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Hey, podcast family, this is Michael, the producer of the no Spend podcast. Let's start with a clinical question. Do you routinely order antibiotics at time of repair of a second degree obstetrical laceration? In this episode, Dr. Chapa will summarize a new study on this and provide some real world applications. And now here's Dr. C.

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So podcast family medicine always moves fast. That of course, is our tagline. And in this episode we're going to cover that very issue. Okay. Because as of right now, as it still stands, as of October 5, 2025, which by point of reference is when we're recording this, there are no major OB, women's health professional organizations that have guidance or recommendations for the use of antibiotics at time of repair for a first or second degree laceration. I mean, we just don't do it. It's probably not needed. However, it's a little bit different for OASIS injuries. That's obstetrical anal sphincter injuries. Of course, OASIS tears where antibiotics may be considered because that's closer to a very contaminated area otherwise known as the anus. And so ACOG says in the prevention and management of OASIS lacerations that for those severe forms of lacerations, third or fourth degrees antibiotics can be considered. I'll read that in just a minute. But what about second degrees? Well, as we've already stated, no major medical professional organizations has guidance and or recommendations for that. But medicine does move fast. So on October 29, 2025, out of BMJ British Medical Journal, there's a brand new single center, double blind, placebo controlled randomized trial that was pretty good. Little confusing, but pretty good. And it's kind of throwing this curveball into this issue of the potential, that's the key word there, potential benefit of adding antibiotics at time of closure of a second degree laceration. Now, let me be very clear before we go into this repair study, because that's the name of the title repair, which actually stands for risk of infection and wound dehiscence after use of prophylactic antibiotics in episiotomy or second degree tears. That's the repair study. Before we get into that, I'm going to tell you what they found because it sounds pretty good, but you got to know the details in this and dissect some of the data, which of course we're going to do. But let me be very clear. I am not advocating right now for universal use of antibiotics at time of second degree lacerations. Although. Although it's not necessarily a bad thing. So again, at Journal Club, consider this BMJ publication from 29 October 2025 called the Repair Study because it's something to talk about. Talk amongst yourselves and see if this is something you want to do. I'm going to give you our clinical implications of this or at least my stance on this towards the end of let you know how we can do the best practice for this without going gung ho and everybody gets antibiotics at time of second degree repair which probably is not needed but where in sum, maybe with a second degree repair it may be more beneficial. All right, so of course in true style we're going to let you know what this found very quickly as we stick to our new commitment to let you know what you need to know and then move on. We're going to highlight there is a systematic review and meta analysis that tackled this and said, eh, maybe, I mean it's not like really impressive but it's probably not going to hurt. So. And that's exactly what they found. I'll give you that reference out of plus one in just a minute. Of course we'll circle back to more severe lacerations with ACOG's little blurb on that for OASIS injuries where antibiotics, quote, it's reasonable to consider, end quote for those more severe lacerations to prevent wound breakdown and or infection. But I thought this was interesting because routinely, no, of course I don't give antibiotics for a second degree lack because again, once again there's no professional medical society recommendation to do so. But is it wrong to do it? No. So how can that be the case here? How can we give antibiotics and it not be wrong yet there not be any medical society guidance for that? Because they seem conflicting when we say that. Well the answer is very simple. In order to make a professional medical society stance or recommendation, those things take a long time, a long time. So as the data first collects, it gets integrated into practice, the bulk of the evidence says yes, this is reasonable. Then the societal recommendation comes out, unless it's something really mind blowing. And this isn't where, for example ACOG would issue a clinical practice update. All right. And that's not the case here because the data, while looking good, is not overwhelmingly clear. All right, so while there is data and we're going to cover this, especially that systematic review meta analysis that says no, it's not wrong to do that, is that it's probably not necessary in the majority of cases. All right, so I think this is good. We're doing this again at the in the fall of 2025. It is oral board season for a bog is something to consider if you're asked, do you routinely give antibiotics for second degree lacks have a defense for it? Right now, the current answer, the best answer is, you know what, that's a great question. I follow professional medical society guidance and recommendations and that's all they are, it's guidance and recommendations. We can do whatever we want as long as there's evidence for it, we're not hurting anybody. Those are just guidances, you know, just suggestions. But that does kind of make standard of care and right now we really don't have that for first or second degree lacks. However, data absolutely exists where it possibly could be helpful and that includes systematic reviews and meta analysis. So it is reasonable to do that, although there's not yet, not yet a professional recommendation for that. As long as it's not a more severe laceration like a third or fourth degree, otherwise known as, as oasis injuries. So that's the answer. But let's talk about the repair study. Let's briefly, just briefly talk about the systematic review and meta analysis that looked at this and then we will call it a day because I don't want to belabor this. All right, I think I've set it up enough. We will be right back. This is Dr. Chapa's OBGYN no Spin podcast. All right, yo, let's get started. So first of all, let me be very clear. Let me just start with the basic consensus and then we'll move on to this repair study. I'll tell you about the recent systematic review and meta analysis that was earlier this year, 2025. I mean this is, this is a thing of interest. So let me, and before I get into all that, let me just say what I said in the intro. Did I say that in the intro? I think I did. Yes I did. Let me just state the two camps here. Is there data that antibiotics at time of repair of a second degree laceration can be helpful? For sure. Yeah, there is. The problem is, is that it hasn't yet had a sufficient quality and or qu of high level data meaning well designed multi center RCTs that show that the benefit is real enough to move the needle to inform new guideline changes. All right, so if you, if my point is, if you're looking, if you sit on somebody's at your hospital's quality care committee and or you know, quality assurance committee, you're like, oh, I can't believe Bob, Bob gave this patient, you know, Ancef or Unison as a one time dose at time of repair of the second degree lack. That's stupid. I'm gonna put him in peer review. No, no, no, not so much, Karen. Not so much. Because there is data and it's okay to do that. It's just probably not necessary routinely for everybody. So this is the issue. And again, at the end, I'll give you some clinical implications that are reasonable, even though it's not yet professional medical society guidance, because the guidance can take a long time to happen. It's reasonable, Especially those patients that are at high risk of wound breakdown at a second degree lack. Okay, now remember, we're talking about second degrees. First degrees probably don't need it at all. But for second degrees, this is the question here. OASIS tears third and fourth degrees. That is totally reasonable and is acceptable to give a single dose of antibiotics at time of closure because you're right by the poopy area. Okay? And so there's nothing wrong with that. That is actually mentioned in ACOG's guidance on prevention and management of OASIS injuries, which states, quote, a single dose. All right, guys, we're not talking about three days of antibiotics here, okay? This is just a single dose of antibiotic at the time of repair. So when you're doing it is reasonable. Now remember, remember, words matter. It doesn't say maybe considered, which is more of a bleh. It's not a is recommended, which is a stronger thing. It's hey, it' reasonable. Which means just that, it's reasonable. A single dose of antibiotic at the time of repair is reasonable in the setting of obstetric anal sphincter injuries. But further research is needed to determine whether severe perinatal lacerations. That's third or fourth degree lacks. Warrant routine postpartum antibiotics to prevent complications, end quote. That's right out of ACOG's guidance, which is ACOG's practice bulletin. 198. 198, all right. From 2018. So in other words, yeah, give a single dose of something at time of repair of a third or fourth degree, that's very reasonable. It can be unison, it can be even clinda. That's fine. I've seen that it can be Ancef. Give something that's appropriate. That's, you know, that's coverage of the area that you're talking about. Again, Unison works. Ancef works, Augmentin would work. Any of those are acceptable, but single dose to continue that postpartum. We don't have any guidance, any evidence for that. All right, but a single dose, totally reasonable for oasis Injuries. So that's fine, that's a different issue. But what we're talking about here is for second degrees. And again, as I said, let me just tell you which societies do not do nothing, have specific statements saying that you should do this for second degrees. And there are a lot of them. Obviously for us here in the America, usa, it's acog and there's no guidance for antibiotics at routine second degree lac. Also the Society of Obstetrics Gynecology, Canada, sogc, they also don't have any recommendation for antibiotics routinely at time of second degree. Lack of the Royal Australian and New Zealand College of Obstetricians and Gynecologists. They also do not recommend routine antibiotic prophylaxis for first or second degree tears with vaginal delivery. Okay, so it's not just acog, it's acog, it's Canada, it's our friends down under and also in New Zealand, the Kiwis, they don't have it. Now, could it one day as the data kind of builds on this, including that recent systematic review and meta analysis that was just done in May, in May of 2025 at a plus one, you know, maybe, or at least I think it could be something like shared decision making or consider in high risk patients. So that's how I use it. So if I, if I got a patient, guys, here's where I'm going. Who's. And again, I'm not throwing anybody under the bus, but, but who is living with obesity, which is the new PC term, You know, patients don't have obesity anymore, they're living with obesity as if obesity is their roommate. So in patients who are living with obesity, and especially those who are class three obese, so in other words, BMI of 40, 45, we're just, I don't want to be mean, but come on guys, this would be reasonable also and realistic. It's kind of hard to see down there. First of all, they're postpartum and it's kind of hard to see your perineum maybe beyond a certain bmi. So if that's an issue and, or patients who have a poorly controlled diabetes where potentially there's bad vascularity, I got no beef with giving these patients a single dose of Unison or Ancef at time of repair of a second degree. It's just a one time dose. Why not? And because they're higher risk. So spoiler, that's my clinical application. I don't think this is applicable to every single patient with a second degree. But in those who have poor vascularity, those who definitely have a history of a previous breakdown. I mean, please give them something. Or those who have morbid obesity just because of moisture which collects down there and the possibility for not the best hygiene down there just because you can't really see that's something where this possibly may be of benefit. All right, so let me do this plus one systematic review and meta analysis on this very issue and then we're going to go into the repair study. So out of May of 2025, this is, quote, antibiotic prophylaxis for childbirth related perineal trauma. A systematic review and meta analysis, end quote. Now. Yeah, so this found, hey, if you give prophylactic antibiotics at a time of perineal laceration. Now remember, we're not talking about specifically oasis. Let's just bring this back to what we're talking about. First and second degree lacks they found for sure. Yeah, this is definitely helpful. There's a reduced risk of perineal wound infection and that's a good thing to like. Okay, well, sold. But no, no, hold on, there's more. Quote, despite these findings, now I'm reading directly from this systematic review and meta analysis. Despite these findings, there are not sufficient high quality randomized controlled trials to adequately inform guideline change among women with first or second degree tears or episiotomies. End quote. Of course, we don't routinely do episiotomies, although maybe you might could consider it, of course, with shoulder dystocia to get your hand into the posterior compartment for posterior arm delivery. Okay. But yes, it is reasonable. So this systematic review from May says, yes, there is data. The problem is it's kind of quasi really good data, it's fair data and it's not enough to move the needle, quote, not enough to inform guideline change, end quote. At this time in this systematic review and meta analysis, they also call for more, quote, adequately powered robust randomized control trials which are needed to inform clinical practice change, end quote. So there it is then. Now this is May. This is. So this is just six months ago from when we were recording this that says, yeah, for sure. Yeah, there's data, but I don't know if it's enough to really make this a recommendation across the board. Okay, so that's, I just wanted to put that to bed because if somebody ever tells you, or again you're trying to put somebody in your peer review because they do this for second degree lacks, you really can't do that. You can't put them into peer review because there is Data for it, it's not yet professional society guidance, but that can lag before. Lag after the data first comes out. Right, so before that happens, clinicians adopt the data and then societies go, yeah, sure, why not? Let's change practice. Right? So I just wanted to give that quick little shout out to this May 2025 systematic review and meta analysis that came out not long ago. And I'll of course put that reference in our show notes. All right, now that we've done all that, let's get to this new publication, which is the repair study. The repair study from bmj. Okay, it is a single site. This is from Denmark. It's double blind, is placebo controlled. And they found that in the group that was randomized to treatment. Now, in the treatment group, it was three doses of Augmentin. Okay, so amoxylin, clavulanic acid at the 500 milligram amoxicillin dose. Right? So 500 and 125. They gave a tablet at time of repair or within six hours of the repair, and then they repeated it again at eight hour intervals for a total of three doses. All right, so three doses of Augmentin at time of repair or within six hours of repair, repeated every eight hours for three doses. Again, that's just what they did. Okay, I think that's a little overkill because I'm perfectly okay with giving a single dose. If a single dose, guys, is okay for an OASIS tear. Y' all following me here? Okay, so in ACOGs, remember practice guidance number 198, they said, just give a single dose, single dose at time of repair for an OASIS tear. Why would it not be okay for a second degree? You see, guys, why you have to marry all the data together? Okay? Do you get that? So if you just look at this, you're like, oh, three doses. I'm going to do that. Is that really necessary, though? I mean, it's okay. That's what they did in this trial. But if a single dose is good enough for a severe laceration, a 3A, B or C and or a 4th degree, why would that not be good enough for a second? All right, I digress. So anyway, in this new study, in this repair trial, they did give a three dose regimen, all right? And it helped. But it didn't. Okay, it helped, but it didn't. And on that note, we're taking a quick break. That's a cliffhanger. And I'll come back. I'll tell you how it helped. And it didn't. And then we'll call it a day. We'll be right back. Foreign, you're listening to the Ob GYN no Spin podcast. All right, let's wrap this up so we can get out of here. So in this new publication that just came out at the end of October 2025, I said before the break it helped, but it really didn't help. And that's totally true. That's why I said it's a little confusing. I like the design. I think it's. I'm all for new data. It builds on that systematic review and meta analysis, but eh, I mean, honestly, it's the MEH emoji and no beef with the people in Denmark. All right, but meh. So let me just tell you how this worked. So again, double blind randomized. These were patients. Patients who were included were those who had either a second degree laceration or an episiotomy. Now when I get into the whole episiotomy thing, remember, definitely not guidance to do that routinely unless you're doing a shoulder dystocia and putting your hand in for the posterior arm. So I don't know, maybe they still do it routinely in Denmark. They don't, but they included it in the study design. All right, so 442 women with episiotomies or second degree tears were then recruited for randomization. Those that were randomized to the treatment group had the Augmentin regimen that we talked about, and those who didn't, didn't. And the primary outcome was some kind of wound complication and, or quote, clinically relevant wound complication, end quote. What? So that's why I say it's kind of confusing. And I'm reading directly here, guys, from the paper, the main outcome were wound complications as a primary outcome and clinically relevant wound complications as a secondary outcome. Let me paraphrase that. Huh? Huh? Michael, be quiet. So this is what I'm saying. So wound complication. And they did. Now that was an overall like, hey, is it a little bit of breakdown? Is it an abscess? Is it purulent? That's. We're going to call that the primary outcome. And then clinically relevant wound breakdown was something that they added kind of before the first recruited patient because we're like, well, what if it's really, really just a minor separation, like 5 millimeters, which can be part of normal healing? That's okay. So they said, well, we're going to call it clinically relevant if it's more than 10 millimeters of separation. And we're going to call that potentially a breakdown. So it's not a complete breakdown. This is a very, very low bar of what is considered a clinically relevant wound complication, end quote. So, again, based on their criteria here of 10 millimeters. Guys, is that really clinically relevant? I don't know. That's why I said meh. So let me give you the results, because again, it helped, but it didn't. Quote, no significant differences were observed in overall wound complications. Let's stop there. Okay, so the p value was 0.10, not less than 0.05. No significant differences were observed in the overall wound complications. Remember, this is second degrees and or episiotomies. Well, I'm done there. I would pretty much stop there. However, they continue for clinically relevant wound complications. Remember, that's 10 millimeters or more, little bit of separation, which can be normal, FYI, can be normal for clinically relevant wound complications. Significantly fewer events occurred in the treatment group than in the control group with the risk difference of minus 8. So. And the relative risk was 0.52. Okay, so it dropped the risk down by half. Well, that's good. I'll take that. Yeah. But what you're looking for is a pretty minor change when overall your primary outcome was, quote, no significant differences were observed, end quote. Fine, so it helped, but it didn't really help. That's what I meant by this. It's a very small benefit here based on what they were looking for. This is exactly what the Cochrane review has said previously and the systematic review and meta analysis from May has said again, which, yes, there's data, but it's not really great data. So these authors concluded the number needed to treat here for a clinically relevant wound complication was 12, although no significant effect was seen for overall wound complication. Prophylactic antibiotics significantly reduce the risk of clinically relevant wound complication, meaning a little bit of separation more than 10 millimeters, and therefore consideration of antibiotics should be done in the postpartum care. I don't know. I don't know. It wasn't like they had massive breakdown. It wasn't like they couldn't sit down. It wasn't like they couldn't pee because it was some kind of regional inflammation from this if they didn't get antibiotics. So this is what I'm telling you, and this is exactly what I'm trying to make the case for, that the May 2025 systematic review and meta analysis, which came out before this study is saying the exact same thing I told you. Yeah. There's data, but is it really great data? This is why I'm saying there's not enough to do this routinely on every single second degree. I don't think that's necessary. I have done it. I have given prophylactic single dose unison for a second degree in patients where there's a lot of redundant tissue down there. I know it's going to be a collection of both sweat and humidity and maybe not the best perineal health. Because guys, I mean, we've had patients with BMIs of 60 and I'm like, I'm just worried that there's just not good vascularity down here. And I'll give them for a second degree a single dose of antibiotic and I document my rationale. I know that there is no professional medical guidance for this. I know that this maybe is not standard. However, in this patient, which is high risk for infection, I don't want to jeopardize her having a wound breakdown. So I'm going to err on the side of conservatism and give a one or two gram of Ancef to protect this wound. And that's the end of that. And I document that so it doesn't go into peer review. And it has never gone into peer review because it's justified in those cases. Right. Again, not talking about OASIS injuries where that is totally reasonable as per ACOGs practice bullet. So, podcast family, I think that brings us to a wrap. We have covered this new BMJ British Medical Journal new publication from 29th of October 2025 risk of infection and wound dehiscence after use of prophylactic antibiotics in episiotomy or second degree tear. The repair study. There was no case of major dehiscence here and no overall change in the primary outcome of overall wound complication. Once again, meh. Is the emoji applicable here? Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community. Thank you for your support. And now that we've done all that, now let's take it home. This has been Dr. Chapa Zobichyn, no Spin Podcast podcast family. Thank you for your support. Support. Thank you for listening. And as always, we'll see you on another episode of the no Spin Podcast.