Dear Respectable Editors and Reviewers Please, see my comment as a reviewer for the article entitled (Surgical site infections after cesarean delivery: epidemiology, prevention and treatment) published in the Matern Health Neonatol Perinatol. 2017; 3: 12 online 2017 Jul 5. Doi: 10.1186/s40748-017-0051-3.

Regarding the abstract and reference sections The abstract is unstructured abstract missing the background which inserted after the abstract by the authors. In addition; the abstract missing the objectives of the article and the methods used for collection of the data used in this review article.
Title is informative and relevant, but the authors should mention in the title that their article is review article. References of the article is relevant to the review article and referenced correctly using the Vancouver style and the appropriate key studies included in the references. Unfortunately; the article published in 2017 and approximately 62% (51/82) of the references older than the last 5 years.

Regarding the abstract section In my opinion the information mentioned in the abstract section can be mentioned under the title of introduction for this review article Authors identified the magnitude of the problem clearly in the abstract section (authors mentioned that; cesarean delivery (CD) is one of the most common procedures performed in the United States, accounting for 32% of all deliveries. Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and burden to the health care system). In addition; they mentioned that SSIs complicate a significant number of patients who undergo CD – 2-7% will experience sound infections and 2-16% will develop endometritis (as another burden and/or magnitude for the SSI problem). They also mentioned the suggested effective interventions to decrease SSI which include; prophylactic antibiotic use, chlorhexidine skin preparation instead of iodine, hair removal using clippers, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples.

Regarding the methods section The article missing the methods used for collection of the data used in this review article. How the authors collected the data mentioned in their review article. Example; the authors collected the data for this review article after PubMed or Cochrane data base search using the key words; surgical, site, infection, cesarean delivery and reviewing the article published from year 2012 to year 2017.

Epidemiology section In my opinion; the epidemiology section data should be mentioned under the title of the results section, where the authors can mention the wound complications, relative risk, and odds ratio of SSI in different previous studies. In addition; they can mention the risk factors and the suggested preventive measures for SSI in different previous studies. The authors mentioned and defined in the epidemiology section the wound complications (wound hematoma, seroma, dehiscence, wound infection and necrotizing fasciitis and endometritis) and the incidence of each of those complications. In addition; the authors mentioned the risk factors for SSI as measured by the relative Risk and odds ratio.
They also mentioned the risk factors of SSI; pre-operative risk factors (subcutaneous hematoma, tobacco use in pregnancy, limited prenatal care, obesity (BMI > 30-35 kg/m2), corticosteroid use, nulliparity, twin gestations, hypertensive disorders with pregnancy, gestational and pre-gestational diabetes and previous CD). Intrapartum risk factors (chorioamnionitis, premature rupture of membranes, prolonged rupture of membranes, prolonged labor, prolonged second stage, large incision length, subcutaneous tissue thickness > 3 cm, subcutaneous hematoma, lack of antibiotic prophylaxis, emergency delivery, operating time ≥ 38 min and excessive blood loss). They also mentioned the suggested effective interventions to decrease or prevent the SSI which include; include prophylactic antibiotic use, chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples.

Regarding the results section The authors did not provide the results section. In my opinion; the epidemiology section data should be mentioned under the title of the results section, where the authors can mention the wound complications, relative risk, and odds ratio of SSI in different previous studies. In addition; they can mention the risk factors and the suggested preventive measures for SSI in different previous studies.

Burden to healthcare systems and the prevention section The authors did not provide a discussion section In my opinion; the authors can insert the data mentioned under the titles burden to healthcare system and the prevention section under the title of discussion. In the discussion section they can start the discussion by the burden of the condition on the health care system followed by the suggested measures from their side to prevent the SSI and support their suggested measures by the meta-analysis, RCTs or Cochrane, ACOG or CDC recommendations. Then, at the end of the discussion, they can suggest and recommend the development of SSI bundles for each hospital and future studies. The authors mentioned the burden of SSI to healthcare system that postpartum infections are a major cause of prolonged hospital stay and comprise a large burden to their health care system (attributed additional costs of $3700 for wound infection and an additional $4000 for endometritis). Authors mentioned this burden as the magnitude and the burden of the SSI on health care system followed by the preventive measures for the SSI. In the prevention section they mentioned that the preoperative, intraoperative and post-operative suggested preventive measures to decrease and/or avoid the SSI problem; Preoperative suggested preventive measures include; 1. Preoperative antibiotics (first generation cephalosporin) and support their recommendation by the results of metanalysis and American College of Obstetricians and Gynecologists (ACOG) recommendations. 2. Chlorhexidine alcohol skin preparation and provide the results of two randomized controlled trials (RCTs). 3. Use of clippers instead of razor and support their recommendation by the Cochrane data base meta-analysis. 4. Preoperative vaginal cleansing and support their recommendation by the Cochrane Data base meta-analysis Intraoperative suggested preventive suggested measures include; 1. Uterine exteriorization (they used a meta-analysis comparing in situ and by uterine exteriorization). 2. Removal of placenta by traction of umbilical cord (they used a meta-analysis which concluded that manual removal of the placenta associated with a higher risk of endometritis). 3. Intra-abdominal irrigation (they used findings of previous two studies and concluded that evidence does not support use of routine intraabdominal irrigation). 4. Suture closure of subcutaneous tissue if wound thickness > 2 cm (they supported their suggestion by the results of meta-analysis of randomized controlled trials (RCTs)). 5. Subcutaneous drain (routine subcutaneous drain is not recommended and supported their recommendation by the RCTs of 280 women). 6. Suture skin closure instead of staple closure (routine staple skin closure is not recommended and they recommended further studies to compare skin closure with staple closure in vertical skin incision). 7. Prophylactic negative pressure wound therapy (authors mentioned that data on prophylactic negative pressure wound therapy after CD are limited and they recommended large RCTs trials). Post-operative suggested measures include; 1. Dressing removal between 24 and 48 h and authors supported their recommendation by the Centers for Disease Control (CDC) recommendations. 2. Daily use of chlorhexidine gluconate soap after removal of dressing (authors mentioned that the information on daily use of chlorhexidine gluconate soap after dressing removal in women after CD is limited and recommended further studies). In addition; authors recommended the development of SSI bundles for each hospital. The authors mentioned also the management of infected wound which include; antibiotics, incision and drainage, wound dressing, delayed closure and management of endometritis.

Regarding the discussion The authors did not provide a discussion section In my opinion; the authors can insert the data mentioned under the titles burden to healthcare system and the prevention section under the title of discussion. In the discussion section they can start the discussion by the burden of the condition on the health care system followed by the suggested measures from their side to prevent the SSI and support their suggested measures by the meta-analysis, RCTs or Cochrane, ACOG or CDC recommendations. Then, at the end of the discussion, they can suggest and recommend the development of SSI bundles for each hospital and future studies. Unfortunately, the authors did not mention the strength and/or the limitation of their review article. In addition; they did not mention the future recommended studies or directions. Regarding the conclusion section Authors mentioned in the conclusion clearly the complex situation of SSI following Cesarean delivery, the burden of health care system and the suggested creation bundles of evidence-based elements may decrease the rates of post-CD SSIs.

Overall The review article trying to solve the burden of the SSI and trying to mention the suggested preventive measure for such problem. Unfortunately, the review article has major weakness and flaws in its design and its structure as a review article including; 1. Authors did not mention in the title that their article is review article. 2. Regarding the methods section; the article missing the methods used for collection of the data used in this review article. How the authors collected the data mentioned in their review article. Example; the authors collected the data for this review article after PubMed or Cochrane data base search using the key words; surgical, site, infection, cesarean delivery and reviewing the article published from year 2012 to year 2017. 3. Authors did not provide the results section and in my opinion; the epidemiology section data should be mentioned under the title of the results section, where the authors can mention the wound complications, relative risk, and odds ratio of SSI in different previous studies. In addition; they can mention the risk factors and the suggested preventive measures for SSI in different previous studies. 4. The authors did not provide the discussion section. In my opinion; the authors can insert the data mentioned under the titles burden to healthcare system and the prevention section under the title of discussion. In the discussion section they can start the discussion by the burden of the condition on the health care system followed by the suggested measures from their side to prevent the SSI and support their suggested measures by the meta-analysis, RCTs or Cochrane, ACOG or CDC recommendations. Then, at the end of the discussion, they can suggest and recommend the development of SSI bundles for each hospital and future studies.

Overall statement or Summary The authors in their review article identified the burden and the cost of the SSI after CS on the health care system. Authors mentioned the risk factors of SSI (preoperative, intraoperative and postoperative risk factors) and their suggested preventive measure for prevention of SSI.

Specific points of weakness Major flaws of the article 1. Authors did not mention in the title of the article that its review article. 2. Regarding the methods section; the article missing the methods used for collection of the data used in this review article. How the authors collected the data mentioned in their review article. 3. Authors did not provide the results section and in my opinion; the epidemiology section data should be mentioned under the title of the results section, where the authors can mention the wound complications, relative risk, and odds ratio of SSI in different previous studies. In addition; they can mention the risk factors and the suggested preventive measures for SSI in different previous studies. 4. The authors did not provide the discussion section. In my opinion; the authors can insert the data mentioned under the titles burden to healthcare system and the prevention section under the title of discussion. In the discussion section they can start the discussion by the burden of the condition on the health care system followed by the suggested measures from their side to prevent the SSI and support their suggested measures by the meta-analysis, RCTs or Cochrane, ACOG or CDC recommendations. Then, at the end of the discussion, they can suggest and recommend the development of SSI bundles for each hospital and future studies.

Minor points of weakness in the article 1. Abstract unstructured abstract missing the objectives, how the data used in this review article collected, results and the final conclusion. 2. Missing the strength and/or the limitation of their review article and future suggested research or studies. 3. 62% (51/82) of the references older than the last 5 years (before 2012 and the article published in 2017).

Although; this review article is very interesting, it cannot be accepted for publication in its current form and it should be revised carefully with correction of the major and minor flaws. Regards