Cochrane Database Syst Rev. 2020 Mar 26;3:CD004455. doi: 10.1002/14651858.CD004455.pub5.
Antibiotic prophylaxis for operative vaginal delivery.
The Cochrane database of systematic reviews
Tippawan Liabsuetrakul, Thanapan Choobun, Krantarat Peeyananjarassri, Q Monir Islam
Affiliations
Affiliations
- Prince of Songkla University, Epidemiology Unit, Faculty of Medicine, Hat Yai, Songkhla, Thailand, 90110.
- Prince of Songkla University, Department of Obstetrics and Gynecology, Faculty of Medicine, Hat Yai, Songkhla, Thailand, 90110.
- Liverpool School of Tropical Medicine, Liverpool, UK.
PMID: 32215906
PMCID: PMC7096725 DOI: 10.1002/14651858.CD004455.pub5
Abstract
BACKGROUND: Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. This is an update of a review last published in 2017.
OBJECTIVES: To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps delivery, or both.
SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies.
SELECTION CRITERIA: All randomised controlled trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium).
DATA COLLECTION AND ANALYSIS: Two review authors assessed trial eligibility and risk of bias. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the two included studies using the GRADE approach.
MAIN RESULTS: Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials.
AUTHORS' CONCLUSIONS: Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
References
- BMJ Open. 2017 Feb 10;7(2):e012766 - PubMed
- Zentralbl Gynakol. 1988;110(9):570-4 - PubMed
- Eur J Obstet Gynecol Reprod Biol. 2010 Jul;151(1):46-51 - PubMed
- Int J Gynaecol Obstet. 2014 Jun;125(3):206-9 - PubMed
- Obstet Gynecol. 2018 Sep;132(3):e103-e119 - PubMed
- J Health Popul Nutr. 2005 Jun;23(2):121-30 - PubMed
- J Gynecol Obstet Biol Reprod (Paris). 1990;19(7):909-18 - PubMed
- Acta Obstet Gynecol Scand. 2002 Mar;81(3):214-21 - PubMed
- Obstet Gynecol. 1991 Mar;77(3):356-60 - PubMed
- Obstet Gynecol. 2005 Apr;105(4):836-42 - PubMed
- Am J Obstet Gynecol. 2001 May;184(6):1112-4 - PubMed
- Infect Control Hosp Epidemiol. 1996 Jan;17(1):36-41 - PubMed
- Cochrane Database Syst Rev. 2017 Aug 05;8:CD004455 - PubMed
- Obstet Gynecol. 1992 Jul;80(1):117-22 - PubMed
- Am J Obstet Gynecol. 2000 May;182(5):1083-5 - PubMed
- Cochrane Database Syst Rev. 2004;(3):CD004455 - PubMed
- Trials. 2018 Jul 24;19(1):395 - PubMed
- Obstet Gynecol. 2013 Jan;121(1):122-8 - PubMed
- Birth. 2011 Sep;38(3):191-9 - PubMed
- Best Pract Res Clin Obstet Gynaecol. 2019 Apr;56:93-106 - PubMed
- Infect Dis Obstet Gynecol. 2000;8(2):77-82 - PubMed
- Obstet Gynecol. 2015 Nov;126(5):e56-65 - PubMed
- Br J Obstet Gynaecol. 1998 Dec;105(12):1262-72 - PubMed
- Eur J Obstet Gynecol Reprod Biol. 1993 Aug;50(3):169-75 - PubMed
- Cochrane Database Syst Rev. 2014 Oct 28;(10):CD007482 - PubMed
- Int J Gynaecol Obstet. 2014 Mar;124(3):240-3 - PubMed
- Wien Klin Wochenschr. 1979 Mar 30;91(7):227-30 - PubMed
- J Infect Dis. 1986 Jun;153(6):1038-45 - PubMed
- Lancet. 2010 Feb 6;375(9713):490-9 - PubMed
- South Med J. 1989 Aug;82(8):960-2 - PubMed
- J Obstet Gynaecol. 2008 Apr;28(3):305-9 - PubMed
- PLoS Med. 2014 Jul 08;11(7):e1001672 - PubMed
- Trop Doct. 1998 Apr;28(2):92-5 - PubMed
- Cochrane Database Syst Rev. 2014 Oct 13;(10):CD004455 - PubMed
- Am J Obstet Gynecol. 1998 Oct;179(4):879-83 - PubMed
- P N G Med J. 2011 Sep-Dec;54(3-4):174-84 - PubMed
- Eur J Obstet Gynecol Reprod Biol. 1989 May;31(2):163-71 - PubMed
- Am J Obstet Gynecol. 2003 Apr;188(4):1063-7 - PubMed
- Lancet Infect Dis. 2004 Oct;4(10):611-9 - PubMed
- Lancet. 2019 Jun 15;393(10189):2395-2403 - PubMed
- Cochrane Database Syst Rev. 2014 Oct 07;(10):CD005125 - PubMed
- Akush Ginekol (Sofiia). 1993;32(1):12-4 - PubMed
- Obstet Gynecol. 2008 Jun;111(6):1268-73 - PubMed
- Obstet Gynecol. 2010 Jun;115(6):1201-8 - PubMed
- Trop Doct. 2011 Jan;41(1):5-7 - PubMed
- Obstet Gynecol. 2004 Mar;103(3):513-8 - PubMed
- Obstet Gynecol. 1991 Nov;78(5 Pt 1):789-94 - PubMed
- Hippokratia. 2009 Jan;13(1):41-5 - PubMed
- Eur J Obstet Gynecol Reprod Biol. 2013 Nov;171(1):40-3 - PubMed
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