This randomized double blind clinical trial was carried out at public clinical training hospital of Hajar, Shahrekord, Iran from December 2013 to March 2014. Subjects included 90 pregnant women who underwent elective cesarean delivery and had fulfilled the consent form to enter the study. Objective and type of the study and how it will be carried out were explained to all eligible subjects and the consent form was filled by all of them. Exclusion criteria were PROM more than three hours, symptoms of endometritis, fever of any cause (temperature above 38°C), diabetes, abuse of immunosuppressive drugs and bleeding. The patients enrolled for the study were randomly assigned to two groups of 45 individuals, including the rinsed 500ml of normal saline solution during cesarean delivery (intervention group) and non-rinsed (control group). Samples of vaginal discharge cultures for GBS and other pathogens affecting postoperative complications were routinely taken of the patients before cesarean and sent to a laboratory. The sample culture and urine analysis were taken from all patients in a sterile manner. In this study, both groups underwent the same surgery in terms of open abdominal surgery, repair of layers, peritoneum and rectus muscle suturing with same duration and condition of surgery. For all patients, foley catheter was used during operation. Patient’s abdomen was scrubed with betadine (usual method). Then, abdomen and the uterus was opened and the baby was delivered. After delivery and cord clamping, a dose of one gram of intravenous antibiotics cefazolin was injected to all patients. Corpus luteum placenta and uterus was evacuated spontaneously. The control group did not receive any intervention before the involution of the uterus but in the intervention group, the uterine was thoroughly cleansed by 500-1000 mL of saline [7] and, the additional serum was cleaned from the operating section by suction method. Uterine lining was repaired by chromic suture and in three layers and the abdominal cavity, and paracolic and the posterior vagina was completely scrubbed and became quite clean from clots, vernix and meconium. All layers of the abdominal wall were repaired. Postoperative care were done by obstetrics and gynaecology residents and supervised by the researcher. Temperature was measured by mouth (orally) every 6 hours and high fever (oral temperature greater than 38°C) was evaluated every 6 hours for 24 hours after operation. After discharge, patients were not given antibiotics. All of the Patients were examined in terms of the probability of mastitis, vein thrombosis of the lower extremities, urinary tract infection (urine culture) and in the case of fever incidence. Patients after discharge were examined to determine postoperative complication including bleeding, fever, wound infection, the data related to postoperative gastrointestinal complications and endometritis at the second day and one and six weeks postoperation were collected.

All data were entered and analysed by using SPSS software version 17. Statistical analysis of the data was performed using the chi-square test to compare percentages between groups and Student’s t-test for correlated means.

In this study, statistical analysis showed that there was no statistically significant difference between two groups regarding age, parity, mean of gestational age and mean weight (p>0.05) [Table/Fig-1]. Possible febrile complication factors like recent respiratory infection, recent urinary infection and previous medical history was examined. The result of the study indicated that no case of fever, wound infection and endometritis was observed at the second day after surgery in intervention and control groups. Abnormal bleeding after cesarean delivery was observed in the control group in 4.4% of cases, but there was no statistically significant difference between the groups (p=0.21). The incidence of fever one week after the surgery was 2.2% and 8.9% in intervention and control groups respectively. Although febrile morbidity was slightly higher in the control than intervention group, this difference was not statistically significant (p=0.16). There was no significant correlation between the incidences of wound infection one week after the surgery in two groups but the incidence of wound infection was 11.1% and 8.9% in the intervention and control groups respectively. The incidence of endometritis in the first week after cesarean delivery showed no significant difference between the two groups. Postoperative febrile morbidity at 6 weeks post-surgery in the two groups was not statistically significant (p=0.15). Although the incidence of wound infection was not statistically significant in two groups, it is considerable that the cases of incidence of infection were much less in the intervention than the control group (7.7% and 15.6% the in intervention and the control groups, respectively). Incidence of endometritis at 6 weeks post-surgery was 6.7% and 26.7% in the intervention and control groups, respectively there was statistically significant difference between intervention and control groups (p=0.011). In comparison to uterine cavity cleansing on the postoperative gastrointestinal symptoms, nausea and vomiting after surgery and defecation timing and the incidence of nausea and vomiting during the early postoperative hours were 11.1% and 24.4% in the intervention and control groups, respectively (p=0.09). In 24.4% of the intervention group and 46.7% of control groups, time of defecation was more than 12 hours after surgery. This difference was statistically significant between two groups (p=0.02). In comparison, postpartum hemorrhage between the two groups was not statistically significant. The mean of labor lochia was 39.6% in control group and 37.4% in the intervention group that was 2 days fewer in the intervention group. In the examination of incidence rate of endometritis, fever and wound infection, vaginal discharge, except in cases where the culture was pathogenic organisms (GBS and Staph), no statistically significant relationship was observed between complications and the cultured organisms [Table/Fig-2].

The uterus cavity cleansing is a simple method that can cause the reduction of wound infection and febrile morbidity [5]. In this study, 6 weeks postoperative endometritis was considerably and significantly reduced by washing the uterine cavity. The incidence of fever, febrile morbidity and wound infection 6 weeks post-surgery was less in intervention group than control group, although this difference was not significant. Different studies have investigated uterine cavity cleansing with normal saline solution or with antibiotics. Lewis in his study compared rinsing uterine with saline and Cefoxitin and Ticarcillin with each other in the incidence of infection after caesarean and came to the conclusion that rinsing with antibiotics reduces postoperative febrile morbidity [8]. In a study by Memon et al., vaginal cleansing with 10% pyodine had shown a statistically significant reduction in postoperative composite infectious morbidities [9] and it showed a statistically significant reduction in the incidence of post caesarean endometritis. In contrast, in study by Viney aimed at evaluating the efficacy of antibiotics on wound infection and febrile morbidity, it has been shown that rinsing with antibiotics does not reduce fever, abdominal complication [10]. It was noteworthy that the cost of this method is relatively high and does not have special impact on the complications after cesarean delivery. In our study, it was suggested that rinsing with normal saline solution is cost effective compared to the use of antibiotics and cause reduction in infection and endometritis after cesarean delivery. In a study by Gungorduk, it was demonstrated that although rinsing with saline reduces caesarean wound infection, this reduction was not statistically significant [11]. In the study by Viney, intraoperative vomiting was more in the group who had underwent rinsing but there was no statistically significant difference in terms of vomiting during operation, chorioamnionitis, endometritis, postoperative vomiting and febrile morbidity after surgery [10]. In our study, vomiting during the first hours after surgery was less and it can be said that uterine cavity cleansing and full suction of discharge can be helpful in reducing nausea and vomiting after surgery. Due to pathogenic factors in the incidence of endometritis after cesarean, intrapartum vaginal culture is considered as a unique measure in this study. In one study, the percentage of incidence of cultured factors through vagina and cervix were compared considering the complications after cesarean delivery. The results showed that there was no significant difference in the incidence of complications after cesarean delivery between the two groups showing culture of pathogenic and non-pathogenic vaginal discharge [12].

The size of study sample was small. This study suggested that further studies are needed with larger sample size for evaluating infection, as well as complications like pain and discomfort during and after surgery until 6 weeks and the impact of uterus cavity cleansing on the possibility of adhesion after caesarean and its impact on endometriosis after cesarean.

Although in the current study, the reduction was not statistically significant in intervention group. Still, uterine cavity cleansing with normal saline solution during cesarean delivery may decrease postoperative complication. Further studies on larger group, at different institutes are suggested to validate the results.