Thousands of women could have been spared pain and infection if they were given prophylactic antibiotics following assisted childbirth, advise researchers. The researchers are now calling for health authorities to change the advice they provide.
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Administering just a single dose of antibiotics after an assisted birth (one that requires forceps or vacuum) could prevent women from experiencing painful infections.
In an article published in The Lancet, Marian Knight from Oxford University and colleagues said that prescribing antibiotics could prevent more than 7,000 maternal infections per year in the UK, around 5,000 in the United States and around 200,000 worldwide.
In a major trial involving 3,420 women at 27 units across Britain, a single dose of antibiotics given within six hours of childbirth almost halved the number of infections among mothers whose births were medically assisted using forceps or ventouse suction cups. In the UK, assisted births account for one in eight pregnancies.
Knight and team are calling on the World Health Organization and other health authorities to revise their recommendations in light of the findings.
Currently, infections occur in around 16% of assisted deliveries globally and in around 25 percent of cesarean sections.
Infections ‘need to be caught early’
The microbes introduced into the genital tract when forceps and ventouse suction cups are used increases the risk of infection developing. Furthermore, women who have assisted births tend to have longer labors, more vaginal examinations, and more tears and surgical cuts, compared with women who do not have assisted deliveries. They are also more likely to have urinary catheters fitted.
All of these factors raise the risk for infection, which in some cases can turn out to be life-threatening. In Western countries, such infections cause around one in 20 maternal deaths and for every case of those, a further 70 mothers develop serious infections that lead to long-term health complications.
For the study, women were randomly assigned to be intravenously administered either amoxicillin with clavulanic acid or a saline placebo within six hours of having given birth. One-third of the births were assisted using ventouse suction cups and two-thirds were assisted using forceps.
Of those who received the placebo, 19% developed an infection following childbirth, compared with only 11% of those in the antibiotic group. The proportion of more serious infections (sepsis) arising was 1.5% in the placebo group (as confirmed by blood tests), compared with only 0.6% in the antibiotic group.
I was surprised by the proportion of women who got an infection. The majority are not serious, life-threatening infections, but they do need to be caught early to make sure they don’t progress to those major infections.”
Marian Knight, Study Author
Using antibiotics as a prophylactic measure resulted in fewer antibiotics being needed later.
For every 100 doses of prophylactic antibiotics, doctors avoided the need to administer 168 doses for post-delivery infections that developed later on after birth. Thus, changing health policies to recommend universal prophylactic treatment with antibiotics following assisted delivery could decrease antibiotic use by 17%.
The reduced infection rate among the women who received antibiotics also had a beneficial effect on the women’s general recovery from childbirth.
Compared with those who received placebo, women who were given antibiotics were less likely to need treatment for perineal pain or for burst stitches. They also attended fewer outpatient appointments and did not need as many home visits from doctors, nurses or midwives.
The researchers also estimate that the average cost to the NHS six weeks following birth for each woman who received the antibiotic was £102.50, compared with £155.10 for each woman who received the placebo.
These findings highlight the urgent need to change current [...] guidelines. Pregnancy-associated infection is a major cause of death and serious illness. Our results show this could be reduced by almost half by a single dose of prophylactic antibiotic.”
Marian Knight, Study Author
Clinicians not involved in the study are calling the results “practice-changing” and the UK’s Royal College of Obstetricians and Gynaecologists will be publishing new recommendations in light of the findings later this year.
Knight says this will have a huge effect on women, not only in terms of infection rate, but also in terms of reducing rates of perineal pain, burst stitches and problems feeding babies as a consequence of pain.
Ensuring ‘the best possible health outcomes for women’
Consultant obstetrician and spokesperson for the Royal College of Obstetricians and Gynaecologists, Pat O’Brien, referred to the trial as “very interesting and well-conducted.”
In the UK, around 12% of women have medically assisted births, he says, and the findings from the current study suggest that administering single doses of antibiotics could halve infection rate to the equivalent of about 7,000 per year.
O’Brien points out that it is standard practice to provide a single-dose antibiotic to protect against infection in cases of cesarean and that it makes sense that this should also be the case for women who have assisted births.
Based on these findings alone, it does seem that routine use of a single dose of antibiotic following an assisted birth would help to reduce infections and ensure the best possible health outcomes for women, as well as reduce costs of complications for the health service.”
Pat O’Brien, Consultant Obstetrician
Knight, M., et al. (2019). Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial. The Lancet. doi.org/10.1016/S0140-6736(19)30773-1.