Vaginal prep prior to cesarean section

[Ruralnurse76]

Our small hospital has historically prepped the abdomen with Chlorahexadine prior to a cesarean section (Iodine in emergences to avoid dry time). We have been told by our OB educator that we need to change our practice to include a vaginal prep prior to surgery. They want us to prep the Vagina with Chlorahexadine. I have two issues with this recommendation.

1. I understand that research backs this up, that this should reduce the rate of infection, but the vagina isn't in our surgical field. It will have a nonsterile blanket over it after it's prepped which would totally contaminate the area. If we are doing a vaginal prep, we should do a real prep with stirrups and sterile sleeves over the stirrups. However, placing the patient in stirrups would prevent us from placing a safety strap to keep her safely secured on the bed.

2. They are recommending that we prep with chlorahexadine, which is contraindicated on mucous membranes. It says right on the manufactures IFUs "do not use in vagina." We're told it's "an off label use" and they have been doing it for years at our bigger sister facility.

As a surgical nurse, I'm a stickler for following the standards of care. In this case, I'm just finding the logic contradictory and it's causing me angst. Can anyone help me understand or give me an alternative I can propose to management?

[Rose_Queen, BSN, MSN, RN]

1. It's not part of your sterile, draped field, but is actually part of the surgical anatomy. Think about a patient in labor and even many before labor starts- cervical dilation means an enlarged opening between the vagina and uterus, an initiating path for normal flora to head north into the uterus. The unsterile blanket covers the patient, but doesn't actually contaminate the prep unless the blanket is inside the vagina. All of my abdominal hysterectomy cases have included a vaginal prep with the patient in supine position with a blanket over the lower body.

2. ACOG has provided guidance for utilizing CHG for vaginal preps. And in fact, it's fairly established data with articles going back to at least 2019. Many medications and treatments are used off label. Heck, my migraine medication started out as a cardiac med! It may simply be the preference of the providers to use CHG instead of povidone-iodine based on the ACOG guidance.

NOTE: This applies to using CHG, brand name being Hibiclens, Exidine, etc. and not CHG+alcohol, AKA Chloraprep intravaginally. 

[Ruralnurse76]

Thank you. I've been reading a lot of research articles that support what you are saying,  but it helps hearing how you do it.