Cesarean section has become one of the most frequently performed operations in the world. Roughly one in five women now give birth by cesarean, and this proportion is projected to approach 29% by 2030, with most of the growth expected in low- and middle-income countries (1). Pakistan has followed the same course; national survey data show cesarean births rising from 2.7% in 1990 to 22.3% by 2017 (2). When vaginal birth is unsafe the operation saves lives, yet each additional procedure also adds to the number of women exposed to surgical complications.

Surgical-site infection (SSI) is the most frequent of these complications. A recent meta-analysis of 49 cohort studies placed the overall incidence of SSI after cesarean section at about 7%, with an incidence of 8% in low- and middle-income countries against 5% in high-income settings (3). Pooled estimates from Africa have exceeded 10%, and rupture of membranes before delivery raised the odds of infection almost six-fold (4,5). Apart from the suffering it causes, wound infection lengthens hospitalisation, delays recovery and places an avoidable financial burden on families and health services (6).

The risk is shaped by maternal as well as procedural factors. In a large British cohort, high BMI, smoking and emergency operation were each independent predictors of SSI (7), while a Norwegian case-control study recorded infection after 5.4% of emergency but only 0.4% of elective cesareans (8). An analysis of more than 78,000 cesarean sections in the German national surveillance network likewise found that urgency roughly doubled the SSI rate and remained significant after multivariable adjustment (9). Emergency procedures commonly follow prolonged labour or ruptured membranes, and there may be little opportunity to optimise the mother, prepare the skin carefully or give prophylactic antibiotics at the ideal time (10). In one Indian tertiary hospital, inappropriate pre-surgical antibiotic prophylaxis was among the factors most strongly associated with post-cesarean SSI (11).

In Pakistan, public-sector maternity units manage heavy caseloads and many unbooked emergency referrals, and infected cesarean wounds remain a familiar clinical problem that often requires weeks of dressings before healing (12). Even so, local comparative data quantifying how much more often emergency procedures become infected than planned ones are limited, and such figures are needed to guide infection-control priorities in obstetric theatres. The present study was therefore undertaken to compare the rate of wound infection after emergency and planned cesarean section, and to describe differences in maternal characteristics, operative duration, antibiotic use and length of hospital stay between the two groups.

This comparative cross-sectional study was carried out in the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital Abbottabad from January 2026 to June 2026. Written informed consent was obtained from all participants the requirement for consent was waived for record review, and patient identity was kept confidential throughout. A total of 60 women who underwent cesarean section were included through [consecutive non-probability sampling], 30 of whom had a planned procedure and 30 an emergency procedure. [Inclusion and exclusion criteria to be stated by the authors, for example singleton pregnancy and exclusion of women with pre-existing skin or systemic infection.] A planned cesarean section was defined as one scheduled in advance for a recognised obstetric indication, whereas an emergency cesarean section was one performed for an acute maternal or fetal indication arising before or during labour. For every woman, maternal age in completed years, BMI in kg/m², parity, gestational age in completed weeks, duration of surgery in minutes, administration of perioperative antibiotic prophylaxis (yes or no) and length of postoperative hospital stay in days were recorded on a structured proforma. The primary outcome was wound infection, recorded as present or absent during the postoperative period [according to the CDC surgical-site infection criteria, if applied; state the follow-up duration]. Statistical analysis was performed with the SciPy library (version 1.18) in Python. Continuous variables were expressed as mean ± standard deviation and compared between the two groups with Welch's independent-samples t-test, which does not assume equal variances; mean differences were reported with 95% confidence intervals and effect sizes as Cohen's d. Categorical variables were expressed as frequencies and percentages and compared using Pearson's chi-square test, with Fisher's exact test applied wherever an expected cell count was below five. The strength of association between emergency surgery and wound infection was expressed as relative risk, odds ratio and absolute risk difference, each with a 95% confidence interval. Because antibiotic administration differed between groups, a sensitivity analysis was repeated after restricting the sample to women who received prophylaxis. A two-sided p-value below 0.05 was considered statistically significant.

Sixty women were analysed, 30 in each group. The two groups were similar in age and parity. Women undergoing emergency cesarean section had a significantly higher mean BMI than those undergoing a planned procedure, with a mean difference of 2.46 kg/m² (p = 0.003), and they were delivered about one week earlier on average (37.6 vs. 38.5 weeks, p < 0.001). These baseline comparisons are shown in Table 1.

Table 1. Baseline maternal characteristics according to type of cesarean section

Values are mean ± SD. Mean difference = emergency minus planned. Welch's independent-samples t-test.

Operative and postoperative characteristics are compared in Table 2. Emergency operations lasted on average 32.7 minutes longer than planned ones, a very large effect (Cohen's d = 2.89, p < 0.001). Hospital stay was nearly two days longer after emergency surgery (p < 0.001). Every woman in the planned group received perioperative antibiotic prophylaxis, compared with 26 of 30 (86.7%) in the emergency group; this difference did not reach statistical significance (Fisher's exact p = 0.112).

Table 2. Operative and postoperative characteristics according to type of cesarean section

Values are mean ± SD or n (%). d = Cohen's d. Welch's t-test for continuous variables; Fisher's exact test for antibiotic use.

Overall, 23 of 60 women (38.3%) developed a wound infection. As shown in Table 3, infection occurred in 19 of 30 (63.3%) emergency procedures compared with 4 of 30 (13.3%) planned procedures (χ² = 15.86, df = 1, p < 0.001; Fisher's exact p < 0.001). The absolute risk difference was 50.0 percentage points, which corresponds to one additional wound infection for every two emergency procedures when compared with planned surgery. Women undergoing emergency cesarean section had a 4.75-fold higher risk and 11.23-fold higher odds of wound infection.

Table 3. Wound infection according to type of cesarean section

Reference category: planned cesarean section. Confidence intervals for relative risk and odds ratio were calculated on the log scale.

Because four women in the emergency group did not receive prophylaxis, the role of antibiotics was examined further (Table 4). Infection was more frequent among women who did not receive antibiotics (75.0% vs. 35.7%), although the very small number in this subgroup meant that the difference was not significant. Within the emergency group, infection rates were similar with and without prophylaxis. When the analysis was restricted to the 56 women who received antibiotics, emergency surgery remained strongly associated with wound infection (RR 4.62, 95% CI 1.76–12.07; p < 0.001), indicating that the main finding was not explained by differences in antibiotic use.

Table 4. Antibiotic prophylaxis and wound infection, with sensitivity analysis restricted to antibiotic recipients

n/N = infected women/women in the subgroup. The first data column is the first-named category in each comparison.

The central finding of this study is that wound infection was almost five times as likely after emergency cesarean section as after a planned operation, with rates of 63.3% and 13.3% respectively. The absolute difference of 50 percentage points means that, in this cohort, one extra infection occurred for every two emergency procedures. The direction of this association agrees with most of the published work. Sree et al. reported more infections after emergency than elective obstetric surgery in South India (13), Snehaa et al. found that emergency surgery was among the predictors of SSI and that the cesarean stitch line had the highest infection rate of all procedure categories (14), and Liu et al. identified emergency cesarean delivery as an independent predictor of poor wound healing in women with gestational diabetes (15). Large surveillance data from Norway and Germany point the same way (8,9). The size of the effect in our study was greater than in most of these reports, which may reflect the risk profile of women who need emergency surgery in busy public hospitals, many of whom arrive after prolonged labour or referral from another facility. Operative duration was one of the clearest differences between the groups. Emergency procedures lasted on average more than half an hour longer, and the effect size was very large. A longer operation keeps the wound open to the theatre environment for longer, increases tissue handling and may mean that the protective level of a single prophylactic dose falls before closure. Liu et al. found that an operating time of one hour or more more than doubled the risk of wound complications (15), and Erenberg et al. retained surgery lasting longer than 60 minutes as a covariate when modelling post-cesarean infection (16). In emergency settings, longer surgery may also be a marker of difficulty, such as a deeply engaged head, adhesions from previous surgery or haemorrhage, each of which carries its own infection risk. Women in the emergency group were also heavier. Obesity is one of the most consistently reported risk factors for cesarean wound infection, through a thicker subcutaneous layer, poorer tissue perfusion and greater wound tension. Gadeer et al. linked higher BMI to wound infection in a Saudi cohort (17), and Erritty et al. reported a four-fold increase in risk among women with a BMI of 35 kg/m² or more (7). Because our analysis was unadjusted, part of the difference between the groups could reflect BMI rather than urgency alone, and this possibility should be addressed in larger studies with multivariable modelling. Antibiotic prophylaxis deserves particular attention. All women undergoing planned surgery received prophylaxis, but four emergency cases had no record of it, and three of these four developed an infection. Current guidance recommends that prophylaxis for cesarean section be given before skin incision rather than after cord clamping (18), and inappropriate prophylaxis was linked to higher SSI rates in a North Indian hospital (11). Choice of agent seems less critical than timing and reliable delivery; in a South African trial of more than 1,000 women, adding metronidazole to cefazolin did not lower infection rates (19). Importantly, our sensitivity analysis showed that the excess risk after emergency surgery persisted among women who did receive antibiotics, suggesting that missed doses explain only a small part of the gap. Even so, a missed dose in an emergency is a preventable system failure, and checklists that make prophylaxis a mandatory step before incision would close it. Several inexpensive interventions could narrow the difference. Vaginal cleansing with povidone-iodine or chlorhexidine immediately before cesarean delivery reduces post-cesarean wound infection, and the benefit appears greatest in women who are already in labour (20). A recent meta-analysis restricted to emergency cesarean deliveries confirmed lower rates of endometritis and postoperative fever with this simple step (21). Chlorhexidine-based skin preparation probably lowers SSI slightly more than povidone-iodine (22), and monofilament subcuticular sutures have been associated with fewer infections than multifilament material (23). A recent review from Pakistan has proposed a context-sensitive checklist that combines such pre-, intra- and postoperative measures for low-resource settings (24), and adopting a bundle of this kind in emergency theatres seems a sensible next step. The overall infection rate of 38.3% is clearly higher than the pooled estimates of 7% to 11% reported in meta-analyses (3,5). Differences in case mix, outcome definition and the intensity of wound surveillance make direct comparison difficult, and the small sample means that our estimates carry wide confidence intervals. Nevertheless, even the 13.3% observed after planned surgery exceeds most international benchmarks, which suggests that factors affecting both groups, including theatre environment, postoperative wound care and hygiene at home, need review alongside the specific problems of emergency surgery. The longer hospital stay after emergency cesarean section is consistent with the known cost of wound infection (6), though prolonged stay may also reflect the obstetric problems that prompted emergency delivery in the first place. The main strength of the study is the direct comparison of two equal-sized groups using the same set of maternal and operative variables, together with a sensitivity analysis addressing antibiotic use. Its limitations should also be recognized. The sample was small and drawn from a single centre, which limits precision and generalizability. Important variables were not available, including diabetes, duration of labour and of ruptured membranes, number of vaginal examinations, indication for surgery, type of skin closure, blood loss and the timing of antibiotic doses relative to incision. Wound infection was recorded as a binary outcome without microbiological confirmation or grading of severity. Finally, the analysis was unadjusted, so the association between emergency surgery and infection may be partly confounded by BMI, gestational age and operative duration.

Emergency cesarean section was associated with a markedly higher rate of wound infection than planned surgery, with an almost five-fold increase in risk that persisted among women who received prophylaxis. Emergency operations were also longer and were followed by longer hospital stay. Ensuring that antibiotic prophylaxis is never omitted, applying the same standard of asepsis in emergency and elective theatres, and following up high-risk women closely after discharge could reduce this burden. Larger multicentre studies with adjusted analyses are needed to identify the modifiable factors that drive the excess risk.

Declarations

Acknowledgements

The authors thank the nursing and theatre staff of the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital Abbottabad, for their help with data collection, and the women who took part in the study.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Conflict of Interest

The authors declare no conflict of interest.