This survey shows that the great majority of Norwegian maternity departments have written guidelines for antibiotic prophylaxis in connection with caesarean sections, and these are largely in line with Guidelines in clinical obstetrics. As shown for Denmark, we found that the practice of antibiotic prophylaxis in connection with caesarean sections varies, with regard to indication, time of administration, type of antibiotic and dose (6).
At four Norwegian maternity departments it is routine practice to administer prophylaxis in all caesarean sections – in line with the most recent Cochrane recommendations (7). In a metaanalysis based on seven randomised surveys, it is pointed out that when the incidence of post-operative surgical site infections is higher than 5 %, antibiotic prophylaxis ought also to be administered in elective operations (8). NOIS data from 2005 – 2007 show that the total incidence of post-operative surgical site infections, including endometritis, for all caesarean sections was 8.3 %, and that it was 7.9 % for elective caesareans (5).
Most maternity departments recommend a single dose of first- or second-generation cefalosporins. A minority recommend ampicillin. A Cochrane analysis of 51 randomised studies showed that ampicillin and first-generation cephalosporins have the same infection-preventing effect, that the use of second-generation cephalosporins is not more effective and that a single dose is sufficient (9). Two maternity departments in this survey routinely administered metronidazole in combination with cefalosporins. This combination has been shown to result in fewer infections, shorter time in hospital and lower medicine costs than use of first-generation cefalosporins alone (10). In a recent study based on 10 000 caesarian sections, the combination of cefalosporins at the start and azitromycin after umbilical cord severance resulted in significantly fewer cases of endometritis (11). None of the Norwegian maternity departments reported that they used this combination.
More than two third of maternity departments routinely administered antibiotics after umbilical cord clamping. In a metaanalysis from 2008 based on five studies, two of them randomised, it was concluded that antibiotic prophylaxis administered before the start of the operation reduced the incidence of post-operative infections more than antibiotics administered after umbilical cord severance. The neonatal outcome was not affected, but the follow-up time was often limited to the first six weeks of life (12).
The Norwegian recommendations in Guidelines in clinical obstetrics correspond to the Danish ones in terms of both indication and recommendation of a single dose intravenously (13). In contrast to the Norwegian recommendations, the Danish ones prefer second-generation rather than first-generation cefalosporins. The Swedish Association of Obstetrics and Gynaecology has published a report in which antibiotic prophylaxis is recommended for all acute caesarean sections and on indication for elective caesareans (14). In Finland there are no national recommendations for antibiotic prophylaxis in connection with caesarian sections.
NOIS data from 2009 showed that 13 % of the women who had acute caesarians did not get antibiotic prophylaxis, and that the percentage of women who did varied from one maternity department to the next and from one hospital level to the next. Only 2 % of woen did not get prophylaxis at maternity departments that had written procedures about administering antibiotic prophylaxis for all caesarian sections. This indicates that compliance is better when the procedure requires that antibiotic prophylaxis be given for all caesarian sections, not just the acute ones.
This is the first systematic survey of guidelines for antibiotic prophylaxis in connection with caesarean sections at Norwegian maternity departments. We used NOIS data to determine whether the guidelines are complied with in practice. The study is strengthened by the fact that the guidelines were assessed against practice in independent data sets.
A possible weakness of the survey is that the NOIS data have not been quality assured against patient records data or other registry data, for example the Medical Birth Registry or the Norwegian Patients Register. A major register integration study is currently in progress with data from all three of these registers.
We did not systematically read the written guidelines of the Norwegian maternity departments. Nor did we quality assure the data on antibiotic prophylaxis. The use of antibiotic prophylaxis in connection with caesarean sections is not included in entries in the Medical Birth Register.
In the analyses of whether the guidelines were followed, 569 (of 2 183) women, mainly at two maternity departments, were excluded because the use of antibiotic prophylaxis was not reported to NOIS. However, there were no essential differences in age between the women who were included and those who were excluded, but the number of elective caesarean sections and the ASA Score (American Society of Anesthesiology Score) was somewhat higher among those who were excluded.
One of the purposes of NOIS is to describe the incidence of infection by patient characteristics and type of treatment. The information is used as the basis for advice on infection prevention measures, among other things. This survey is an example of how the NOIS register can also be used to evaluate clinical practice. The register does not contain information about risk factors like haemorrhaging, type of antibiotic, time of administration and dose. These are data that should be considered for inclusion in any revised version of NOIS or the Medical Birth Registry.
The recommendations in Guidelines on maternity assistance do not correspond to either the Cochrane Reviews of 2010 (7) or a newly published review article in BJOG (15), in which antibiotic prophylaxis is recommended for all caesarean sections. Nor do the Norwegian guidelines say anything about the time of administering antibiotic prophylaxis, or the dose. There have been discussions for many years (16) – (18) as to what should be standard procedure for antibiotic prophylaxis in connection with caesarean sections. Our survey shows that there is still a need for a technical clarification of the contents of the Norwegian recommendations.