Executive summary

Executive summary

Introduction

Direct maternal infections around the time of childbirth account for about one tenth of the global burden of maternal death. Women who develop peripartum infections are also prone to severe morbidity, long-term disabilities such as chronic pelvic pain, fallopian tube blockage and secondary infertility. Maternal infections before or during childbirth are also associated with an estimated 1 million newborn deaths annually.

Several factors increase the risk of maternal peripartum infections, including pre-existing maternal conditions (e.g. malnutrition, diabetes, obesity, severe anaemia, bacterial vaginosis and group B streptococcus infections), as well as prolonged prelabour rupture of membranes, multiple vaginal examinations, manual removal of the placenta, operative vaginal birth and caesarean section. As such, the strategies to reduce maternal peripartum infections and their short- and long-term complications have been directed at improving infection prevention and control practices.

Globally, an effective intervention for preventing morbidity and mortality related to maternal infection is the prophylactic and therapeutic use of antibiotics. However, the misuse of antibiotics for obstetric conditions and procedures is common in many settings. Inappropriate antibiotic use has implications for the global effort to prevent and reduce antimicrobial resistance. The WHO global strategy for containment of antimicrobial resistance underscores the importance of appropriate use of antimicrobials at different levels of the health system to reduce the impact of antimicrobial resistance, while ensuring access to the best treatment available. WHO guidelines for health professionals and policy-makers on the need for antibiotics – and the type of antibiotics – for the prevention and treatment of maternal peripartum infections align with the WHO strategy and, if implemented, will improve maternal and newborn outcomes.

In 2019, the Executive Guideline Steering Group (GSG) for World Health Organization (WHO) maternal and perinatal health recommendations prioritized updating of the existing WHO recommendation on prophylactic antibiotics for women undergoing caesarean section in response to the availability of new evidence. The recommendation in this document thus supersedes the previous WHO recommendation on prophylactic antibiotics for women undergoing caesarean section as published in the 2015 guideline WHO recommendations for the prevention and treatment of maternal peripartum infections.

Target audience

The primary audience for this recommendation includes health professionals who are responsible for developing national and local health-care guidelines and protocols (particularly those related to the prevention and treatment of peripartum infections) and those involved in the provision of care to women and their newborns during labour and childbirth, including midwives, nurses, general medical practitioners and obstetricians, as well as managers of maternal and child health programmes, and relevant staff in ministries of health and training institutions, in all settings.

Guideline development methods

The updating of this recommendation was guided by standardized operating procedures in accordance with the process described in the WHO handbook for guideline development. The recommendation was initially developed and updated using this process, namely: (i) identification of priority questions and outcomes; (ii) retrieval of evidence; (iii) assessment and synthesis of evidence; (iv) formulation of the recommendations; and (v) planning for the dissemination, implementation, impact evaluation and future updating of the recommendation.

The scientific evidence supporting the recommendation was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. An updated systematic review was used to prepare the evidence profiles for the prioritized question. WHO convened a meeting on 19–20 October 2020 where the Guideline Development Group (GDG) members reviewed, deliberated and achieved consensus on the strength and direction of the recommendation presented herein. The recommendation was formulated under one of the following categories: recommended, not recommended, recommended only in specific contexts (the intervention is applicable only to the condition, setting or population specified in the recommendation), recommended only in the context of rigorous research (implementation of the recommendation can still be undertaken provided it takes the form of research that addresses unanswered questions). Through a structured process, the GDG reviewed the balance between the desirable and undesirable effects and the overall certainty of supporting evidence, values and preferences of stakeholders, resource requirements and cost–effectiveness, acceptability, feasibility and equity.

Recommendation

The GDG issued the recommendation on prophylactic antibiotics for women undergoing caesarean section with remarks and implementation considerations. To ensure that the recommendation is correctly understood and applied in practice, guideline users may want to refer to the remarks, as well as to the evidence summary, including the considerations on implementation.

Table

WHO recommendation on prophylactic antibiotics for women undergoing caesarean section.

Publication Details

Copyright

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/).

Publisher

World Health Organization, Geneva

NLM Citation

WHO recommendation on prophylactic antibiotics for women undergoing caesarean section [Internet]. Geneva: World Health Organization; 2021. Executive summary.

WHO recommendation on prophylactic antibiotics for women undergoing caesarean section

Recommendation: For antibiotic prophylaxis for caesarean section, a single dose of first-generation cephalosporin or penicillin should be used in preference to other classes of antibiotics. (Recommended)

Remarks:

Antibiotic classes

The Guideline Development Group noted that the available evidence on the effectiveness of antibiotics for caesarean section was largely derived from trials that tested first- or second-generation cephalosporins or penicillins in the 1980s and 1990s. Based on consensus, the Guideline Development Group favoured these classes of antibiotics over other classes of antibiotics, as they have a broad spectrum of activities and are widely available in all settings. While the Guideline Development Group members acknowledged the lack of clear difference between first- and second-generation cephalosporins, they noted that the evidence suggests that third-generation cephalosporins may be less effective than penicillins for this indication, and therefore suggests that this class of antibiotics should be avoided.
The Guideline Development Group noted that first-generation cephalosporins are the preferred antibiotic class for prophylaxis in general surgery, as part of efforts to contain antimicrobial resistance.
In acknowledgement of the lack of evidence on the comparative effectiveness of different classes of antibiotics, the Guideline Development Group concluded that when the recommended antibiotic classes are not available, other classes of antibiotics may also be used. The Guideline Development Group noted that the choice of an antibiotic class should be informed by local antimicrobial resistance guidance, local bacteriologic patterns of post-caesarean infectious morbidity, safety profile, the clinician’s experience with that particular class of antibiotics, availability and cost.

Regimen

The Guideline Development Group emphasized the importance of using a simple and short (single dose, 30–60 minutes before surgery) antibiotic regimen for prophylaxis. There are other clinical factors (e.g. high maternal body mass index, prolonged labour, prolonged duration of surgery, extensive surgical manipulation or massive blood loss) that might increase the risk of developing post-caesarean infections. Clinical judgement is needed to evaluate if a different regimen (higher dose, second dose) of prophylactic antibiotics is warranted in the presence of risk factors.

Risk of necrotizing enterocolitis

Due to the increased risk of necrotizing enterocolitis among preterm babies exposed to amoxicillin plus clavulanate, the use of amoxicillin plus clavulanate for antibiotic prophylaxis should be avoided before cord clamping for caesarean section of preterm infants.

Timing and provision

The Guideline Development Group acknowledged that for caesarean section, prophylactic antibiotics are recommended for women undergoing elective or emergency caesarean section and should be given 30–60 minutes prior to skin incision, rather than intraoperatively after umbilical cord clamping, consistent with recommendation No. 18.1 of the 2015 WHO recommendations for prevention and treatment of maternal peripartum infections.

Previous recommendation

This recommendation revalidates recommendation No. 18.2 of the 2015 WHO recommendations for prevention and treatment of maternal peripartum infections, where this was considered a strong recommendation based on moderatequality evidence.