Prophylactic co-amoxiclav after second-degree tears: fewer wound complications

Design

Secondary cohort analysis of a randomised placebo-controlled trial

Population

433 women with second-degree tears or episiotomy in Denmark

Primary outcome

Clinically relevant perineal wound complication

Effect

12.7% had a complication; antibiotics aOR 0.34 (0.18 to 0.65)

This secondary analysis treated the REPAIR trial as a single cohort: 442 Danish women with second-degree perineal tears or episiotomy, randomised in 2023 to prophylactic amoxicillin-clavulanate or placebo. Of 433 assessed, 55 (12.7%) had a clinically relevant wound complication.

Prophylactic antibiotics were associated with markedly lower odds of complication (adjusted OR 0.34, 95% CI 0.18 to 0.65). Prolonged active second stage (aOR 2.25, 1.11 to 4.46) and deep tear (aOR 2.11, 1.10 to 4.24) raised the odds. Doctor involvement in suturing was also associated (aOR 2.47), which the authors suspect reflects tear complexity rather than the repairer. Episiotomy was borderline (aOR 2.01, 0.92 to 4.21).

One in eight women having a wound complication is a higher burden than many units assume for second-degree tears. The antibiotic effect is the randomised element and the strongest finding; the risk factors are exploratory. Before changing unit policy, weigh this single-centre result against local antimicrobial stewardship and resistance patterns, particularly in Indian units where co-amoxiclav resistance varies.

• Discuss a single prophylactic course of amoxicillin-clavulanate after second-degree tear or episiotomy repair, in line with your unit's stewardship policy.
• Prioritise prophylaxis for women with a prolonged active second stage or a deep tear, who had about double the odds of breakdown.
• Check penicillin allergy before prescribing and have an agreed alternative in the unit protocol.
• Audit your own perineal wound complication rate; about 1 in 8 women had one in this cohort.

Why it matters

Antibiotic prophylaxis is standard after sphincter injuries but not after second-degree tears, where most women sit.

Don't overread it

The risk-factor findings are exploratory and single-centre; only the antibiotic comparison was randomised.

The statistics, in plain English

An adjusted odds ratio of 0.34 means the odds of a wound complication were about one-third as high with antibiotics. The interval (0.18 to 0.65) stays well below 1.0, so this is unlikely to be chance. The risk factors have wide intervals that almost touch 1.0, so their true size is less certain.

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