Antibiotic Prophylaxis for Cesarean Section with Prolonged Rupture of Membranes
For cesarean section with prolonged rupture of membranes, the recommended antibiotic prophylaxis is intravenous cefazolin 2g plus azithromycin administered within 60 minutes before skin incision. 1, 2
First-Line Antibiotic Regimen
- Cefazolin 2g IV as a single dose within 60 minutes before skin incision is the primary recommendation for all cesarean sections 1, 2
- For women with prolonged rupture of membranes, add azithromycin for additional reduction in postoperative infections 1, 2
- This combination provides broader coverage against potential pathogens in the setting of prolonged membrane rupture, which increases infection risk 1
Alternative Regimens for Penicillin/Cephalosporin Allergic Patients
- Clindamycin 900 mg IV slow infusion as a single dose for patients with penicillin/cephalosporin allergy 2
- Gentamicin 5 mg/kg/day as a single dose may be considered in addition to clindamycin for allergic patients 2
Timing of Administration
- Antibiotics must be administered 30-60 minutes before skin incision, not after cord clamping 1, 2
- This timing has been shown to significantly reduce postoperative infectious morbidity compared to post-cord clamping administration 2
Additional Considerations
- Vaginal preparation with povidone-iodine solution before cesarean delivery should be performed in women with ruptured membranes to further reduce postcesarean infections 1, 2
- Chlorhexidine-alcohol is preferred over aqueous povidone-iodine solution for abdominal skin cleansing 1
- No additional doses are needed if the procedure duration is less than 4 hours 2
- If the cesarean procedure lasts longer than 4 hours, an additional dose of cefazolin (1g) may be considered 2
Risk Stratification
- Cesarean delivery with prolonged rupture of membranes is classified as a clean-contaminated (class II) incision with higher infection risk 1, 3
- Risk factors that increase infection risk include:
Special Circumstances
- If chorioamnionitis is suspected, broader spectrum antibiotic therapy should replace standard prophylaxis 1
- For women with suspected chorioamnionitis, consider broader coverage with piperacillin-tazobactam or a combination of ceftriaxone plus metronidazole 3
Evidence Quality
- The recommendation for cefazolin plus azithromycin for women with prolonged rupture of membranes is supported by high-quality evidence with strong recommendation grade 1, 2
- Studies have demonstrated that appropriate antibiotic prophylaxis can reduce infection rates from approximately 50% to 15-21% in high-risk cesarean deliveries with prolonged rupture of membranes 6, 7
This approach to antibiotic prophylaxis for cesarean section with prolonged rupture of membranes follows current guidelines and is designed to minimize the risk of postoperative infectious complications, which directly impacts maternal morbidity, mortality, and quality of life.