Use of Prophylactic Antibiotics in Labor and Delivery

Publication Date: September 1, 2018
Last Updated: March 14, 2022


Antibiotic prophylaxis is recommended for all cesarean deliveries unless the patient is already receiving an antibiotic regimen with equivalent broad-spectrum coverage (eg, for chorioamnionitis), and such prophylaxis should be administered within 60 minutes before the start of the cesarean delivery. (A)

For cesarean delivery prophylaxis, a single dose of a targeted antibiotic, such as a first-generation cephalosporin, is the first-line antibiotic of choice, unless significant drug allergies are present. (A)

The addition of azithromycin, infused over 1 hour, to a standard antibiotic prophylaxis regimen may be considered for women undergoing a nonelective cesarean delivery. (A)

Vaginal cleansing before cesarean delivery in laboring patients and those with ruptured membranes using either povidone–iodine or chlorhexidine gluconate may be considered. Chlorhexidine gluconate solutions with high concentrations of alcohol are contraindicated for surgical preparation of the vagina, but solutions of chlorhexidine gluconate with low concentrations of alcohol (eg, 4%) are safe and effective for off-label use as vaginal surgical preparations and may be used as an alternative to iodine-based preparations in cases of allergy or when preferred by the surgeon. (A)

Preoperative skin cleansing before cesarean delivery with an alcohol-based solution should be performed unless contraindicated. A reasonable choice is a chlorhexidine–alcohol skin preparation. (A)

For patients with prelabor rupture of membranes (PROM) at less than 34 0/7 weeks of gestation, antibiotic prophylaxis is indicated to prolong the latency period between membrane rupture and delivery. (A)

Antibiotic prophylaxis should not be used for pregnancy prolongation in women with preterm labor and intact membranes. This recommendation is distinct from recommendations for antibiotic use for preterm PROM and GBS carrier status. (A)

For women with a history of a significant penicillin or cephalosporin allergy (anaphylaxis, angioedema, respiratory distress, or urticaria), a single-dose combination of clindamycin with an aminoglycoside is a reasonable alternative for cesarean delivery prophylaxis. (B)

Infective endocarditis prophylaxis is not recommended for women with acquired or congenital structural heart disease for vaginal or cesarean delivery in the absence of infection, except possibly for the small subset of patients at highest potential risk of adverse cardiac outcomes. Those at highest risk are women with cyanotic cardiac disease, or prosthetic valves, or both. Mitral valve prolapse is not considered a lesion that ever needs infective endocarditis prophylaxis. (B)

A single dose of antibiotic at the time of repair is reasonable in the setting of obstetric anal sphincter injuries (OASIS). (B)

Patients with lengthy surgical procedures (eg, greater than two drug half-lives of the antibiotic, which is 4 hours for cefazolin and measured from the initiation of the preoperative dose, not from the onset of surgery) or those who experience excessive blood loss (eg, greater than 1,500 mL) should receive an additional intraoperative dose of the same antibiotic given for preincision prophylaxis. (C)

A 1-g intravenous dose of cefazolin as prophylaxis before cesarean delivery may be considered for women weighing 80 kg or less. Increasing the dose to 2 g for patients weighing 80 kg or more is recommended; however, the benefit of administering 3 g in obstetric patients weighing 120 kg or more has not yet been established. (C)

Evidence is insufficient to recommend antibiotic prophylaxis for history-, ultrasonography-, or examination-indicated cervical cerclage. (C)

Routine screening of obstetric patients for MRSA colonization is not recommended. However, in obstetric patients known to be MRSA colonized, consideration may be given to adding a single dose of vancomycin to the recommended antibiotic prophylaxis regimen for women undergoing cesarean delivery. (C)

There are currently insufficient data in pregnant patients to warrant or recommend screening all women preoperatively for MRSA colonization status, particularly because most colonized patients will not develop invasive disease. (C)

Recommendation Grading




Use of Prophylactic Antibiotics in Labor and Delivery

Authoring Organization

Publication Month/Year

September 1, 2018

Last Updated Month/Year

January 5, 2023

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings


Intended Users

Physician, nurse midwife, nurse, epidemiology infection prevention, nurse practitioner, physician assistant



Diseases/Conditions (MeSH)

D019072 - Antibiotic Prophylaxis, D003696 - Delivery Rooms, D036861 - Delivery, Obstetric


antimicrobial prophylaxis, labor and delivery