1

2
3
4 Prophylactic antibiotics
5
6 with cesarean section
7
8 1 Introduction
9 2 Effects on infection and febrile morbidity
10 3 Choice of antibiotic preparation
1 4 Route of administration
2 5 Potential adverse consequences of antibiotic prophylaxis
3 6 Conclusions
4
5
6
7
8 1 Introduction
9
20 Maternal morbidity after cesarean section has not been studied as
1 systematically as the maternal mortality associated with the operation,
2 but the problem is undoubtedly substantial. Febrile morbidity, caused
3 by postoperative infection or by other factors, appears to follow
4 cesarean section in at least one in five women. Serious infections, such
5 as pelvic abscess, septic shock, and septic pelvic vein thrombophlebitis,
6 are not rare.
7 Labour and ruptured membranes are the most important factors
8 associated with an increased risk of infection, the risk rising with
9 increased duration of each. Obesity appears to be a risk factor of partic-
30 ular importance for wound infection. At one time, extraperitoneal
1 cesarean section was proposed to reduce infectious morbidity in
2 women at high risk of infection, but this approach is now of historical
3 interest only.
4 The first step toward reducing the infectious morbidity that is so
5 common after cesarean section is to minimize the number of unnec-
6 essary operations. The second step requires attention to the many
7 factors that reduce the risk of infection when the operation is justi-
8 fied, such as: minimizing the length of hospital admission before
9 surgery; delaying shaving of the operation site until immediately
40 before the operation; sterilizing swabs, instruments, the gloves worn
41 by the operating team; cleaning the skin of the woman; air exchanges
SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise website at www.maternitywise.org/prof/
Oxford University Press 2000


1 in the operating theatre; and paying attention to good surgical tech-

2 nique.
3 The potential for prophylactic antibiotics to reduce maternal
4 morbidity after cesarean section has by now been investigated system-
5 atically. The benefits have been unequivocally demonstrated. Although
6 the extent to which toxic or allergic effects of antibiotics may cause
7 maternal morbidity is not well established, the information that is
8 available provides clear guidelines for practice.
9
10
1 2 Effects on infection and febrile morbidity
2
3 Antibiotic prophylaxis markedly reduces the risk of serious post-
4 operative infection, such as pelvic abscess, septic shock, and septic
5 pelvic vein thrombophlebitis. A protective effect of the same order
6 of magnitude is seen for endometritis. The degree of reduction in the
7 risk of wound infection is slightly less but still substantial. The evidence
8 for these benefits is overwhelming.
9 Prophylactic antibiotics reduce the relative risk of endometritis to a
20 similar extent for women having planned (elective) cesarean sections,
1 as for those having emergency procedures, whilst the impact on
2 wound infection seems greater after emergency procedures. The
3 absolute numbers of serious infections avoided by prophylactic
4 administration are greater with emergency cesarean sections because
5 the rates of infection are higher. Postoperative febrile morbidity has
6 fewer sequelae than the more serious infections, but is important
7 because of its higher incidence. Secondary effects, such as the economic
8 impact of prolongation of hospital stay and interference with mother
9 infant contact, must also be considered.
30
1
2 3 Choice of antibiotic preparation
3
4 The risk of postoperative febrile morbidity is reduced to a comparable
5 extent by broad-spectrum penicillins, such as ampicillin, and cephalo-
6 sporins. The evidence from direct comparisons between broad-
7 spectrum penicillins and cephalosporins suggests that they have similar
8 effects on the risk of postoperative febrile morbidity. There is no
9 convincing evidence that antibiotics with a broader spectrum of
40 activity, such as second- and third-generation cephalosporins, are more
41 efficacious than a first-generation cephalosporin.


1 Trials comparing different regimens show no clear advantage to a

2 combination of antibiotics over single agents. Likewise, the use of three
3 to five doses, rather than a single dose of antibiotics for prophylaxis of
4 infection with cesarean section does not appear to confer any addi-
5 tional benefit.
6
7
8
9
4 Route of administration
10 Intra-operative irrigation with antibiotics has been shown to be more
1 effective than irrigation with placebo in reducing the risk of post-
2 operative febrile morbidity, but trials do not suggest that antibiotic
3 irrigation is more effective than systemic administration.
4
5
6
7 5 Potential adverse consequences of antibiotic
8 prophylaxis
9
20 Only a minority of the reports of controlled trials included informa-
1 tion about adverse effects of the prophylactic agents used, and even in
2 these reports the reference was usually rather casual. It is thus not
3 surprising that the reported incidence of adverse reactions was very
4 low 1% or less. This is well below the rate of adverse reactions that
5 one would expect of antibiotics, especially broad-spectrum antibiotics
6 given intravenously.
7 Drug effects on the infant (which might include protective as well as
8 unwanted effects) have not been studied systematically by the majority
9 of investigators. Many clinicians prefer to prevent exposure of the baby
30 to antibiotics by starting them after the umbilical cord has been
1 clamped, as was done in most of the trials reported, even if there is
2 some slight, as yet undetected, loss of prophylactic efficacy.
3 Antibiotics received by the mother can also reach the baby through
4 breast milk. The drug levels involved seem likely to be very low, partic-
5 ularly if the course of prophylactic antibiotics has been relatively short.
6 An important argument of those who have objected to routine
7 antibiotic prophylaxis has been their concern about the effects of this
8 practice on the bacterial flora, namely replacement of non-pathogenic
9 bacteria with pathogenic ones, and a rise in resistance of bacteria in
40 the women and in the hospital environment generally. At least some
41 antibiotics appear to cause these changes with relatively few doses.


1 There is some suggestion that certain prophylactic regimens, e.g.

2 trimethoprim and sulfamethoxazole, may be less disruptive of flora,
3 yet remain effective.
4 Adverse ecological effects on bacterial flora are difficult to quantify
5 and predict, but are potentially of greater concern than adverse drug
6 reactions in individual mothers and babies. Although routine culture
7 of genital tract specimens to manage infections following cesarean
8 section is not recommended, the hospital bacteriology laboratory
9 should monitor and report on the susceptibility patterns of commonly
10 isolated organisms to detect gradual changes in antibiotic resistance
1 and advise on appropriate empiric treatment regimens.
2
3
4 6 Conclusions
5
6 Antibiotic prophylaxis can reduce the risk of serious infections. If the
7 level of post-cesarean infectious morbidity is very low without a policy
8 of antibiotic prophylaxis, the ratio of benefits to costs, in absolute
9 terms, might argue against instituting such a policy. Such circum-
20 stances are rare, and the evidence justifies far wider adoption of anti-
1 biotic prophylaxis than currently exists. Although the incidence of
2 adverse drug effects among women receiving prophylactic antibiotics
3 has probably been underestimated, it is inconceivable that it could
4 outweigh the reduction in serious maternal morbidity that can be
5 achieved by a policy of antibiotic prophylaxis. Potential adverse drug
6 effects in the baby may be lessened by beginning prophylaxis after the
7 umbilical cord has been divided.
8 The risk of adverse ecological effects is likely to be reduced if the total
9 load of antibiotics is reduced. The disadvantages of longer courses of
30 antibiotics, in terms of an increase in the total antibiotic load and in
1 the number of women experiencing side effects, and the additional
2 financial cost, may outweigh the advantages of greater prophylactic
3 efficacy compared with shorter or single-dose regimens.
4 In regard to choice of antibiotic, the broad-spectrum penicillins are
5 as effective as the cephalosporins. No strong case for using a second-
6 or third-generation cephalosporin, or adding aminoglycosides to
7 broad-spectrum penicillins, can be made.
8 Withholding prophylactic antibiotics from women having cesarean
9 section will increase the chances that they will experience serious
40 morbidity. Further trials which include no-treatment controls would
41 be unethical.


1 Sources
2
3 Effective care in pregnancy and childbirth
4
5 Enkin, M., Enkin. E, and Chalmers. I., Prophylactic antibiotics in asso-
6 ciation with caesarean section.
7
8 Cochrane Library
9 Hopkins, L. and Smaill, F., Antibiotic prophylaxis regimens and drugs
10 for caesarean section.
1 Smaill, F. and Hofmeyr, G.J., Antibiotic prophylaxis for caesarean
2 section.
3
4 Other sources
5
Mugford, M., Kingston, J. and Chalmers, I. (1989). Reducing the inci-
6
dence of infection after caesarean section: implications of prophy-
7
laxis with antibiotics for hospital resources. BMJ, 299, 10036.
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9
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