-related information will be completed from either the patient’s or their record or at follow-up visits. Occurrence of post-CS infection, as measured by primary and secondary outcomes, will be compared between the groups. Discussion The results of this study may provide important data to define the future uniform use of vaginal antiseptic wash immediately prior to CS and to determine the best antiseptic wash details in reducing post-operative infections or complications. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000971932p. Registered on 28 September 2020
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Affiliation(s)
- Monika Trivedi
- Goulburn Valley Health, Graham Street, Shepparton, Victoria, 3630, Australia.
| | - Ainsley M Robinson
- Goulburn Valley Health, Graham Street, Shepparton, Victoria, 3630, Australia
| | - Md Rafiqul Islam
- Goulburn Valley Health, Graham Street, Shepparton, Victoria, 3630, Australia.,Department of Rural Health, The University of Melbourne, Shepparton, Victoria, 3630, Australia.,Rural Health School, La Trobe University, Shepparton, Victoria, 3630, Australia
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