Chlorhexidine is the preferred agent for vaginal antisepsis prior to cesarean delivery: a systematic review and network meta-analysis.

Summary

Across 50 trials (n=14,515), vaginal antisepsis before cesarean delivery reduced postoperative infectious morbidity, with chlorhexidine consistently ranking as most effective. Concentration-stratified analyses identified 0.2% chlorhexidine as the top option for wound infection reduction, and results were robust across subgroups and sensitivity analyses.

Key Findings

• Vaginal antisepsis reduced endometritis, wound infection, wound complications, and postpartum fever versus no preparation.
• Chlorhexidine was most consistently effective; 0.2% chlorhexidine achieved the highest SUCRA for wound infection (0.995).
• Compared to chlorhexidine, no preparation had higher odds of endometritis (OR 3.65), wound infection (OR 2.34), wound complications (OR 2.28), and fever (OR 3.60).
• Findings were consistent across subgroup and sensitivity analyses, with integrity screening of trials.

Clinical Implications

Adopt chlorhexidine for pre-cesarean vaginal antisepsis, preferentially near 0.2% when available; standardize protocols and documentation of concentration. Incorporate into infection prevention bundles alongside antibiotics.

Limitations

• Heterogeneity in antiseptic concentrations and formulations across trials
• Some agents (e.g., clindamycin, cetrimide) supported by few small trials; reliance on indirect comparisons for ranking

Future Directions

Head-to-head RCTs comparing chlorhexidine concentrations; standardization of outcome definitions and follow-up; assessment of safety and tolerance across concentrations.