Key messages
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Antibiotics (germ-killing medicine) may have little to no effect on infection of the lining of the uterus after a retained placenta is manually removed, but the evidence is very uncertain.
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A larger study with a better design and a better fit for our research question may be needed to give better estimates of the benefits and potential harms of prophylactic (preventive) antibiotics.
What is a retained placenta?
In natural birth, placenta delivery occurs shortly after the delivery of the baby. Occasionally, the placenta cannot be delivered, and is retained in the uterus. This could lead to a significant amount of blood loss and severe consequences, such as the death of the mother.
How is the retained placenta treated?
After the woman is given anaesthesia, the doctor will put their hand into the uterus to take out the placenta. This can possibly introduce germs into the uterus, and cause an infection in the lining of the uterus.
What did we want to find out?
We wanted to find out if giving an antibiotic just before the manual removal of a retained placenta could prevent infection of the lining of the uterus. We also wanted to find out if it was associated with a lot of blood loss, bloodstream infection, any unwanted side effects, and admission of the baby to the intensive care unit.
What did we do?
We searched for studies that investigated prophylactic antibiotics compared with no antibiotics in women who received manual placenta removal. We compared and summarised the results of the studies, and rated our confidence in the evidence, based on factors, such as study methods and sizes.
What did we find?
We found four studies that involved 974 women with a retained placenta. All of them compared prophylactic antibiotics with no antibiotics. The biggest study was in 407 women and the smallest study was in 100 women. The studies were conducted in Bulgaria, Germany, Norway, and Israel. No study reported a source of funding.
Compared with no antibiotics, prophylactic antibiotics:
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have an unclear effect on infection of the uterine cavity,
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may have little or no influence on whether a lot of blood is lost, or the baby is admitted to the intensive care unit.
We found no studies to help us answer the effect of prophylactic antibiotics on bloodstream infection or any unwanted side effects.
What are the limitations of the evidence?
We are not confident in the results of the effect on infection of the lining of the uterus, because some unknown factors might be interfering with its effect. Some evidence focused on any post-delivery uterine intervention, whereas the procedure we wanted to assess was more specific. The evidence is based on only a few cases of infection.
We have little confidence in the evidence for a large blood loss or admission of the baby to the intensive care unit, because some unknown factors might be interfering with its effect, and there were not enough studies to be certain about the results of our outcomes.
How up-to-date is this evidence?
This review updates our 2014 Cochrane review. The evidence is up-to-date until May 2024.
There is very uncertain evidence supporting the use of prophylactic antibiotics for manual removal of placenta for preventing postpartum endometritis. The evidence suggests that prophylactic antibiotics result in little to no difference in postpartum haemorrhage or admission to a neonatal intensive care unit. There were no available data on other important outcomes.
Multicentre, randomised controlled trials comparing antibiotic prophylaxis and placebo or no antibiotic, or one antibiotic and another, for manual removal of placenta in vaginal birth are needed to provide more robust evidence.
Retained placenta is a potentially life-threatening condition because of its association with postpartum hemorrhage. Manual removal of placenta increases the likelihood of bacterial contamination in the uterine cavity.
To compare the effectiveness and adverse effects of routine prophylactic antibiotics for the manual removal of placenta after vaginal birth.
To identify appropriate prophylactic antibiotic regimens.
For this update, we searched CENTRAL, MEDLINE, Embase, CINAHL, and two trials registries, in addition to screening the reference lists of retrieved studies and systematic reviews. The last search was 14 May 2024.
All randomized controlled trials comparing antibiotic prophylaxis and placebo or non antibiotic use to prevent endometritis after manual removal of placenta in vaginal birth.
There are no included trials. In future updates, if we identify eligible trials, two review authors will independently assess trial quality and extract data
No studies that met the inclusion criteria were identified.
This systematic review received support from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP).
Protocol and previous versions are available at https://10.1002/14651858.CD004904.pub3.