Antibiotics and operative vaginal birth

The authors of an updated Cochrane review entitled ‘Antibiotic prophylaxis for operative vaginal delivery’ have drawn the same conclusion as in previous versions of the review: that routinely giving antibiotics to women who have forceps or ventouse births leads to little or no difference in endometritis or how long the women stay in hospital after birth.

Although the authors suggest that more research is required (not least because there has only ever been one small study into this area), concerns about the overuse of antibiotics may be an even more important factor. Some people argue that we should save antibiotics as treatment except in situations where there is real evidence that they make a difference. In the reality of maternity care, this doesn’t always happen, as the example of group B strep shows, and this is despite our growing knowledge of the importance of the microbiome.

I’ve been thinking about antibiotics a lot lately, because they are a key topic for discussion in my Group B Strep Explored online course and I’ve also been looking at how they relate to the issue of vitamin K for my upcoming book on that subject – more on which soon! I’m often stunned at the lack of congruence between the theory (which, in this case, includes the content of a number of recent medical journals) and the reality on this topic, so I welcome the fact that the Cochrane Collaboration keep updating such reviews and reminding us that, so often, a policy of routine intervention isn’t supported by the evidence.

Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD004455.

The Research

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.

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