What is the recommended management for a patient with chorioamnionitis (inflammation of the chorion and amnion membranes) who is undergoing a cesarean section (C-section)?

Management of Chorioamnionitis in Cesarean Section

Initiate ampicillin (2g IV initial dose, then 1g IV every 4 hours) and gentamicin (weight-based dosing) immediately upon diagnosis, and add clindamycin (900mg IV) at the time of umbilical cord clamping during cesarean delivery. 1, 2

Antibiotic Management Algorithm

Standard Regimen (No Penicillin Allergy)

• Start intrapartum antibiotics within 3 hours of fever recognition (or within 1 hour if septic shock suspected) 1
• Ampicillin 2g IV loading dose, then 1g IV every 4 hours until delivery 1
• Gentamicin loading dose followed by weight-based maintenance dosing 1
• At cord clamping during cesarean section: add clindamycin 900mg IV 3
• This triple-drug regimen (ampicillin-gentamicin-clindamycin) is critical for cesarean delivery due to exponentially increased endometritis risk 4

Penicillin Allergy Modifications

• Non-severe allergy: Replace ampicillin with cefazolin 2g IV loading dose, then 1g IV every 8 hours until delivery 1, 2
• Severe allergy: Use clindamycin 900mg IV every 8 hours OR vancomycin 1g IV every 12 hours until delivery 1, 2

Postoperative Antibiotic Duration

Discontinue antibiotics after delivery—no additional postoperative doses are necessary following cesarean section. 3 If your institution protocol requires postdelivery antibiotics, limit to a single additional dose only 3. The evidence clearly shows that continuing antibiotics beyond delivery provides no additional benefit for maternal outcomes 3, 4.

Critical Timing Considerations

• Never delay antibiotics pending amniocentesis results or waiting for fever to worsen 1
• Obtain blood cultures before antibiotic administration when feasible, but do not delay treatment 1
• Proceed with delivery once chorioamnionitis is diagnosed—vaginal delivery remains safer than cesarean when obstetric indications don't mandate surgical delivery 3

Intraoperative Considerations

Oxytocin Requirements

• Patients with chorioamnionitis require higher oxytocin doses to achieve adequate uterine contractility 3
• Hyperthermia adversely impacts uterine contractility and may lower the threshold for fetal hypoxic brain injury 1
• Maintain normothermia with antipyretics (acetaminophen) during labor and surgery 3

Surgical Technique

• Use two-layer hysterotomy closure to reduce future uterine rupture risk 5
• Blunt expansion of transverse uterine incision reduces blood loss 5
• Reapproximate subcutaneous tissue if ≥2cm thickness 5
• Use subcuticular suture for skin closure rather than staples 5

Neonatal Management Coordination

• Well-appearing newborns: Limited evaluation (blood culture, CBC with differential) plus empirical antibiotics pending cultures 1, 2
• Newborns with sepsis signs: Full diagnostic workup including lumbar puncture if stable, plus IV ampicillin and gentamicin 1
• Coordinate with pediatrics team before delivery to ensure immediate neonatal assessment 2

Common Pitfalls to Avoid

• Do not withhold clindamycin at cord clamping during cesarean delivery—this is the most common error that leads to postpartum endometritis 3, 4
• Do not continue antibiotics beyond delivery unless there are persistent signs of infection unrelated to the uterus 3, 4
• Do not delay delivery to complete corticosteroid or magnesium sulfate courses in preterm gestations—deliver once chorioamnionitis is diagnosed 3
• Epidural analgesia can cause fever and lead to overdiagnosis, but err on the side of treatment when clinical suspicion exists 2