Enemas during labour

Ludovic Reveiz; Hernando G Gaitán; Luis Gabriel Cuervo

doi:10.1002/14651858.CD000330.pub4

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Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Enema versus no enema, Outcome 1 Episiotomy dehiscence.

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Analysis 1.2

Comparison 1 Enema versus no enema, Outcome 2 Neonatal infection (all infections, including umbilical).

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Analysis 1.3

Comparison 1 Enema versus no enema, Outcome 3 Neonatal infection (not specified) at 4 days.

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Analysis 1.4

Comparison 1 Enema versus no enema, Outcome 4 Neonatal Infection (any infectious outcome, during the first month of life).

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Analysis 1.5

Comparison 1 Enema versus no enema, Outcome 5 Neonatal infection: umbilical infection.

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Analysis 1.6

Comparison 1 Enema versus no enema, Outcome 6 Neonatal infection: respiratory tract infection (high ‐ during first month).

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Analysis 1.7

Comparison 1 Enema versus no enema, Outcome 7 Neonatal infection: respiratory tract infection (low ‐ during first month).

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Analysis 1.8

Comparison 1 Enema versus no enema, Outcome 8 Neonatal infection: meningitis.

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Analysis 1.9

Comparison 1 Enema versus no enema, Outcome 9 Neontal infection: sepsis.

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Analysis 1.10

Comparison 1 Enema versus no enema, Outcome 10 Perineal tear: skin or superficial tissue without compromising muscle.

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Analysis 1.11

Comparison 1 Enema versus no enema, Outcome 11 Perineal tear: perineal muscle without anal muscles.

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Analysis 1.12

Comparison 1 Enema versus no enema, Outcome 12 Perineal tear: compromises anal muscles but not the mucosa.

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Analysis 1.13

Comparison 1 Enema versus no enema, Outcome 13 Perineal tear: complete tear that compromises anal mucosa.

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Analysis 1.14

Comparison 1 Enema versus no enema, Outcome 14 No episiotomy wound ‐ no further tear.

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Analysis 1.15

Comparison 1 Enema versus no enema, Outcome 15 No episiotomy wound ‐ further tear: 1st degree tear.

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Analysis 1.16

Comparison 1 Enema versus no enema, Outcome 16 Episiotomy wound ‐ no further tear.

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Analysis 1.17

Comparison 1 Enema versus no enema, Outcome 17 Episiotomy wound ‐ further tear: 3rd degree tear.

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Analysis 1.18

Comparison 1 Enema versus no enema, Outcome 18 One‐minute Apgar < 7.

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Analysis 1.19

Comparison 1 Enema versus no enema, Outcome 19 Five‐minute Apgar < 7.

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Analysis 1.20

Comparison 1 Enema versus no enema, Outcome 20 Faecal soiling during delivery.

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Analysis 1.21

Comparison 1 Enema versus no enema, Outcome 21 Duration of labour (minutes).

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Analysis 1.22

Comparison 1 Enema versus no enema, Outcome 22 Duration of labour (second stage).

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Analysis 1.23

Comparison 1 Enema versus no enema, Outcome 23 Parturients' levels of satisfaction (Likert scale).

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Analysis 1.24

Comparison 1 Enema versus no enema, Outcome 24 Labour attendants' levels of satisfaction (Likert scale).

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Analysis 1.25

Comparison 1 Enema versus no enema, Outcome 25 Accoucheurs' levels of satisfaction (Likert scale).

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Analysis 1.26

Comparison 1 Enema versus no enema, Outcome 26 Perineorrhaphy operators' levels of satisfaction (Likert scale).

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Analysis 1.27

Comparison 1 Enema versus no enema, Outcome 27 Pelvic infection: infected episiotomy.

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Analysis 1.28

Comparison 1 Enema versus no enema, Outcome 28 Pelvic infection: vulvovaginitis.

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Analysis 1.29

Comparison 1 Enema versus no enema, Outcome 29 Pelvic infection: endometritis.

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Analysis 1.30

Comparison 1 Enema versus no enema, Outcome 30 Pelvic infection: myometritis.

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Analysis 1.31

Comparison 1 Enema versus no enema, Outcome 31 Urinary tract infection.

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Analysis 1.32

Comparison 1 Enema versus no enema, Outcome 32 Other puerperal Infections.

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Analysis 1.33

Comparison 1 Enema versus no enema, Outcome 33 Other puerperal infections: Intrapartum infection rates.

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Analysis 1.34

Comparison 1 Enema versus no enema, Outcome 34 Need for systemic antibiotics (postpartum).

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Analysis 1.35

Comparison 1 Enema versus no enema, Outcome 35 Need for systemic antibiotics (neonatal ‐ after hospital discharge during the first month).

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Analysis 1.36

Comparison 1 Enema versus no enema, Outcome 36 Opthalmic infection (dacriocistitis or conjunctivitis in first month).

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Analysis 1.37

Comparison 1 Enema versus no enema, Outcome 37 Skin infection (first month).

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Analysis 1.38

Comparison 1 Enema versus no enema, Outcome 38 Intestinal infection.

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Table 1. Findings of individual studies

Study ID	Comments
Drayton 1984	The RCT from Wales investigated the incidence of maternal and neonatal infections. None of the women had a perineal wound infection. Regarding neonatal infections, no significant differences were found between the enema and the no‐enema groups (one RCT; 222 women; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.31 to 2.56; Analysis 1.2). The RCT also evaluated women's views on enemas. In the no‐enema group, 14.1% of women willingly accepted to receive a future enema compared to 39.6% in the enema group (P < 0.01).
Kovavisarach 2005	In the trial from Thailand, the duration of labour was shorter in the enema group (1027 women; 409.4 minutes versus 459.8 minutes; mean difference (MD) ‐50.40, 95% CI ‐75.68 to ‐25.12; P < 0.001; Analysis 1.21) but no adjustment was done by parity. No significant differences were found in the route of delivery, degree of perineal tear and perineal wound infection rates. No neonatal infections occurred during the four‐day follow‐up, which seems a short time to identify infections comprehensively. No significant differences were found with regard to satisfaction between women receiving an enema versus those not receiving an enema, as assessed using a five‐point Likert scale (1027 women; 3.58 versus 3.58; MD 0.00, CI 95% ‐0.10 to 0.10; P = 0.922; Analysis 1.23). Satisfaction levels of labour attendants and healthcare providers were significantly higher in the enema group (P < 0.01) than in the control group (measured using the Likert scale).
Cuervo 2006	The trial from Colombia investigated the effect of enemas on labour duration adjusted by parity. It found no statistically significant differences between groups for delivery types, episiotomy rates, or prescription of antibiotics. No significant differences were found in lower and upper respiratory tract infections rates. Similarly, no significant differences were found for ophthalmic infection rates, skin infections, or intestinal infections. The authors reported no significant differences in the distribution between groups for newborns' "Ballard" score, birthweight, diagnosis of neonatal apnoea, or the administration of ocular and umbilical prophylaxis. Twelve per cent of women had caesarean sections with no significant differences in rates between groups. In addition, no significant differences were found for the duration of labour (for all women for first stage of labour: median 515 minutes with enemas versus 585 minutes without enemas, P = 0.24; for second stage of labour: mean 43.2 minutes with enemas and 38 minutes without; MD 5.20, 95% CI ‐2.56 to 12.96; P=0.19; Analysis 1.22). These results could not be aggregated with the RCT from Thailand (Kovavisarach 2005) as times did not follow a normal distribution and, therefore, trialists considered non‐parametric measures (differences between medians). Finally, there were no significant difference in the degree of perineal tear between groups. The Colombian RCT found no significant differences between groups in the rate of neonatal infection after one month of follow‐up (370 newborns; RR 1.12, 95% CI 0.76 to 1.67; Analysis 1.4)
Clarke 2007	In the trial from the United States, the mean times to delivery were 504.7 minutes and 392.7 minutes for enema and no enema respectively (152 women; MD 112, 95% CI 48.13 to 175.87; Analysis 1.21); we estimated the standard deviations because these were not provided by the researchers. Intrapartum infection rates were significantly higher in the enema group (RR 4.62, 95% CI 1.03 to 20.68; Analysis 1.33). However, when controlling for duration of membrane rupture, enema use fell below the level of significance for infection (no data was provided by trialists). Women who received enemas had significantly less faecal soiling at delivery (RR 0.36, 95% CI 0.17 to 0.75; Analysis 1.20). There was no significant difference in the mode of delivery between the two groups. No neonatal outcomes were reported.
RCT: randomised controlled trial

Table 1. Findings of individual studies

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Comparison 1. Enema versus no enema

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Episiotomy dehiscence Show forest plot	1	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.69 [0.41, 1.14]

2 Neonatal infection (all infections, including umbilical) Show forest plot	1	222	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.31, 2.56]

3 Neonatal infection (not specified) at 4 days Show forest plot	1	1027	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

4 Neonatal Infection (any infectious outcome, during the first month of life) Show forest plot	1	370	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.76, 1.67]

5 Neonatal infection: umbilical infection Show forest plot	2	592	Risk Ratio (M‐H, Fixed, 95% CI)	3.16 [0.50, 19.82]

6 Neonatal infection: respiratory tract infection (high ‐ during first month) Show forest plot	1	369	Risk Ratio (M‐H, Fixed, 95% CI)	1.82 [0.73, 4.52]

7 Neonatal infection: respiratory tract infection (low ‐ during first month) Show forest plot	1	369	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.01, 1.73]

8 Neonatal infection: meningitis Show forest plot	1	370	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

9 Neontal infection: sepsis Show forest plot	1	370	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

10 Perineal tear: skin or superficial tissue without compromising muscle Show forest plot	2	1448	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.76, 1.71]

11 Perineal tear: perineal muscle without anal muscles Show forest plot	1	421	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.37, 1.40]

12 Perineal tear: compromises anal muscles but not the mucosa Show forest plot	2	1448	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.13, 1.64]

13 Perineal tear: complete tear that compromises anal mucosa Show forest plot	1	421	Risk Ratio (M‐H, Fixed, 95% CI)	2.93 [0.12, 71.51]

14 No episiotomy wound ‐ no further tear Show forest plot	1	1027	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.43, 1.27]

15 No episiotomy wound ‐ further tear: 1st degree tear Show forest plot	1	1027	Risk Ratio (M‐H, Fixed, 95% CI)	1.17 [0.63, 2.19]

16 Episiotomy wound ‐ no further tear Show forest plot	1	1027	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.98, 1.05]

17 Episiotomy wound ‐ further tear: 3rd degree tear Show forest plot	1	1027	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.01, 4.38]

18 One‐minute Apgar < 7 Show forest plot	1	431	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.57, 3.06]

19 Five‐minute Apgar < 7 Show forest plot	1	431	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.57, 3.06]

20 Faecal soiling during delivery Show forest plot	1	152	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.17, 0.75]

21 Duration of labour (minutes) Show forest plot	2	1179	Mean Difference (IV, Random, 95% CI)	28.04 [‐131.01, 187.10]

22 Duration of labour (second stage) Show forest plot	1	347	Mean Difference (IV, Fixed, 95% CI)	5.20 [‐2.56, 12.96]

23 Parturients' levels of satisfaction (Likert scale) Show forest plot	1	1027	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.10, 0.10]

24 Labour attendants' levels of satisfaction (Likert scale) Show forest plot	1	1027	Mean Difference (IV, Fixed, 95% CI)	0.17 [0.08, 0.26]

25 Accoucheurs' levels of satisfaction (Likert scale) Show forest plot	1	1027	Mean Difference (IV, Fixed, 95% CI)	0.26 [0.15, 0.37]

26 Perineorrhaphy operators' levels of satisfaction (Likert scale) Show forest plot	1	1027	Mean Difference (IV, Fixed, 95% CI)	0.11 [0.02, 0.20]

27 Pelvic infection: infected episiotomy Show forest plot	1	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.18, 2.00]

28 Pelvic infection: vulvovaginitis Show forest plot	1	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.01, 2.87]

29 Pelvic infection: endometritis Show forest plot	1	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.03, 2.31]

30 Pelvic infection: myometritis Show forest plot	1	372	Risk Ratio (M‐H, Fixed, 95% CI)	3.13 [0.13, 76.37]

31 Urinary tract infection Show forest plot	1	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.18, 2.00]

32 Other puerperal Infections Show forest plot	2	594	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.42, 1.04]

32.1 First 24 hours by interview	1	222	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
32.2 Infection during the first month	1	372	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.42, 1.04]
33 Other puerperal infections: Intrapartum infection rates Show forest plot	1	152	Risk Ratio (M‐H, Fixed, 95% CI)	4.62 [1.03, 20.68]

34 Need for systemic antibiotics (postpartum) Show forest plot	1	428	Risk Ratio (M‐H, Fixed, 95% CI)	1.16 [0.73, 1.84]

35 Need for systemic antibiotics (neonatal ‐ after hospital discharge during the first month) Show forest plot	1	367	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.03, 1.80]

36 Opthalmic infection (dacriocistitis or conjunctivitis in first month) Show forest plot	1	370	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.62, 1.71]

37 Skin infection (first month) Show forest plot	1	370	Risk Ratio (M‐H, Fixed, 95% CI)	1.60 [0.27, 9.47]

38 Intestinal infection Show forest plot	1	368	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.07, 16.94]

Comparison 1. Enema versus no enema

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