The patient is then brought to the operating room for cesarean delivery. Which of the following represents the correct procedure for antibiotic administration?

A 32-year-old nulliparous woman at 38 weeks’ gestation comes to the labor and delivery ward with regular painful contractions after a gush of fluid two hours ago. Her temperature is 98.6 F (37 C). She is found to have gross rupture of membranes and to have a cervix that is 6 centimeters dilated. The fetus is in breech position. The patient is then brought to the operating room for cesarean delivery. Which of the following represents the correct procedure for antibiotic administration?

A. Administer intravenous antibiotics 30 minutes prior to the procedure
B. Administer intravenous antibiotics after the cord is clamped
C. Administer intravenous antibiotics immediately after the procedure
D. Administer intravenous antibiotics for 24 hours after the procedure
E. Administer oral antibiotics for 1 week following the procedure.

Explanation: The correct answer is B. One of the major risk factors for developing postpartum endometritis is cesarean delivery. Therefore, prophylactic antibiotics are recommended in all cases of nonscheduled cesarean delivery (i.e., a cesarean delivery that is not anticipated). This patient is having a cesarean delivery because she is a nulliparous woman in labor with a fetus in the breech position. The fact that her membranes broke a few hours ago, and that she has dilated to 6 centimeters puts her at even higher risk for postpartum endometritis because of the possible exposure that has occurred to the vaginal flora. Intravenous antibiotics will help to prevent infection of the mother if they are given before or after the umbilical cord is clamped. Therefore, to minimize fetal exposure to the antibiotics, the medication should be given after the umbilical cord is clamped. This patient has no evidence of chorioamnionitis; therefore there is no indication to give the antibiotics immediately. To administer intravenous antibiotics 30 minutes prior to the procedure (choice A) is proper management in a non-pregnant patient undergoing, for example, a hysterectomy. In the pregnant patient, administering the antibiotic prior to clamping the umbilical cord results in unnecessary fetal exposure. To administer intravenous antibiotics immediately after the procedure (choice C) is incorrect because there is a needless delay. Once the umbilical cord is clamped, there is no further concern regarding unnecessary fetal exposure and the antibiotic may be given immediately. To administer intravenous antibiotics for 24 hours after the procedure (choice D) is indicated when the patient has chorioamnionitis. This patient, however, has no evidence of being infected and the antibiotics are being given for prophylaxis. To administer oral antibiotics for 1 week following the procedure (choice E) is unnecessary. Once the single dose is given at the time of cord clamping, there is no need for further treatment.