CD000330_2007 Enema Cochrane Review

Enemas during labour (Review) Cuervo LG, RodrĂ­guez MN, Delgado MB

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2007, Issue 3 http://www.thecochranelibrary.com

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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TABLE OF CONTENTS ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .

SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .

METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .

ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison 01. Newborn Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison 02. Puerperal Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Comparison 03. Labour duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 01.01. Comparison 01 Newborn Outcomes, Outcome 01 Infection in newborns diagnosed by interview first 24 hours of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 01.02. Comparison 01 Newborn Outcomes, Outcome 02 Umbilical infection of the new-born . . . . .

Analysis 01.04. Comparison 01 Newborn Outcomes, Outcome 04 Infection in newborns during the first month of life Analysis 01.05. Comparison 01 Newborn Outcomes, Outcome 05 Dacriocistitis or Conjuntivitis (first month) . .

Analysis 01.06. Comparison 01 Newborn Outcomes, Outcome 06 Skin infection (first month) . . . . . . . .

Analysis 01.07. Comparison 01 Newborn Outcomes, Outcome 07 Upper respiratory tract infection during first month Analysis 01.08. Comparison 01 Newborn Outcomes, Outcome 08 Lower respiratory tract infection during first month Analysis 01.09. Comparison 01 Newborn Outcomes, Outcome 09 Newborn required systemic antibiotics after delivery but prior to hospital discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 01.10. Comparison 01 Newborn Outcomes, Outcome 10 Newborn required systemic antibiotics after hospital discharge during the first month . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 01.11. Comparison 01 Newborn Outcomes, Outcome 11 Intestinal infection . . . . . . . . . . .

Analysis 01.12. Comparison 01 Newborn Outcomes, Outcome 12 Meningitis . . . . . . . . . . . . . .

Analysis 01.13. Comparison 01 Newborn Outcomes, Outcome 13 Sepsis . . . . . . . . . . . . . . .

Analysis 01.14. Comparison 01 Newborn Outcomes, Outcome 14 First minute Apgar < 7 . . . . . . . . .

Analysis 01.15. Comparison 01 Newborn Outcomes, Outcome 15 Five minute Apgar < 7 . . . . . . . . .

Analysis 02.01. Comparison 02 Puerperal Outcomes, Outcome 01 Perineal tear: skin or superficial tissue without compromising muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 02.02. Comparison 02 Puerperal Outcomes, Outcome 02 Perineal tear: perineal muscle without anal muscles Analysis 02.03. Comparison 02 Puerperal Outcomes, Outcome 03 Perineal tear: compromises anal muscles but not the mucosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 02.04. Comparison 02 Puerperal Outcomes, Outcome 04 Perineal tear: complete tear that compromises anal mucosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 02.05. Comparison 02 Puerperal Outcomes, Outcome 05 Infections during puerperium . . . . . . .

Analysis 02.06. Comparison 02 Puerperal Outcomes, Outcome 06 Episiotomy dehiscence . . . . . . . . .

Enemas during labour (Review) Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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Analysis 02.07. Comparison 02 Puerperal Outcomes, Outcome 07 Urinary tract infection . . . . . .

Analysis 02.08. Comparison 02 Puerperal Outcomes, Outcome 08 Pelvic infection: infected episiotomy . .

Analysis 02.09. Comparison 02 Puerperal Outcomes, Outcome 09 Pelvic infection: vulvovaginitis . . . .

Analysis 02.10. Comparison 02 Puerperal Outcomes, Outcome 10 Pelvic infection: endometritis . . . .

Analysis 02.11. Comparison 02 Puerperal Outcomes, Outcome 11 Pelvic infection: myometritis . . . .

Analysis 02.12. Comparison 02 Puerperal Outcomes, Outcome 12 Needed post-partum systemic antibiotics Analysis 03.01. Comparison 03 Labour duration, Outcome 01 Total labour duration . . . . . . . .

Analysis 03.02. Comparison 03 Labour duration, Outcome 02 First stage of labour duration . . . . . .

Analysis 03.03. Comparison 03 Labour duration, Outcome 03 Second stage of labour duration . . . . .

Analysis 03.04. Comparison 03 Labour duration, Outcome 04 Third stage of labour duration . . . . .

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Enemas during labour (Review) Cuervo LG, Rodríguez MN, Delgado MB

This record should be cited as: Cuervo LG, Rodríguez MN, Delgado MB. Enemas during labour. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000330. DOI: 10.1002/14651858.CD000330.

This version first published online: 25 October 1999 in Issue 4, 1999.

Date of most recent substantive amendment: 01 July 1999

ABSTRACT Background The use of enemas during labor usually depends on the preference of the attending physician and available resources. However enemas cause discomfort in women and increase the costs of delivery.

Objectives The objective of this review was to assess the effects of enemas during the first stage of labor on infection rates in mothers and newborns, duration of labor, perineal wound dehiscence in the mother, perineal pain, faecal soiling and costs.

Search strategy We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effectiveness, Medline and reference lists of articles.

Selection criteria Randomised trials in which an enema was administered during the first stage of labor and which included assessment of possible neonatal or puerperal morbidity or mortality.

Data collection and analysis Selected studies were assessed by three reviewers independently.

Main results Two trials involving 665 women were included. These showed no clear difference in infection rates for puerperal mothers (odds ratio 0.61, 95% confidence interval 0.36 to 1.04) or newborn children.

Authors’ conclusions There is not enough evidence to evaluate the use of routine enemas during the first stage of labor.

BACKGROUND

The use of enemas during labor usually depends on the preference of, and the resources available to, the attending physician. Since this intervention generates discomfort in women and increases the costs of delivery, an evaluation of the effectiveness of enemas during labor is important.

Some have proposed that enemas should be used on the basis that:

(i) they will lessen the degree of contamination of broken skin with faeces thus reducing puerperal infections; (ii) they will diminish the contact of faeces with the newborn consequently reducing newborn infection rates.

On the other hand, others have recommended avoiding the use of enemas on the basis of: (i) unproven effectiveness; (ii) watery faeces will increase the contamination of wounds in-

Enemas during labour (Review) Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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creasing maternal and neonatal contamination with enteric bacteria; (iii) it is widely accepted that this intervention generates discomfort to women and increases the costs of care.

OBJECTIVES To determine the effect of enemas during the first stage of labor on rates of morbidity in the mother and the newborn, specifically: · Postpartum infection rates · Rates for specific puerperal infections · Neonatal infection rates · Rates for specific neonatal infections · Maternal non-infectious morbidity · Neonatal non-infectious morbidity · Episiotomy dehiscence rates · Other maternal or neonatal mortality · Faecal soiling during first stage of labour · Faecal soiling during delivery · Duration of labor and its different stages

· Skin infections · Respiratory tract infections · Intestinal infections · Meningitis · Sepsis · Need for systemic antibiotics · Other outcomes · Perineal wound · Perineal pain · Maternal mortality · New-born mortality · Faecal soiling during labour · Faecal soiling during delivery · Economic outcomes · Duration of labour and its different stages · 1 minute Apgar of the new-born · 5 minute Apgar of the new-born

SEARCH METHODS FOR IDENTIFICATION OF STUDIES See: methods used in reviews.

CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW Types of studies Randomized controlled trials (RCTs) comparing the use of enemas versus no enema, or between different types of enema.

Types of participants Women during the first stage of labor.

Types of intervention Enema of high or low volume, soapsuds, saline solutions, medicated or tap water enemas.

Types of outcome measures · Puerperal infections · Episiotomy dehiscence · Urinary tract infection · Pelvic Infections · Vulvovaginitis · Endometritis · Myometritis · Vulvovaginitis · Other puerperal infections · Need for systemic antibiotics · Neonatal infections · Any infection · Umbilical infection · Ophthalmic infection

This review has drawn on the search strategy developed for the Pregnancy and Childbirth Group as a whole.

Relevant trials were identified in the Group’s Specialized Register of Controlled Trials. See Review Group’s details for more information.

In addition, the following were searched: · The Cochrane Controlled Trials Register and the Database of Abstracts of Reviews of Effectiveness (DARE) in the Cochrane Library. The search used the terms ’Enema*’ AND (’Labor OR Labour’ OR ’Intrapartum’ OR ’delivery’ OR ´ Pregnan*´ ). · Previously published revisions in the Cochrane Pregnancy and Childbirth Database. · Reference list of relevant articles were reviewed.

After the titles of articles were reviewed, abstracts were studied to determine if the inclusion criteria were met. If doubt existed, the full text article was reviewed.

METHODS OF THE REVIEW The three reviewers independently assessed trial reports. It was decided, in advance, that the methodological quality of each study would be assessed by the three reviewers and disagreements resolved by discussion, when possible by consensus, otherwise by the majority (two of the three reviewers). Aspects related to randomization method, precision of outcome evaluation, follow-

Enemas during labour (Review) Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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up, if intention to treat analysis was done, women lost to followup, protocol violations, sample size determinations or if any degree of blinding existed would be stated. In the study by Cuervo 1999, the other two reviewers did the assessment.

Data were extracted by one of the reviewers (MN Rodriguez) and cross checked.

A sensitivity analysis to evaluate result modification with different types of enemas would have been considered if more trial data had been available. Results are reported as odds ratios. The proportional and absolute risk changes can be calculated for each outcome, as can homogeneity by the software used by the Cochrane Collaboration.

DESCRIPTION OF STUDIES Drayton 1984: details about the women are poorly described. The study was conducted at the University Hospital of Wales, Cardiff (UK). Three hundred and seventy women fulfilled the inclusion criteria and were invited to participate. Of those, 222 (60%) agreed to be randomized to enema versus no enema. A low volume disposable phosphate enema was used in the intervention group. No caesarean section rates were mentioned in the study. Randomization was stratified by primigravidae (43%) or multigravidae (57%).

Enemas were administered during the first stage of labor.

Cuervo 1999: This study was conducted in the San Ignacio Hospital, a tertiary care referral centre. A total of 443 women were randomized with well balanced groups. There is no information about the number of women that would have been eligible or those who did not agree to participate. There were 12 violations of the protocol distributed similarly in both groups. Approximately 17% of the intervention and 14% of the control group participants were lost during follow-up.

METHODOLOGICAL QUALITY Drayton 1984: Inclusion bias seemed to happen when clinic staff excluded women if they had faecal soiling prior to their evaluation (timespan unspecified). Randomization technique is not specified. The authors provide no data regarding demographic data and other data that would be relevant to know the external validity of the study. Sample size estimation was not calculated beforehand.

Women, workers and study personnel were aware of the intervention. Infection seemed to be measured in an unreliable way and follow-up was too short (their infection rates were remarkably under the usual rates for newborns and puerperal women appropriately followed). For several reasons, we considered this a poor quality study.

Cuervo 1999: There were 12 protocol violations reported and excluded from the final analysis. Intention to treat analysis was done.

Nearly 17% of the participants from the intervention group and 14% of the control group were lost during the follow-up and excluded from the main analysis. It was impossible to blind physicians and women, but an effort was made to keep the hypothesis unknown to these people. Aside from the enema, groups apparently received the same treatment. Groups were similar when included. The study had enough power to find the differences for respiratory tract infections in newborns. Related to the other outcomes, it was not possible to draw conclusions because of a lack of power.

RESULTS High volume enemas seem to reduce the risk of lower respiratory tract infections and the need for systemic antibiotics in newborns and puerperal women. However, this conclusion by itself does not imply that enemas should be recomended. More trials and economic analysis are needed to give an evidence-based recommendation.

DISCUSSION Available data are insufficient to provide a recommendation regarding the use of enemas during labor.

AUTHORSâ&#x20AC;&#x2122; CONCLUSIONS Implications for practice There is insufficient evidence to recommend the use of enemas during labor. Enemas generate discomfort and generate costs and unless there is evidence to promote their use, this should be discouraged.

Implications for research Better quality and ideally blind, randomized clinical trials are needed to provide data to this review in order to give an evidencebased recommendation.

POTENTIAL CONFLICT OF INTEREST Dr Luis-Gabriel Cuervo conducted a randomised controlled trial included in this review. His study fulfilled the inclusion criteria for this review. Information from this study was gathered independently by other reviewers.

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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ACKNOWLEDGEMENTS This review was developed with support given by the Clinical Epidemiology Unit of the Universidad Javeriana and a research and development grant given by the Colombian National Institute for Development of Science and Technology (COLCIENCIAS).

SOURCES OF SUPPORT External sources of support • COLCIENCIAS Colombian National Institute for Development of Science and Technolo COLOMBIA Internal sources of support • Clinical Epidemiology Research and Training Center-Universidad Javeriana-Bogotá COLOMBIA

REFERENCES

References to studies included in this review

References to other published versions of this review

Cuervo 1999 {unpublished data only} ∗ Cuervo LG, Bernal MP, Mendoza N. Evaluation of the use of enema during labour: Randomised clinical trial [thesis]. Bogota DC, Colombia: The Clinical Epidemiology and Biostatistics Unit. Pontificia Universidad Javeriana, 1999.

Hay-Smith 1995a Hay-Smith J. Routine enema on admission in labour. [ revised 27 January 1994] In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.

Drayton 1984 {published data only} Drayton S, Rees C. Nursing Mirror midwifery forum. Elegance for pregnant mothers: ’They know what they’re doing’. Nurs Mirror 1984;159(5):IV–VIII. [MedLine: 1984297440].

References to studies excluded from this review Mathie 1959 Mathie JG, Dawson BH. Effect of Castor Oil, Soap Enema and Hot Bath on the Pregnant Human Uterus Near Term - a tocographic study. BMJ 1959;1:1162–5. [MedLine: 1980239583].

Romney 1981 Romney ML, Gordon H. Is your enema really necessary?. BMJ 1981 Apr 18;282(6272):1269–71. [MedLine: 1981185288].

Rosenfield 1958 Rosenfield HH, Burke L, Rubin H. Disposable enema unit in obstetrics. Obstet Gynecol 1958;11(2):222–5.

Rutgers 1993 Rutgers S. Hot, high and horrible. Should routine enemas still be given to women in labour?. Cent Afr J Med 1993;39:117–20. [MedLine: 1994177622].

Whitley 1980 Whitley N, Mack E. Are enemas justified for women in labor?. Am J Nurs 1980;80(7):1339. [MedLine: 1980239583].

Hay-Smith 1995b Hay-Smith J. Soapsuds vs tapwater enema on admission in labour. [ revised 26 January 1994] In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module.

In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.

Hay-Smith 1995c Hay-Smith J. ‘Medicated’ vs soapsuds enema on admission in labour. [ revised 26 January 1994] In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.

Hay-Smith 1995d Hay-Smith J. ‘Medicated’ vs tapwater enema on admission in labour. [ revised 27 January 1994] In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module.

In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995. ∗

Indicates the major publication for the study

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TABLES

Characteristics of included studies Study

Cuervo 1999

Methods

Randomized clinical trial. Block randomization in blocks of 2 (20%), 4 (60%) and 6 (20%) using sealed envelopes when participants visited the Obstetrics admission ward and filled inclusion criteria.

Participants

Women attending a tertiary care hospital in Bogota for delivery. Inclusion criteria included: living and staying in Bogota the month following delivery; gestational age of 36 or more weeks; willingness to participate.

Exclusion criteria: medical emergency; use of antibiotics the week prior to admission; rupture of amniotic membranes; cervical dilatation over 7 cm.

High volume (1000 ml) saline solution enema or no enema.

Interventions Outcomes

Participants and new-borns were followed for one month after delivery. Visits were done at the puerperium and paediatrics ward and neonatal intensive care unit. Participants were evaluated through telephone interviews and/or physical examination done one and four weeks after delivery. Twenty four hour pager service was offered to inform of any health problems. Telephone follow-up was performed when patients failed to attend programmed visits. Infections were diagnosed on clinical grounds.

Notes

Blinding was not possible although an effort was made to keep the hypothesis unknown to staff and participants.

Allocation concealment

A – Adequate

Study

Drayton 1984

Methods

Randomized clinical trial, with stratified allocation (primigravid vs multigravid). Randomization method not explained.

Participants

Women entering labor ward during the first stage of labor, for vaginal delivery, single pregnancy and 37 or more weeks of gestation. Exclusion criteria included diabetes, cardiac disease or pregnancy complicated by antepartum haemorrhage or severe pre-eclampsia. 370 women were eligible and 222 (60%) agreed to participate.

Interventions

Low-volume disposable phosphate enema in the study group vs no enema. Inclusion bias could have occurred when the clinic staff avoided the inclusion of women who had faecal deposition prior to admission.

Outcomes

Faecal contamination was evaluated with an arbitrary scale, not validated, previously described by Romney and Gordon (Romney 1981).

Infection evaluation is not clear. Follow-up time is not clearly discussed, but there are no data suggesting that women were followed-up after leaving the hospital. Infections were confirmed bacteriologically and association between the organism and soiling was established by a microbiologist and a research sister.

Duration of labor: it was stratified between primigravidae and multigravidae. Data were collected in six ordinal and arbitrary categories.

Notes

Stratification would be better done by parity instead of gravidity. Randomization method was not discussed in the article.

B – Unclear

Allocation concealment

vs = versus; cm = centimetre; ml = millilitre

Characteristics of excluded studies Study

Reason for exclusion

Mathie 1959

This is a trial that used for controls, women receiving other interventions such as oral administration of castor oil and hot baths. It evaluated outcomes through physiologic measurements with tocodynamometer. The studies were

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Characteristics of excluded studies (Continued ) performed before labor. Neonatal or maternal morbidity or mortality was not evaluated. Labor duration was not evaluated either. It does not comply with inclusion criteria for this review.

Romney 1981

This was not a randomized controlled trial. A pilot study was done with a population of 84 consecutively admitted women who had no enema and compared them with 111 women admitted for induction of labor who received an enema. Later, they recruited 50 women with a haphazard allocation of enema vs no enema. The authors group the populations studied in the pilot and the main study together. No information regarding sample size selection is described. There is no description of the methodology of statistical analysis.

Rosenfield 1958

This is not a randomized controlled trial. Although the study mentions that the women and researchers were blind to the intervention, they used a strategy susceptible to being unblinded easily (marked phospho-soda enemas with ’A’ and watery enemas with ’B’). No definition of effectiveness was given and outcome evaluation was susceptible to bias. There was no information about the characteristics of the included women.

Rutgers 1993

This was a case-control study as described in the abstract. Sample size is not adjusted and its calculation is not based on risk analysis for case-control studies.

Whitley 1980

Observational study. Contamination was the main outcome and was measured according to the opinion of researchers. Labor duration, morbidity and mortality were not assessed.

vs = versus

ANALYSES

Comparison 01. Newborn Outcomes Outcome title 01 Infection in newborns diagnosed by interview first 24 hours of delivery 02 Umbilical infection of the newborn 04 Infection in newborns during the first month of life 05 Dacriocistitis or Conjuntivitis (first month) 06 Skin infection (first month) 07 Upper respiratory tract infection during first month 08 Lower respiratory tract infection during first month 09 Newborn required systemic antibiotics after delivery but prior to hospital discharge 10 Newborn required systemic antibiotics after hospital discharge during the first month 11 Intestinal infection 12 Meningitis 13 Sepsis 14 First minute Apgar < 7 15 Five minute Apgar < 7

No. of studies

No. of participants

1

222

Peto Odds Ratio 95% CI

0.88 [0.29, 2.70]

2

592

Peto Odds Ratio 95% CI

3.53 [0.61, 20.47]

1

370

Peto Odds Ratio 95% CI

1.16 [0.70, 1.91]

1

370

Peto Odds Ratio 95% CI

1.03 [0.57, 1.86]

1 1

370 369

Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI

1.60 [0.27, 9.34] 1.85 [0.74, 4.66]

1

369

Peto Odds Ratio 95% CI

0.14 [0.02, 0.82]

1

419

Peto Odds Ratio 95% CI

0.13 [0.02, 0.74]

1

367

Peto Odds Ratio 95% CI

0.27 [0.05, 1.38]

1 1 1 1 1

368 370 370 431 431

Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI

1.07 [0.07, 17.16] Not estimable Not estimable 1.33 [0.55, 3.19] 1.33 [0.55, 3.19]

Statistical method

Enemas during labour (Review) Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

Effect size

6

Comparison 02. Puerperal Outcomes No. of studies 1

No. of participants 421

Peto Odds Ratio 95% CI

1.12 [0.61, 2.06]

1

421

Peto Odds Ratio 95% CI

0.70 [0.35, 1.43]

1

421

Peto Odds Ratio 95% CI

0.59 [0.15, 2.37]

1

421

Peto Odds Ratio 95% CI

7.22 [0.14, 363.85]

2 1 1 1

594 372 372 372

Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI

0.61 [0.36, 1.04] 0.65 [0.36, 1.16] 0.60 [0.18, 1.98] 0.53 [0.11, 2.66]

1 1 1 1

372 372 372 419

Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI Peto Odds Ratio 95% CI

0.14 [0.01, 1.35] 0.31 [0.05, 1.81] 7.72 [0.15, 389.47] 0.13 [0.02, 0.74]

No. of studies 1

No. of participants 345

Weighted Mean Difference (Fixed) 95% CI

02 First stage of labour duration

1

347

Weighted Mean Difference (Fixed) 95% CI

03 Second stage of labour duration 04 Third stage of labour duration

1 1

347 347

Weighted Mean Difference (Fixed) 95% CI Weighted Mean Difference (Fixed) 95% CI

Outcome title 01 Perineal tear: skin or superficial tissue without compromising muscle 02 Perineal tear: perineal muscle without anal muscles 03 Perineal tear: compromises anal muscles but not the mucosa 04 Perineal tear: complete tear that compromises anal mucosa 05 Infections during puerperium 06 Episiotomy dehiscence 07 Urinary tract infection 08 Pelvic infection: infected episiotomy 09 Pelvic infection: vulvovaginitis 10 Pelvic infection: endometritis 11 Pelvic infection: myometritis 12 Needed post-partum systemic antibiotics

Statistical method

Effect size

Comparison 03. Labour duration Outcome title 01 Total labour duration

Statistical method

Effect size -38.00 [-100.68, 24.68] -38.00 [-99.81, 23.81] 5.20 [-2.56, 12.96] 0.10 [-1.08, 1.28]

INDEX TERMS Medical Subject Headings (MeSH) ∗ Enema; ∗ Labor

Stage, First; Risk

MeSH check words Female; Humans; Pregnancy

COVER SHEET Title

Enemas during labour

Authors

Cuervo LG, Rodríguez MN, Delgado MB

Contribution of author(s)

Information not supplied by author

Issue protocol first published

1997/3

Enemas during labour (Review) Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

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Review first published

1999/1

Date of most recent amendment

19 August 2005

Date of most recent SUBSTANTIVE amendment

01 July 1999

What’s New

Information not supplied by author

Date new studies sought but none found

Information not supplied by author

Date new studies found but not yet included/excluded

Information not supplied by author

Date new studies found and included/excluded

Information not supplied by author

Date authors’ conclusions section amended

Information not supplied by author

Contact address

A/Prof Luis Gabriel Cuervo-Amore Research Promotion and Development Unit (IKM/RC) Pan American Health Organization 525 23rd St NW Washington DC 20037-2895 USA E-mail: cuervolu@paho.org Tel: +1 202 9743135

DOI

10.1002/14651858.CD000330

Cochrane Library number

CD000330

Editorial group

Cochrane Pregnancy and Childbirth Group

Editorial group code

HM-PREG

Analysis 01.01.

Review:

GRAPHS AND OTHER TABLES Comparison 01 Newborn Outcomes, Outcome 01 Infection in newborns diagnosed by interview first 24 hours of delivery

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 01 Infection in newborns diagnosed by interview first 24 hours of delivery Study

Drayton 1984 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

6/109

7/113

100.0

0.88 [ 0.29, 2.70 ]

109

113

100.0

0.88 [ 0.29, 2.70 ]

Total events: 6 (Enema), 7 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=0.22

p=0.8

0.1 0.2

0.5

Protective effect

1

2

5

10

Higher risk

Enemas during labour (Review) Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

8

Analysis 01.02.

Review:

Comparison 01 Newborn Outcomes, Outcome 02 Umbilical infection of the new-born

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 02 Umbilical infection of the new-born Study

Enema

No-enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

Cuervo 1999

3/179

0/191

60.0

7.99 [ 0.83, 77.39 ]

Drayton 1984

1/109

1/113

40.0

1.04 [ 0.06, 16.69 ]

288

304

100.0

3.53 [ 0.61, 20.47 ]

Total (95% CI)

Total events: 4 (Enema), 1 (No-enema) Test for heterogeneity chi-square=1.24 df=1 p=0.26 I² =19.6% Test for overall effect z=1.41

p=0.2

0.1 0.2

0.5

1

Protective effect

Analysis 01.04.

Review:

2

5

10

Higher risk

Comparison 01 Newborn Outcomes, Outcome 04 Infection in newborns during the first month of life

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 04 Infection in newborns during the first month of life Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

40/179

38/191

100.0

1.16 [ 0.70, 1.91 ]

179

191

100.0

1.16 [ 0.70, 1.91 ]

Total events: 40 (Enema), 38 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=0.58

p=0.6

0.1 0.2

0.5

Protective effect

1

2

5

10

Higher risk

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

9

Analysis 01.05.

Review:

Comparison 01 Newborn Outcomes, Outcome 05 Dacriocistitis or Conjuntivitis (first month)

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 05 Dacriocistitis or Conjuntivitis (first month) Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

25/179

26/191

100.0

1.03 [ 0.57, 1.86 ]

179

191

100.0

1.03 [ 0.57, 1.86 ]

Total events: 25 (Enema), 26 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=0.10

p=0.9

0.1 0.2

0.5

1

Protective effect

Analysis 01.06.

Review:

2

5

10

Higher risk

Comparison 01 Newborn Outcomes, Outcome 06 Skin infection (first month)

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 06 Skin infection (first month) Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

3/179

2/191

100.0

1.60 [ 0.27, 9.34 ]

179

191

100.0

1.60 [ 0.27, 9.34 ]

Total events: 3 (Enema), 2 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=0.52

p=0.6

0.1 0.2

0.5

Protective effect

1

2

5

10

Higher risk

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

10

Analysis 01.07.

Review:

Comparison 01 Newborn Outcomes, Outcome 07 Upper respiratory tract infection during first month

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 07 Upper respiratory tract infection during first month Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

12/179

7/190

100.0

1.85 [ 0.74, 4.66 ]

179

190

100.0

1.85 [ 0.74, 4.66 ]

Total events: 12 (Enema), 7 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=1.31

p=0.2

0.1 0.2

0.5

1

Protective effect

Analysis 01.08.

Review:

2

5

10

Higher risk

Comparison 01 Newborn Outcomes, Outcome 08 Lower respiratory tract infection during first month

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 08 Lower respiratory tract infection during first month Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

0/179

5/190

100.0

0.14 [ 0.02, 0.82 ]

179

190

100.0

0.14 [ 0.02, 0.82 ]

Total events: 0 (Enema), 5 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=2.18

p=0.03

0.1 0.2

0.5

Protective effect

1

2

5

10

Higher risk

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

11

Analysis 01.09.

Review:

Comparison 01 Newborn Outcomes, Outcome 09 Newborn required systemic antibiotics after delivery but prior to hospital discharge

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 09 Newborn required systemic antibiotics after delivery but prior to hospital discharge Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

0/214

5/205

100.0

0.13 [ 0.02, 0.74 ]

214

205

100.0

0.13 [ 0.02, 0.74 ]

Total events: 0 (Enema), 5 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=2.30

p=0.02

0.1 0.2

0.5

1

Protective effect

Analysis 01.10.

Review:

2

5

10

Higher risk

Comparison 01 Newborn Outcomes, Outcome 10 Newborn required systemic antibiotics after hospital discharge during the first month

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 10 Newborn required systemic antibiotics after hospital discharge during the first month Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

1/178

5/189

100.0

0.27 [ 0.05, 1.38 ]

178

189

100.0

0.27 [ 0.05, 1.38 ]

Total events: 1 (Enema), 5 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=1.57

p=0.1

0.1 0.2

0.5

Protective effect

1

2

5

10

Higher risk

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

12

Analysis 01.11.

Review:

Comparison 01 Newborn Outcomes, Outcome 11 Intestinal infection

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 11 Intestinal infection Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

1/178

1/190

100.0

1.07 [ 0.07, 17.16 ]

178

190

100.0

1.07 [ 0.07, 17.16 ]

Total events: 1 (Enema), 1 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=0.05

p=1

0.1 0.2

0.5

1

Protective effect

Analysis 01.12.

Review:

2

5

10

Higher risk

Comparison 01 Newborn Outcomes, Outcome 12 Meningitis

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 12 Meningitis Study

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

x Cuervo 1999

0/179

0/191

0.0

Not estimable

Total (95% CI)

179

191

0.0

Not estimable

Total events: 0 (Enema), 0 (No-enema) Test for heterogeneity: not applicable Test for overall effect: not applicable

0.1 0.2

0.5

Protective effect

1

2

5

10

Higher risk

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

13

Analysis 01.13.

Review:

Comparison 01 Newborn Outcomes, Outcome 13 Sepsis

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 13 Sepsis Study

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

x Cuervo 1999

0/179

0/191

0.0

Not estimable

Total (95% CI)

179

191

0.0

Not estimable

Total events: 0 (Enema), 0 (No-enema) Test for heterogeneity: not applicable Test for overall effect: not applicable

0.1 0.2

0.5

1

Protective effect

Analysis 01.14.

Review:

2

5

10

Higher risk

Comparison 01 Newborn Outcomes, Outcome 14 First minute Apgar < 7

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 14 First minute Apgar < 7 Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

12/217

9/214

100.0

1.33 [ 0.55, 3.19 ]

217

214

100.0

1.33 [ 0.55, 3.19 ]

Total events: 12 (Enema), 9 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=0.64

p=0.5

0.1 0.2

0.5

Protective effect

1

2

5

10

Higher risk

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

14

Analysis 01.15.

Review:

Comparison 01 Newborn Outcomes, Outcome 15 Five minute Apgar < 7

Enemas during labour

Comparison: 01 Newborn Outcomes Outcome: 15 Five minute Apgar < 7 Study

Cuervo 1999 Total (95% CI)

Enema

No-enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

12/217

9/214

100.0

1.33 [ 0.55, 3.19 ]

217

214

100.0

1.33 [ 0.55, 3.19 ]

Total events: 12 (Enema), 9 (No-enema) Test for heterogeneity: not applicable Test for overall effect z=0.64

p=0.5

0.1 0.2

0.5

1

Protective effect

Analysis 02.01.

Review:

2

5

10

Higher risk

Comparison 02 Puerperal Outcomes, Outcome 01 Perineal tear: skin or superficial tissue without compromising muscle

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 01 Perineal tear: skin or superficial tissue without compromising muscle Study

Cuervo 1999 Total (95% CI)

Enema

No-Enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

25/213

22/208

100.0

1.12 [ 0.61, 2.06 ]

213

208

100.0

1.12 [ 0.61, 2.06 ]

Total events: 25 (Enema), 22 (No-Enema) Test for heterogeneity: not applicable Test for overall effect z=0.38

p=0.7

0.1 0.2

0.5

1

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

2

5

10

15

Analysis 02.02.

Review:

Comparison 02 Puerperal Outcomes, Outcome 02 Perineal tear: perineal muscle without anal muscles

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 02 Perineal tear: perineal muscle without anal muscles Study

Cuervo 1999 Total (95% CI)

Enema

No-Enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

14/213

19/208

100.0

0.70 [ 0.35, 1.43 ]

213

208

100.0

0.70 [ 0.35, 1.43 ]

Total events: 14 (Enema), 19 (No-Enema) Test for heterogeneity: not applicable Test for overall effect z=0.98

p=0.3

0.1 0.2

Analysis 02.03.

Review:

0.5

1

2

5

10

Comparison 02 Puerperal Outcomes, Outcome 03 Perineal tear: compromises anal muscles but not the mucosa

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 03 Perineal tear: compromises anal muscles but not the mucosa Study

Cuervo 1999 Total (95% CI)

Enema

No-Enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

3/213

5/208

100.0

0.59 [ 0.15, 2.37 ]

213

208

100.0

0.59 [ 0.15, 2.37 ]

Total events: 3 (Enema), 5 (No-Enema) Test for heterogeneity: not applicable Test for overall effect z=0.75

p=0.5

0.1 0.2

Analysis 02.04.

Review:

0.5

1

2

5

10

Comparison 02 Puerperal Outcomes, Outcome 04 Perineal tear: complete tear that compromises anal mucosa

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 04 Perineal tear: complete tear that compromises anal mucosa Study

Cuervo 1999 Total (95% CI)

Enema

No-Enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

1/213

0/208

100.0

7.22 [ 0.14, 363.85 ]

213

208

100.0

7.22 [ 0.14, 363.85 ]

Total events: 1 (Enema), 0 (No-Enema) Test for heterogeneity: not applicable Test for overall effect z=0.99

p=0.3

0.1 0.2

0.5

1

2

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

5

10

16

Analysis 02.05.

Review:

Comparison 02 Puerperal Outcomes, Outcome 05 Infections during puerperium

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 05 Infections during puerperium Study

Enema

No - Enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

01 First 24 hours by interview x Drayton 1984

0/109

0/113

0.0

Not estimable

Subtotal (95% CI)

109

113

0.0

Not estimable

26/182

41/190

100.0

0.61 [ 0.36, 1.04 ]

182

190

100.0

0.61 [ 0.36, 1.04 ]

303

100.0

0.61 [ 0.36, 1.04 ]

Total events: 0 (Enema), 0 (No - Enema) Test for heterogeneity: not applicable Test for overall effect: not applicable 02 Infection during the first month Cuervo 1999 Subtotal (95% CI)

Total events: 26 (Enema), 41 (No - Enema) Test for heterogeneity: not applicable Test for overall effect z=1.83

p=0.07

Total (95% CI)

291

Total events: 26 (Enema), 41 (No - Enema) Test for heterogeneity: not applicable Test for overall effect z=1.83

p=0.07

0.1 0.2

0.5

1

Protective effect

Analysis 02.06.

Review:

2

5

10

Risk of infection

Comparison 02 Puerperal Outcomes, Outcome 06 Episiotomy dehiscence

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 06 Episiotomy dehiscence Study

Cuervo 1999 Total (95% CI)

Enema

No - Enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

21/182

32/190

100.0

0.65 [ 0.36, 1.16 ]

182

190

100.0

0.65 [ 0.36, 1.16 ]

Total events: 21 (Enema), 32 (No - Enema) Test for heterogeneity: not applicable Test for overall effect z=1.46

p=0.1

0.1 0.2

0.5

Protective effect

1

2

5

10

Risk of infection

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

17

Analysis 02.07.

Review:

Comparison 02 Puerperal Outcomes, Outcome 07 Urinary tract infection

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 07 Urinary tract infection Study

Cuervo 1999 Total (95% CI)

Enema

No - Enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

4/182

7/190

100.0

0.60 [ 0.18, 1.98 ]

182

190

100.0

0.60 [ 0.18, 1.98 ]

Total events: 4 (Enema), 7 (No - Enema) Test for heterogeneity: not applicable Test for overall effect z=0.84

p=0.4

0.1 0.2

0.5

1

Protective effect

Analysis 02.08.

Review:

2

5

10

Risk of infection

Comparison 02 Puerperal Outcomes, Outcome 08 Pelvic infection: infected episiotomy

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 08 Pelvic infection: infected episiotomy Study

Cuervo 1999 Total (95% CI)

Enema

No - Enema

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

2/182

4/190

100.0

0.53 [ 0.11, 2.66 ]

182

190

100.0

0.53 [ 0.11, 2.66 ]

Total events: 2 (Enema), 4 (No - Enema) Test for heterogeneity: not applicable Test for overall effect z=0.77

p=0.4

0.1 0.2

0.5

Protective effect

1

2

5

10

Risk of infection

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

18

Analysis 02.09.

Review:

Comparison 02 Puerperal Outcomes, Outcome 09 Pelvic infection: vulvovaginitis

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 09 Pelvic infection: vulvovaginitis Study

Cuervo 1999 Total (95% CI)

Enema

No - Enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

0/182

3/190

100.0

0.14 [ 0.01, 1.35 ]

182

190

100.0

0.14 [ 0.01, 1.35 ]

Total events: 0 (Enema), 3 (No - Enema) Test for heterogeneity: not applicable Test for overall effect z=1.70

p=0.09

0.1 0.2

0.5

1

Protective effect

Analysis 02.10.

Review:

2

5

10

Risk of infection

Comparison 02 Puerperal Outcomes, Outcome 10 Pelvic infection: endometritis

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 10 Pelvic infection: endometritis Study

Cuervo 1999 Total (95% CI)

Treatment

Control

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

1/182

4/190

100.0

0.31 [ 0.05, 1.81 ]

182

190

100.0

0.31 [ 0.05, 1.81 ]

Total events: 1 (Treatment), 4 (Control) Test for heterogeneity: not applicable Test for overall effect z=1.30

p=0.2

0.1 0.2

Analysis 02.11.

Review:

0.5

1

2

5

10

Comparison 02 Puerperal Outcomes, Outcome 11 Pelvic infection: myometritis

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 11 Pelvic infection: myometritis Study

Cuervo 1999 Total (95% CI)

Treatment

Control

Peto Odds Ratio

Weight

Peto Odds Ratio

n/N

n/N

95% CI

(%)

95% CI

1/182

0/190

100.0

7.72 [ 0.15, 389.47 ]

182

190

100.0

7.72 [ 0.15, 389.47 ]

Total events: 1 (Treatment), 0 (Control) Test for heterogeneity: not applicable Test for overall effect z=1.02

p=0.3

0.1 0.2

0.5

1

2

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

5

10

19

Analysis 02.12.

Review:

Comparison 02 Puerperal Outcomes, Outcome 12 Needed post-partum systemic antibiotics

Enemas during labour

Comparison: 02 Puerperal Outcomes Outcome: 12 Needed post-partum systemic antibiotics Study

Cuervo 1999 Total (95% CI)

Enema

No - Enema

Peto Odds Ratio

Weight

n/N

n/N

95% CI

(%)

Peto Odds Ratio 95% CI

0/214

5/205

100.0

0.13 [ 0.02, 0.74 ]

214

205

100.0

0.13 [ 0.02, 0.74 ]

Total events: 0 (Enema), 5 (No - Enema) Test for heterogeneity: not applicable Test for overall effect z=2.30

p=0.02

0.1 0.2

0.5

1

Protective effect

Analysis 03.01.

Review:

2

5

10

Risk of infection

Comparison 03 Labour duration, Outcome 01 Total labour duration

Enemas during labour

Comparison: 03 Labour duration Outcome: 01 Total labour duration Study

Treatment

Cuervo 1999 Total (95% CI)

Control

N

Mean(SD)

N

Mean(SD)

176

578.00 (291.03)

169

616.00 (302.48)

176

Weighted Mean Difference (Fixed)

Weight

Weighted Mean Difference (Fixed)

95% CI

(%)

95% CI

169

100.0

-38.00 [ -100.68, 24.68 ]

100.0

-38.00 [ -100.68, 24.68 ]

Test for heterogeneity: not applicable Test for overall effect z=1.19

p=0.2

-10.0

-5.0

0

Favours Treatment

Analysis 03.02.

Review:

5.0

10.0

Favours Control

Comparison 03 Labour duration, Outcome 02 First stage of labour duration

Enemas during labour

Comparison: 03 Labour duration Outcome: 02 First stage of labour duration Study

Cuervo 1999 Total (95% CI)

Treatment

Control

N

Mean(SD)

N

Mean(SD)

177

534.00 (288.00)

170

572.00 (299.00)

177

Weighted Mean Difference (Fixed)

Weight

Weighted Mean Difference (Fixed)

95% CI

(%)

95% CI

170

100.0

-38.00 [ -99.81, 23.81 ]

100.0

-38.00 [ -99.81, 23.81 ]

Test for heterogeneity: not applicable Test for overall effect z=1.20

p=0.2

-10.0

-5.0

Favours Treatment

0

5.0

10.0

Favours Control

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

20

Analysis 03.03.

Review:

Comparison 03 Labour duration, Outcome 03 Second stage of labour duration

Enemas during labour

Comparison: 03 Labour duration Outcome: 03 Second stage of labour duration Study

Treatment

Cuervo 1999 Total (95% CI)

Control

N

Mean(SD)

N

Mean(SD)

176

43.20 (37.23)

171

38.00 (36.50)

176

Weighted Mean Difference (Fixed)

Weight

95% CI

(%)

171

Weighted Mean Difference (Fixed) 95% CI

100.0

5.20 [ -2.56, 12.96 ]

100.0

5.20 [ -2.56, 12.96 ]

Test for heterogeneity: not applicable Test for overall effect z=1.31

p=0.2

-10.0

-5.0

0

Favours Treatment

Analysis 03.04.

Review:

5.0

10.0

Favours Control

Comparison 03 Labour duration, Outcome 04 Third stage of labour duration

Enemas during labour

Comparison: 03 Labour duration Outcome: 04 Third stage of labour duration Study

Cuervo 1999 Total (95% CI)

Treatment

Control

N

Mean(SD)

N

Mean(SD)

176

9.30 (5.97)

171

9.20 (5.27)

176

Weighted Mean Difference (Fixed)

Weight

Weighted Mean Difference (Fixed)

95% CI

(%)

95% CI

171

100.0

0.10 [ -1.08, 1.28 ]

100.0

0.10 [ -1.08, 1.28 ]

Test for heterogeneity: not applicable Test for overall effect z=0.17

p=0.9

-10.0

-5.0

Favours Treatment

0

5.0

10.0

Favours Control

Enemas during labour (Review) Copyright Š 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

21