Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth

An audit of clinician compliance with best practice recommendations to repair severe obstetric anal sphincter injuries

CONTEXT

Obstetric anal sphincter injuries occur uncommonly in Caribbean practice but are accompanied by substantial morbidity.

OBJECTIVE

To evaluate clinicians' compliance with management guidelines at a national referral hospital in Jamaica.

DESIGN

Retrospective review of the records of all consecutive obstetric patients with anal sphincter injuries between November 1, 2007, and December 30, 2012.

MAIN OUTCOME MEASURES

The primary end point was the completion of each of 8 tasks from existing management guidelines: 1) interdisciplinary consultation, 2) perineal examination with the patient under anesthesia, 3) injury repair in the operating room, 4) prophylactic antibiotics at induction, 5) repair by an experienced clinician, 6) repair method appropriate for injury grade, 7) slowly absorbable suture chosen for sphincter repair, and 8) rapidly absorbable suture for mucosal repair. We quantified clinician compliance with the guidelines by assigning a score of 1 for each task completed and 0 for an incomplete task. Individual task scores were summed. Clinicians were considered compliant when their overall score was above 6.

RESULTS

Twenty-six women (mean age = 27 years; standard deviation = 5.78 years) had obstetric anal sphincter injuries. Nine cases (34.6%) earned clinician compliance scores above 6, and 17 (65.4%) had scores of 6 or below. Experienced clinicians repaired all the injuries in this study-the only task for which compliance was 100%.

CONCLUSION

Despite attempts at improving therapeutic outcomes by creating tailored guidelines for repair of obstetric anal sphincter injuries, there is a serious barrier to success because 65% of senior clinicians were noncompliant.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum.

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Methods of repair for obstetric anal sphincter injury

BACKGROUND

Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. Many women do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS) are end-to-end (approximation) repair and overlap repair.

OBJECTIVES

To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed independently by all authors.

MAIN RESULTS

Six eligible trials, of variable quality, involving 588 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (average RR 0.77, 95% CI 0.48 to 1.24, two trials, 151 women), flatus incontinence (average RR 1.14, 95% CI 0.58 to 2.23, three trials, 256 women) between the two repair techniques at 12 months. However, it showed a statistically significant lower incidence of faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women), and lower anal incontinence score (standardised mean difference (SMD) -0.70, 95% CI -1.26 to -0.14, one trial, 52 women) in the overlap group. The overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women).

AUTHORS' CONCLUSIONS

The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing faecal urgency and anal incontinence symptoms. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.

Operative vaginal deliveries: practical aspects

Forceps, vacuum, and cesarean sections are relatively recent additions to the obstetrician's armamentarium. The art of modern obstetrics is one that mandates from obstetricians the attentive vigilance of the development of natural processes and an active intervention when such processes fall outside normally accepted standards. What constitutes the "normal process" and the "accepted standard" is subject to discussion, and international variations in obstetric practice are in part the reflection of such controversies. This article presents a practical approach to the contemporary issue of instrumental deliveries, outlining supporting evidence (when available) and the most current position of professional colleges in obstetrics and gynecology.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2010) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the reports and extracted data.

MAIN RESULTS

We identified and included one trial (147 participants) that compared the effect of prophylactic antibiotic (single-dose, second generation cephalosporin, intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio 0.34, 95% confidence interval 0.12 to 0.96).

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Antibiotic prophylaxis in obstetric procedures

OBJECTIVE

To review the evidence and provide recommendations on antibiotic prophylaxis for obstetrical procedures.

OUTCOMES

Outcomes evaluated include need and effectiveness of antibiotics to prevent infections in obstetrical procedures.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Library on the topic of antibiotic prophylaxis in obstetrical procedures. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and articles published from January 1978 to June 2009 were incorporated in the guideline. Current guidelines published by the American College of Obstetrics and Gynecology were also incorporated. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Implementation of this guideline should reduce the cost and harm resulting from the administration of antibiotics when they are not required and the harm resulting from failure to administer antibiotics when they would be beneficial. SUMMARY STATEMENTS: 1. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following operative vaginal delivery. (II-1) 2. There is insufficient evidence to argue for or against the use of prophylactic antibiotics to reduce infectious morbidity for manual removal of the placenta. (III) 3. There is insufficient evidence to argue for or against the use of prophylactic antibiotics at the time of postpartum dilatation and curettage for retained products of conception. (III) 4. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity following elective or emergency cerclage. (II-3) RECOMMENDATIONS: 1. All women undergoing elective or emergency Caesarean section should receive antibiotic prophylaxis. (I-A) 2. The choice of antibiotic for Caesarean section should be a single dose of a first-generation cephalosporin. If the patient has a penicillin allergy, clindamycin or erythromycin can be used. (I-A) 3. The timing of prophylactic antibiotics for Caesarean section should be 15 to 60 minutes prior to skin incision. No additional doses are recommended. (I-A) 4. If an open abdominal procedure is lengthy (>3 hours) or estimated blood loss is greater than 1500 mL, an additional dose of the prophylactic antibiotic may be given 3 to 4 hours after the initial dose. (III-L) 5. Prophylactic antibiotics may be considered for the reduction of infectious morbidity associated with repair of third and fourth degree perineal injury. (I-B) 6. In patients with morbid obesity (BMI>35), doubling the antibiotic dose may be considered. (III-B) 7. Antibiotics should not be administered solely to prevent endocarditis for patients who undergo an obstetrical procedure of any kind. (III-E).

Antibioprophylaxie dans le cadre d'interventions obstétricales

Objectif

Analyser les résultats et formuler des recommandations sur le recours à l'antibioprophylaxie dans le cadre d'interventions obstétricales.

Issues

Parmi les issues évaluées, on trouve la nécessité et l'efficacité du recours à des antibiotiques aux fins de la prévention des infections dans le cadre d'interventions obstétricales.

Résultats

La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline et The Cochrane Library au moyen de la rubrique « antibioprophylaxie dans le cadre d'interventions obstétricales ». Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Les recherches ont été mises à jour de façon régulière et les articles publiés entre janvier 1978 et juin 2009 ont été incorporés à la directive clinique. Les lignes directrices actuellement publiées par le American College of Obstetrics and Gynecology ont également été incorporées à la directive clinique. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales.

Valeurs

Les résultats obtenus ont été analysés et évalués par le comité sur les maladies infectieuses de la Société des obstétriciens et gynécologues du Canada sous la gouverne des auteures principales, et les recommandations ont été formulées conformément aux lignes directrices élaborées par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1).

Avantages, désavantages et coûts

La mise en œuvre de la présente directive clinique devrait réduire les coûts et les torts attribuables à l’administration d’antibiotiques lorsque celle-ci ne s’avère pas requise, ainsi que les torts attribuables à la non-administration d’antibiotiques lorsque ceux-ci pourraient s’avérer bénéfiques.

Déclarations sommaires

1.

Les données disponibles ne soutiennent pas le recours à l'antibioprophylaxie en vue d'atténuer la morbidité infectieuse à la suite d'un accouchement vaginal opératoire. (II-1)

2.

Nous ne disposons pas de données suffisantes pour soutenir ou déconseiller le recours à l'antibioprophylaxie en vue d'atténuer la morbidité infectieuse dans les cas de retrait manuel du placenta. (III)

3.

Nous ne disposons pas de données suffisantes pour soutenir ou déconseiller le recours à l'antibioprophylaxie au moment de la dilatation-curetage postpartum visant des produits de conception en rétention. (III)

4.

Les données disponibles ne soutiennent pas le recours à l'antibioprophylaxie en vue d'atténuer la morbidité infectieuse à la suite d'un cerclage planifié ou d'urgence. (II-3)

Recommandations

1.

Toutes les femmes qui subissent une césarienne planifiée ou d'urgence devraient se voir administrer une antibioprophylaxie. (I-A)

2.

Une dose unique d'une céphalosporine de première génération devrait constituer l'antibiotique à privilégier pour ce qui est des césariennes. Lorsque la patiente présente une allergie à la pénicilline, on peut avoir recours à la clindamycine ou à l'érythromycine. (I-A)

3.

Dans le cas de la césarienne, l'antibioprophylaxie devrait être administrée de 15 à 60 minutes avant l'incision de la peau. Aucune dose additionnelle n'est recommandée. (I-A)

4.

Lorsqu'une intervention à abdomen ouvert est de longue durée (>3 heures) ou que la perte sanguine estimée est supérieure à 1 500 ml, une dose additionnelle d'antibiotique prophylactique peut être administrée de 3 à 4 heures à la suite de la dose initiale. (III-L)

5.

L'administration d'une antibioprophylaxie peut être envisagée pour atténuer la morbidité infectieuse associée à la réparation d'une lésion périnéale du troisième ou du quatrième degré. (I-B)

6.

Chez les patientes massivement obèses (IMC > 35), il est possible d'envisager le doublement de la dose d'antibiotiques. (III-B)

7.

L’administration d’antibiotiques aux seules fins de prévenir l’endocardite ne devrait pas être mise en œuvre chez les patientes qui doivent subir une intervention obstétricale, quelle qu’en soit la nature. (III-E)

Methods of repair for obstetric anal sphincter injury

BACKGROUND

Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - is associated with significant maternal morbidity including perineal pain, dyspareunia and anal incontinence. Anal incontinence affects women psychologically and physically. Many do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS): are end-to-end (approximation) repair and overlap repair.

OBJECTIVES

To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 January 2006), MEDLINE (January 1966 to 31 January 2006), EMBASE (January 1974 to 31 January 2006), SciSearch (January 1974 to 31 January 2006) and conference proceedings of obstetrics and gynaecology, surgery and coloproctology.

SELECTION CRITERIA

Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed independently by all authors.

MAIN RESULTS

Three eligible trials, of grade A quality, involving 279 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (relative risk (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (RR 0.62, 95% CI 0.11 to 3.39, one trial, 52 women), flatus incontinence (RR 0.93, 95% CI 0.26 to 3.31, one trial, 52 women) and faecal incontinence (RR 0.07, 95% CI 0.00 to 1.21, one trial, 52 women) between the two repair techniques at 12 months but showed a statistically significantly lower incidence in faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women) and lower anal incontinence score (weighted mean difference -1.70, 95% CI -3.03 to -0.37) in the overlap group. Overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life.

AUTHORS' CONCLUSIONS

The limited data available show that compared to immediate primary end-to-end repair of OASIS, early primary overlap repair appears to be associated with lower risks for faecal urgency and anal incontinence symptoms. As the experience of the surgeon is not addressed in the three studies reviewed, it woudl be inappropriate to recommend one type of repair in favour of another.