Summary of findings 7. Fever.
| 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: fever 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 | 1.58 (0.27 to 9.35) | ⊕⊕⊕⊝ MODERATE a | 0.77 (0.18 to 3.42) |
⊕⊕⊝⊝ LOWb | 1.07 (0.43 to 2.69) |
⊕⊕⊕⊝ MODERATE c | 29 per 1000 | 31 per 1000 | 2 more per 1000 (17 fewer to 49 more) |
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| Vaginal birth: 24 per 1000 | Vaginal birth: 26 per 1000 | Vaginal birth: 2 more per 1000 (14 fewer to 41 more) |
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| Caesarean birth: 55 per 1000 | Caesarean birth: 59 per 1000 | Caesarean birth: 4 more per 1000 (31 fewer to 93 more) | |||||||||
| Misoprostol | 3.75 (2.73 to 5.15) |
⊕⊕⊝⊝ LOW d | 6.49 (2.24 to 18.76) |
⊕⊕⊕⊝ MODERATE e | 3.87 (2.90 to 5.16) |
⊕⊕⊕⊝ MODERATE c | 29 per 1000 | 112 per 1000 | 83 more per 1000 (55 more to 121 more) | ||
| Vaginal birth: 24 per 1000 | Vaginal birth: 93 per 1000 | Vaginal birth: 69 more per 1000 (46 more to 100 more) | |||||||||
| Caesarean birth: 55 per 1000 | Caesarean birth: 213 per 1000 | Caesarean birth: 158 more per 1000 (105 more to 229 more) | |||||||||
| Injectable prostaglandins | 2.00 (0.18 to 21.71) | ⊕⊝⊝⊝ VERY LOW f | 0.96 (0.24 to 3.87) |
⊕⊕⊝⊝ LOW b | 1.12 (0.33 to 3.86) |
⊕⊕⊝⊝ LOWg | 29 per 1000 | 32 per 1000 | 3 more per 1000 (19 fewer to 83 more) |
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| Vaginal birth: 24 per 1000 | Vaginal birth: 27 per 1000 | Vaginal birth: 3 more per 1000 (16 fewer to 69 more) |
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| Caesarean birth: 55 per 1000 (for caesarean birth) | Caesarean birth: 61 per 1000 (for caesarean birth) | Caesarean birth: 6 more per 1000 (37 fewer to 153 more) | |||||||||
| Ergometrine | 2.97 (0.97 to 9.05) |
⊕⊝⊝⊝ VERY LOW f | 0.63 (0.35 to 1.16) |
⊕⊕⊝⊝ LOW h | 0.77 (0.44 to 1.35) |
⊕⊝⊝⊝ VERY LOW i | 29 per 1000 | 22 per 1000 | 7 fewer per 1000 (16 fewer to 10 more) |
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| Vaginal birth: 24 per 1000 | Vaginal birth: 18 per 1000 | Vaginal birth: 6 fewer per 1000 (13 fewer to 8 more) |
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| Caesarean birth: 55 per 1000 | Caesarean birth: 42 per 1000 | Caesarean birth: 13 fewer per 1000 (31 fewer to 18 more) | |||||||||
| Ergometrine plus oxytocin | 1.08 (0.48 to 2.43) |
⊕⊕⊝⊝ LOW j | 0.54 (0.22 to 1.32) |
⊕⊕⊝⊝ LOW k | 0.70 (0.35 to 1.42) |
⊕⊕⊝⊝ LOW l | 29 per 1000 | 20 per 1000 | 9 fewer per 1000 (19 fewer to 12 more) |
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| Vaginal birth: 24 per 1000 | Vaginal birth: 17 per 1000 | Vaginal birth: 7 fewer per 1000 (16 fewer to 10 more) |
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| Caesarean birth: 55 per 1000 | Caesarean birth: 42 per 1000 | Caesarean birth: 13 fewer per 1000 (31 fewer to 19 more) | |||||||||
| Misoprostol plus oxytocin | 2.99 (2.00 to 4.45) |
⊕⊕⊕⊝ MODERATE m | 5.43 (1.48 to 19.95) |
⊕⊕⊝⊝ LOW n | 3.14 (2.20 to 4.49) |
⊕⊕⊕⊝ MODERATE o | 29 per 1000 | 91 per 1000 | 62 more per 1000 (35 more to 101 more) | ||
| Vaginal birth: 24 per 1000 | Vaginal birth: 75 per 1000 | Vaginal birth: 51 more per 1000 (29 more to 84 more) | |||||||||
| Caesarean birth: 55 per 1000 | Caesarean birth: 173 per 1000 | Caesarean birth: 118 more per 1000 (66 more to 192 more) | |||||||||
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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 multiple limitations in study design, severe unexplained statistical heterogeneity and serious imprecision
c Network evidence downgraded ‐1 due to moderate certainty direct evidence (no intransitivity or incoherence, network estimate remains imprecise)
d Direct evidence downgraded ‐2 due to multiple limitations in study design and severe unexplained statistical heterogeneity
e Indirect evidence downgraded ‐1 due to multiple limitations in study design and serious imprecision
f Direct evidence downgraded ‐3 due to multiple limitations in study design and very serious imprecision
g Network evidence downgraded ‐2 due to low certainty indirect evidence (no intransitivity or incoherence, network estimate remains imprecise)
h Indirect evidence downgraded ‐2 due to multiple limitations in study design, severe unexplained statistical heterogeneity and strong suspicion of publication bias. The indirect estimate is imprecise, however the effect estimates for the two head‐to‐head comparisons in the dominant first‐order loop were not imprecise, so we have not downgraded for imprecision
i Network evidence initially downgraded ‐2 due to low certainty indirect evidence; however, downgraded further ‐1 due to incoherence between the direct and indirect estimates (no intransitivity. Network estimate is imprecise, unlike indirect evidence, however no further downgrade considered because certainty already very low)
j Direct evidence downgraded ‐2 due to very serious imprecision
k Indirect evidence downgraded ‐2 due to multiple limitations in study design and severe unexplained statistical heterogeneity. The indirect estimate is imprecise, however the effect estimates for the two head‐to‐head comparisons in the dominant first‐order loop were not imprecise, so we have not downgraded for imprecision
l Network evidence downgraded ‐2 due to low certainty direct and indirect evidence (no intransitivity or incoherence, network estimate remains imprecise)
m Direct evidence downgraded ‐1 due to multiple limitations in study design
n Indirect evidence downgraded ‐2 due to multiple limitations in study design and severe unexplained statistical heterogeneity
o Network evidence downgraded ‐1 due to moderate certainty direct evidence (no intransitivity, incoherence or imprecision)