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.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Obstetrics & Gynecology MFMAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333
- The continuum of maternal sepsis severity: incidence and risk factors in a population-based cohort study.PLoS One. 2013; 8: e67175
- Incidence and causes of maternal mortality in the USA.J Obstet Gynaecol Res. 2016; 42: 661-668
- Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births.Obstet Gynecol. 2007; 109: 669-677
- Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section.Cochrane Database Syst Rev. 2014; 10CD007482
- ACOG Practice Bulletin No. 199: use of prophylactic antibiotics in labor and delivery.Obstet Gynecol. 2018; 132: e103-e119
- Antibiotic prophylaxis for operative vaginal delivery.Cochrane Database Syst Rev. 2017; 8CD004455
- ACOG Practice Bulletin No. 198: prevention and management of obstetric lacerations at vaginal delivery.Obstet Gynecol. 2018; 132: e87-102
- Puerperal sepsis: a preventable post-partum complication.Trop Doct. 1998; 28: 92-95
- Adjunctive azithromycin prophylaxis for Cesarean delivery.N Engl J Med. 2016; 375: 1231-1241
- Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial.Lancet. 2019; 393: 2395-2403
- Evaluation of a risk-stratified, heparin-based, obstetric thromboprophylaxis protocol.Obstet Gynecol. 2021; 138: 530-538
- Operative vaginal birth: ACOG Practice Bulletin, Number 219.Obstet Gynecol. 2020; 135: e149-e159
- Trends in operative vaginal delivery, 2005-2013: a population-based study.BJOG. 2017; 124: 1365-1372
- Morbidity and mortality associated with forceps and vacuum delivery at outlet, low, and midpelvic station.J Obstet Gynaecol Can. 2019; 41: 327-337
- Episiotomy in vacuum-assisted delivery affects the risk of obstetric anal sphincter injury: a systematic review and meta-analysis.Eur J Obstet Gynecol Reprod Biol. 2016; 207: 193-199
- Operative vaginal delivery and post-partum infection.Best Pract Res Clin Obstet Gynaecol. 2019; 56: 93-106
- Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth.Cochrane Database Syst Rev. 2014; 10CD005125
- Factors associated with wound complications in women with obstetric anal sphincter injuries (OASIS).Am J Obstet Gynecol. 2013; 208 (327.e1–6)
- Epidemiology of and surveillance for postpartum infections.Emerg Infect Dis. 2001; 7: 837-841
- Williams obstetrics.Mcgraw-hill, New York, NY2014
- Wound complications after obstetric anal sphincter injuries.Obstet Gynecol. 2015; 125: 1088-1093
- 118: antibiotics at time of operative vaginal delivery: a cost-effectiveness analysis.Am J Obstet Gynecol. 2020; 222
Article info
Publication history
Published online: August 02, 2022
Accepted:
July 28,
2022
Received in revised form:
July 14,
2022
Received:
May 25,
2022
Footnotes
The authors report no conflict of interest.
No funding was received for this work.
This study was presented as a poster at the 41st annual meeting of the Society for Maternal-Fetal Medicine, held virtually, January 25–30, 2021.
Cite this article as: Dunk SA, Owen J, Lu MY, et al. Operative vaginal delivery as an independent risk factor for maternal postpartum infectious morbidity. Am J Obstet Gynecol MFM 2022;XX:x.ex–x.ex.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
