Puerperal sepsis: a preventable post-partum complication

Can Clean Delivery Kits Prevent Infections? Lessons from Traditional Birth Attendants in Nigeria

Background

In resource-poor settings, perinatal infections contribute significantly to maternal and neonatal deaths, and the use of clean delivery kits (CDKs) has been proposed as a tool to reduce the risk of infection-related deaths. This study aims to assess the acceptability and effectiveness of CDKs in preventing infections in deliveries attended by traditional birth attendants (TBAs) in Abeokuta, Nigeria.

Methods

The study was a cluster-randomized trial with 67 birth centres/clusters, 453 births/mothers, and 457 babies randomized to intervention or control arms; intervention involved supplementation of delivery with JANMA CDKs. Interviews were conducted at the birth homes, and the primary outcomes were neonatal infection and puerperal fever. The association between infection and perinatal risk factors was tested using the Chi-square and Fisher's exact tests.

Results

CDKs were well accepted by TBAs. The incidence of puerperal fever and neonatal infection was 1.1% and 11.2%, respectively. Concurrent infection was found in 1 (0.22%) of the mother-neonate pair. There was no significant association between any of the sociodemographic factors and infection for both mothers and neonates. PROM and prolonged labour were significantly associated with puerperal infection. All mothers with puerperal fever were from the control group. Compared to the control group, the relative risk of puerperal infection and neonatal infection in the intervention group was 0.08 (0.004 -1.35, p = 0.079) and 0.64 (0.37 to 1.1, p = 0.10), respectively.

Conclusion

CDKs hold promising results in attenuating maternal infections in resource-poor settings. Larger studies with greater statistical power are required to establish statistically reliable information.

Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity

BACKGROUND

A recent study from the United Kingdom suggested that a single dosage of adjunctive amoxicillin/clavulanic acid with operative vaginal delivery reduces maternal infectious morbidity by 40% (from 19% to 11%). However, 89% of their study population received an episiotomy.

OBJECTIVE

This study aimed to evaluate whether operative vaginal delivery is an independent risk factor for composite maternal postpartum infectious morbidity in a population with a low episiotomy rate.

STUDY DESIGN

This was a retrospective cohort study of patients with viable singleton vaginal deliveries after ≥34 weeks gestation at a single perinatal center (2013-2018). The patients were categorized by the mode of delivery: spontaneous vaginal delivery or operative vaginal delivery (forceps or vacuum-assisted). The primary outcome was a composite of maternal infectious morbidity up to 6 weeks after delivery, defined as (1) endometritis, (2) perineal wound morbidity (infection, breakdown, or dehiscence), or (3) culture-proven urinary tract infection. The patient characteristics and outcomes were compared between the groups using appropriate tests. Multivariable models were used to estimate the association between operative vaginal delivery and study outcomes compared with spontaneous vaginal delivery, with adjustment for selected confounders.

RESULTS

Of 14,647 deliveries meeting the inclusion criteria, 732 (5.0%) were operative vaginal deliveries: 354 (48%) forceps and 378 (52%) vacuums. Overall, 210 (1.4%) patients developed the morbidity composite. Patients having an operative vaginal delivery were more likely to be nulliparous, have labor inductions, develop intrapartum chorioamnionitis, receive an episiotomy, and sustain a third- or fourth-degree laceration. After adjusting for confounding factors, no significant association was observed between operative vaginal delivery and composite morbidity (adjusted odds ratio, 1.4 [0.8-2.4]) or any of its individual components. Administration of postpartum antibiotics and documented fever were also similar between groups. There was also no significant association between instrument (forceps vs vacuum) and the maternal infection composite.

CONCLUSION

In this single-center US cohort, operative vaginal delivery was not an independent risk factor for maternal composite postpartum infectious morbidity.

Incidence of postpartum infections and outcomes associated with antibiotic prophylaxis after normal vaginal birth

Antibiotic consumption accounted for approximately 15–20% of total drug costs in Thailand. From 2017 to 2018, 24.86% of Thai women who experienced vaginal delivery during normal term labour received antibiotics for postpartum infection. The Thai national practice guidelines set the target use of antibiotic prophylaxis in women following vaginal delivery of normal term labour to be no more than 10%. This study aimed to determine the incidence of postpartum infections and the outcomes and factors associated with antibiotic prophylaxis in women following vaginal delivery. The prospective cohort study was collected from 909 eligible patients who delivered infants in 7 secondary hospitals in Chiang Mai from July 2020 to February 2021. Antibiotic prescribing data and infections in women experiencing vaginal delivery during normal term labour were collected. The incidence of postpartum infections was calculated at 2 periods, 48 h and 6 weeks, after labour. Factors associated with the prescription of antibiotic prophylaxis in vaginal delivery were analysed using multivariate logistic regression. The results showed that the prevalence of antibiotic prescribing was 12.87% in a cohort of 117 patients. Postpartum infection was reported in 3 of 117 patients with antibiotics prophylaxis and 11 of 792 without antibiotics, with no statistically significant difference (RR: 1.04, 95% CI: 0.26–4.14; p = 0.956). Postpartum hygiene self-care practices were collected in the 6th week. The results found that there were no statistical differences in mean scores for all questions on postpartum hygiene self-care practices between the infected and non-infected groups (p-value > 0.05). One of the factors associated with antibiotic prophylaxis was third to fourth degree of tear and episiotomy (OR: 7.72, 95% CI: 1.13–52.75; p = 0.037 and OR: 2.41, 95% CI: 1.24–4.70; p = 0.010, respectively). There was no significance difference in postpartum infection among patients receiving antibiotic and those who did not receive antibiotics. Third to fourth degree of tear and episiotomy were significantly factors related to antibiotic prophylaxis in women with vaginal delivery after labour. This study supports practice guidelines and helps healthcare team to be assured on the use of antibiotics in no more than 10% of women experiencing normal vaginal delivery.

Preoperative vaginal cleansing with chlorhexidine vs. placebo in patients with rupture of membranes. A prospective randomized double blind placebo control study

OBJECTIVE

To demonstrate that vaginal cleansing with a 4% chlorhexidine solution, before cesarean section in patients with a history of rupture of membranes, prevents postoperative infectious complications (endometritis, surgical site infections).

MATERIAL AND METHODS

A total of 204 patients with premature rupture of membranes or in labor with more than six hours of ruptured membranes were randomized before a cesarean section to preoperative vaginal cleansing with a chlorhexidine solution (97 patients) vs. saline solution (107). The management of the rupture of membranes and the cesarean procedure were standard in both groups, according to our local protocol, including the use of antibiotics.

RESULTS

Vaginal cleansing with chlorhexidine reduces the risk of endometritis after cesarean section in patients with rupture of membranes, when compared to placebo (Chlorhexidine: 7.21% vs. Placebo: 18.8%; RR, 0.39; 95% CI: 0.17-0.87; p=0.015). Likewise, there was a statistical significant reduction in the number of cases of puerperal fever (Chlorhexidine: 9.28% vs. Placebo: 19.8%; RR, 0.47; 95% CI: 0.23-0.98; p=0.037). There was a statistical difference in regards to prolongation of hospitalization > 72 hours (Chlorhexidine: 1.03% vs. Placebo: 7.55%; RR, 0.14; 95% CI: 0.02-1.08; p=0.02), although the confidence interval suggests an effect due to chance. There were no statistical differences in surgical site infection at 7 days (Chlorhexidine: 1.03% vs. Placebo: 0.94%; RR, 1.1; 95% CI: 0.07-17.4; p=0.94) and at 15 days post procedure (Chlorhexidine: 1.03% vs. Placebo: 0%; RR, 3.31 [using a continuity correction]; 95% CI: 0.14-80.21; p=0.29), CONCLUSION: The use of chlorhexidine for vaginal cleansing before a cesarean in patients with rupture of membranes reduces the risk of endometritis and puerperal fever. It reduces also the number of cases that required hospitalization for more than three days, but the confidence interval suggests that could be due to chance. It has no effect on the number of cases with surgical site infection.

Antibiotic prophylaxis for operative vaginal delivery

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. This is an update of a review last published in 2017.

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 delivery, or both.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

All randomised controlled 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. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium).

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias. 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 two included studies using the GRADE approach.

MAIN RESULTS

Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials.

AUTHORS' CONCLUSIONS

Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.

Determinants and aetiologies of postpartum pyrexia; a retrospective analysis in a tertiary health facility in the Littoral Region of Cameroon

BACKGROUND

Postpartum febrile morbidity is relatively common, occurring in approximately 5-7% of births. Differentiating between potentially serious and benign causes of postpartum pyrexia (PP) is fundamental in curbing the mortality rate from sinister causes such as sepsis. The paucity of data on PP in Cameroon makes it difficult to access its actual burden. This study was aimed at determining the prevalence, risk factors and aetiologies of PP at a tertiary hospital in Douala, Cameroon.

METHODS

This was a 2 - year hospital - based retrospective cohort study carried out at the Douala General Hospital (DGH), during which medical records of all postpartum admissions between January 1st 2017 and December 31st 2018 were reviewed. The review consisted of collecting data on socio-demographic characteristics, clinical profile, investigations and final diagnoses. The collected data was analysed in SPSS 23.0. Chi-squared test was used to test the association between variables and a logistic regression analysis was fitted to identify risk factors associated to PP.

RESULTS

A total of 1520 postpartum files were reviewed. The prevalence of PP was 8.82%. The most frequent causes of PP were: malaria (46.7%), urinary tract infections (18.7%), puerperal sepsis (17.9%) and pneumonia (8.7%). E. coli was the most (49.3%) cultured germ isolated in positive cultures. Onset of PP was more common (85%) within the first 3 days postpartum and malaria (60%) was the leading aetiology within this period. Five or more vaginal examinations prior to delivery (OR 59.151, 95% CI: 21.463-163.019; p < 0.001), perineal tears (OR 45.157, 95% CI: 2.266-899.722; p < 0.001), and duration of labour > 18 h (OR 26.760, 95% CI: 7.100-100.862; p < 0.001) were the most significant risk factors associated with PP.

CONCLUSION

Approximately 1 in every 12 postpartum cases in the DGH presents with PP. Malaria was the leading cause of PP at DGH especially for cases registered within 3 days postpartum. The risk factors identified were mostly associated to perinatal events, such as frequent vaginal examinations, perineal tears and prolonged labour. Efforts towards preventing identified risk factors thus becomes paramount in order to curb this high rate of PP in the DGH.

Proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a referral Hospital in Bahir Dar, Northwest Ethiopia

Background

Puerperal sepsis is any bacterial infection of the genital tract that occurs after childbirth. It is among the leading causes of maternal morbidity and mortality especially in low-income countries including Ethiopia. The aim of this study was to determine the proportion of bacterial isolates, their antimicrobial susceptibility profile and factors associated with puerperal sepsis among post-partum/aborted women at a Referral Hospital in Bahir Dar, Northwest Ethiopia.

Methods

A cross sectional study was conducted from January to May 2017 among 166 post-partum/aborted women admitted to Felege Hiwot Referral Hospital for medical services and suspected for puerperal sepsis.. Socio-demographic data and associated factors were collected using structured questionnaire. Bacteria were isolated and identified from blood samples on Trypton soya broth, blood, Chocolate and MacConkey agars following standard bacteriological procedures. The VITEK 2 identification and susceptibility testing system was used to determine the antimicrobial susceptibility profiles of bacterial isolates. Data were entered and analyzed using SPSS version 20. Factors associated with puerperal sepsis were considered statistically significant at P-value < 0.05.

Results

The overall proportion of bacterial isolates among post-partum/aborted women was 33.7% (56/166); of which 55.4% was caused by Gram-negative and 44.6% was by Gram-positive bacteria. The most frequently isolated bacteria were Escherichia coli (32.1%) from Gram-negatives and Staphylococcus aureus (33.9%) from Gram-positives. The proportion of other isolates was (7.2%) for Coagulase Negative Staphylococci (CoNS), (12.5%) for Klebsiella pneumoniae, (10.7%) for Acinetobacter baumanni and (3.6%) for Raoultella ornithinolytica. All isolates of Gram-positive and Gram-negative bacteria were resistant to tetracycline (100%). The gram negatives show resistance to Cefazolin (72.7%), Tetracycline (93.9%) and Ampicillin (100%). The overall prevalence of multidrug resistance (MDR) was 84%. Women having multiparous parity were more likely to develop puerperal sepsis than primiparous parity (AOR 4.045; 95% CI: 1.479-11.061; P < 0.05). Other socio-demographic and clinical factors had no significant association with puerperal sepsis.

Conclusion

About one third of post-partum/aborted women suspected for puerperal sepsis were infected with one or more bacterial isolates. Significant proportion of bacterial isolates showed mono and multi-drug resistance for the commonly prescribed antibiotics. Women with multiparous parity were more likely to develop puerperal sepsis than primiparous parity.

Geographic variation in fatty acid composition and food source of the commercial clam (

Lake and coastal Tunisian areas are rich biodiversity habitats, although little information is available about the distribution of food sources for the inhabitant species. In this study, a fatty acid analysis was used to study the trophic ecology of Venerupis decussatac ommunities from 10 sites located along the Tunisian Coast. The richest population in fatty acids was found in S4 followed by S5 and S8, while that of S1, S3 and S10 were the least rich. Results from multivariate analysis confirmed the ecological position of the studied population based on their fatty acid composition. Our results divided the ten studied populations into three similar groups according to their ecological and geographical positions in relation to environmental parameters and food and trophic links. A principal component analysis revealed that diatoms and dinoflagellates were the predominate diets in all the sampling stations. Bacteria and urban discharge dominated the dietary source of clams from S10 and S9. Zooplankton were the preferred diet of V. decussata harvested from the two S2 and S3 lakes; although green algae, phytoplankton and detritus were absent from the dietary source of the two previous populations. Despite spatial differences, clams from the north and the south could be easily distinguished from each other, which indicates the utility of this method in the dietary analysis of different food chain links. This study proves that geographic, ecologic and abiotic factors as well as their mutual interaction should be properly investigated in studies focusing on the trophic chains of aquatic ecosystems.

Antibiotic prophylaxis for operative vaginal delivery

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 METHODS

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.

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.

The role of Escherichia coli in reproductive health: state of the art

Escherichia coli is a well-known commensal of the normal intestinal microbiome that can also colonize the vaginal microbiome, usually without symptoms. However, E. coli can also be a highly virulent and frequently deadly pathogen. In this review, I will discuss the role E. coli has in reproductive health and disease.

Effect of Puerperal Infections on Early Neonatal Mortality: A Secondary Analysis of Six Demographic and Health Surveys

Background

Around 1.5 million annual neonatal deaths occur in the first week of life, and infections represent one of the major causes in developing countries. Neonatal sepsis is often strictly connected to infection of the maternal genital tract during labour.

Methods

The association between signs suggestive of puerperal infection and early neonatal mortality (<7 days of life) was performed using Demographic and Health Surveys (DHS) data of six countries, conducted between 2010 and 2013. The population attributable fraction (PAF) was generated using the estimates on early neonatal mortality of a 1990–2013 systematic analysis for the Global Burden of Disease Study.

Results

Signs of puerperal infection ranged from 0.7% in the Philippines to 16.4% in Honduras. Infection was associated with a 2.1 adjusted Risk Ratio (95% CI: 1.4–3.2) of early neonatal mortality. Around five percent of all deaths in the first week of life were attributable to signs suggestive of puerperal infections and varied from 13.9% (95% CI: 1.0–26.6) in Honduras to 3.6% (95% CI: 1.0–8.5) in Indonesia.

Conclusions

Targeted interventions should be addressed to contain the burden of puerperal infections on early neonatal mortality. Consideration of the PAF will help in the discussion of the benefits of antenatal and perinatal measures.

Antibiotic prophylaxis for operative vaginal delivery

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 METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014).

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. For this update, we assessed methodological quality of the one included trial using the standard Cochrane criteria and the GRADE approach. We calculated the risk ratio (RR) and mean difference (MD) using a fixed-effect model and all the review authors interpreted and discussed the results.

MAIN RESULTS

One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. This trial identified only two out of the nine outcomes specified in this review. It reported seven women with endomyometritis in the group given no antibiotic and none in prophylactic antibiotic group. This difference did not reach statistical significance, but the risk reduction was 93% (risk ratio (RR) 0.07; 95% confidence interval (CI) 0.00 to 1.21). 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). Overall, the risk of bias was judged as low. The quality of the evidence using GRADE was low for both endometritis and maternal length of stay.

AUTHORS' CONCLUSIONS

The data were too few to make any recommendations for practice. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.

Risk factors and complications of puerperal sepsis at a tertiary healthcare centre

Objective: To determine the risk factors and complications of puerperal sepsis.

Methods: This was an observational prospective Cohort study conducted from January 2011 to December 2011 at the Obstetrics and Gynaecology Department Liaquat University of Medical & Health Sciences Jamshoro/Hyderabad, Sindh Pakistan. During this study period, all the women who delivered in this hospital or referred to this hospital within 42 days after delivery with puerperal pyrexia/sepsis diagnosed on clinical examination as well as with relevant investigations were included in the study. Women with other ailments like malaria, typhoid fever and postpartum eclampsia during the puerperal period were excluded. The subjects were registered on predesigned proforma after giving informed written consent. The data was collected and analyzed using SPSS version 17.

Results: During this period there were 3316 obstetrical admission and out of these 129(3.89%) women had puerperal sepsis. Most of these women 84(65.11%) were aged 31 years and above, multiparous 101 (78.29%), and unbooked 98 (75.96%) cases. Common risk factors found were absent membranes in 108(83.72%) of the women, delivered or undelivered and mismanaged, referred cases 95(73.64%), are being delivered in this hospital 34(26.35%). Morbidities seen were septicemia in 35 (27.13%) cases, and disseminated intra vascular coagulation in 23(17.82%) cases, while 11 (8.52%) of the women died.

Conclusion: Common risk factors were anaemia; suboptimal personal hygiene as well as improper sterilization which resulted in severe health hazards such as septicemia, disseminated intravascular coagulation as well as death.

Antibiotic prescribing in women during and after delivery in a non-teaching, tertiary care hospital in Ujjain, India: a prospective cross-sectional study

Objectives

Antibacterial drugs (hereafter referred to as antibiotics) are crucial to treat infections during delivery and postpartum period to reduce maternal mortality. Institutional deliveries have the potential to save lives of many women but extensive use of antibiotics, add to the development and spread of antibiotic resistance. The aim of this study was to present antibiotic prescribing among inpatients during and after delivery in a non-teaching, tertiary care hospital in the city of Ujjain, Madhya Pradesh, India.

Methods

A prospective cross-sectional study was conducted including women having had either a vaginal delivery or a cesarean section in the hospital. Trained nursing staff collected the data on daily bases, using a specific form attached to each patient file. Statistical analysis, including bivariate and multivariable logistic regression was conducted.

Results

Of the total 1077 women, 566 (53%) had a vaginal delivery and 511 (47%) had a cesarean section. Eighty-seven percent of the women that had a vaginal delivery and 98% of the women having a cesarean section were prescribed antibiotics. The mean number of days on antibiotics in hospital for the women with a vaginal delivery was 3.1 (±1.7) and for the women with cesarean section was 6.0 (±2.5). Twenty-eight percent of both the women with vaginal deliveries and the women with cesarean sections were prescribed antibiotics at discharge. The most commonly prescribed antibiotic group in the hospital for both the women that had a vaginal delivery and the women that had a cesarean section were third-generation cephalosporins (J01DD). The total number of defined daily doses (DDD) per100 bed days for women that had a vaginal delivery was 101, and 127 for women that had a cesarean section.

Conclusions

The high percentage of women having had a vaginal delivery that received antibiotics and the deviation from recommendation for cesarean section in the hospital is a cause of concern. Improved maternal health and rational use of antibiotics are intertwined. Specific policy and guidelines on how to prescribe antibiotics during delivery at health care facilities are needed. Additionally, monitoring system of antibiotic prescribing and resistance needs to be developed and implemented.

Barriers to utilisation of maternal health services in a semi-urban community in northern Nigeria: The clients' perspective

Background:

Low level of utilisation of maternal health services is a major factor responsible for high maternal mortality in northwestern region of Nigeria. This study was aimed at determining the barriers to utilisation of maternal health services from the perspective of mothers in northwestern Nigeria.

Materials and Methods:

A cross-sectional study of 150 mothers, selected through multistage technique, was conducted. Data were collected using a structured interviewer-administered questionnaire, and analysed using SPSS statistics 17.0.

Results:

Only 2.7% utilised preconception service, 98.7% antenatal care service (ANC), 24.0% delivery, 35.3% postnatal care and 14.0% utilised family planning service. Major reasons for non-utilisation of delivery service were not having a delivery complication in the past (57% (CI = 47.4-66.1)) and negative provider attitude (23.7% (CI = 16.4-32.7)). For non-utilisation of postnatal care, the major reasons were also not having a postnatal complication in the past (60.8% (CI = 50.4-70.4)) and negative provider attitude (27.8% (CI = 19.4-38.0)). As for non-utilisation of family planning service, the major reason was desire to have more children (32.6% (CI = 24.7-41.4)). Reasons for non-use of preconception care and ANC were not computed because respondents to these questions were not enough; only 6 (4.0%) were aware of preconception care in the first place and only 2 (1.3%) were not using ANC.

Conclusion:

Despite living near a health facility, most of the mothers were not using maternal health services. It is recommended that while there is the need to raise awareness on the utilisation of maternal health services, bring it closer to the mothers and make it more affordable, there is a more pressing need to improve its quality, especially through the alleviation of negative attitude of health care providers.

Is intravenous iron sucrose the treatment of choice for pregnant anemic women?

Anemia during pregnancy remains an important public health problem in developing countries like India. Anemia is the direct cause of 12-15% of maternal deaths. Iron deficiency is the commonest cause for anemia in the Indian subcontinent. Several preventive and therapeutic approaches are in practice. The available routes of iron supplementation are oral and intravenous. In spite of oral iron being least invasive, cheap and safe, the ineffectiveness of oral iron due to dietary inhibitors and poor compliance are well known. Intravenous iron sucrose can be a promising therapy for moderate to severely anemic pregnant women and has been in practice for quite some time in private and public health practices. In this article, we report the current evidence on the safety and efficacy of intravenous iron sucrose in anemic pregnant women on hematological and clinical outcomes. Though the evidence on its efficacy in improving hemoglobin and serum ferritin is convincing, its effect on maternal and fetal outcomes are unclear. This is primarily due to lack of well-designed and larger studies powered to detect difference in clinical outcomes. Hence, there is a need to gather evidence from a well-designed large randomized clinical trial conducted in a developing country. The results of such a study would feed into the national policy and would form the basis to frame guidelines for management of anemia in developing countries.

Assessment of infection control practices in maternity units in Southern Nigeria

OBJECTIVE

Puerperal sepsis accounts for 12% of maternal deaths in Nigeria. To date, little is known about the background hospital factors that predispose pregnant women to puerperal infection that leads to mortality. The objective of this study was to investigate the nature and pattern of existing policies and practices relating to infection control in maternity care centres in Edo state, South-South Nigeria.

DESIGN

Cross-sectional study consisting of in-depth interviews with service providers, observation of clinical practices and examination of medical records.

SETTING

Public and private health-care facilities in eight local government areas (LGAs) selected from the three senatorial districts of Edo State, Nigeria.

PARTICIPANTS

Health providers from 63 primary, secondary and tertiary maternity care centres.

METHODS

Sixty-three health-care facilities were sampled from eight LGAs from the three senatorial districts in Edo State. Three pre-tested tools were adapted to the local setting and used to interview key informants in the health facilities and to observe for practices and records relating to infection control.

RESULTS

Of the 63 health facilities, 68% (43) reported that they had infection control procedures in place, while only 25% (16) reported that they documented these as manuals or charts. Only 13% (8) of facilities had infection control committees; 11% (7) routinely carried out audits of maternal deaths, while 33% (21) reported that they had an ongoing programme for staff training on infection control. A high proportion of the health facilities reported that staff routinely wash their hands before and after sterile procedures, but only half of the facilities were observed to have 24-h running water and only two-thirds had soap and antiseptic solutions in delivery and operating theatre areas. Although more than 90% (57) of the health facilities reported that they use sterile gloves routinely, unused sterile gloves were found in only 60% (38) of these facilities, and recycled gloves in 11.1% (7).

CONCLUSION

The results of this study suggest the need for improved record-keeping procedures, the development of appropriate policies and protocols for infection control and staff training on infection control in maternity care facilities in Edo State. A public health education and advocacy programme to create awareness on clean delivery places as an approach for reducing maternal morbidity and mortality and to build political will for implementing related activities is also urgently needed.

Risk factors and microbial isolates of puerperal sepsis at the University of Maiduguri Teaching Hospital, Maiduguri, North-eastern Nigeria

PURPOSE

To determine the risk factors and microbial isolates of puerperal sepsis.

METHODS

A 12 year retrospective review of patients with puerperal sepsis from January 1999 to December 2010 at the University of Maiduguri Teaching Hospital (UMTH) was conducted. Information on socio-demographic characteristics, clinical presentations, place and mode of delivery and microorganism isolated from the endocervical swabs was collected and analysed. Comparison was also made with the other women that delivered during the period of study.

RESULTS

The incidence of puerperal sepsis was 0.78%. Majority (88.0%) of the patients were unbooked, 59.1% delivered at home and 23.1% delivered in other peripheral hospitals. The major risk factors for developing puerperal sepsis were unbooked status, home delivery, perineal trauma, caesarean section (C/S) and maternal age <24 years with OR of 56.60, 39.25, 8.52, 4.99 and 1.32, respectively. The commonest microorganism isolated were Staphylococcus aureus and Escherichia coli seen in 35.4 and 20.9%, respectively. Streptococcus species was found in 6.9%, while 20.3% had polymicrobials isolated.

CONCLUSION

Puerperal sepsis continues to present a significant risk of maternal mortality in developing countries. The risk factors are unbooked women, home delivery, perineal trauma, caesarean section and maternal age <24 years. S. aureus and E. coli are the commonest isolated organisms. There is a need to enlighten the populace on the need for booking, skilled attendant at delivery and hospital delivery under aseptic conditions.

Use of A Clean Delivery Kit and Factors Associated with Cord Infection and Puerperal Sepsis in Mwanza, Tanzania

Our objective was to determine the effectiveness of an intervention that incorporated education about the "six cleans" with the use of a clean delivery kit in preventing cord infection and puerperal sepsis. A stepped-wedge, cross-sectional study was conducted in 10 surveillance sites across two rural districts of Mwanza Region, Tanzania. A total of 3262 pregnant women between the ages of 17 and 45 years were enrolled in the study. Village health workers administered questionnaires to each mother at 5 days postpartum and inspected the infants' umbilical cord stumps for signs of infection. Newborns whose mothers used the delivery kit were 13.1 times less likely to develop cord infection than infants whose mothers did not use the kit. Furthermore, women who used the kit for delivery were 3.2 times less likely to develop puerperal sepsis than women who did not use the kit. Women who bathed before delivery were 2.6 times less likely to develop puerperal sepsis than women who did not bathe, and their infants were 3.9 times less likely to develop cord infection. Single-use delivery kits, when combined with education about clean delivery, can have a positive impact on the health of women and their newborns by significantly decreasing the likelihood of developing puerperal sepsis or cord infection.

Perfil epidemiológico e clínico de pacientes admitidas com diagnóstico de sepse puerperal de origem pélvica em uma UTI obstétrica no Nordeste do Brasil

OBJETIVOS: descrever o perfil epidemiológico e clínico das pacientes admitidas com o diagnóstico de sepse puerperal de origem pélvica em uma Unidade de terapia intensiva (UTI) obstétrica. MÉTODOS: um estudo de corte transversal, de fevereiro a agosto de 2010, foi conduzido. Foram investigados os casos de sepse puerperal de origem pélvica admitidas na UTI obstétrica do Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) - Recife - Brasil. As variáveis analisadas foram: idade, procedência, realização de pré-natal, via de parto, uso de sonda vesical, uso de cateter venoso central, intubação, uso de droga vasoativa, realização de relaparotomia, o número de relaparotomias realizadas, realização de histerectomia, ocorrência de complicações e óbito. RESULTADOS: identificamos 77 admissões por sepse, sendo 35 puerperal de origem genital. A idade média foi de 22,6 anos, a maioria procedente de cidades do interior do estado. 52,9% das mulheres tinham até 20 anos. 62,5% eram primíparas e 68,6% haviam sido submetidas a cesárea. Em relação à temperatura, 42,8% das pacientes apresentaram valores abaixo de 35ºC ou acima de 37,8ºC. Complicações ocorreram em 45,7% das pacientes. Diálise foi indicada em 40% e droga vasoativa utilizada em 22,9%. Histerectomia foi realizada em 44,1% das pacientes, sendo necessário relaparotomia em 54,3%. CONCLUSÕES: a sepse puerperal de origem genital é doença grave, que acomete mulheres jovens de baixa paridade. A freqüência de complicações e de procedimentos invasivos nesse grupo de mulheres é alto o que implica em alta morbidade e mortalidade. Conhecer de forma mais detalhada esse grupo de pacientes contribui com o conhecimento atual sobre a doença, melhorando a preparação dos centros para lidar a sepse puerperal de origem genital.

Maternal and early onset neonatal bacterial sepsis: burden and strategies for prevention in sub-Saharan Africa

Maternal and child health are high priorities for international development. Through a Review of published work, we show substantial gaps in current knowledge on incidence (cases per live births), aetiology, and risk factors for both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa. Although existing published data suggest that sepsis causes about 10% of all maternal deaths and 26% of neonatal deaths, these are likely to be considerable underestimates because of methodological limitations. Successful intervention strategies in resource-rich settings and early studies in sub-Saharan Africa suggest that the burden of maternal and early onset neonatal bacterial sepsis could be reduced through simple interventions, including antiseptic and antibiotic treatment. An effective way to expedite evidence to guide interventions and determine the incidence, aetiology, and risk factors for sepsis in sub-Saharan Africa would be through a multiarmed factorial intervention trial aimed at reducing both maternal and early onset neonatal bacterial sepsis in sub-Saharan Africa.

Childbirth practices in rural Rajasthan, India: implications for neonatal health and survival

In a rural community of Rajasthan in north India, we explored family, community and provider practices during labor and childbirth, which are likely to influence newborn health outcomes. A range of qualitative data-gathering methods was applied in two rural clusters of Udaipur district. This paper reports on the key findings from eight direct observations of labor and childbirth at home and in primary health facilities, as well as 10 focus group discussions, 18 case interviews with recently delivered women and 39 key informant interviews carried out within the community. Although most families preferred home delivery, health-facility deliveries were preferred for first births, especially among adolescents. A team of birth attendants led by a traditional birth attendant or an elder female relative took decisions and performed key functions during home childbirth. Modern providers were commonly invited to administer intramuscular oxytocin injections to hasten home delivery, whereas health staff tended to do the same during facility deliveries. The practice of applying forceful fundal pressure, stemming from overriding concern about the woman's inability to deliver spontaneously, was near universal in both situations. In both facilities and homes, monitoring of labor was largely restricted to repeated unhygienic vaginal examinations with little or no monitoring of fetal or maternal well-being. Babies born at home remained lying on the wet floor till the placenta was delivered. The cord was usually tied using available twine or ceremonial thread and cut using a new blade. In facility settings, drying and wrapping of the baby after birth was delayed and preparedness for resuscitation was minimal. Families believed in delaying breast-feeding till 3 days after birth, when they believed breast milk became available. Even hospital staff discharged the mother and newborn without efforts to initiate breast-feeding. A combination of traditional and modern practices, rooted in the concept of inducing heat to facilitate labor, occurred in both home and facility delivery settings. Programs to improve neonatal survival in such rural settings will need to invest both in strengthening primary health services provided during labor and delivery through training and monitoring, and in community promotion of improved newborn care practices.

Puerperal Pyrexia: A Review. Part I

Puerperal pyrexia and sepsis are among the leading causes of preventable maternal morbidity and mortality not only in developing countries but in developed countries as well. Most postpartum infections take place after hospital discharge, which is usually 24 hours after delivery. In the absence of postnatal follow-up, as is the case in many developing countries, many cases of puerperal infections can go undiagnosed and unreported. Besides endometritis (endomyometritis or endomyoparametritis), wound infection, mastitis, urinary tract infection, and septic thrombophlebitis are the chief causes of puerperal infections. The predisposing factors leading to the development of sepsis include home birth in unhygienic conditions, low socioeconomic status, poor nutrition, primiparity, anemia, prolonged rupture of membranes, prolonged labor, multiple vaginal examinations in labor, cesarean section, obstetrical maneuvers, retained secundines within the uterus and postpartum hemorrhage. Maternal complications include septicemia, endotoxic shock, peritonitis or abscess formation leading to surgery and compromised future fertility. The transmissions of infecting organisms are typically categorized into nosocomial, exogenous, and endogenous. Nosocomial infections are acquired in hospitals or other health facilities and may come from the hospital environment or from the patient's own flora. Exogenous infections come from external contamination, especially when deliveries take place under unhygienic conditions. Endogenous organisms, consisting of mixed flora colonizing the woman's own genital tract, are also a source of infection in puerperal sepsis. Aseptic precautions, advances in investigative tools and the use of antibiotics have played a major role in reducing the incidence of puerperal infections. Part I of this review provides background information and definitions, discusses the incidence and risk factors, explains the microbiology and pathophysiology of various infections, and delineates the signs and symptoms of major puerperal infection.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that world wide puerperal sepsis is a leading cause of maternal mortality, state that many of the predisposing factors are preventable, explain that both nosocomial infections as well as exogenous infections are serious factors, and relate that septic techniques and antibiotics can play a major role in reducing the incidence of puerperal infections.

Post-traumatic stress disorder after childbirth in Nigerian women: prevalence and risk factors

OBJECTIVE

To estimate the prevalence of post-traumatic stress disorder (PTSD) after childbirth in a group of postpartum Nigerian women and to examine any associated factors.

DESIGN

A cross-sectional survey.

SETTING

Postnatal clinics and infant immunisation clinics of the five health centres in Ilesa Township, Nigeria.

POPULATION

A total of 876 women at 6 weeks postpartum.

METHODS

The postpartum women were assessed for PTSD at 6 weeks. Other data collected were demographic characteristics, details of pregnancy and delivery and neonatal outcome. Additionally, the following measures were used: the MINI International Neuropsychiatric Interview to assess PTSD, the Index of Marital Satisfaction to measure the degree of problem a spouse encounters in the marital relationship, the Medical Outcome Study Social Support Survey to measure social support, the Life Events Scale to measure the life stress covering the preceding 12 months and the Labour Agentry Scale that measures the maternal experiences of control during childbirth.

MAIN OUTCOME MEASURES

Prevalence of PTSD in this population of postpartum Nigerian women, and how this prevalence related to other maternal and neonatal characteristics.

RESULTS

The prevalence of PTSD was 5.9%. The factors independently associated with PTSD after childbirth include hospital admission due to pregnancy complications (OR 11.86, 95% CI 6.36-22.10), instrumental delivery (OR 7.94, 95% CI 3.91-16.15), emergency caesarean section (OR 7.31, 95% CI 3.53-15.10), manual removal of placenta (OR 4.96, 95% CI 2.43-10.14) and poor maternal experience of control during childbirth (OR 5.05, 95% CI 2.69-9.48).

CONCLUSIONS

The prevalence of PTSD after childbirth in Nigerian women is slightly higher than those found in western culture. An effective model for the prediction of the development of PTSD after childbirth needs to be developed and evaluated, and interventions aimed at reducing the incidence of PTSD after childbirth need further research.

Sociodemographic and obstetric risk factors for postpartum depressive symptoms in Nigerian women

OBJECTIVE

Studies from the Western culture have emphasized psychosocial risk factors for the development of postnatal depression (PND). In Africa, poor obstetrics practice and sociodemographic factors may contribute significantly to the risk of PND. The goal of this study was to examine sociodemographic and obstetric risk factors for postnatal depressive symptoms in a Nigerian community.

METHODS

876 women recruited at 6 weeks postpartum from the postnatal and infant immunization clinics of 5 participating health centers were screened with the Edinburgh Postnatal Depression Scale (EPDS). Sociodemographic and obstetric information were also obtained through a structured questionnaire.

RESULTS

The mean EPDS score was 5.66 (SD = 4.20). Depression was diagnosed in 128 (14.6 %) of the postpartum women. The predictors of PND include hospital admissions during the pregnancy (OR 3.95, CI 2.57-6.07), female sex of the baby (OR 2.74, CI 1.87-4.03), preterm delivery (OR 4.21, CI 2.78-6.39), instrumental delivery (OR 3.32, CI 1.79-6.16), Cesarean section (OR 3.58, CI 1.72-7.48), and being single (OR 3.44, CI 2.15-5.53).

CONCLUSION

Although the prevalence of PND symptoms seems to be the same across cultures, risk factors differ significantly. This study identified certain sociodemographic and obstetric risk factors for postnatal depressive symptoms in an underdeveloped community. These factors must be taken into consideration when planning intervention and preventive strategies for these women.

Socioeconomic barriers to safe motherhood among booked patients in rural Nigerian communities

This study examines the socioeconomic barriers to safe motherhood in booked patients in the Ife-Ijesha health administrative zone, Nigeria. During the period of study (January 1998 to December 1998), 161 booked patients of Ife State Hospital, Ile-Ife and Wesley Guild Hospital, Ilesha presented with an avoidable obstetric emergency, Seventeen (10.6%) presented during the antenatal period, while 89 (55.3%) and 55 (34.2%) presented in labour and postpartum respectively. The patients presented with obstetric complications such as obstructed labour (24.2%), postpartum haemorrhage (21.1%), puerperal sepsis (24.2%), imminent eclampsia and eclampsia (15.5%), retained second twin (9.3%). Three maternal deaths occurred (MMR 1467/100 000 births) and the perinatal mortality rate was 290/1000 total births. The adduced reasons for late presentation included, financial constrains (85.1%), poor access to hospital/transportation difficulties (33.5%), objection to hospital admission by relatives (23.0%), aversion to caesarean section (21.7%) and attitude to hospital staff (8.1%). The patients were of the opinion that reducing the economic burden associated with hospital fee, provision of transportation, encouraged family support and reduction of operation rate would lead to reduction in late presentation.

Postpartum maternal morbidity requiring hospital admission in Lusaka, Zambia - a descriptive study

Background

Information on the extent of postpartum maternal morbidity in developing countries is extremely limited. In many settings, data from hospital-based studies is hard to interpret because of the small proportion of women that have access to medical care. However, in those areas with good uptake of health care, the measurement of the type and incidence of complications severe enough to require hospitalisation may provide useful baseline information on the acute and severe morbidity that women experience in the early weeks following childbirth. An analysis of health services data from Lusaka, Zambia, is presented.

Methods

Six-month retrospective review of hospital registers and 4-week cross-sectional study with prospective identification of postpartum admissions.

Results

Both parts of the study identified puerperal sepsis and malaria as, respectively, the leading direct and indirect causes of postpartum morbidity requiring hospital admission. Puerperal sepsis accounted for 34.8% of 365 postpartum admissions in the 6-month period. Malaria and pneumonia together accounted for one-fifth of all postpartum admissions (14.5% & 6% respectively). At least 1.7% of the postpartum population in Lusaka will require hospital-level care for a maternal morbidity.

Conclusions

In developing country urban settings with high public health care usage, meticulous review of hospital registers can provide baseline information on the burden of moderate-to-severe postpartum morbidity.

The evidence for emergency obstetric care

PURPOSE

We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries.

METHODS

We reviewed population-based studies with maternal mortality as the outcome variable and ranked them according to the system for ranking the quality of evidence and strength of recommendations developed by the US Preventive Services Task Force. A systematic search of published literature was conducted for this review, including searches of Medline, PubMed, Cochrane Database of Systematic Reviews, the Cochrane Pregnancy and Childbirth Database and the Cochrane Controlled Trials Register.

RESULTS

The strength of the evidence is high in several studies with a design that places them in the second and third tier in the quality of evidence ranking system. No studies were found that are experimental in design that would give them a top ranking, due to the measurement challenges associated with maternal mortality, although many of the specific individual clinical interventions that comprise EmOC have been evaluated through experimental design. There is strong evidence based on studies, using quasi-experimental, observational and ecological designs, to support the contention that EmOC must be a critical component of any program to reduce maternal mortality.

Antibiotic prophylaxis for operative vaginal delivery

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 are 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 and/or forceps deliveries.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (November 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2003) and MEDLINE (1966 to November 2003).

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

Four reviewers assessed trial eligibility and methodological quality. Two reviewers extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all reviewers. We assessed methodological quality of the included trial using the standard Cochrane criteria and the CONSORT statement of randomised controlled trials. We calculated the relative risks using a fixed effect model and all the reviewers interpreted and discussed the results.

MAIN RESULTS

One trial, involving 393 women undergoing either vacuum or forceps deliveries, was included. This trial identified only two out of the nine outcomes specified in this review. It reported seven women with endomyometritis in the group given no antibiotic and none in prophylactic antibiotic group. This difference did not reach statistical significance, but the relative risk reduction was 93% (relative risks 0.07; 95% confidence interval (CI) 0.00 to 1.21). There was no difference in the length of hospital stay between the two groups (weighted mean difference 0.09 days; 95% CI -0.23 to 0.41).

REVIEWERS' CONCLUSIONS

The data were too few and of insufficient quality to make any recommendations for practice. Future research on antibiotic prophylaxis for operative vaginal delivery is needed to conclude whether it is useful for reducing postpartum morbidity.