We identified seven articles that reported the rate of endometritis following cesarean delivery. There were 1298 cases of endometritis Brefeldin A among 41,569 deliveries, for an overall rate of endometritis rate following cesarean delivery of 3.1% (Table 5). Similarly, we identified 18 articles reporting the rate of SSI after cesarean delivery. There were 68,424 cases of SSI among 1,440,104 deliveries, for an overall rate of SSI after cesarean of 4.8% (Table 5). However, these crude infection rates do not take into account the a priori surgical risk of the patient. Table 5 Rates of Infection Following Cesarean Delivery To address this limitation, the 2009 NHSN report published pooled mean rates of SSI after cesarean delivery of 1.46%, 2.43%, and 3.82% for risk index category 0, 1, and 2/3, respectively.

7 Although comparison to a national benchmark is helpful for individual institutions to gauge their clinical performance, there are a number of limitations to the utilization of 2009 NHSN risk categorization benchmarks. First, the 2009 NHSN report only describes the rate of SSI following cesarean delivery without considering the rate of endometritis. Second, rates of SSI are based on voluntary reporting data from only 59, 61, and 52 hospitals for risk index categories 0, 1, and 2/3, respectively.7 Given the lack of mandatory reporting and the limited number of hospitals, this may not qualify as an accurate national representation. Finally, the data do not distinguish between low-risk community and high-risk academic institutions, which limits the ability to make an accurate comparison to national benchmarks for high-risk patients.

With known risk factors for wound infection such as body mass index (BMI),8 diabetes, and severe hypertension,9 an institution that delivers patients with many of these pre-existing conditions is likely to have a higher rate of postcesarean infectious morbidity. Furthermore, for some procedures, the focus on length of surgery, wound classification, and ASA score within the NHSN criteria may not be useful. In some surgical specialties, these three variables have not been associated with an increased risk of infection, may not be particularly important in the risk they confer, and should likely be replaced by other more important risk factors.

For example, a recent study demonstrated that Drug_discovery inclusion of BMI and the presence of labor resulted in significant improvement in predictive performance for a postcesarean infection when compared with procedure duration, wound class, and ASA score alone.10 For the obstetric population, there is little variation in the ASA score between patients (most with an ASA score of I or II [Table 4]) and in the duration of operating time (usually less than the established cutpoint of 56 minutes). The 2009 NHSN scoring system does not allow such stratification of high-risk patients and does not consider risk factors that may develop during the intrapartum period.