Summary of findings 4. Blood transfusion.
| Patient or population: women in the third stage of labour Interventions: carbetocin, misoprostol, injectable prostaglandins, ergometrine, ergometrine plus oxytocin (Syntometrine ®), misoprostol plus oxytocin Comparison (reference): oxytocin Outcome: blood transfusion Setting: hospital or community setting | |||||||||||
| Uterotonic agent(s) | Direct evidence | Indirect evidence | NMA evidence | Anticipated absolute effects for NMA estimate | |||||||
| RR (95% CI) | Certainty | RR (95% CI) | Certainty | RR (95% CI) | Certainty | Risk with oxytocin | Risk with intervention (other uterotonics) | Risk difference with intervention | |||
| Carbetocin | 0.68 (0.38 to 1.22) | ⊕⊕⊕⊝ MODERATE a | 0.62 (0.21 to 1.85) | ⊕⊕⊝⊝ LOW b | 0.81 (0.49 to 1.32) | ⊕⊕⊕⊝ MODERATE c | 22 per 1000 | 18 per 1000 | 4 fewer per 1000 (11 fewer to 7 more) | ||
| Vaginal birth: 15 per 1000 |
Vaginal birth: 12 per 1000 | Vaginal birth: 3 fewer per 1000 (5 fewer to 4 more) | |||||||||
| Caesarean birth: 81 per 1000 |
Caesarean birth:66 per 1000 | Caesarean birth:15 fewer per 1000 (41 fewer to 26 more) | |||||||||
| Misoprostol | 0.81 (0.65 to 1.00) |
⊕⊕⊕⊝ MODERATE a | 1.02 (0.59 to 1.77) | ⊕⊕⊝⊝ LOW d | 0.88 (0.68 to 1.13) | ⊕⊕⊕⊝ MODERATE c | 22 per 1000 | 19 per 1000 | 3 fewer per 1000 (7 fewer to 3 more) | ||
| Vaginal birth: 15 per 1000 | Vaginal birth: 13 per 1000 | Vaginal birth: 2 fewer per 1000 (5 fewer to 2 more) | |||||||||
| Caesarean birth: 81 per 1000 | Caesarean birth: 71 per 1000 | Caesarean birth: 10 fewer per 1000 (26 fewer to 11 more) | |||||||||
| Injectable prostaglandins | 1.01 (0.04 to 23.65) | ⊕⊝⊝⊝ VERY LOW e | 0.49 (0.16 to 1.52) | ⊕⊝⊝⊝ VERY LOW f | 0.66 (0.25 to 1.72) | ⊕⊝⊝⊝ VERY LOW g | 22 per 1000 | 15 per 1000 | 7 fewer per 1000 (17 fewer to 16 more) | ||
| Vaginal birth: 15 per 1000 | Vaginal birth: 10 per 1000 | Vaginal birth: 5 fewer per 1000 (11 fewer to 11 more) | |||||||||
| Caesarean birth: 81 per 1000 | Caesarean birth: 56 per 1000 | Caesarean birth: 28 fewer per 1000 (61 fewer to 58 more) | |||||||||
| Ergometrine | 1.44 (0.20 to 10.23) | ⊕⊝⊝⊝ VERY LOW h | 1.01 (0.38 to 2.68) | ⊕⊕⊝⊝ LOW i | 1.11 (0.54 to 2.28) | ⊕⊕⊝⊝ LOW j | 22 per 1000 | 24 per 1000 | 2 more per 1000 (10 fewer to 28 more) | ||
| Vaginal birth: 15 per 1000 | Vaginal birth: 17 per 1000 | Vaginal birth: 2 more per 1000 (7 fewer to 19 more) | |||||||||
| Caesarean birth: 81 per 1000 | Caesarean birth: 90 per 1000 | Caesarean birth: 9 more per 1000 (37 fewer to 104 more) | |||||||||
| Ergometrine plus oxytocin | 0.88 (0.53 to 1.44) | ⊕⊕⊝⊝ LOW k | 0.64 (0.41 to 1.00) | ⊕⊕⊝⊝ LOW i | 0.77 (0.58 to 1.03) | ⊕⊕⊝⊝ LOW j | 22 per 1000 | 17 per 1000 | 5 fewer per 1000 (9 fewer to 1 more) | ||
| Vaginal birth: 15 per 1000 | Vaginal birth: 12 per 1000 | Vaginal birth: 3 fewer per 1000 (6 fewer to 0 fewer) | |||||||||
| Caesarean birth: 81 per 1000 | Caesarean birth: 63 per 1000 | Caesarean birth: 18 fewer per 1000 (33 fewer to 2 more) | |||||||||
| Misoprostol plus oxytocin | 0.50 (0.37 to 0.67) | ⊕⊕⊝⊝ LOW l | 0.77 (0.27 to 2.26) | ⊕⊕⊕⊝ MODERATE m | 0.51 (0.37 to 0.70) | ⊕⊕⊕⊝ MODERATE c | 22 per 1000 | 11 per 1000 | 11 fewer per 1000 (14 fewer to 7 fewer) | ||
| Vaginal birth: 15 per 1000 | Vaginal birth: 8 per 1000 | Vaginal birth: 7 fewer per 1000 (9 fewer to 5 fewer) | |||||||||
| Caesarean birth: 81 per 1000 | Caesarean birth: 42 per 1000 | Caesarean birth: 39 fewer per 1000 (50 fewer to 24 fewer) | |||||||||
|
The assumed risks in the oxytocin group are based on weighted means of baseline risks from the studies with oxytocin groups in the network meta‐analysis. The corresponding risks in the carbetocin, misoprostol, injectable prostaglandins, ergometrine, ergometrine plus oxytocin (Syntometrine ®), misoprostol plus oxytocin groups (and their 95% confidence interval) are based on the assumed risk in the oxytocin group and the relative effect of individual uterotonic when compared with oxytocin (and its 95% CI) derived from the network meta‐analysis. * No included studies or there are no event in included studies to estimate the baseline risk ** Absolute risk with uterotonic cannot be estimated in the absence of absolute risk with oxytocin ***Risk difference cannot be estimated in the absence of absolute risks with intervention and oxytocin CI: Confidence interval; RR: Risk ratio. | |||||||||||
| GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect | |||||||||||
a Direct evidence downgraded ‐1 due to serious imprecision
b Indirect evidence downgraded ‐2 due to very serious imprecision
c Network evidence downgraded ‐1 due to moderate certainty direct evidence (no intransitivity or incoherence, network estimate remains imprecise)
d Indirect evidence downgraded ‐2 due to multiple limitations in study design and strong suspicion of publication bias
e Direct evidence downgraded ‐3 due to multiple limitations in study design and very serious imprecision
f Indirect evidence downgraded ‐3 due to multiple crucial limitations in study design and very serious imprecision
g Network evidence downgraded ‐3 due to very low certainty direct and indirect evidence (no intransitivity or incoherence, network estimate remains imprecise)
h Direct evidence downgraded ‐3 due to multiple limitations in study design, severe unexplained statistical heterogeneity and very serious imprecision
i Indirect evidence downgraded ‐2 due to multiple limitations in study design and serious imprecision
j Network evidence downgraded ‐2 due to low certainty indirect evidence (no intransitivity or incoherence, network estimate remains imprecise)
k Direct evidence downgraded ‐2 due to multiple limitations in study design and serious imprecision
l Direct evidence downgraded ‐2 due to multiple limitations in study design and strong suspicion of publication bias
m Indirect evidence downgraded ‐1 due to multiple limitations in study design and serious imprecision