Is antibiotic prophylaxis effective or safe for women undergoing operative vaginal delivery?

What is the issue?

We wanted to assess whether giving antibiotics to all women undergoing operative vaginal deliveries (using vacuum suction or forceps) prevents infections in the mother without increasing other adverse outcomes in the mother and baby.

Why is this important?
Women who undergo vacuum or forceps assisted vaginal births may be more likely to have an infection after the birth or be re-admitted to hospital after the birth when compared to women who experience a normal spontaneous vaginal birth. The main reasons for an operative vaginal delivery are a prolonged second stage of labour, suspicion of problems with the baby and a desire to shorten the second stage of labour for maternal benefit.

Prophylactic antibiotics may be used to prevent or reduce the risk of these infections. However, there are still some doubts about the benefit of prophylactic antibiotics in reducing postpartum infection after operative vaginal delivery.

What evidence did we find?

We searched for evidence in July 2017 and identified only one study published in 1989. The study included 393 women undergoing either vacuum or forceps delivery comparing those receiving the antibiotic cefotetan with those women who received no treatment. There were no differences between the two groups of women in terms of age, previous pregnancies and other important characteristics. The only two outcomes reported in the trial were infection of the uterus (endometritis) and length of hospital stay. The trial reported that seven women had an infection of the uterus (endometritis) in the group that did not receive any antibiotics. No woman in the antibiotic group was reported to have an infection. Giving antibiotics had no effect on length of hospital stay for the mother for either group. The quality of the evidence for these two outcomes was assessed as being low: the evidence comes from a single trial, which included a very small number of women and reported on only two outcomes.

What does this mean?

Evidence from this single trial suggests that antibiotic prophylaxis may lead to little or no difference in endometritis or maternal length of stay. There were no data on any other outcomes to evaluate the impact of antibiotics for preventing infection after operative vaginal delivery. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to provide evidence on whether it is a useful intervention.

Authors' conclusions: 

One small trial was identified reporting only two outcomes. Evidence from this single trial suggests that antibiotic prophylaxis may lead to little or no difference in endometritis or maternal length of stay. There were no data on any other outcomes to evaluate the impact of antibiotic prophylaxis after operative vaginal delivery. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.

Read the full 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.

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 deliveries, or both.

Search strategy: 

We searched Cochrane Pregnancy and Childbirth's Trials Register (12 July 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (12 July 2017) and reference lists of retrieved studies.

Selection criteria: 

All randomised 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 undergoing vacuum or forceps delivery for any indications. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium) compared with either placebo or no treatment.

Data collection and analysis: 

Two review authors assessed trial eligibility and methodological quality. 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 one included trial using the GRADE approach.

Main results: 

One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. The trial compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. This trial reported only two out of the nine outcomes specified in this review. Seven women in the group given no antibiotics had endomyometritis and none in prophylactic antibiotic group, the risk reduction was 93% (risk ratio (RR) 0.07; 95% confidence interval (CI) 0.00 to 1.21; low-quality evidence). There was no difference in the length of hospital stay between the two groups (mean difference (MD) 0.09 days; 95% CI -0.23 to 0.41; low-quality evidence). Overall, the risk of bias was judged to be unclear. The quality of the evidence using GRADE was low for both endometritis and maternal length of stay.

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