Introduction
Cesarean section comes from the Latin caedere which means
to cut or slash. In obstetrics, the term cesarean section refers to a surgical
procedure that aims to give birth to a baby by opening the walls of the
mother's abdomen and uterus (Todman, 2007). Cesarean section is
divided into two, namely elective (planned) and cito (immediate). The reasons
that led to an elective (planned) cesarean section were insufficient hip diameter
for normal delivery, breech baby position, placenta previa, previous cesarean
sections and at the request of patients without indications (Prasetya, 2014). According to WHO
provisions, the prevalence of cesarean delivery is around 10-15% of the total
delivery process. From the results of the 2017 Indonesian Demographic and
Health Survey, Indonesia's cesarean delivery rate was 17.02% with the lowest
cesarean delivery rate being East Nusa Tenggara with 5% and the highest being
Bali with 34.7% (Yogatama & Budiarti, 2019).
According to 2016 Riskesdas data in East Java, the rate of cesarean delivery
has increased by 10%, while for post-date indications it has increased by 0.5%
of the total population in East Java in 2016. C-section cases are included in
the clean contaminated surgery (class 2). Clean contaminated operations are
operations that penetrate the respiratory, gastrointestinal tract and
urogenital tract but are still under controlled conditions and without
significant contamination (Berr�os-Torres et al., 2017). Thus the
use of prophylactic antibiotics is recommended for cases of cesarean section.
There are several risks from cesarean section, but about 90% of postoperative
morbidity is caused by Surgical Wound Infection (Hardiyanti, 2020).
Postpartum infection is common after cesarean section.
Occurs due to surgical incision scars which are commonly called surgical site
infections (SSI) which are characterized by the presence of several
inflammatory symptoms such as fever, redness, pain and swelling, especially in
the area around the surgical incision (Prasetya, 2014). The use of
prophylactic antibiotics is one of the prevention of complications in sectio
caesarea patients in the form of surgical wound infections with a decrease of
about 30-65% (Hardiyanti, 2020).
Recommendations from WHO state that prophylactic
antibiotics for surgery, especially cesarean section, are from the penicillin
group, namely ampicillin and the first generation cephalosporin group, namely
cefazolin. This is supported by a statement by the Ministry of Health (2011)
which recommends the use of generation I and generation II cephalosporins for
surgical prophylaxis. In certain cases suspected of involving anaerobic
bacteria can be added with metronidazole. In addition, the use of prophylactic
antibiotics in cesarean section is included in the Highly Recommended. In this
category, antibiotics have been shown to be firmly proven to reduce morbidity,
reduce treatment costs and reduce overall antibiotic consumption (Sumanti, Ayu, & Rusli, 2016).
The occurrence of a fairly large risk of infection has
prompted researchers to evaluate the relationship between prophylactic
antibiotics with infection prevention or the incidence of postoperative infections,
especially in Soetomo hospitals. With this research, it is hoped that it can
become a means of information for patients and hospitals in the use of
prophylactic antibiotics in cesarean sections.
Method
This study is a non-experimental analytical observational
study with a Prospective Case Control approach using observational data and
patient medical records. The population in this study were hospitalized
patients in the pigeon room who gave birth by cesarean section and used
prophylactic antibiotics at RSUD Dr. Soetomo in January 2021 � June 2021.
Researchers took research data from the population adjusted to the inclusion
and exclusion criteria set. This study took data on age, BMI, indication for
cesarean section, and prophylactic antibiotics used. All data were recorded on
the medical record recording sheet, then the data received by the researcher
was examined and sorted including inclusion or exclusion criteria.
Results
and Discussion
1.
Characteristics of patiens cesarean section
Based on the total research subjects,
there were 72 pregnant women divided by age classification. The age group of
cesarean section patients in this study was 20-35 years old (68%). The largest
number was in the BMI group > 30 (obesity grade II) with a total of 31 people
(43.1%). The most indications for cesarean section patients are patients with a
history of previous cesarean section with a total of 30 people (30%). Most
patients were found in only 1 indication with a total of 37 people (51.4%). The
highest use of prophylactic antibiotics was cefazolin as many as 69 people
(95.8%).
In this study, bivariate analysis was also carried out to
compare the types of prophylactic antibiotics used in RSUD Dr. Soetomo for
patients after cesarean section. Based on table 3, the significance value of p
or p-value is 0.160, which means p> 0.05 which indicates that there is no
significant or statistically significant relationship between the incidence of
infection with the use of cefazolin and non-cefazolin antibiotics. It can also
be seen that the relationship strength parameter used in this study is the odds
ratio (OR) which is 11,000 with a 95% confidence interval (CI) having a lower
limit of 0.766 and an upper limit of 158.008.
According to the characteristics of the subjects based on
the patient's age in table 1, it can be seen that the total research subjects
amounted to 72 pregnant women who were divided based on age classification. The
age group of cesarean section patients in this study was 20-35 years old (68%).
While the least age group is <20 years (2.8%). This age group of cesarean
section patients is based on the risk of pregnancy, i.e. patients aged less
than 20 years and more than 35 years have a greater risk than those aged 20-35
years (Barutu, 2018). The
age group of 20-35 years has a smaller risk because they have psychological and
biological readiness in dealing with pregnancy and childbirth. At this age
range, the risk of pregnancy and childbirth is minimal, because at that range
the reproductive system has matured (Cunningham, 2005).
According to (Kartikasari
& Apriningrum, 2020) research, it was found that
out of 59 post-cesarean patients in the risky age category, there were 9
respondents (31.0%) who had surgical wound infections. The age of pregnant
women has no significant relationship with the incidence of surgical wound infection
in cesarean section patients. However, this is different from the results of
previous studies which showed that the average age of mothers who experienced
Surgical Site Infection was at the average age of 31 years and 32.5 years,
which was the age not at risk (Wardoyo, Tjoa, Ocvyanty, & Moehario, 2014).
Next in table 1 the subjects were divided based on the
characteristics of BMI in post-cesarean patients. Body Mass Index (BMI) is a
standard ratio of weight to height, and is often used as an indicator of
general health. BMI is calculated by dividing body weight (in kilograms) by the
square of height (in meters). The distribution of BMI is divided into 5 groups according
to WHO, a normal person's BMI is 18.5 � 22.9, a BMI less than 18.5 is said to
be underweight, a BMI of 23-24.9 is said to be overweight and if it is more
than 25 it is said to be obese. Obesity is divided into obesity grade 1 (BMI
25-29.9) and obesity grade 2 (BMI > 30) (Yuliasih, 2017). The
group of patients who are obese is at twice the risk of developing Surgical
Site Infection compared to mothers with normal weight (Rivai, Koentjoro, & Utarini, 2013)
and according to (Husen, 2012) Four
pharmacokinetic studies stated that the administration of cefazolin 2 grams was
inadequate in obese patients undergoing cesarean section because the drug
concentration was below the minimum inhibitory level so that it could increase
the risk of surgical wound infection. From Table 1, we can see that the
research subjects were divided into several based on the WHO BMI
classification. The largest number was in the BMI group > 30 (obese grade
II) with a total of 31 people (43.1%), while the smallest number was in the BMI
<18.5 (underweight) group with a total of 1 person (1.4%) and a total of 1
person (1.4%) Normal BMI is group 18.5-22.9 only 6 people (8.3%). According to
the research of Makani and Andayani (2019), 13 patients with obese BMI
experienced Surgical Site Infection (23.6%), and 8 patients with non-obese BMI
status experienced Surgical Site Infection (27.6%) and according to research by
(Rivai et al., 2013) BMI
shows that most respondents are in the non-ideal category (90.3%), either
because they are overweight or underweight.
C-section patients have a higher risk of infection. Based
on the risk, there are several factors or indications that cause a cesarean
delivery to be performed. The indications for cesarean section are umbilical
cord prolapse, placenta previa, placental abruption, disease in the mother with
pregnancy and repeat cesarean section, prolonged labor, malpresentation or
malposition, cephalopelvic disproportion, fetal distress (Cunningham, 2005). In
this study, the researchers divided into 5 categories, namely hypertension
induced preeclampsia, heart defects, location abnormalities, antepartum
bleeding and history of cesarean section. In this study, the researchers
divided into 5 categories, namely hypertension induced preeclampsia, heart
defects, location abnormalities, antepartum bleeding and history of cesarean
section. Based on table 1, it can be seen that the research subjects were
divided into several categories based on the indications for cesarean section.
The most indications for cesarean section patients were patients with a history
of previous cesarean sections with a total of 30 people (30%) and the least
indications for patients with cesarean section were cardiac abnormalities with
a total of 6 people (6%).
According to research Begum et al. (2017), a history of
cesarean delivery is a common indication. In this study, 24.1% of the total
patients had an indication of a previous cesarean delivery. Similar to (Barutu, 2018),
patients with an indication of a previous cesarean section had the highest
percentage of 39%, however, in this study, those with the same percentage were
indications for pre-eclampsia cesarean section. Indications for cesarean
section can be divided into two, namely absolute and relative. Absolute
indications are in the form of narrow pelvis, eclampsia and HELLP syndrome,
placenta previa, uterine rupture, and so on. If a patient has one absolute
indication, then the patient must undergo a cesarean section and relative
indications, namely a history of previous cesarean delivery, cardiotocographic
pathology, and so on (Mylonas & Friese, 2015).
Cesarean patients who already have one of the indications may have other
indications for a cesarean section. The indications set in this study are in
accordance with table 1. Based on table 1 it can be seen that patients
undergoing cesarean section are not only based on 1 indication. Most patients
were found in only 1 indication with a total of 37 people (51.4%) and the least
patients were in patients who had 3 indications at the same time with a total
of 5 people (7%). In (Barutu, 2018) the
indications for cesarean section were grouped into four, namely a group of one
indication to a group of four indications. The group of two indications was the
highest percentage of indication combinations in the study, which was 40%.
Cesarean delivery is a clean operation contaminated with a
risk of infection of more than 10% with the main risk of delivery by cesarean
section, namely the occurrence of surgical site infection. Infection can cause
complications after cesarean section which results in morbidity and mortality,
so prophylactic antibiotics are used to prevent the infection. Pathophysiology
Surgical wound infection is caused by microorganisms from the patient's normal
flora and the operating room environment. The potential for surgical wound
infections due to incisions in the abdominal and uterine walls, bacteria will
contaminate and infect the incision wound during surgery. Prophylactic
antibiotics are antibiotics given to patients who have not had an infection.
The purpose of giving prophylactic antibiotics is to prevent infection in
patients or prevent the emergence of dangerous diseases that are triggered by
infection (Brunton, Chabner, & Knollmann, 2018).
Table 1 shows that the most prophylactic antibiotics used were cefazolin as
many as 69 people (95.5%) while the antibiotics used were not cefazolin as many
as 3 people (4%). This is in accordance with (Barutu, 2018). In
cesarean delivery at SMF Obgyn RSUD Dr. Soetomo for the period of July-December
2017, there were two types of antibiotics used as prophylaxis, namely cefazolin
and ceftriaxone, Cefazolin was the prophylactic antibiotic with the highest
percentage, namely 96% and ceftriaxone with a percentage of 4%. According to (Aufa, 2018), the most
prophylactic antibiotics for post-cesarean section patients used by RSUD Dr.
Moewardi were cefadroxil as many as 34 patients, after that cefaozlin as many
as 16 patients, and the least was vicillin-amoxicillin, dexamethasone,
ceftriaxone-metronidazole, ampicillin-metronidazole and vicillin-ampicillin 1
patient each. In accordance with the guidelines for the use of prophylactic
antibiotics in obstetric and gynecological surgery, cefazolin is the antibiotic
of choice for prophylaxis, because the bacterial spectrum covers the area of
the surgical wound (Barutu, 2018) and
Based on the accuracy of the selection of prophylactic antibiotics, POGI (2013)
recommends cefazolin as a prophylactic antibiotic (Soejoenoes, A., Moegni, E. M., Kuntaman, Santoso, B. I.,
& Hadi, 2013). The use of prophylactic
antibiotics must be used rationally, there are several things that need to be
known with the use of prophylactic antibiotics in cesarean section patients,
namely the 4T, namely the right indication, the right drug, the right time and
method of administration, and the right dose according to the standards of the
Minister of Health of the Republic of Indonesia Number 2406/Menkes/
Per/XII/2011 concerning Guidelines for the Use of Antibiotics Clinical Practice
Guidlines for Antimicrobial Prophylaxis in Surgery.
In table 2 it can be seen that the infection in patients
who used cefazolin as a prophylactic antibiotic was 3 of the total patients who
were given Cefazolin, namely 69 people, while the incidence of infection who
did not use cefazolin prophylactic antibiotics was 1 patient out of 3 patients.
Based on the percentage of 72 samples of post-cesarean patients, it was found that
4 patients (4.2%) had Surgical Site Infection and 69 patients (95.8%) did not.
According to research by (Rivai et al., 2013) from
154 patients who underwent cesarean section, it was found that 12 (7.8%) had
Surgical Site Infection and 142 (92.2%) did not. The risk factors that increase
the occurrence of Surgical Site Infection according to the Ministry of Health
in 2011 include the patient's condition, operating procedures, types of
surgery, and post-infection care.
In this study, bivariate analysis was also carried out to
compare the types of prophylactic antibiotics used in RSUD Dr. Soetomo for
patients after cesarean section and obtained a significant p value or p-value
of 0.160 which means p> 0.05 which indicates that there is no statistically
significant or significant relationship between the incidence of infection with
the use of cefazolin and non-cefazolin antibiotics. In this study, it was found
that P was not significant, it could be due to the very small number of
patients using non-cefazolin prophylactic antibiotics. It can also be seen that
the relationship strength parameter used in this study is the odds ratio (OR)
which is 11,000 with a 95% confidence interval (CI) having a lower limit of
0.766 and an upper limit of 158.008. This shows that patients with cesarean
section who use cefazolin antibiotics are 11 times more likely to not get
infection compared to patients with cesarean sections who use non-cefazolin
prophylactic antibiotics. So in this study, although p does not mean that the
use of non-cefazolin antibiotics is more at risk of infection than cefazolin
antibiotics. In addition, based on the accuracy of the selection of prophylactic
antibiotics, (Soejoenoes, A., Moegni, E. M., Kuntaman, Santoso, B. I.,
& Hadi, 2013) recommends cefazolin as a
prophylactic antibiotic, so that the antibiotic cefazolin is appropriate to be
used as a prophylactic antibiotic in RSUD Dr. Soetomo.
Conclusion
There is a relationship between the use of pre-operative
prophylactic antibiotics to the prevention of infection after cesarean section
at RSUD Dr. Soetomo Surabaya in the period January 2021�June 2021.
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