Episode Overview

Title: Use Antibiotics at 2nd Degree OB Lac Repair?
Podcast: Dr. Chapa’s OBGYN Clinical Pearls
Host: Dr. Chapa
Date: November 6, 2025

This episode tackles the clinical question: Should antibiotics be routinely given at the time of repair of a second degree obstetrical laceration? Dr. Chapa reviews the latest evidence, including a brand new BMJ study (the REPAIR trial), summarizes professional guidelines, and shares his clinical approach, offering nuanced, practical advice for situations where antibiotic prophylaxis may be beneficial.

Key Discussion Points & Insights

1. Current Professional Guidance (00:28–04:40)

• No Routine Antibiotic Use for 2nd Degree Tears:
  None of the leading professional organizations—including ACOG (US), SOGC (Canada), RANZCOG (Australia & New Zealand)—recommend routine antibiotic prophylaxis for first or second degree perineal lacerations.
• Exception: OASIS Injuries:
  For more severe lacerations (OASIS: third- and fourth-degree perineal tears), "it is reasonable" to provide a single dose of prophylactic antibiotics at repair to reduce risk of infection and wound breakdown.
• Rationale:
  The evidence to support universal antibiotic use in second degree tears isn’t robust enough to alter guidelines, but this is evolving with new studies.

2. Barriers to Guideline Adoption (04:41–06:56)

• Lag Behind Evidence:
  "In order to make a professional medical society stance or recommendation, those things take a long time...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..." – Dr. Chapa [05:21]
• Current Best Practice:
  Until high-quality, multi-center RCTs are available, Dr. Chapa advises following existing society guidance and having a rationale for any deviation, especially in chart documentation.

3. Review of the May 2025 Systematic Review & Meta-analysis (10:28–13:59)

• Reference:
  "Antibiotic prophylaxis for childbirth related perineal trauma. A systematic review and meta analysis" (May 2025, PLOS One)
• Findings:
  Prophylactic antibiotics may reduce perineal wound infections in first and second degree tears.
• Caveat:
  "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."
• Practical Application:
  "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." – Dr. Chapa [13:28]

4. New Evidence: The REPAIR Study (15:01–22:50)

• Design:
  Single-center, double-blind, placebo-controlled RCT in Denmark; published October 29, 2025 (BMJ).
  • 442 women with episiotomies or second degree tears.
  • Treatment arm: 3 doses of Augmentin (amoxicillin-clavulanic acid), one at repair or within 6 hours, followed by two more every 8 hours.
• Primary Outcome:
  "Wound complications" (which included any wound complication, even minor separations/normal healing).
• Secondary Outcome:
  "Clinically relevant wound complications" (separation >10mm).
• Results:
  • No significant difference in overall wound complications (p=0.10).
  • Statistically significant reduction in “clinically relevant” complications in the antibiotic group, but the threshold for clinical relevance was low and the benefit marginal (number needed to treat = 12).
  • "It helped, but it didn't..." – Dr. Chapa [20:32]
• Take-home:
  Majority of observed benefit is for fairly minor wound separations, which may not always be truly 'clinically relevant.'

5. Clinical Application and Context (19:50–28:13)

• Who Might Benefit?
  Not routine for all, but reasonable for:
  • Patients "living with obesity," especially class III (BMI >40–45).
  • Poorly controlled diabetes or poor vascularity.
  • Prior history of wound breakdown.
  • "Those who have morbid obesity just because of moisture which collects down there and the possibility for not the best hygiene down there..." – Dr. Chapa [16:56]
• Antibiotic Choice:
  • A single dose of Unasyn, Ancef, or Augmentin is usually sufficient.
  • "If a single dose...is okay for an OASIS tear...why would that not be good enough for a second?" – Dr. Chapa [17:47]
• Documentation:
  Clearly document rationale for antibiotic use in higher-risk patients to avoid peer review concerns.

6. Notable Quotes & Memorable Moments

• On professional guidelines lagging:
  "We can do whatever we want as long as there's evidence for it, we're not hurting anybody...But that does kind of make standard of care and right now we really don't have that for first or second degree lacks." [05:36]
• Pragmatic view on the REPAIR study results:
  "It’s the MEH emoji and no beef with the people in Denmark. All right, but meh." [21:15]
• On choosing patients for antibiotics:
  "I have done it. I have given prophylactic single dose unison for a 2nd degree in patients, where there’s a lot of redundant tissue down there...Because guys, I mean, we've had patients with BMIs of 60." [23:54]
• Summing up the findings:
  "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." [27:39]

Timestamps for Key Segments

• 00:28–04:40
  Current consensus among professional organizations & exception for OASIS tears
• 10:28–13:59
  May 2025 systematic review & meta-analysis
• 15:01–22:50
  In-depth analysis of the REPAIR study from BMJ
• 19:50–28:13
  Clinical application—who should get antibiotics, documentation, practical tips
• 21:15, 27:39
  Dr. Chapa’s “MEH” conclusion on the REPAIR study and summary of episode

Summary Table: Antibiotics at 2nd Degree Laceration Repair

| Situation | Professional Guidance | Evidence/Recent Data | Clinical Pearl | |------------------------------|----------------------------|----------------------------|--------------------------| | 1st Degree Laceration | No antibiotics | No supporting evidence | Not indicated | | 2nd Degree Laceration | No routine antibiotics | Some benefit (minor/low NNT)| Consider in high-risk | | OASIS (3rd/4th Degree) | Single-dose reasonable | Clearer benefit | Do give single dose | | High-risk (obesity/DM) | Not specified | Reasonable extrapolation | Doc. rationale if used |

Final Clinical Pearls

• No routine antibiotics for 1st or 2nd degree tears, but not "wrong" if justified by patient risk profile.
• Professional societies (ACOG, SOGC, RANZCOG) do not recommend prophylaxis for 2nd degree tears as of fall 2025.
• BMJ REPAIR study: Minor reduction in wound separation with antibiotics but not clear clinical benefit for most.
• Reserve antibiotics (single dose) for 2nd degree tears in patients at high risk for wound complications (obesity, diabetes, prior breakdown).
• Always document rationale for deviation from guidelines.

Dr. Chapa’s Bottom Line:
"Podcast family, as always...this is exactly what I’m trying to make the case for: 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." [24:36]