剖宫产术脊椎麻醉期间预防低血压的技术
Referencias
References to studies included in this review
References to studies excluded from this review
References to studies awaiting assessment
References to ongoing studies
Additional references
References to other published versions of this review
Characteristics of studies
Characteristics of included studies [ordered by study ID]
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: healthy term parturients, elective CS under spinal anaesthesia, ASA I‐II. Exclusion criteria: women with chronic hypertension, multiple pregnancy, pregnancy‐induced hypertension, diabetes mellitus, body weight > 110 kg and contraindications to a spinal anaesthetic Setting: USA | |
| Interventions | Compression device versus no compression device Group 1 (n = 25): sequential compression device; with thigh‐high sleeves and a preset pressure of 50 mmHg Group 2 (n = 25): no sleeves on lower limbs Preloading with 20 mL/kg Ringer's lactate Standardised anaesthetic technique and dose for all women | |
| Outcomes | Maternal: hypotension Neonatal: Apgar score < 8 at 5 min | |
| Notes | Hypotension: defined as decrease MAP measurement by > 20% of baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Randomisation method unknown |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelopes." No further detail given |
| Blinding of participants and personnel (performance bias) | Low risk | Hypotension treated by an anaesthetist who was blinded to the assigned group |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 19 women Inclusion criteria: healthy women undergoing elective caesarean under spinal anaesthesia (38‐42 weeks' gestation) for fetal breech presentation or cephalopelvic disproportion in otherwise uncomplicated singleton pregnancies Exclusion criteria: not reported Setting: Finland | |
| Interventions | Ephedrine versus phenylephrine Group 1 (n = 9): ephedrine (mean 27.9 mg, range 16.7 to 32.5) Group 2 (n = 8): phenylephrine (mean 488 µg, range 334 to 767) Standardised anaesthetic technique for all women but variable heavy 0.5% bupivicaine dose (range 2.3‐2.6 mL) | |
| Outcomes | Maternal: hypotension (defined as a fall in SAP of more than 10 mmHg from baseline); heart rate | |
| Notes | Hypotension requiring intervention: not stated | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Low risk | Described as "double blind" – third‐party preparation and coding of solutions |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: 2/19 – 1 from each group; 1 technical failure, 1 maternal bradycardia requiring atropine treatment |
| Selective reporting (reporting bias) | Unclear risk | Not all expected outcomes were reported |
| Other bias | High risk | Similar baseline characteristics Variable dose of local anaesthetic used for spinal anaesthesia |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women undergoing elective caesarean section Inclusion criteria: normal single pregnancy, gestational age > 37 weeks, no history of hypertension Exclusion criteria: contraindications for spinal anaesthesia, third trimester bleeding, BMI > 30 kg/m², previous allergy to hydroxyethyl starch (HES) preparations, known cardiomyopathy, height < 155 cm, sympathetic block higher than T4 Setting: France and USA | |
| Interventions | Ringer's lactate preload vs sodium chloride preload vs HES preload Group 2: sodium chloride 0.9% group, 1000 mL Group 3: HES group, 7.5 mL/kg | |
| Outcomes | Maternal: BP, heart rate Neonatal: umbilical cord pH, Apgar score | |
| Notes | Hypotension was defined as a drop in systolic blood pressure of > 20% from baseline or systolic blood pressure < 100 mmHg. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Block randomisation technique |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Double blind" – no further detail provided |
| Blinding of outcome assessment (detection bias) | Unclear risk | "Double blind" – no further detail provided |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes reported |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 109 women Inclusion criteria: ASA physical status I and II pregnant women scheduled for elective caesarean delivery under spinal anaesthesia; singleton gestation at a gestational age of > 36 weeks Exclusion criteria: women who were in labour, BMI > 45 kg/m², type 1 diabetes mellitus, hypertensive disease, cardiac disease, a fetus with severe congenital anomalies, history of monoamine oxidase inhibitor use, or those who were included in any other anaesthesia drug studies Setting: USA | |
| Interventions | Phenylephrine dosage variations versus placebo Group 1: phenylephrine infusion 25 μg/min Group 2: phenylephrine infusion 50 μg/min Group 3: phenylephrine infusion 75 μg/min Group 4: phenylephrine infusion 100 μg/min Group 5: placebo (normal saline 50 mL) infusion All infusions were commenced immediately after spinal injection, at 60 mL/h in combination with a standardised fluid coload. The study drug was infused until 10 min after delivery, after which the study ended and further management was at the discretion of the anaesthesiologist. All women received a standardised aspiration prophylaxis, a standardised spinal anaesthetic technique and dose, and a standardised oxytocin bolus and subsequent infusion after delivery. Hypotension (requiring intervention) was treated by administering a 100 μg bolus of phenylephrine. Hypertension treatment: treated by stopping the infusion. Infusions were only restarted when the SBP decreased to below the upper limit of the target range above baseline). NOTE: if the study drug infusion had to be stopped on 3 occasions, then it was stopped permanently, and BP was maintained with phenylephrine boluses for the remainder of the study. Bradycardia treatment: administration of glycopyrrolate 0.4 mg | |
| Outcomes | Maternal: hypotension, pre and postdelivery birth; hypotension requiring intervention; nausea and vomiting; cardiac dysrhythmia; pre and postbirth reactive hypertension; bradycardia Neonatal: acidosis (cord or neonatal bloods with pH < 7.2); neonatal Apgar score < 8 at 5 min | |
| Notes | Hypotension defined as SBP < 20% below baseline Hypotension requiring intervention defined as SBP decrease > 20% baseline or < 90 mmHg Hypertension defined as SBP > 20% above baseline Bradycardia defined as < 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation in blocks of 20 |
| Allocation concealment (selection bias) | Unclear risk | Each study syringe was identified by a study number. The infusions were prepared in identical 50 mL syringes by a physician not involved in the study. |
| Blinding of participants and personnel (performance bias) | Low risk | "Double blind". To maintain blinding, the infusions were prepared in identical 50 mL syringes containing normal saline for the placebo, or the appropriate concentrations of phenylephrine (25 μg, 50 μg, 75 μg, or 100 μg) for the drug interventions. A physician not involved in the study coded and prepared the syringes. |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not stated who was responsible for recording of outcomes, and whether they were blinded to the allocated intervention |
| Incomplete outcome data (attrition bias) | Unclear risk | 8/109 patients excluded (not specified which groups they were from), due to inadequate or failed spinal anaesthesia. Insufficient samples were obtained for umbilical cord blood gases for some babies because of insufficient samples, clotted samples or sampling errors: 1 (placebo group); 2 (phenylephrine 25 μg group); 2 (phenylephrine 50 μg group) and 5 (phenylephrine 100 μg group). |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes reported |
| Other bias | Low risk | No apparent sources of other bias Study funded by Duke University Medical Center Department of Anesthesiology, Division of Women's Anesthesia |
| Study characteristics | ||
| Methods | Randomisation: method not described | |
| Participants | 40 women Inclusion criteria: ASA I, term, singleton, cephalic, elective CS Exclusion criteria: not specified Setting: Brazil | |
| Interventions | Crawford's wedge versus uterine displacement Group 1 (n = 20): wedged lateral position using modified Crawford's wedge (15 degrees left lateral tilt) Group 2 (n = 20): manual uterine displacement by surgical assistant | |
| Outcomes | Maternal: hypotension, magnitude of BP reduction and time of occurrence, block height, ephedrine consumption, induction – and hysterotomy – birth times. Neonatal: umbilical artery pH (expressed as mean and SD), Apgar scores at 1 min and 5 min | |
| Notes | Hypotension defined as decrease in SBP > 20% baseline or < 100 mmHg absolute | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Randomisation methods not described |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 128 women Inclusion criteria: women with a normal singleton pregnancy at 37 weeks' gestation or more scheduled for elective CS Exclusion criteria: ASA grade III or more; height < 150 cm or > 180 cm; body mass < 60 kg or > 100 kg; pre‐eclampsia; known fetal abnormality; or any other contraindication to spinal anaesthesia Setting: United Arab Emirates | |
| Interventions | Phenylephrine 50 μg versus 100 μg infusion Group 1: phenylephrine 50 μg/mL infusion Group 2: phenylephrine 100 μg/mL infusion Phenylephrine infusion was commenced immediately after spinal anaesthesia in conjunction with standardised IV coload with warm Hartmann's solution. Initial phenylephrine rate of 60 mL/h for the first 3 min and stopped if SBP was > 120% of the baseline. After the first 3 min, the infusion was continued at the same rate if SBP was between 80% and 100% of baseline, until the time of giving birth; infusion was discontinued if the SBP was more than 100% of baseline value. All women received standardised aspiration prophylaxis and standardised spinal anaesthetic technique and dose. Hypotension requiring intervention: rescue dose of phenylephrine 50 μg if BP decreased to < 80% baseline for 2 consecutive readings, despite phenylephrine infusion. Bradycardia requiring intervention: if bradycardia without hypotension, phenylephrine infusion was discontinued for 1 min; if bradycardia developed with hypotension, IV glycopyrronium 200 μg was administered. | |
| Outcomes | Maternal: BP; hypotension; hypertension; bradycardia; total dose of phenylephrine; nausea and vomiting Neonatal: Apgar scores at 1 min and 5 min; umbilical arterial pH and gases | |
| Notes | Hypotension defined as SBP < 80% baseline Hypertension defined as SBP > 120% baseline Bradycardia defined as heart rate < 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomised" – no further details reported |
| Allocation concealment (selection bias) | Unclear risk | "Closed similar" envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | An anaesthetist who was not involved in case management prepared a 20 mL syringe for phenylephrine infusion with the designated concentration; both women and the anaesthetist in charge of the case were blinded to the concentration of phenylephrine in the syringe |
| Blinding of outcome assessment (detection bias) | Low risk | Not reported, but likely in view of the above. |
| Incomplete outcome data (attrition bias) | Unclear risk | 11/128 lost to follow‐up (not reported by assigned group):
|
| Selective reporting (reporting bias) | Low risk | Most expected outcomes were reported. |
| Other bias | Unclear risk | Some suggestion of imbalance in randomisation and/or differential losses to follow‐up (54 and 63 women analysed in each group) |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: ASA grade I/II, full term (36‐40 weeks' gestation), uncomplicated singleton pregnancy, elective LSCS under spinal anaesthesia Exclusion criteria: fetal distress, antepartum haemorrhage, pregnancy‐induced hypertension, diabetes mellitus, multiple gestation, significant cardiorespiratory disorder or intrapartum cardiomyopathy Setting: India | |
| Interventions | Colloid preload versus colloid coload versus crystalloid preload Group 1: 10 mL/kg colloid preload (6% HES administered 20 min prior to SAB) Group 2: 10 mL/kg colloid co‐load (6% HES administered by rapid infusion in 10 min immediately after SAB) Group 3: 10 mL/kg crystalloid preload (Ringer's lactate administered 20 min prior to SAB) All women received the same aspiration prophylaxis, anaesthetic technique and dose, IV cannula. 10 min after induction of spinal anaesthesia, normal saline was given in all 3 groups at rate of 200 mL/h. Hypotension was treated by increasing rate of fluid infusion and IV ephedrine 5 mg until the BP had improved to within 20% of baseline. | |
| Outcomes | Maternal: incidence of hypotension, dose of ephedrine | |
| Notes | Hypotension was defined as SBP < 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random allocation |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 24 women Inclusion criteria: healthy, term parturients undergoing elective CS. Exclusion criteria: placental dysfunction, intrauterine growth retardation, abnormal fetal presentation, weight more than 90 kg Setting: South Africa | |
| Interventions | Lower limb compression versus control Group 1: legs wrapped with 10 cm Esmarch bandages from ankle to mid‐thigh immediately following spinal with preservation of pedal pulses Group 2: control All women received standardised IV preload with plasmalyte followed by a standardised spinal anaesthetic technique and dose | |
| Outcomes | Maternal: hypotension; spinal to birth time; uterine incision to birth time Neonatal: Apgar scores (minus colour) at 2 min and 5 min; umbilical arterial and venous blood gas oxygen tension and saturation | |
| Notes | Hypotension defined as SBP < 100 mmHg or less than 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | High risk | Blinding not reported – unlikely due to nature of intervention (leg wrapping) |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not reported |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes reported |
| Other bias | Low risk | Similar baseline characteristics. None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: ASA grade I, elective CS under spinal anaesthesia, singleton pregnancy, no fetal abnormalities, no pre‐eclampsia, no cerebrovascular diseases Setting: India | |
| Interventions | Phenylephrine infusion versus ephedrine infusion versus metaraminol infusion Group 1: phenylephrine 30 μg/mL (15 μg/min) Group 2: ephedrine 5 mg/mL (2.5 mg/min) Group 3: metaraminol 0.5 mg/mL (0.25 mg/min) Immediately following SAB, patients received 1 mL bolus of study drug and then a infusion at 15 mL/h All women received standardised: aspiration prophylaxis, monitoring, IV cannulation, isotonic saline coload, spinal anaesthetic technique and dose If SBP increased 1.25 times above baseline, infusion was ceased. If SBP dropped 10% below the baseline, 1 mL bolus of study drug given. If maternal heart rate < 60 bpm and SBP < 80% of baseline, or if maternal heart rate < 50 and SBP < 100% of baseline, or if maternal heart rate < 45 regardless of BP, glycopyrrolate 0.2 mg IV given | |
| Outcomes | Maternal: incidence of maternal hypotension, incidence of maternal hypertension, heart rate, nausea/vomiting, total dose of vasopressor Neonatal: Apgar scores at 1 min and 5 min, umbilical cord gases | |
| Notes | Hypotension: SBP < 80% of baseline Hypertension: SBP > 120% of baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomised sequence |
| Allocation concealment (selection bias) | Low risk | Sequentially numbered sealed envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blind Study drugs prepared by another anaesthetist not involved in other aspects of the participants' care, into a unlabelled 20 mL syringe |
| Blinding of outcome assessment (detection bias) | Low risk | Blinded |
| Incomplete outcome data (attrition bias) | Low risk | Below exclusions reported: Group 2 – 1 failed SAB Group 3 – 1 failed SAB Group 1 – 2 pump failures |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I/II, elective caesarean delivery Exclusion criteria: none stated Setting: USA | |
| Interventions | Crystalloid preload versus colloid preload Group 1: crystalloid preload (1500 mL Ringer's lactate) Group 2: colloid preload (0.5L 6% HES) Women in both groups received 100 μg/min phenylephrine infusion following spinal anaesthesia which continued until uterine incision. The phenylephrine infusion was adjusted according to heart rate and SBP which was maintained at 20% of the baseline. No further information regarding spinal anaesthetic technique/dose etc was provided. | |
| Outcomes | Maternal: vasopressor dose, incidence of hypotension, incidence of nausea and vomiting, incidence of bradycardia Neonatal: Apgar score | |
| Notes | Hypotension was defined as a 20% fall in SBP from baseline. Hypertension was defined as an increase of 20% from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Method not explicitly stated |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | High risk | 3 women excluded for unspecified reasons and at an unclear point along the study pathway Additionally, study states "60 patients were included as part of a 90 patient study" |
| Selective reporting (reporting bias) | Low risk | None evident |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I scheduled for elective CS, singleton term pregnancy Exclusion criteria: chronic or gestational hypertension, cardiac disease, diabetes, known fetal abnormalities, contraindication to spinal anaesthesia Setting: Tunisia | |
| Interventions | Colloid preload versus crystalloid preload Group 1: HES 130/0.4 500 mL preload 15 min prior to spinal anaesthesia. Group 2: saline – normal saline solution preload 1000 mL within 15 min prior to spinal anaesthesia All women received standardised anaesthetic technique and dose. Hypotension requiring intervention: 6 mg bolus ephedrine when SBP was < 80% of baseline. | |
| Outcomes | Maternal: hypotension; SBP; adverse effects; need for ephedrine; heart rate; tachycardia (> 100 bpm); nausea; vomiting; pruritus Neonatal: umbilical blood gases; Apgar scores ar 1 min and 5 min; birthweight | |
| Notes | Hypotension defined as SBP < 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Reported only as "randomized" |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Some outcomes not fully (numerically) reported |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 80 women Inclusion criteria: ASA I/II women aged 18‐45 years with an uncomplicated singleton pregnancy at term who were scheduled for caesarean under spinal anaesthesia Exclusion criteria: pregnancy‐induced hypertension, cardiac disease, diabetes, fetal complications and women in labour: post hoc exclusions (surgery lasting > 2 h; requirement for perioperative sedation; conversion to general anaesthesia, surgical complications such as intraoperative haemorrhage, protocol violations) Setting: Colombia | |
| Interventions | Wedge versus supine position Group 1: wedge after intrathecal injection women were placed from the left lateral position to the supine position, with a right‐lumbar pelvic wedge (wooden, 35 cm long, 20 cm wide and with 20 degrees inclination), placed at the right posterior‐superior iliac crest and lumbar region Group 2: supine: after intrathecal injection, women were placed from the left lateral position to the supine position All women received no premedication, standardised oxygen therapy, standardised spinal anaesthetic technique and dose, and standardised crystalloid co‐load Hypotension was treated with IV boluses of ethylephrine 1 mg until hypotension was corrected. Bradycardia was treated with 0.5 mg atropine. | |
| Outcomes | Maternal: hypotension BP; vasopressor requirements (median ethylephrine consumption); nausea; vomiting; bradycardia | |
| Notes | Hypotension was defined as a 25% reduction in SBP from baseline. Bradycardia was defined as heart rate < 40 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated sequence |
| Allocation concealment (selection bias) | Unclear risk | "Randomly allocated" ... "by independent anesthetist"; no further details provided |
| Blinding of participants and personnel (performance bias) | High risk | A single unblinded anaesthetist performed spinal anaesthesia, positioning of women, anaesthetic management and data collection |
| Blinding of outcome assessment (detection bias) | Unclear risk | Data analysis was blinded, but not mentioned if outcome assessment was blinded. |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | High risk | No neonatal outcomes reported |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: term singleton pregnancies, ASA I, undergoing caesarean under spinal anaesthesia Exclusion criteria: chronic hypertension, gestation‐induced hypertension, cardiovascular or vascular brain disease, known fetal abnormalities and women with total or partial spinal anaesthesia failure Setting:Brazil | |
| Interventions | Colloid versus crystalloid preload: Group 1: received preload of modified fluid gelatin, 10 mL/kg Group 2: received preload of Ringer's lactate, 10 mL/kg All women received a standardised spinal anaesthetic technique and dose and standardised uterine displacement. | |
| Outcomes | Maternal: hypotension; nausea; vomiting; vasopressor consumption Neonatal: cord blood (presented as mean and SD); Apgar < 7 at 5 min | |
| Notes | Hypotension was defined as decreases of more than 10% or more than 20% of baseline SBP. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | "Randomly allocated": method not described |
| Allocation concealment (selection bias) | Unclear risk | "Drawing of closed envelopes" |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Double blind" – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | "Double blind" – no further details |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | High risk | Minimal results reporting: outcomes reported as means and SD only |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | N = 80 Inclusion criteria: healthy women undergoing spinal anaesthesia for elective caesarean Exclusion criteria: not specified Setting: Brazil | |
| Interventions | Ephedrine (different doses) versus control Group 1: 5 mg ephedrine administered immediately after spinal anaesthesia Group 2: 10 mg ephedrine administered immediately after spinal anaesthesia Group 3: 15 mg ephedrine administered immediately after spinal anaesthesia Group 4: control – no ephedrine Standardised spinal anaesthetic technique and dose | |
| Outcomes | Maternal: hypotension; nausea; vomiting; hypertension requiring intervention Neonatal: cord/neonatal blood < 7.2; Apgar < 8 at 5 min | |
| Notes | Hypotension defined as fall in SAP below 20% baseline Abstract only | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Randomised, but method not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Unclear risk | Not reported |
| Study characteristics | ||
| Methods | Randomised trial | |
| Participants | 100 women Inclusion criteria: healthy women undergoing spinal anaesthesia for elective caesarean Exclusion criteria: not specified Setting: Brazil | |
| Interventions | Ephedrine infusion (different rates) versus control Group 1: ephedrine infusion 0.5 mg/min administered immediately after spinal anaesthesia Group 2: ephedrine infusion 1 mg/min administered immediately after spinal anaesthesia Group 3: ephedrine infusion 2 mg/min administered immediately after spinal anaesthesia Group 4: ephedrine infusion 4 mg/min administered immediately after spinal anaesthesia Group 5: no ephedrine All women received a standardised anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; vomiting; hypertension requiring intervention. Neonatal: cord/neonatal blood < 7.2; Apgar < 8 at 5 min | |
| Notes | Hypotension defined as fall in SAP below 20% baseline Abstract only | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method of randomisation not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Unclear risk | Not reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 120 women Inclusion/exclusion criteria: not available as whole paper was not translated Setting: Brazil | |
| Interventions | Ephedrine bolus + infusion versus ephedrine infusion alone versus rescue bolus of ephedrine only Group 1: ephedrine 10 mg in bolus followed by continuous infusion of 2 mg/min until birth Group 2: ephedrine 8 mg/min for 3 min, followed by 4 mg/min for 2 min, then 2 mg/min until birth Group 3: control: Ringer's lactate preload and rescue bolus of ephedrine in case of hypotension All women received a standardised preload of Ringer's lactate and standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; nausea; vomiting; hypertension requiring intervention Neonatal: umbilical artery pH; Apgar < 8 at 5 min | |
| Notes | Hypotension defined as SBP < 80% of baseline Abstract only | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method of randomisation not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: 2/120 for cord blood pH measurement (in the ephedrine infusion group) |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Unclear risk | Not reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 46 women Inclusion criteria: women scheduled for caesarean under spinal anaesthesia; age 18‐54 years; weight ≤ 100 kg; height ≥ 150 cm; ASA physical status I or II; uncomplicated term pregnancy Exclusion criteria: pregnancy‐induced hypertension; cardiac disease; diabetes or fetal complications; women in labour Setting: USA | |
| Interventions | Colloid preloading versus colloid coloading Group 1: colloid preload: 500 mL 6% hetastarch IV slowly over 20 min before spinal anaesthesia Group 2: colloid coload: 500 mL 6% hetastarch IV as quickly as possible, with the aid of a pressure bag, immediately after spinal anaesthesia All women received standardised aspiration prophylaxis and standardised spinal anaesthetic technique and dose. Hypotension requiring intervention was managed with vasopressor mix of 5 mg/mL ephedrine plus 25 μg/mL phenylephrine given according to a strict predefined algorithm (systolic pressure ≥ 90% of baseline: no vasopressor; 80%‐89% systolic pressure: 1 mL equivalent to ephedrine 5 mg + phenylephrine 25 μg; 79%‐79% systolic pressure: 2 mL equivalent to ephedrine 10 mg + phenylephrine 50 μg; systolic pressure < 70%: 3 mL equivalent to ephedrine 15 mg + phenylephrine 75 μg) | |
| Outcomes | Maternal: hypotension; bradycardia; tachycardia; nausea, vomiting; total vasopressor dose Neonatal: umbilical and venous arterial pH; Apgar scores; neonatal weight | |
| Notes | Hypotension defined as SBP < 90% baseline Bradycardia defined as heart rate < 40 bpm Tachycardia defined as heart rate > 140 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Random numbers generated using MS Excel |
| Allocation concealment (selection bias) | Unclear risk | Sealed, opaque envelopes |
| Blinding of participants and personnel (performance bias) | High risk | Not feasible to blind the interventions |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Unclear risk | Most expected outcomes were reported, although some were reported in a form that could not used in this review |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 46 women Inclusion criteria: healthy parturients with normal pregnancies undergoing elective CS at term Exclusion criteria: not specified Setting: China | |
| Interventions | Prophylactic ephedrine versus crystalloid preload Group 1: ephedrine 0.25 mg/kg in 5 mL normal saline over 3 min immediately after spinal injection Group 2: Hartmann's solution 20 mL/kg 10‐15 min prior to spinal injection Standardised spinal anaesthetic technique and dose | |
| Outcomes | Maternal: hypotension); level of sensory block; Doppler ultrasound uterine blood flow measurements before and 5 min after spinal injection; nausea and vomiting; shivering; cardiac dysrhythmia; uterine incision‐birth time Neonatal: arterial and venous cord blood gases; Apgar scores at 1 min and 5 min | |
| Notes | Hypotension defined as a decrease in systolic pressure of > 20% of baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly assigned": method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Neonatal assessment only (a preoperative Doppler ultrasound of uterine blood flow conducted by obstetrician who was blinded to the "treatment received") – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | Methods not described |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: none |
| Selective reporting (reporting bias) | Unclear risk | Most expected outcomes reported |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I‐II ambulatory pregnant women for whom elective caesarean with spinal anaesthesia was planned (no instances of fetal distress) Setting: Iran | |
| Interventions | Ephedrine: comparison of different routes of administration Group 1: oral ephedrine, 25 mg administered before spinal Group 2: IM injection of ephedrine, 25 mg, 30 min before spinal Group 3: IV bolus of ephedrine, 25 mg in 2 mL injected over a 1‐min period, immediately after spinal induction All women received a standardised 20 mL/kg preload of Ringer's lactate solution and a standardised spinal anaesthetic technique. The anaesthetic dose was increased from 60 mg lidocaine to 70 mg lidocaine if the woman's height was > 160 cm. Hypotension requiring intervention was managed with 10 mg ephedrine IV bolus increments every min until SBP returned to normal (> 100 mmHg and > 70% baseline). | |
| Outcomes | Maternal: hypotension; hypertension (increase of 30% from baseline); heart rate (tachycardia increase of 30% from baseline), nausea Neonatal: Apgar scores | |
| Notes | Hypertension was defined as an increase in BP by 30% from baseline. Tachycardia was defined as an increase in heart rate of 30% from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | "[R]andomly divided into three equal groups of 20" |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Double blind" – no further detail provided |
| Blinding of outcome assessment (detection bias) | Unclear risk | "Double blind" – no further detail provided |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Unclear risk | Not all expected outcomes were reported, e.g. only 1 neonatal outcome reported in a way that could not be used in this review |
| Other bias | Low risk | No apparent source of other bias |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 45 women Inclusion criteria: women aged > 18 years, > 34 weeks' gestation, singleton pregnancy presenting for elective CS under spinal anaesthesia Exclusion criteria: women unable to stand or walk for 15 min, with pre‐existing hypertension or pre‐eclampsia, multiple pregnancy or grade 3‐4 placenta praevia Setting: Australia | |
| Interventions | Walking versus lying down Group 1: walking: women were asked to walk to the operating theatre for at least 15 min prior to positioning for spinal anaesthesia Group 2: lying: women were taken to theatre on a barouche or trolley; lying with a wedge Spinal anaesthesia technique, IV fluids given, vasopressors given were not reported | |
| Outcomes | Maternal: incidence of hypotension | |
| Notes | Hypotension defined as fall in SBP 20% from baseline or < 100 mmHg systolic Ephedrine and metaraminol were used to treat hypotension | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated sequence |
| Allocation concealment (selection bias) | Low risk | "Consecutively numbered sealed opaque envelopes" |
| Blinding of participants and personnel (performance bias) | High risk | Participants and anaesthetists not blinded |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | 1 participant's data were lost, leaving 44 women suitable for analysis. Lying group: 3 participants in the lying group has a failed spinal and converted to general anaesthesia; 2 participants withdrew without explanation Walking group: 2 patients had protocol violation (not given 6 mg prophylactic ephedrine) Intention‐to‐treat analyses performed 17 women in lying group and 20 women in walking group were analysed. |
| Selective reporting (reporting bias) | Unclear risk | Exact values of outcomes not reported in abstract |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 110 women Inclusion criteria: healthy women with normal term singleton pregnancies presenting for elective CS Setting: Sweden | |
| Interventions | Crystalloid versus colloid preload Group 1: acetated Ringer's solution, 1000 mL, preceded by 20 mL 15% saline 0.9% IV Group 2: dextran 60 3%, 1000 mL, preceded by 20 mL dextran 1 IV All women received a standardised spinal anaesthetic technique and dose. Hypotension was managed by a standardised regimen of ephedrine dosing. | |
| Outcomes | Maternal: hypotension; clinically significant hypotension; severe hypotension ephedrine consumption; blood loss Neonatal: umbilical artery < pH 7.2; pCO2; base deficit | |
| Notes | Hypotension defined as SAP dropping below 100 mmHg; clinically significant hypotension as drop in SAP > 20% below baseline and severe hypotension defined as SAP < 80 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelope" |
| Blinding of participants and personnel (performance bias) | Low risk | "Double‐blinded" – solution prepared and administered by an anaesthetic nurse not otherwise involved in the care of the woman (including the initial injection) |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | Losses: 1/110 – 1 woman from crystalloid group excluded due to protocol violation; 1 woman allocated to crystalloid subsequently found to have received colloid. |
| Selective reporting (reporting bias) | High risk | Not all outcomes listed in the paper were reported |
| Other bias | Low risk | Some baseline differences, e.g. 32% nulliparous in the crystalloid group compared with 21% in the colloid group |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 55 women presenting for elective CS Inclusion criteria: healthy women with term singleton normal pregnancies Setting: Sweden | |
| Interventions | Colloid versus crystalloid preload Group 1: colloid group: 20 mL of 15% dextran 1, followed by 1000 mL IV infusion of 3% dextran 60. This solution was administered during 20 min immediately preceding intrathecal injection. Group 2: crystalloid group: 20 mL IV injection of 0.9% saline, followed by 1000 mL IV infusion of acetated Ringer's solution. This solution was administered during 20 min immediately preceding intrathecal injection. All women received standardised fasting protocol, no premedication and a standardised spinal anaesthetic technique and dose. Hypotension requiring intervention was managed with ephedrine 5 mg if SBP dropped below 100 mmHg, and repeated as required. | |
| Outcomes | Maternal: hypotension – overall, clinically significant or severe Criteria for rescue: if the woman developed discomfort associated with a decrease in SBP of at least 20% from baseline, even if it was above 100 mmHg | |
| Notes | 'Overall' hypotension defined as a fall in systolic pressure below 100 mmHg 'Clinically significant' hypotension defined as hypotension associated with maternal discomfort (nausea, retching/vomiting, dizziness or chest symptoms) 'Severe' hypotension defined as a reduction of the SAP below 80 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | "Randomly allocated" – method not specified |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelope |
| Blinding of participants and personnel (performance bias) | Low risk | 'Double‐blind'. The woman, the anaesthesiologist and all other personnel in the operating room were unaware of the study group. The study solutions were prepared and administered by an anaesthetic nurse who was not otherwise involved in the care of the patient, and were covered by a non‐transparent plastic bag. The anaesthesiologist did not enter the operating room until the study solution had been given. |
| Blinding of outcome assessment (detection bias) | Low risk | All personnel were blinded to treatment allocation, except for the anaesthetic nurse who prepared the solutions (who was not involved in the care of the patient). |
| Incomplete outcome data (attrition bias) | Low risk | 2/55 excluded due to protocol violation (1 was given ephedrine despite a normal BP and the other could not go through the SST because of leg muscle spasm). Not specified which groups they were from |
| Selective reporting (reporting bias) | Low risk | Only maternal outcome reported was hypotension; no infant outcomes were reported |
| Other bias | Low risk | No apparent sources of other bias |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: ASA I, women aged 21‐28 years with normal pregnancies, elective caesarean for breech presentation, cephalopelvic disproportion, re‐operation Exclusion criteria: body weight > 90 kg, women who refused caesarean Setting: Macedonia | |
| Interventions | Ephedrine infusion versus crystalloid preload Group 1: ephedrine: continuous fast‐drop infusion of 500 mL Ringer's solution with 50 mL ephedrine, commenced immediately after venous cannulation for spinal anaesthesia, and continued until the umbilical cord was clamped Group 2: crystalloid: 20 mL/kg Ringer's solution, warmed to room temperature, commenced 20‐30 min prior to spinal anaesthesia, and continued until the umbilical cord was clamped All women received a standardised spinal anaesthetic technique and dose, standardised oxygen therapy, and standardised oxytocin regimen. Hypotension requiring intervention received 5 mg IV boluses of ephedrine in group 1 (ephedrine group) and 10 mg IV boluses of ephedrine in group 2 (crystalloid group). | |
| Outcomes | Maternal: hypotension; quantity of crystalloid; quantity of ephedrine; nausea and vomiting Neonatal: Apgar scores | |
| Notes | Hypotension defined as SBP < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomised" – no further details reported |
| Allocation concealment (selection bias) | Unclear risk | As above |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Unclear risk | Not all outcomes available (e.g. Apgar scores presented only as medians) |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 120 women Inclusion criteria: physical status ASA I, with an indication for elective CS, singleton term pregnancy Exclusion criteria: history of hypertension or pregnancy‐induced hypertension, cardiovascular or cerebrovascular disease, fetal abnormalities, history of hypersensitivity to the drugs used in the study, and contraindications to spinal block Setting: Brazil | |
| Interventions | Phenylephrine: prophylactic infusion versus therapeutic dosing Group 1: continuous IV infusion of phenylephrine, using a 1‐channel "Baxter" volumetric infusion pump (containing a solution of 10 mL of NS with 10 mg phenylephrine (100 μg/mL)), at 0.15 μg/kg/min, which was started immediately after the spinal block Group 2: a single dose of phenylephrine, 50 μg IV, administered immediately after the spinal block. Baxter volumetric infusion pump connected, containing 100 mL NS Group 3: a single dose of phenylephrine, 50 μg IV, administered in case of hypotension, defined as a fall in SBP and/or DBP of up to 20% of mean baseline levels. Baxter volumetric infusion pump connected, containing 100 mL NS All women received a standardised spinal anaesthetic technique and dose followed by a standardised crystalloid infusion and standardised positioning. Hypotension treatment involved a bolus of 30 μg of phenylephrine IV repeated every 2 min if a drop in BP > 20% that was not controlled with the therapeutic regimen used. Bradycardia was treated when associated with hypotension with 0.5 mg of atropine IV. | |
| Outcomes | Maternal: hypotension; reactive hypertension; bradycardia; nausea and vomiting Neonatal: Apgar score < 8 at 5 min | |
| Notes | Hypotension defined as a drop in SBP and/or DBP > 20% of mean baseline levels Reactive hypertension defined as BP 20% > mean baseline levels after the use of the vasopressor Bradycardia defined as heart rate lower than 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated numbers |
| Allocation concealment (selection bias) | Unclear risk | Sequential sealed envelopes |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Double blind." Patients, and physicians responsible for collecting and analysing the data were blinded; anaesthetist administering the anaesthesia was not blinded. This anaesthetist was not involved in data collection and analysis. |
| Blinding of outcome assessment (detection bias) | Low risk | Those collecting and analysing the data were blinded |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up occurred |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Unclear risk | No apparent sources of other bias |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 70 women Inclusion criteria: ASA physical status I or II, women scheduled for elective CS under spinal anaesthesia, > 37 weeks' gestation Exclusion criteria: pregnancy‐induced hypertension, multiple pregnancy, fetal compromise, diabetes mellitus, polyhydramnios, weight > 100 kg, renal or hepatic disease, anaemia (haemoglobin < 10 g/dL), clotting Setting: UK | |
| Interventions | Colloid: 5 mL/kg versus 10 mL/kg preload Group 1: 5 mL/kg pentastarch, volume preload before spinal anaesthesia (infused over 10 min) Group 2: 10 mL/kg pentastarch, volume preload before spinal anaesthesia (infused over 10 min) All women received standardised aspiration prophylaxis, a standardised spinal anaesthetic technique and dose, and standardised positioning. Hypotension requiring intervention was treated with 6 mg increments of ephedrine until resolution; smaller decreases in BP were similarly treated if accompanied by nausea, vomiting or dizziness. | |
| Outcomes | Maternal: hypotension; ephedrine use Neonatal: Apgar score at 1 min | |
| Notes | Hypotension was defined as a decrease in SBP to < 70% baseline or < 90 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomisation according to sealed envelopes"; no further details |
| Allocation concealment (selection bias) | Unclear risk | As above |
| Blinding of participants and personnel (performance bias) | Low risk | "A technician prepared the calculated volume of pentastarch and covered it with a black bag to blind the anaesthetist to the volume administered." |
| Blinding of outcome assessment (detection bias) | Low risk | Not reported but probably done |
| Incomplete outcome data (attrition bias) | Unclear risk | No losses reported |
| Selective reporting (reporting bias) | Unclear risk | Not all expected outcomes were reported |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 69 women Inclusion criteria: ASA physical status I/II; aged 18 years and older; weight 50‐100 kg; height between 150 and 180 cm Exclusion criteria: allergy or hypersensitivity to phenylephrine; hypertension; cardiovascular or cerebrovascular disease; fetal abnormalities; diabetes (excluding gestational diabetes); or contraindications to spinal anaesthesia Setting: Canada | |
| Interventions | Phenylephrine infusion versus phenylephrine bolus Group 1: infusion: fixed rate phenylephrine infusion 120 μg/min; infusion was started immediately on completion of intrathecal injection, at a rate of 1 mL/min and continued for a minimum of 2 min, and continued if maternal SBP was equal to or lower than baseline. If maternal BP was higher than baseline, the infusion was discontinued and the BP reassessed after 2 min Group 2: bolus: intermittent phenylephrine bolus of 120 μg; women received 1 mL of bolus solution every time SBP was equal to or lower than baseline. A bolus was not administered when SBP was above baseline All women received an IV infusion of Ringer's lactate started at a minimal rate in the holding area, with subsequent standardised crystalloid coload on administration of spinal anaesthetic. No antiemetic premedication was given. All women received a standardised spinal anaesthetic technique, dose and positioning. Hypotension requiring intervention received rescue dose of 5 mg ephedrine. Bradycardia requiring intervention received 0.6 mg atropine if heart rate < 60 bpm for 2 consecutive readings and SBP equal to or lower than baseline (infusion was discontinued if bradycardia with SBP higher than baseline). | |
| Outcomes | Maternal: BP; cardiac output; heart rate, hypotension; hypertension; nausea/vomiting; bradycardia; total dose of phenylephrine Neonatal: umbilical blood gases; neonatal weight; Apgar score at 1 min and 5 min | |
| Notes | Hypotension was defined as SBP < 80% baseline. Hypertension was defined as SBP > 120% baseline. Bradycardia was defined as heart rate < 60 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random number table |
| Allocation concealment (selection bias) | Unclear risk | Sealed, opaque envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | "Double blind": women and attending anaesthetists were blinded to the group allocation. 2 syringes, 1 20 mL bolus and 60 mL infusion were prepared for each woman. 1 syringe contained 120 μ/mL phenylephrine and the second syringe contained saline. Both syringes were labelled 'phenylephrine/placebo' and 'bolus syringe' and 'infusion syringe' respectively. The anaesthetist then received 1 syringe of infusion solution and 1 syringe of bolus solution (but did not know which syringe contained the phenylephrine). Each was administered according to the protocol for bolus and infusion as described above. |
| Blinding of outcome assessment (detection bias) | Low risk | Not specifically stated, but probably done |
| Incomplete outcome data (attrition bias) | Low risk | 9/69 were lost to follow‐up: 4/35 from the intervention group (3 pump errors; 1 unable to calibrate properly) and 5/35 from the bolus group (2 required additional anaesthesia (ketamine), 2 pump errors and 1 unable to calibrate properly) |
| Selective reporting (reporting bias) | Unclear risk | Most expected outcomes were reported, although blood gases reported only as mean and SD, and not specified if maternal hypertension required intervention |
| Other bias | Low risk | Baseline characteristics were similar |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: less than 90 kg, ASA I and II, singleton pregnancy, presenting for elective caesarean under spinal anaesthesia Exclusion criteria: pre‐eclamptic women Setting: South Africa | |
| Interventions | Crystalloid: preload versus rapid infusion Group 1: preload – modified Ringer's lactate, 20 mL/kg preload 20 min before spinal Group 2: coload – rapid infusion of an equivalent volume of modified Ringer's lactate immediately after induction of spinal All women received a standardised spinal anaesthetic technique and dose. Hypotension < 80% of baseline treated with 5 mg boluses of ephedrine; < 70% of baseline treated with 10 mg ephedrine until a return to within 80% of baseline | |
| Outcomes | Maternal: hypotension; BP; heart rate; time to block; induction to incision times; incision to birth times; anaesthesia and surgery times; blood loss; urine output; nausea; ephedrine dose Neonatal: birthweight; Apgar scores; umbilical arterial pH; umbilical arterial base deficit | |
| Notes | Hypotension defined as BP < 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly allocated" – methods not described |
| Allocation concealment (selection bias) | Unclear risk | "Allocation card contained within a sealed envelope" |
| Blinding of participants and personnel (performance bias) | High risk | "Since there were clearly pre‐defined target MAPs for vasopressor administration for each individual, the study was not blinded" |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: none |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: ASA I, singleton pregnancy, term gestation, non‐life‐threatening cause for emergency CS under spinal anaesthesia (prolonged labour or dystocia, failed labour induction or amniotic rupture) Exclusion criteria: patient refusal, fetal distress, known fetal abnormalities, cardiovascular, renal or liver diseases, chronic hypertension or gestational hypertension, coagulation disorders, and those with total or partial spinal anaesthesia failure Setting: Egypt | |
| Interventions | Crystalloid co/postload versus colloid co/postload versus ephedrine infusion Group 1: 0.5 mL/kg/min Ringer's lactate via infusion pump: co/post loading started at time of spinal injection and continued after spinal injection with until fetus delivery (clamping of umbilical cord) Group 2: 0.5 mL/kg/min Voluven (6% HES 130/0.4 in isotonic NaCl solution) via infusion pump: co/post loading started at time of spinal injection and continued after it with until fetus delivery Group 3: ephedrine infusion at 1 mg/min via infusion pump commenced immediately after spinal anaesthesia until fetus delivery. Accompanied by infusion of Ringer's lactate at minimal infusion rates required to keep vein open Hypotension treated by 5 mg bolus of IV ephedrine every 2 min until SBP returned to normal value in all groups Bradycardia treated immediately using 0.5 mg atropine IV Nausea and vomiting treated with 10‐20 mg IV metoclopramide when unrelated to hypotension or not corrected by ephedrine bolus alone | |
| Outcomes | Maternal: BP, heart rate, adverse effects (nausea, vomiting, dizziness, chest symptoms, dyspnoea, tachypnoea), total IV fluid given, total ephedrine dose, time from spinal anaesthesia to delivery of fetus (clamping of umbilical cord) Neonatal: heart rate was monitored by CTG continuously until delivery; Apgar scores at 1 min and 5 min; arterial blood gas sample taken from umbilical cord for blood gas analysis (pH, pCO2) within 2 min after delivery | |
| Notes | Hypotension was defined as 20% decrease in SBP from the baseline. Maternal bradycardia was defined as heart rate < 60 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method of randomisation not reported |
| Allocation concealment (selection bias) | Unclear risk | Closed envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Neither participants nor personnel were blinded, however this was unlikely to have impacted upon the measured results. |
| Blinding of outcome assessment (detection bias) | Low risk | Outcome assessor not blinded; however this was unlikely to have impacted upon the measured results. |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | Non apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 200 women Inclusion criteria: ASA I/II, aged 18‐30 years, elective CS Exclusion criteria: patient refusal, contraindication to spinal anaesthesia, known allergy to granisetron, patients receiving serotonin agonists or antagonists, ischaemic heart disease, chronic hypertension or pregnancy‐induced hypertension Setting: Egypt | |
| Interventions | Granisetron versus control Group 1: 1 mg granisetron diluted in 10 mL normal saline IV administered slowly over 1 min, 5 min prior to spinal anaesthesia Group 2: 10 mL normal saline IV administered slowly over 1 min, 5 min prior to spinal anaesthesia (placebo) All women received a crystalloid preload (500 mL Ringer's lactate), standardised positioning, standardised spinal anaesthetic technique and dose, standardised maintenance IVT. Hypotension was managed with a rapid bolus of 100 mL of Ringer's lactate. Vasopressors administered if MABP < 70 mmHg: ephedrine 5 mg IV bolus if heart rate was < 90 bpm, phenylephrine 0.1 mg IV bolus if heart rate > 90 bpm. Bradycardia (if not associated with hypotension) was treated with 0.5 mg atropine. | |
| Outcomes | Maternal: incidence of hypotension, heart rate Neonatal: Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as MAP < 70 mmHg. Bradycardia defined as heart rate < 50 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐based randomisation |
| Allocation concealment (selection bias) | Unclear risk | Assignment in sealed envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blinded. Syringed were prepared by an anaesthetist who was blinded to the study protocol |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | High risk | 5 excluded (3 from group 1 and 2 from group 2) due to conversion to GA No statement with respect to 'intention‐to‐treat' |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes reported |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Exclusion criteria: patients with pre‐existing hypertension or pregnancy‐induced hypertension, cardiovascular or cerebrovascular disease, autonomic neuropathy, spinal deformities, infections in the lumbar area, coagulopathies, hypovolaemia from any cause and SBP < 100 mmHg. Patients aged < 18 or > 40 years, weighing < 50 kg or > 100 kg, taller than 180 cm or shorter than 140 cm, and patients with placental complications, cord complications, fetal malformations and those babies whose birthweights were < 2.5 kg or > 4.5 kg by ultrasound Setting: Nigeria | |
| Interventions | Colloid preload versus crystalloid preload Group 1: 500 mL HES IV IV 10 min before SAB Group 2: 1000 mL of Ringer's lactate IV 10 min before SAB All patients: standardised preparation, monitoring, positioning, spinal anaesthetic dose and technique, IV fluids, oxygen delivery Hypotension treated with (unspecified) rapid infusion of IV fluids, followed by IV ephedrine 5 mg if not responding | |
| Outcomes | Maternal: incidence of hypotension, nausea and vomiting, dizziness and breathlessness, interval between preload‐to‐spinal injection and delivery and uterine incision‐to‐delivery Neonatal: Apgars at 1 min and 5 min | |
| Notes | Hypotension defined as SBP < 80% of baseline or absolute value of SBP < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Patients were randomly allocated by drawing sealed envelopes which were shuffled |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Bag placed over fluid to conceal identity |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | None apparent |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 74 women Inclusion criteria: healthy patients; elective CS Exclusion criteria: patients who experienced complications during the surgery Setting: Pakistan | |
| Interventions | Crystalloid preload versus crystalloid coload Group 1 (P): received crystalloid preload 15 mL/kg Hartmann's solution 20 min prior to spinal anaesthesia Group 2 (C): received crystalloid coload 15 mL/kg Hartmann's solution at time of administration of spinal anaesthesia All women received standardised monitoring, standardised cannulation, standardised spinal anaesthetic technique and dose Hypotension was treated with vasopressor (phenylephrine or ephedrine) | |
| Outcomes | Maternal: incidence of hypotension | |
| Notes | Hypotension was defined as reduction in MAP by > 20% from baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly assigned by trainee anaesthesia or anaesthetist in charge of case" |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | "Patients going into complications during surgery were excluded" – unspecified how many patients (if any) this involved. No further details provided |
| Selective reporting (reporting bias) | Low risk | Not evident |
| Other bias | Low risk | Not evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Exclusion criteria: not stated Setting: Turkey | |
| Interventions | Crystalloid preload: different doses Group 1: 10 mL/kg Ringer's lactate Group 2: 15 mL/kg Ringer's lactate Group 3: 20 mL/kg Ringer's lactate All preloads administered over 15 min before SAB with subsequent ephedrine infusion commenced immediately after SAB All women received standardised premedication/fasting, spinal dose and technique, position, monitoring Hypotension was treated with 10 mg IV bolus ephedrine | |
| Outcomes | Maternal: incidence of hypotension, nausea and vomiting, total amount ephedrine Neonatal: cord blood gas analysis, Apgars at 1 min and 5 min | |
| Notes | Hypotension defined as decrease in MAP of > 20% | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random numbers |
| Allocation concealment (selection bias) | Low risk | "Enclosed system" presumably means covered |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 160 women Inclusion criteria: ASA I or II undergoing elective caesarean under spinal anaesthesia | |
| Interventions | Colloid preload versus crystalloid preload Group 1: pentastarch 10% in 0.9% saline 15 mL/kg Group 2: Hartmann's solution 15 mL/kg All women received a standardised anaesthetic technique with variable anaesthetic dose, followed by standardised surgical positioning. | |
| Outcomes | Maternal: BP; hypotension; block height; uterine incision to birth interval Neonatal: Apgar scores at 1 min and 5 min; cord pH | |
| Notes | Hypotension was defined as SBP below 90 mmHg or < 70% below baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Randomisation method not described |
| Allocation concealment (selection bias) | Low risk | Adequate: randomisation code by pharmacy and study drugs "covered with a black plastic bag to ensure blinding" |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: not specifically stated but anaesthetist and women presumably were blinded |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Not reported |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: healthy pregnant women (25 to 40 years) undergoing elective caesarean under spinal anaesthesia Exclusion criteria: women known to be hypertensive Setting: Egypt | |
| Interventions | Ephedrine versus phenylephrine versus control Group 1: ephedrine, 50 mg IM Group 2: phenylephrine, 4 mg IM Group 3: 2 mL saline IM All study drugs given 10 min before spinal anaesthesia All women received a standardised crystalloid preload and a standardised spinal anaesthetic technique and dose followed by standardised surgical positioning. | |
| Outcomes | Maternal: hypotension Neonatal: cord/neonatal blood (reported as mean and SD); Apgar < 8 at 5 min (reported as mean and SD) | |
| Notes | Hypotension was defined as 25% decrease in MAP from baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: drugs were prepared by an anaesthetic assistant not involved in the study and injected by an anaesthetist not involved in data collection or care of the women |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: not stated but losses unlikely |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 24 women Inclusion criteria: pregnant women scheduled for elective caesarean | |
| Interventions | Ephedrine versus control Group 1: ephedrine, 50 mg IM Group 2: saline IM Study drugs administered prior to spinal anaesthetic All women received standardised volume loading and a standardised spinal anaesthetic technique and dose followed by standardised surgical positioning. | |
| Outcomes | Maternal: hypotension; nausea | |
| Notes | Hypotension was defined as defined as SBP < 70% baseline or < 90 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Methods not described |
| Allocation concealment (selection bias) | Unclear risk | Methods not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: described as "double‐blind placebo‐controlled" – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated but losses unlikely |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 105 women Inclusion criteria: ASA I‐II, aged 18‐45 years, elective CS under SAB Exclusion criteria: contraindication to regional anaesthesia, ASA score III‐IV, < 18 years of age, multiple gestation, < 150 cm tall or > 170 cm tall, pre‐eclampsia, eclampsia, diabetes mellitus, intrauterine anomalities, using medications containing ephedrine or phenylephrine, failed SAB requiring conversion to general anaesthesia Setting: Turkey | |
| Interventions | Various doses of ketamine versus control Group 1: 0.25 mg/kg IV ketamine administered immediately following intrathecal injection Group 2: 0.5 mg/kg IV ketamine administered immediately following intrathecal injection Group 3: placebo control: 2 mL physiological saline administered immediately following intrathecal injection Hypotension was managed with 10 mg ephedrine IV. Atropine was administered if heart rate was < 45 bpm. | |
| Outcomes | Maternal: hypotension, ephedrine use, sedation score, shivering, pruritus, nausea and vomiting, hallucinations Neonatal: Apgars, cord blood pH | |
| Notes | Hypotension defined as > 20% reduction in SBP from baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated numbers (Excel) by anaesthetist not involved in study |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Low risk | Blinded outcome data assessors and "ward staff" |
| Blinding of outcome assessment (detection bias) | Low risk | Blinded outcome data assessors and "ward staff" |
| Incomplete outcome data (attrition bias) | High risk | 3 patients excluded with failed blocks, flow diagram does not actually make sense from protocol as patients would have received placebo/Ketamine before exclusion |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA 2 women undergoing elective CS Exclusion criteria: starch allergies, history of anaphylaxis | |
| Interventions | Colloid preload versus crystalloid preload Group 1: IV infusion of 1000 mL Ringer's lactate preloading Group 2: IV infusion of 500 mL colloid Voluven 6% (6% HES 130/0.4 in isotonic NaCl solution) preloading All women received standardised cannulation, aspiration prophylaxis, spinal anaesthesia technique and dose and surgical positioning. Hypotension treated with 10 mg IV ephedrine | |
| Outcomes | Maternal: time for block onset and maximum sensory block level, maximum motor block time, block regression time, motor block duration, first analgesic requirement, mobilisation and onset of bowel sounds, the incidence of hypotension, total used ephedrine amount, nausea and vomiting Neonatal: 1 min and 5 min Apgar scores | |
| Notes | Hypotension defined as a decrease in mean BP to 20% below baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method of sequence generation not specified. Reported as "randomly allocated" |
| Allocation concealment (selection bias) | Unclear risk | Closed envelope method |
| Blinding of participants and personnel (performance bias) | Low risk | Personel were blinded, participants were not blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Blinded |
| Incomplete outcome data (attrition bias) | Low risk | Not data loss, no losses to follow‐up |
| Selective reporting (reporting bias) | Low risk | Not reported |
| Other bias | Low risk | Not reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 120 women Inclusion criteria: healthy women aged 20‐40 years scheduled for elective caesarean delivery under spinal anaesthesia who had uncomplicated singleton, term pregnancy Exclusion criteria: chronic or pregnancy‐induced hypertension, cardiac disease, diabetes mellitus, height < 155 cm, a contraindication to spinal anaesthesia, or known fetal abnormality Setting: Turkey | |
| Interventions | Colloid preload versus crystalloid preload versus ephedrine infusion plus crystalloid co‐load Group 1: crystalloid preload: rapid infusion of Ringer's lactate 20 mL/kg, within 15‐20 min of the spinal block. Following anaesthesia, placebo infusion solution administered at a rate of 2.5 mL/min using an infusion pump. Ringer's lactate 1000 mL administered at minimal maintenance rate via 2nd cannula Group 2: colloid preload: 4% succinated gelatine solution (Gelofusine) 500 mL, within 15‐20 min of the spinal block Following anaesthesia, placebo infusion solution administered at a rate of 2.5 mL/min using an infusion pump. Ringer's lactate 1000 mL administered at minimal maintenance rate via 2nd cannula Group 3: ephedrine infusion plus crystalloid co‐load: no fluid preload given Following anaesthesia, infusion solution of ephedrine 50 mg in 100 mL (1.25 mg/mL) administered at rate of 2.5 mL/min using an infusion pump. Ringer's lactate1000 mL, administered rapidly via 2nd cannula All women received standardised aspiration prophylaxis, a standardised spinal anaesthetic technique and dose, standardised surgical positioning and standardised oxytocin administration. Hypotension (requiring intervention) was treated immediately with an IV bolus of ephedrine 5 mg from a separate syringe, repeated when necessary, every 2 min if hypotension persisted or recurred Hypertension treatment: infusion was stopped if the SBP and heart rate increased above the baseline values Bradycardia treatment consisted of IV atropine 0.5 mg. | |
| Outcomes | Maternal: moderate hypotension; severe hypotension; maternal bradycardia requiring intervention; maternal tachycardia; hypertension; nausea and vomiting Neonatal: acidosis (cord/neonatal blood with pH < 7.2); neonatal Apgar score < 8 at 5 min | |
| Notes | Moderate hypotension was defined as a decrease of 20% from baseline, or an SBP < 95 mmHg. Severe hypotension was defined as a decrease of 30% from baseline. Bradycardia was defined as heart rate < 50 bpm. Tachycardia was defined heart rate > 120 bpm. Hypertension was defined as an increase in SBP > 30% above baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation list |
| Allocation concealment (selection bias) | Unclear risk | "Randomly allocated" – concealment method not specified |
| Blinding of participants and personnel (performance bias) | Unclear risk | Pre‐load fluid in groups CO and CR was administered by an anaesthetic nurse who was not otherwise involved in the care of the patients. Co‐load fluids were prepared by an anaesthetic nurse who was independent of the study. Ringer's lactate in all groups were covered by a similar non‐transparent plastic bag in the perioperative period. The anaesthetist did not enter the operating room until the study solutions had been given, so that those recording data were unaware of the study group allocation. |
| Blinding of outcome assessment (detection bias) | Unclear risk | "Those recording data were unaware of the study group allocation." Attending paediatrician assessed Apgar scores – unclear if blinded to allocated treatment Umbilical blood samples were taken by the same midwife in the operating room – likely to have been blinded to allocated treatment |
| Incomplete outcome data (attrition bias) | Unclear risk | 1/120 – 1 patient in crystalloid preload group was excluded from the study due to an inadequate spinal block |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 30 women Inclusion criteria: elective CS, singleton fetus Exclusion criteria: placental pathology, pregnancy exceeded 37 weeks' gestation Setting: UK | |
| Interventions | Variable ephedrine infusions versus phenylephrine infusion Group 1: infusion of ephedrine 1 mg/mL at 60 mL/h (1 mg/min) Group 2: infusion of ephedrine 2 mg/mL at 60 mL/h (2 mg/min) Group 3: infusion of phenylephrine at 10 μg/mL at 60 mL/h (10 μg/min) All women received the vasopressor for 30 min via Graseby pump All women received standard aspiration prophylaxis, IV cannulation, crystalloid preloading, surgical positioning, invasive arterial and non‐invasive BP monitoring, and standardised spinal anaesthetic technique and dose. Hypotension was managed with a 2 mL bolus of the vasopressor infusion. If pressure was > 20% above baseline for 3 min, the infusion was stopped. | |
| Outcomes | Maternal: incidence of hypotension, time for anaesthesia to reach T4 and maximum height of sensory loss, time between insertion of spinal needle and delivery of fetus, time from uterine incision to delivery of fetus, incidence of complications, total drug dose Neonatal: Apgar score 1 min and 5 min, umbilical arterial and venous blood samples | |
| Notes | Hypotension was defined as SAP decrease > 20% below baseline Bradycardia was defined as heart rate < 40 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Low risk | Anaesthetist who produced infusion not involved in anaesthetic. Blinding: women and anaesthetists blinded to allocation |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: 1 woman excluded from group 2 due to data corruption |
| Selective reporting (reporting bias) | Low risk | None reported |
| Other bias | Low risk | None reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: ASA I or II undergoing elective CS Exclusion criteria: weight > 90 kg, height < 150 cm or > 175 cm, multiple pregnancy, diabetes or hypertension | |
| Interventions | Lateral versus supine wedged Group 1: right‐lateral position adopted 2 min after spinal injection for 10 min, then turned to supine wedged (right hip) position Group 2: supine‐wedged (right hip) position adopted 1 min after spinal injection and maintained throughout Intervention occurred after spinal injection. All women received a standardised crystalloid preload and anaesthetic technique and dose. Bradycardia was managed with atropine. Hypotension was managed with ephedrine. | |
| Outcomes | Maternal: hypotension; heart rate; block height; time to maximum block; time to birth; duration of hypotension; nausea/dizziness; ephedrine requirements | |
| Notes | Hypotension was defined as SBP < 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Randomisation and allocation concealment: sealed envelope |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelope |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: ASA I‐II, age 20‐35 years, weight 45‐60 kg, height 153‐165 cm Exclusion criteria: pregnancy‐induced hypertension, chronic hypertension, pre‐eclampsia, twin pregnancy, fetal compromise, diabetes mellitus, polyhydramnios, renal, liver or heart disease, coagulopathy Setting: Bangladesh | |
| Interventions | Crystalloid preload versus colloid preload versus combination preload Group 1: Ringer's lactate 20 mL/kg preloading Group 2: HES 6% 8 mL/kg preloading Group 3: combination of RL 10 mL/kg and HES 6% 4 mL/kg preloading All women received standardised cannulation, standardised spinal anaesthetic technique and dose, standardised surgical positioning, standardised oxygen therapy and standardised oxytocin dose after delivery Hypotension was treated with IV boluses of ephedrine 5 mg and rapid infusion of Ringer's lactate in all 3 groups | |
| Outcomes | Maternal: systolic, diastolic and mean BP measurements; total dose of ephedrine; total volume of IV fluid given Neonatal: Apgar scores | |
| Notes | Hypotension defined as SBP less than 100 mmHg AND less than 20% of the baseline BP | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Unclear method. "Randomisations were done using card sampling" |
| Allocation concealment (selection bias) | Low risk | Anaesthetist who generated the random sequence infused the allocated fluid behind a screen set, separate from the outcome assessor. |
| Blinding of participants and personnel (performance bias) | Low risk | Participants and outcome assessors were blinded; however, the personnel who generated the random sequence and infused the fluid were not blinded. |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | All participants included in final analysis |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 86 women Inclusion criteria: elective CS Exclusion criteria: pre‐existing hypertension, pre‐eclampsia, cardiovascular disease, diabetes, obesity, multiple pregnancy Setting: South Korea | |
| Interventions | (R) lateral positioning versus wedged supine positioning Group 1: maintain the right lateral position for 6 min after spinal anaesthesia before assuming the wedged supine position Group 2: assumed the wedged supine position immediately after the spinal injection Wedging positioning was achieved with an air balloon (1500 mL) was inserted under the right upper buttock in the supine position in both groups. All women received standardised cannulation, standardised crystalloid preload, standardised oxygen therapy and standardised spinal anaesthetic technique and dose. Ephedrine was given if BP decreased > 30% from baseline ("severe hypotension") with increments of 5 mg at 2 min intervals | |
| Outcomes | Maternal: hypotension, nausea and vomiting, ephedrine requirement, maximum block height Neonatal: Apgar scores at 1 min and 5 min after birth, umbilical arterial blood gas analysis | |
| Notes | Hypotension defined as a decrease in MAP of > 20% from baseline Severe hypotension defined as a decrease in MAP of > 30% from baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Block randomisation (6 subjects per block) |
| Allocation concealment (selection bias) | Low risk | Opaque covers – removed immediately after intrathecal injection |
| Blinding of participants and personnel (performance bias) | Low risk | Unable to blind due to different positions but unlikely to affect observation |
| Blinding of outcome assessment (detection bias) | Low risk | Women were in different positions for 6 minutes therefore assessor was unblinded. After the women were put in the supine position, another observer who was blinded to patient group recorded the measurements. |
| Incomplete outcome data (attrition bias) | Low risk | Group 1: 1 excluded due to hypertension at baseline Group 2: 1 excluded due to inadequate block Excluded women not analysed in final results |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 70 women Inclusion criteria: elective CS, ASA I or II Exclusion criteria: multiple pregnancy, weight > 115 kg, height < 150 cm, diabetes mellitus, hypertensive diseases in pregnancy intra‐uterine death, age < 18 years or > 40 years, patients on diuretics, contraindication to central neuraxial blockade Setting: Nigeria | |
| Interventions | Combination crystalloid/colloid preload versus crystalloid preload Group 1: 1000 mL crystalloid/colloid (6% pentastarch/Ringer's lactate, 750 mL/250 mL) combination IV preload Group 2: 500 mL colloid (6% pentastarch) IV preload Women in both groups received the same aspiration prophylaxis, IV cannulation, spinal anaesthesia technique and dose. Hypotension treated with 3 mg aliquots of ephedrine and rapid infusion of fluid. | |
| Outcomes | Maternal: incidence of hypotension, ephedrine requirement, nausea and vomiting, maximum block height, blood loss, urine output Neonatal: Apgar scores at 1 min and 5 min, birth asphyxia, meconium aspiration | |
| Notes | Hypotension defined as SBP < 80% of baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Blind balloting |
| Allocation concealment (selection bias) | Unclear risk | Not reported, but double‐blinding |
| Blinding of participants and personnel (performance bias) | Low risk | Syringes were preloaded and wrapped |
| Blinding of outcome assessment (detection bias) | Low risk | Investigator who assessed the outcomes was blinded |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: ASA I‐II, elective CS under spinal anaesthesia Setting: Pakistan | |
| Interventions | Crystalloid preload versus ephedrine alone versus combination of preload + ephedrine Group 1 (crystalloid group): fluid preload with Ringer's solution 20 mL/kg over 10‐15 min prior to intrathecal injection Group 2 (ephedrine group): IV ephedrine 0.25 mg/kg immediately after intrathecal injection Group 3 (combination group): fluid preload with Ringer's solution 20 mL/kg over 10‐15 min preceding intrathecal injection plus ephedrine 0.25 mg/kg immediately after intrathecal injection Spinal anaesthesia technique was not described. | |
| Outcomes | Maternal: hypotension, nausea and vomiting | |
| Notes | Hypotension was not defined. It was not clear if they were assessing systolic, diastolic or mean BPs. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | States "randomised" but no elaboration |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | States "blind" but no elaboration |
| Blinding of outcome assessment (detection bias) | Unclear risk | States "blind" but no elaboration |
| Incomplete outcome data (attrition bias) | Unclear risk | None reported |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: women who presented for elective CS at term with a singleton pregnancy receiving spinal anaesthesia Exclusion criteria: women less than 150 cm in height, more than 170 cm in height, or whose babies showed evidence of fetal compromise | |
| Interventions | Right lateral position versus sitting position during spinal anaesthesia Group 1: right lateral (when anaesthesia induced) Group 2: sitting (when anaesthesia induced) All women received a preload of IV Hartmann's solution (1000 mL), a standardised spinal anaesthetic technique and dose, and standardised surgical positioning. | |
| Outcomes | Maternal: hypotension; nausea and vomiting; time to block; women's satisfaction; ephedrine requirements | |
| Notes | Hypotension was defined as systolic pressure decreased to < 70% of baseline or < 100 mmHg. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly allocated" – method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Low risk | Block assessed by an investigator who was unaware of the women's original position |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | 2 from lateral group removed from study (in 1, the spinal needle could not be inserted in the lateral position, but was successfully placed in the sitting position and for the other, a repeat block was needed) |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 150 women Inclusion criteria: singleton pregnancy with ASA physical status I or II scheduled for elective caesarean under spinal anaesthesia, without pre‐existing systemic disease or pregnancy‐induced hypertension, preterm labour or signs of onset of labour, known fetal abnormalities, or without contraindications to spinal anaesthesia Exclusion criteria: any significant history of maternal medical or obstetric illness and any fetal compromise in current pregnancy Setting: Iran | |
| Interventions | Crystalloids versus colloids versus ephedrine Group1: crystalloid preload: Ringer's lactate solution (15 mL/kg) infused in 30 min before spinal injection. Group 2: colloid preload: colloid solution (Hexamel 7 mg/kg) infused in 30 min before spinal injection. Group 3: ephedrine: ephedrine (15 mg IV bolus) immediately after spinal injection, infused in 45 s. All women received a standardised spinal anaesthetic technique and dose, a standardised crystalloid coload, standardised leg wrapping and standardised surgical positioning. Hypotension (requiring intervention) received rescue boluses of 5 mg ephedrine given each 5 min | |
| Outcomes | Maternal: hypotension (SBP); hypotension, bradycardia; BP; heart rate; ephedrine requirement; vomiting; nausea; hypertension Neonatal: Apgar at 1 min and 5 min, umbilical cord blood pH, NACS | |
| Notes | Hypotension was defined as SBP < 90 mmHg or > 20% below baseline. Bradycardia was defined as heart rate < 50 bpm. Hypertension was defined as SBP > 140 mmHg or > 20% baseline values. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random number table |
| Allocation concealment (selection bias) | Unclear risk | "Randomised" – not further specified except that sampling method was "consecutive" |
| Blinding of participants and personnel (performance bias) | Unclear risk | Reported that women and all staff involved in the study were blind to the protocol used; however, colloid and crystalloids were preloads while ephedrine was given immediately after the spinal injection. |
| Blinding of outcome assessment (detection bias) | Unclear risk | Nurse assessing the severity of nausea and physician measuring neonatal outcomes were blinded |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes were reported (although nausea was only reported as a continuous measure). |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women Inclusion criteria: age 20‐40 years, ASA I‐II, singleton uncomplicated pregnancy, scheduled for elective caesarean under spinal anaesthesia Exclusion criteria: chronic hypertension, pregnancy‐induced hypertension, eclampsia, known cardiovascular disease, haematocrit < 30%, any contraindication to spinal anaesthesia, height < 150 cm Setting: India | |
| Interventions | Crystalloid preload versus crystalloid coload Group 1: 15 mL/kg over 20 min before placement of spinal block Group 2: 15 mL/kg of Ringer's lactate over 20 min starting as soon as CSF was tapped All women received standardised aspiration prophylaxis, standardised cannulation, standardised spinal anaesthetic technique and dose, standardised surgical positioning and standardised oxytocin regimen after delivery. Hypotension was treated with crystalloid boluses and 6 mg of ephedrine given intravenously every 3 min until SBP recovered to baseline value. The choice of crystalloid and the volume administered was left to the judgement of the attending anaesthetist. Bradycardia was treated with IV atropine 0.6 mg bolus. | |
| Outcomes | Maternal: hypotension, ephedrine requirement for hypotension, nausea and vomiting, pruritus, headache, hypertension, shivering, time from induction‐delivery and uterine incision to delivery, total IV fluid, blood loss Neonatal: Apgar scores at 1 min and 5 min, umbilical artery and vein blood gas measurements | |
| Notes | Hypotension was defined as decrease in SBP to < 80% of baseline or SBP < 90 mmHg (whichever was lower). Bradycardia was defined as heart rate less than 50 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random numbers |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Neonatologist blinded Anaesthetist – not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Unclear risk | Not reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 79 women Inclusion criteria: normotensive women undergoing repeat or primary CS for cephalopelvic disproportion | |
| Interventions | Lower limb compression versus control Group 1: plastic inflatable boots applied from toes to upper thighs and inflated immediately after spinal Group 2: control All women received a standardised crystalloid preload, a standardised spinal anaesthetic technique with dose adjusted according to subject's height and standardised surgical positioning. | |
| Outcomes | Maternal: hypotension Neonatal: Apgar scores at 1 min and 5 min (expressed as mean score) | |
| Notes | Hypotension was defined as SBP < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding: not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Not apparent |
| Other bias | Unclear risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 30 women Inclusion criteria: healthy, ASA I women undergoing elective CS Exclusion criteria: pre‐eclampsia, pregnancy‐induced hypertension, fetal abnormality, uteroplacental dysfunction | |
| Interventions | Lower limb compression versus control Group 2: control Intervention administered before spinal anaesthetic. All women received a standardised crystalloid preload, a standardised spinal anaesthetic technique with dose adjusted according to subject's height and standardised surgical positioning. | |
| Outcomes | Maternal: hypotension; nausea; total ephedrine dose | |
| Notes | Hypotension was defined as SBP < 100 mmHg or 80% baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Randomisation by "lottery", otherwise not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding: not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: 2 participants excluded from control group (1 failed spinal, 1 found to have pregnancy‐induced hypertension) |
| Selective reporting (reporting bias) | Unclear risk | Not apparent |
| Other bias | Unclear risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 120 women Exclusion criteria: pre‐eclampsia, arterial hypertension or multiple pregnancy Setting: Denmark | |
| Interventions | Warm versus cold crystalloid preload Group 1: cold (21 degrees centigrade 0.9% saline preload) Group 2: warm (37 degrees centigrade saline preload) All women received a standardised spinal anaesthetic technique and dose as well as 5 mg IV ephedrine after spinal injection. | |
| Outcomes | Maternal: hypotension; heart rate; arm discomfort; shivering; nausea; vomiting | |
| Notes | Hypotension was defined as < 70% decrease in SAP from baseline or 100 mmHg or less. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Randomisation: "computer generation" |
| Allocation concealment (selection bias) | Unclear risk | Allocation concealment: "sealed envelopes" |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: not double‐blinded |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding: not double‐blinded |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: 7/120 women were withdrawn from study, 2 because of failed spinal anaesthesia, 1 because of violation of selection criteria, and 5 because of protocol violations |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 26 women Inclusion criteria: term parturients undergoing elective CS, healthy, uncomplicated singleton, non‐labouring | |
| Interventions | Colloid versus crystalloid preload Group 1: 500 mL 6% HES Group 2: 1000 mL Ringer's lactate Study drug infused over 10 min prior to spinal anaesthesia All women received standardised aspiration prophylaxis, standardised spinal anaesthetic technique and dose and standardised crystalloid infusion after spinal anaesthetic. | |
| Outcomes | Maternal: hypotension; uterine artery pulsatile index; CVP; induction‐delivery time | |
| Notes | Hypotension defined as SBP < 80% baseline or < 90 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelopes" – no further details provided |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: obstetrician performing ultrasound blinded to allocation, other blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: none |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women Inclusion criteria: ASA I‐II, age 20‐35, single pregnancy, elective caesarean under spinal anaesthesia Exclusion criteria: hypertension, congestive cardiac failure, cardiovascular disease, fetal distress, any contraindication to spinal anaesthesia, > 800 mL blood loss in theatre Setting: India | |
| Interventions | Crystalloid preload versus crystalloid coload Group 1: preload of 20 mL/kg of Ringer's lactate over 20 min Group 2: coload of 20 mL/kg of Ringer's lactate at the maximal possible rate by pressurise giving set All women received no premedication, standardised cannulation, no further IV fluid except to keep IV line patent, standardised spinal anaesthetic technique and dose and standardised oxytocin postdelivery. Hypotension was treated with boluses of ephedrine 5 mg | |
| Outcomes | Maternal: incidence of hypotension, height of sensory block, systolic/diastolic/mean BP, ephedrine requirement Neonatal: Apgar sores at 1 min and 5 min | |
| Notes | Hypotension was defined as decrease in SBP > 20% from baseline or decrease of systolic pressure to < 90‐100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Low risk | No blinding, but protocol well defined and seems unlikely to have affected results |
| Blinding of outcome assessment (detection bias) | Low risk | No blinding, but protocol well defined and seems unlikely to have affected results |
| Incomplete outcome data (attrition bias) | Low risk | Not reported |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 30 women Inclusion criteria: undergoing elective CS Exclusion criteria: hypertension, pre‐eclampsia, preterm labour, juvenile diabetes, cocaine and methamphetamine use and cardiac disease | |
| Interventions | Ephedrine versus ephedrine + crystalloid versus crystalloid Group 1: ephedrine infusion group: 10 mL saline bolus followed by ephedrine infusion 1 mg/mL, i.e. 20 mg in 12 min Group 2: ephedrine bolus group: 10 mg ephedrine followed by saline infusion 5 mL/min for 2 min followed by 1 mL/min for 10 min All women received a standardised crystalloid preload followed by standardised infusion, a standardised spinal anaesthetic technique and dose and standardised positioning. | |
| Outcomes | Maternal: hypotension; time to first ephedrine rescue dose; number of hypotensive participants; total ephedrine dose Neonatal: Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as SBP < 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Low risk | Adequate: study drugs prepared by a third party (pharmacy) |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: anaesthetist blinded to interventions |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women Inclusion criteria: healthy women (ASA I or II) scheduled for elective CS under spinal anaesthesia Exclusion criteria: pre‐eclampsia, arterial hypertension, gestational age less than 38 weeks or multiple pregnancy | |
| Interventions | Supine versus sitting positioning after spinal anaesthesia Group 1: modified supine (tilted 10 degrees to left) after spinal Group 2: sitting position for 3 min after spinal before modified supine (n = 52) All women received 200‐300 mL isotonic saline given before spinal, then an additional 15 mL/kg after a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; BP; nausea; vomiting; pain; level of anaesthesia; rescue with ephedrine; time from injection to birth; time from incision to birth Neonatal: umbilical arterial and venous blood; Apgar scores at 1 min and 5 min; time to sustained respiration; birthweight | |
| Notes | Hypotension was defined as SBP < 70% of baseline or < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated codes |
| Allocation concealment (selection bias) | Low risk | Adequate: "assignments were kept in sealed sequentially‐numbered opaque envelopes" |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: not mentioned |
| Blinding of outcome assessment (detection bias) | Low risk | Blinding: "haemodynamic data were transferred to a database by a person blind to which group the woman had been allocated" |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: 2/100 – 1 because of electrical power failure and 1 because of violation of selection criteria |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 80 participants Inclusion criteria: age 18‐35 years, ASA I‐II, CS under spinal anaesthesia Exclusion criteria: contraindication to central neuraxial block, chronic hypertension, multiple pregnancy, diabetes mellitus, pregnancy‐induced hypertension, BMI > 30 kg/m² Setting: India | |
| Interventions | Mechanical compression versus control Group 1: sequential compression device used. The chambers of the device sequentially inflated from ankle to knee to a maximum pressure of 45‐50 mmHg at the ankle and 35 mmHg at the calf; the duration of compression was 12 s with a 60 s relaxation period between compressions Group 2: no sequential compression device used All women received "adequate" crystalloid preload, standardised monitoring, standardised spinal anaesthetic technique and dose. All women had SCD put on legs, but only group 1 had their SCDs turned on. Hypotension treated with 6 mg boluses of IV ephedrine. | |
| Outcomes | Maternal: incidence of hypotension, ephedrine use No neonatal outcomes | |
| Notes | Hypotension was defined as decrease in SBP by > 20% from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Unclear risk | Not reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 120 women Inclusion criteria: healthy pregnant women, term pregnancy, elective caesarean delivery, aged 18‐40 years, height 160‐180 cm, pre‐pregnancy BMI < 31 kg/m² Exclusion criteria: pre‐existing or gestation hypertension/pre‐eclampsia/cardiovascular or cerebrovascular disease/psychiatric or somatic disease (other then well‐treated mild asthma/thyroid hypofunction) or contraindications to spinal anaesthesia Setting: Norway | |
| Interventions | Phenylephrine versus leg wrapping versus control Group 1: phenylephrine (initial bolus 0.25 μg/kg followed by infusion 0.25 μg/kg/min) + sham leg‐wrapping Group 2: leg wrapping + IV placebo infusion Group 3: no treatment consisting of sham leg wrapping + IV placebo infusion All women received no premedication or IV prehydration, standardised IV cannulation, standardised monitoring (via LiDCOplus monitor including arterial line), standardised positioning, standardised spinal anaesthesia technique and dose, standardised crystalloid co‐hydration, standardised oxygen therapy, standardised oxytocin regimen. Leg wrapping or sham leg wrapping performed prior to spinal anaesthesia (refer to below for method of blinding) Study medicine infusion commenced at time of spinal anaesthesia, and ceased if SAP > 150 mmHg for > 3 min Hypotension was treated with IV bolus of 30 μg phenylephrine If hypotension was combined with bradycardia, or MAP < 60 mmHg, an IV bolus of 5 mg ephedrine was administered. | |
| Outcomes | Maternal: extent of decrease in SBP; change in cardiac output, systemic vascular resistance, stroke volume; heart rate; nausea and vomiting, pruritus Neonatal: umbilical artery and vein pH and BE, Apgar score | |
| Notes | Hypotension was defined as SAP < 80% of mean SAP or SAP < 90 mmHg Bradycardia was defined as heart rate < 55 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Hospital pharmacy performed block randomisation into 3 groups of equal size using a pool of sealed and shuffled envelopes |
| Allocation concealment (selection bias) | Low risk | Sealed envelopes for leg wrapping, neutral syringes |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blinded Study medicine prepared in 50 mL syringes containing either phenylephrine or placebo, marked with randomisation number and neutral study information Instructions for therapeutic or sham wrapping placed into a sealed envelope for each patient Leg wrapping performed by specifically trained technical assistants after visual shielding between head of bed and lower extremities. Subsequently, legs were covered prior to positioning in lateral for spinal anaesthesia. |
| Blinding of outcome assessment (detection bias) | Low risk | Randomisation codes not revealed until all measurements recorded |
| Incomplete outcome data (attrition bias) | Low risk | Group 1 Ph: 2 excluded (1 GA, 1 low‐quality data) Group 2 LW: 2 excluded (2 low‐quality data) Group 3 Con: 4 excluded (4 low‐quality data) |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes were reported |
| Other bias | Low risk | Funding from South‐Eastern Norway Regional Authority through government research grant |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: ASA physical status I or II, with full‐term singleton pregnancies and scheduled to undergo elective or emergency lower segment CS under subarachnoid block; without maternal or fetal complications Exclusion criteria: essential or pregnancy‐induced hypertension, diabetes, pre‐eclampsia, heart disease, placental abruption, prematurity (< 37 weeks' gestation), obesity, haemoglobin < 7g/dL, intrauterine growth restriction, fetal distress, fetal anomalies Setting: India | |
| Interventions | Left lateral tilt versus left manual uterine displacement Group 1: left lateral tilt: women received 15 degree left lateral tilt immediately following administration of anaesthetic Group 2: left manual uterine displacement: women received manual displacement of the uterus immediately following anaesthetic; positioned supine without left lateral tilt All women received standardised aspiration prophylaxis, standardised crystalloid preload, standardised spinal anaesthetic technique and dose. Hypotension (requiring intervention) was treated with IV boluses of ephedrine (6 mg) until SBP was restored to > 90 mmHg. | |
| Outcomes | Maternal: hypotension; ephedrine requirement Neonatal: Apgar at 1 min, 5 min, and 10 min | |
| Notes | Hypotension was defined as SBP < 90 mmHg or < 80% of baseline value Bradycardia defined as heart rate < 60 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random numbers |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelope technique." |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Manual displacement of the uterus was provided by a person other than the attending anaesthetist who was blinded to the haemodynamic parameters being displayed by screen separation." |
| Blinding of outcome assessment (detection bias) | Unclear risk | Apgar scores were assessed by a clinician who was blinded to group assignment |
| Incomplete outcome data (attrition bias) | Low risk | No losses reported |
| Selective reporting (reporting bias) | Unclear risk | Not all expected outcomes were reported or reported completely |
| Other bias | Low risk | Baseline characteristics were similar |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA class I and II, single term pregnancies, scheduled for elective caesarean under spinal anaesthesia Exclusion criteria: pre‐existing or pregnancy‐induced hypertension, known cardiovascular disease or contraindications to spinal anaesthesia Setting: India | |
| Interventions | Ephedrine versus crystalloid preload Group 1: ephedrine: ephedrine infusion prepared in 0.9% NS (1 mg/mL), started prophylactically at a rate of 5 mg/min for the first 2 min and then at a rate of 1 mg/min for the next 18 min, following administration of spinal anaesthetic Group 2: crystalloid preload: Ringer's lactate 500 mL, infused rapidly over 15‐20 min before institution of spinal anaesthetic All women received a standardised spinal anaesthetic technique and dose followed by a standardised crystalloid infusion. Hypotension requiring intervention received 5 mg IV bolus ephedrine, repeated if necessary. | |
| Outcomes | Maternal: hypotension; induction to birth time; total ephedrine dose; adverse effects; heart rate Neonatal: Apgar scores; umbilical venous gases | |
| Notes | Hypotension was defined as a > 20% fall in SBP | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly divided into two groups" |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelope |
| Blinding of participants and personnel (performance bias) | Unclear risk | Described as "single‐blinded" but unlikely that blinding was possible as women in the ephedrine group had 2 separate IV lines established, while those in the crystalloid group had only 1 line |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Unclear risk | Neonatal outcomes not reported in a form that could be used in this review |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: healthy parturients undergoing primary or repeat CS, gestation 33‐41 weeks, uncomplicated singleton, not in labour, ASA I | |
| Interventions | Colloid preload versus crystalloid preload Group 1: 500 mL dextran 40 (n = 30) Group 2: 1000 mL Ringer's lactate (n = 30) Study drug administered over 20 min prior to spinal All women received a standardised spinal anaesthetic technique with variable dose (1.8‐2.2mL 0.5% bupivacaine). | |
| Outcomes | Maternal: hypotension; uterine incision‐delivery time; estimated blood loss; urine output; nausea Neonatal: Apgar scores at 1 min and 5 min | |
| Notes | Hypotension defined as SBP < 70% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Unclear risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: ASA I women presenting for elective caesarean under spinal anaesthesia | |
| Interventions | Head‐down tilt versus control: Group 1: anaesthesia induced in right lateral position (woman's spine inclined at 5 to 6 degrees from horizontal with head slightly lower); anaesthesia induced in right lateral position 10 degree head‐up tilt Group 2: anaesthesia induced in right lateral position (woman's spine inclined at 4 to 5 degrees from horizontal with head slightly higher). All women received a standardised preload of 1 litre crystalloid IV and a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; sensory block; ephedrine requirement; nausea; pain Neonatal: Apgar scores at 1 min and 5 min | |
| Notes | Hypotension defined as SBP < 90 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelope method" |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not mentioned |
| Blinding of outcome assessment (detection bias) | Low risk | Blinding: outcome assessors were only admitted to the operating room once the position of the operating table had been readjusted |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: none reported but losses unlikely |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: undergoing elective CS, ASA I, age 18 to 40 years, height > 150 cm, weight < 100 kg, full‐term singleton fetus with no congenital abnormalities, no polyhydramnios, no intrauterine growth retardation, and estimated fetal weight > 2500 g | |
| Interventions | Ephedrine + crystalloid co‐load versus crystalloid preload Group 1: prophylactic ephedrine 6 mg IV and 1000 mL Ringer's lactate commenced immediately after spinal anaesthesia Group 2: preload of 1000 mL Ringer's lactate All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension (defined as SBP < 100 mmHg); BP; heart rate; time to block; ephedrine dose Neonatal: Apgar scores | |
| Notes | Hypotension defined as SBP < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Allocation concealment: "divided into two groups" |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: described as "double‐blinded" but no further details provided |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 67 women (= 68 neonates due to 1 twin pregnancy in the control group) Inclusion criteria: term and peri‐term women presenting for elective CS Exclusion criteria: moderate to severe pre‐eclampsia, history of essential hypertension, contraindication to spinal anaesthesia | |
| Interventions | Ephedrine (different doses) versus control Group 1: 6 mg ephedrine Group 2: 12 mg ephedrine Group 3: 0.9% saline IV bolus (control) The study drug was given simultaneously with the anaesthetic. | |
| Outcomes | Maternal: hypotension; doses of ephedrine; heart rate; hypertension; nausea or vomiting Neonatal: cord arterial pH; Apgar score at 5 min | |
| Notes | Hypotension was defined as a reduction in SAP > 30% from baseline or < 90 mmHg. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | "Computer‐generated" |
| Allocation concealment (selection bias) | Low risk | Adequate: study drugs coded by hospital pharmacy |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: "double‐blind" – all observers were blinded |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: 2/67 – 1 woman in the saline group was excluded because an infusion of ephedrine was administered following the spinal injection and another because of administration of IV fentanyl to supplement analgesia |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 43 women Inclusion criteria: ASA I and II non‐labouring women undergoing scheduled elective caesareans; term uncomplicated singleton pregnancies, women taking only prenatal vitamins and weighing less than 100 kg Exclusion criteria: cardiac, pulmonary or renal diseases or systemic diseases that could influence haemodynamic responses, including pre‐eclampsia, hypertension and diabetes; if women were taking or had a history of taking any medications that could influence haemodynamic responses, including magnesium sulphate, terbutaline or B‐blockers | |
| Interventions | Phenylephrine versus control Group 1: 10 mg ephedrine IV Group 2: 40 µg phenylephrine + 10 mg ephedrine The IV bolus of study drug was administered simultaneously with the intrathecal anaesthetic injection. All women received a standardised crystalloid preload, did not wear thromboembolic stockings and received a standardised spinal anaesthetic technique and dose. For rescue from hypotension, women in the ephedrine only group were given 5 mg ephedrine and women in the ephedrine + phenylephrine group were given 5 mg ephedrine + 20 µg phenylephrine. | |
| Outcomes | Maternal: hypotension; heart rate; nausea; rescue boluses; total mean ephedrine dose; total mean phenylephrine dose Neonatal: umbilical artery pH (mean and SD); umbilical vein pH (mean and SD); Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as SBP < 100 mmHg or a decrease in SBP of 20% from baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelope" |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: "double‐blinded"; anaesthetist remained blinded to the study solution throughout |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: 3/43 – 1 woman in the ephedrine only group and 2 in the ephedrine/phenylephrine group were excluded from analysis due to improper data collection before unblinding |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 120 women Inclusion criteria: non‐labouring ASA I and II women having non‐urgent CS Exclusion criteria: obesity (> 115 kg), height < 152 cm, diabetes, pregnancy‐induced hypertension, chronic hypertension, heart disease, multiple gestation, age < 18 or > 40 years Setting: Lebanon | |
| Interventions | Colloid versus crystalloid Group 1: HES (500 mL) Group 2: Ringer's lactate (1000 mL) All women received study fluid administered as preload before spinal. No IV fluids were administered prior to anaesthesia. Standardised spinal anaesthetic technique and dose. Hypotension (requiring intervention) received IV boluses of 3 mg ephedrine; repeated every 2 min if hypotension persisted or recurred | |
| Outcomes | Maternal: hypotension; nausea and/or vomiting Neonatal: Apgar scores; umbilical arterial and venous pH | |
| Notes | Hypotension defined as SBP < 100 mmHg or 20% decrease from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly assigned" – no further details given |
| Allocation concealment (selection bias) | Unclear risk | As above |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Unclear risk | None of the neonatal outcomes were reported in a form that could be used in this review. |
| Other bias | Low risk | Baseline characteristics were similar. |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I or II, term pregnancy, of single fetus, indication for CS Exclusion criteria: refusal to participate in study, patients aged < 18 years, pre‐existing or pregnancy‐induced systemic hypertension, presence of cardiovascular or cerebrovascular diseases, fetal abnormalities, history of allergy to drugs used in the study, contraindications to spinal block Setting: Brazil | |
| Interventions | Prophylactic ephedrine versus prophylactic phenylephrine Group 1: prophylactic IV dose of 10 mg ephedrine immediately after spinal block Group 2: prophylactic IV dose of 80 μg phenylephrine immediately after spinal block Standardised monitoring and positioning, standardised spinal anaesthetic technique (at L2‐L3 or L3‐L4) and dose, standardised crystalloid coload and maintenance No significant baseline differences between groups Hypotension was managed with a bolus dose of 50% of study drug Bradycardia was treated with 0.75 mg atropine | |
| Outcomes | Maternal: level of block, time from blockade at T5 to incision of skin, incision of uterus and removal of fetus was recorded, incidence of maternal hypotension, reactive hypertension, bradycardia, nausea/vomiting, total dose of vasopressor Neonatal: Apgar scores at 1 min and 5 min, pH < 7.2 | |
| Notes | Hypotension was defined as BP less than or equal to 80% baseline. Reactive hypertension was defined as BP > 20% baseline values after the use of the vasopressor. Bradycardia was defined as heart rate < 50 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random numbers |
| Allocation concealment (selection bias) | Low risk | Sequential sealed envelopes |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Double blind": syringes of study drugs prepared by a physician who was not involved with data collection and analysis |
| Blinding of outcome assessment (detection bias) | High risk | "Result of allocation was ignored by both patients & physicians responsible for collecting & analysing study parameters." |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up reported |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes were reported |
| Other bias | Unclear risk | No apparent sources of other bias |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I‐II, elective CS Exclusion criteria: patient refusal to participate in study, contraindication to perineural anaesthesia, multiple pregnancies, body weight > 115 kg, height < 152 cm, age < 18 or > 40 years old, diabetes, pregnancy‐induced hypertension, chronic hypertension, heart disease Setting: Poland | |
| Interventions | Comparison of 2 different colloid solutions as preload: Voluven versus Tetraspan Women were transfused 1 of the following solutions prior to spinal anaesthesia: Group 1: 500 mL transfusion of 6% HES 130/0.4 with 0.9% NaCl prior to anaesthesia (Voluven) over 15 min Group 2: 500 mL of 6% HES 130/0.42 in a physiological electrolyte solution (Tetraspan) over 15 min All women received standardised aspiration prophylaxis, standardised spinal anaesthetic technique and dose, standardised oxygen therapy and standardised oxytocin administration after delivery. Until the birth of the child, the patient did not receive any further IV fluid. Hypotension was managed with 5‐10 mg of IV ephedrine. During delivery 40% O2 given via mask. 10 units oxytocin IV given after delivery | |
| Outcomes | Maternal: BP, time to skin incision/delivery/uterine incision Neonatal: Apgar scores 1, 3, 5, 10 min after birth, pH of venous and arterial umbilical blood | |
| Notes | Hypotension defined as a drop in SBP of 20% below the baseline pressure (or below 100 mmHg) | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Low risk | 5 patients from Group 1 and 4 patients from Group 2 were removed from the study due to problems with cord blood collection for gaso‐metric tests (e.g. inability to perform dual collection of blood samples from the same vessel or no collection). Successful tests were conducted in the remaining 51 patients (25 in Group 1 and 26 in Group 2) |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 72 women Inclusion criteria: ASA I/II, elective CS due to cephalopelvic disproportion, post‐C‐section condition, gluteal position, ophthalmic indications and those without medical indications Exclusion criteria: lack of consent, contraindications to spinal anaesthesia, multiple pregnancy, body weight > 155 kg, height < 152 cm, age < 18 years or > 40 years, diabetes mellitus, pregnancy‐induced hypertension, chronic hypertension, cardiac diseases, use of selective serotonin reuptake inhibitors Setting: Poland | |
| Interventions | Ondansetron versus control Group 1 (O): 8 mg ondansetron in 10 mL 0.9% NaCl IV Group 2 (P): 10 mL 0.9% NaCl IV Syringe content administered over 1 min, after colloid preload and 5 min prior to spinal anaesthesia. All women received standardised aspiration prophylaxis, standardised monitoring, standardised cannulation and colloid prehydration, standardised spinal anaesthetic technique and dose. Hypotension was managed with fractionated IV ephedrine boluses. Bradycardia was managed with 0.5 mg atropine. | |
| Outcomes | Maternal: hypotension, bradycardia Neonatal: Apgar scores at 1 min and 5 min, baby's weight, umbilical vein acid‐base status | |
| Notes | Hypotension was defined as a 20% decrease in systolic pressure or decrease in systolic pressure < 90 mmHg Bradycardia was defined as heart rate < 60 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Online randomisation programme |
| Allocation concealment (selection bias) | Low risk | Study drug prepared by anaesthetist otherwise uninvolved in study |
| Blinding of participants and personnel (performance bias) | Low risk | The anaesthetist preparing the solution was on call, and the anaesthetist administering the solution was blinded. |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | 2 patients in placebo group received IV opioids due to insufficient analgesia and were thus excluded from the study |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes were reported |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 87 women Inclusion criteria: healthy parturients undergoing elective caesarean under spinal anaesthesia | |
| Interventions | Colloid + crystalloid versus crystalloid versus ephedrine + crystalloid versus ephedrine + colloid + crystalloid Group 1: 5% albumin in Ringer's lactate with 5% dextrose solution (15 mL/kg) Group 2: Ringer's lactate with 5% dextrose solution (15 mL/kg) Group 3: Ringer's lactate with 5% dextrose solution (15 mL/kg) plus ephedrine 25 mg IM Group 4: 5% albumin in Ringer's lactate with 5% dextrose solution (15 mL/kg) plus ephedrine 25 mg IM Fluids were administered as a preload over 15‐20 min before spinal anaesthesia. All women received a standardised anaesthetic technique with variable local anaesthetic dose (6‐8 mg 0.5% hyperbaric tetracaine). | |
| Outcomes | Maternal: hypotension; MAP; heart rate Neonatal: Apgar scores | |
| Notes | Hypotension defined as a decrease in SBP below 90 torr | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not stated |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Inadequate reporting |
| Other bias | High risk | Variable dose of local anaesthetic used for spinal anaesthesia |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 167 women Inclusion criteria: ASA I‐II, elective caesarean under spinal anaesthesia, aged > 18 years, weight > 60 kg and < 95 kg, term singleton pregnancy (> 37 weeks' gestation) Exclusion criteria: concomitant diseases (e.g. pregnancy‐induced hypertension, diabetes mellitus, cardiovascular or cerebrovascular disease, coagulation disorders), fetal complications, contraindications to spinal anaesthesia or HES administration, emergency CS, women who received IV fluid prior to admission to theatre Setting: multicentre, France | |
| Interventions | Colloid versus crystalloid preload Group 1: HES: 500 mL 6% HES 130/0.4, followed by 500 mL Ringer's lactate Group 2: RL: 500 mL of Ringer's lactate, followed by second infusion of 500 mL Ringer's lactate All women received standardised aspiration prophylaxis, standardised monitoring, standardised anaesthetic technique and dose. Maternal bradycardia treated with atropine 0.5‐1 mg IV Hypotension treatment: SBP > 95% baseline – no treatment, SBP 94‐80% baseline received 50 μg phenylephrine, SBP 79%‐90% of baseline received 100 μg phenylephrine, SBP < 70% of baseline received 150 μg phenylephrine. Sustained nausea and vomiting was treated with ondansetron 4 mg IV. | |
| Outcomes | Maternal: incidence of hypotension; time of onset of hypotension; symptomatic hypotension; nausea and vomiting; dizziness; minimum heart rate; bradycardia; atropine and phenylephrine requirement Neonatal: Apgar scores at 1 min and 5 min, umbilical arterial and venous pH | |
| Notes | Hypotension defined as SBP < 80% of baseline Bradycardia defined as heart rate < 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation sequence using SAS software; blocks of 4 |
| Allocation concealment (selection bias) | Unclear risk | Not mentioned |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blind: "study fluids were provided in indistinguishable 500 mL bottles |
| Blinding of outcome assessment (detection bias) | Low risk | Double‐blind |
| Incomplete outcome data (attrition bias) | Low risk | Clearly reported in study results 11 protocol violations in HES group, and 10 in the Ringer's group Intention‐to‐treat analysis |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | High risk | Fully funded by Fresenius Kabi, the company that produces HES |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 34 women Inclusion criteria: term parturients undergoing elective CS, ASA I Exclusion criteria: not specified | |
| Interventions | Head‐up versus control Group 1: horizontal Group 2: 10 degree head‐down tilt All women received a standardised anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; block height; fluid; ephedrine doses Neonatal: none stated | |
| Notes | Hypotension defined as SBP < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I or II women with term uncomplicated pregnancies, scheduled to undergo elective CS under subarachnoid block Exclusion criteria: pregnancy‐induced hypertension, cardiovascular disease, cerebrovascular disease, placental or fetal abnormalities, absolute or relative contraindication to spinal anaesthesia and women with SBP < 100 mmHg Setting: India | |
| Interventions | Phenylephrine versus mephentermine Group 1: infusion of phenylephrine (50 μg/mL); administered immediately following spinal anaesthesia, at a rate of 60 mL/h (50 μg/min) Group 2: infusion of mephentermine s (600 μg/mL); administered immediately following spinal anaesthesia, at a rate of 60 mL/h (600 μg/min) All women received a standardised fluid preload and standardised spinal anaesthetic technique. Spinal anaesthetic dose was 2.2 mL of hyperbaric 0.5% bupivacaine unless patient's height was < 150 cm, in which case the dose was 2 mL. Hypotension was managed with a 2 mL bolus dose of respective vasopressor solution (100 μg phenylephrine or 1.2 mg mephentermine). Hypertension was managed with stepwise reduction in infusion by 6 mL/h. Bradycardia was managed with 0.3 mg boluses of atropine. | |
| Outcomes | Maternal: hypotension; reactive hypertension; bradycardia; nausea; vomiting; dizziness Neonatal: umbilical arterial and venous blood gases; Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as fall of ≥ 20% from baseline or an absolute value of < 100 mmHg SBP, whichever was higher. Hypertension was defined as a rise in SBP > 20% above baseline. Bradycardia was defined as heart rate < 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly divided into two groups of 30 each" |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelope" |
| Blinding of participants and personnel (performance bias) | Unclear risk | Described as double‐blind: "the solution of vasopressor for infusion was prepared by an assistant who was not involved in the study, and the investigator, as well as the patient, were thus blinded to the identity of vasopressor used" However, it was not possible for the anaesthetist to be blinded as treatment of hypotension with "the respective vasopressor solution" would have required knowledge of which vasopressor was used. |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes were reported |
| Other bias | Low risk | Similar baseline characteristics except for a lower mean baseline heart rate in the phenylephrine group |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 185 women Inclusion criteria: healthy women with uncomplicated term pregnancies undergoing elective CS Exclusion criteria: not specified | |
| Interventions | Variable ephedrine infusions versus crystalloid preload alone versus crystalloid preload + variable ephedrine infusions Group 1: ephedrine infusion alone at 1 mg/min from spinal injection until birth Group 2: ephedrine infusion alone at 2 mg/min from spinal injection until birth Group 3: ephedrine infusion alone at 3‐4 mg/min from spinal injection until birth Group 4: Ringer's lactate 1000 mL over 20 min before spinal injection Group 5: Ringer's lactate 1000 mL over 20 min before spinal injection plus ephedrine infused at 1 mg/min from spinal injection until birth Group 6: Ringer's lactate 1000 mL over 20 min before spinal injection plus ephedrine infused at 2 mg/min from spinal injection until birth Group 7: Ringer's lactate 1000 mL over 20 min before spinal injection plus ephedrine infused at 3‐4 mg/min from spinal injection until birth All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; heart rate; hypertension Neonatal: umbilical artery pH (expressed as means ± SD), BE | |
| Notes | Hypotension defined as decrease in SBP > 30% from baseline Tachycardia defined as heart rate > 130 bpm Hypertension defined as SBP > 150 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: "double blinded" – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 recruited, 83 completed analysis Inclusion criteria: healthy pregnancy of gestational age 36 weeks or higher, non‐emergency CS Exclusion criteria: below 36 weeks' gestation, emergence CS, high‐risk pregnancies (multiple gestations, intrauterine growth retardation, pre‐eclampsia, maternal cardiovascular or respiratory diseases), any contraindication of spinal anaesthesia (patient refusal, coagulopathy, haemorrhage or hypovolaemic shock), unexpected events during surgery (haemorrhage, sensory block higher or lower than T4‐T5 after spinal anaesthesia) Setting: Iran | |
| Interventions | Phenylephrine versus ephedrine versus crystalloid Group 1: 450 μg phenylephrine in 250 cc normal saline administered over 30 min after preload Group 2: 45 mg ephedrine in 250 cc normal saline administered over 30 min Group 3: 250 cc normal saline infused over 30 min All women received standardised monitoring, standardised crystalloid preload and standardised spinal anaesthetic technique and dose. Hypotension was treated with study vasopressor (clinician blinded to which vasopressor): Group 1 received 50‐100 μg phenylephrine Group 2 and 3 received 5‐10 mg ephedrine. | |
| Outcomes | Maternal: incidence and degree of hypotension, heart rate and rhythm, nausea/vomiting, number of vasopressor therapy and total dose, "any other intra or post‐operative complication". Neonatal: arterial blood gas, Apgar at 1 min and 5 min | |
| Notes | Hypotension defined as drop in BP > 20% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation list |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Low risk | Study drugs labelled with numerical codes and investigators were blinded Double‐blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Double‐blinded |
| Incomplete outcome data (attrition bias) | Low risk | Group 1: 4 excluded due to very high or very low sensory block Group 2: 3 excluded due to very high or very low block |
| Selective reporting (reporting bias) | Low risk | Group 1: 4 excluded due to very high or very low sensory block Group 2: 3 excluded due to very high or very low block |
| Other bias | Low risk | None apparent Funded by: University of Medical Sciences and Women's Reproductive Health Research Centre |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 80 women Inclusion criteria: ASA I or II women scheduled for elective CS under spinal anaesthesia, normal singleton pregnancy; > 36 weeks' gestation; BMI 20‐38 kg/m²; height > 145 cm Exclusion criteria: contraindications for spinal anaesthesia and failed spinal necessitating conversion to GA Setting: Malaysia | |
| Interventions | Crystalloids: different preload volumes Group 1: low volume crystalloid 10 mL/kg of Ringer's lactate infusion preload Group 2: high volume crystalloid 20 mL/kg of Ringer's lactate infusion preload All women received standardised aspiration prophylaxis, standardised anaesthetic technique and dose, standardised fluid maintenance. Hypotension was managed with 6 mg boluses of ephedrine. | |
| Outcomes | Maternal: hypotension; BP; ephedrine requirement; nausea; vomiting; oxygen saturation; respiratory rate | |
| Notes | Hypotension was defined as a > 20% fall in MAP from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Coin toss |
| Allocation concealment (selection bias) | Unclear risk | "Randomly allocated" – no further details reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Described as "single blinded" – no further details reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up reported |
| Selective reporting (reporting bias) | High risk | No neonatal outcomes were reported |
| Other bias | Low risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women Inclusion criteria: ASA grade I women undergoing elective CS under spinal anaesthesia with a normal singleton pregnancy beyond 36 weeks' gestation Exclusion criteria: pregnancy‐induced hypertension, diabetes, cardiovascular or cerebrovascular disease, fetal abnormalities, contraindication to spinal anaesthesia Setting: India | |
| Interventions | Prophylactic ephedrine versus phenylephrine Group 1: prophylactic bolus of ephedrine 10 mg IV 1 min after intrathecal injection Group 2: prophylactic dose of phenylephrine 100 μg IV 1 min after intrathecal injection All women received standardised premedication, a standardised fluid preload, a standardised spinal anaesthetic technique (in either lateral or seated position) and dose, standardised surgical positioning. Hypotension managed with rescue boluses of ephedrine 5 mg IV (group 1) or phenylephrine 50 μg IV (group 2) whenever maternal SBP was recorded as less than 90 mmHg. Bradycardia was treated with atropine 300 μg IV bolus. | |
| Outcomes | Maternal: BP (systolic, diastolic, mean); heart rate; need for rescue bolus(es); need for atropine Neonatal: Apgar scores at 1 min and 5 min; umbilical cord blood pH (unclear as to venous or arterial); results for Apgar and pH < 7.2 | |
| Notes | Definition of hypotension is a SBP measurement < 90 mmHg. Bradycardia was defined as heart rate < 60 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly allocated into two groups of 50 each" – method not specified |
| Allocation concealment (selection bias) | Unclear risk | "Randomly allocated into two groups of 50 each" – method not specified |
| Blinding of participants and personnel (performance bias) | Low risk | "Double blind" – the vasopressor solutions were prepared in identical syringes by an anaesthetist or investigator who was not involved in subsequent patient care |
| Blinding of outcome assessment (detection bias) | Low risk | Not reported, but outcomes probably recorded by staff involved in care |
| Incomplete outcome data (attrition bias) | Low risk | No losses reported |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes reported |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 80 women Inclusion criteria: ASA I or II Asian women with term singleton pregnancies having elective CS Exclusion criteria: pre‐existing or pregnancy‐induced hypertension, known cardiovascular or cerebrovascular disease, or contraindications to spinal anaesthesia Setting: Hong Kong, China | |
| Interventions | Ephedrine + crystalloid preload (different doses) versus crystalloid preload alone Group1: ephedrine 10 mg Group 2: ephedrine 20 mg Group 3: ephedrine 30 mg Group 4: saline control All were diluted to 10 mL with saline and injected intravenously over 30 s. All women received a standardised crystalloid preload with Ringer's lactate followed by a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; hypertension; heart rate; total ephedrine dose; nausea or vomiting; upper sensory level; skin incision to birth and uterine incision to birth time Neonatal: Apgar scores at 1 min and 5 min; umbilical arterial and venous blood gas and pH; cardiotocograph | |
| Notes | Hypotension defined as SBP < 80% baseline or < 100 mmHg Hypertension defined as SBP > 120% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Coded, opaque shuffled envelopes – randomisation method not described |
| Allocation concealment (selection bias) | Low risk | Adequate: coded, opaque shuffled envelopes, study drugs were prepared by an anaesthetist not involved in assessing women |
| Blinding of participants and personnel (performance bias) | Unclear risk | Double‐blind (participants and anaesthetists) – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: maternal heart rate data lost in 1 woman (out of 20) from 10 mg group; cord blood samples incomplete in 2 each from control (n = 20), 20 mg (n = 20) and 30 mg (n = 20) groups |
| Selective reporting (reporting bias) | Low risk | Appears to report all outcomes |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: term singleton pregnancies scheduled for elective caesarean under spinal anaesthesia Exclusion criteria: pre‐existing or pregnancy‐induced hypertension, cardiovascular or cerebrovascular disease, known fetal abnormality or contraindication to spinal anaesthesia Setting: Hong Kong, China | |
| Interventions | Phenylephrine versus control Group 1: phenylephrine IV immediately after intrathecal injection; 100 µg/min for 3 min Group 2: control (saline infusion plus rescue IV bolus of phenylephrine (100 µg) when SAP < 80% baseline Note: women in the phenylephrine group were given phenylephrine 100 µg/min whenever SAP was less than baseline. All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; BP; nausea and vomiting; bradycardia requiring intervention; phenylephrine dose; incision to birth time Neonatal: umbilical arterial blood gases; umbilical venous blood gases; Apgar scores | |
| Notes | Hypotension defined as SAP < 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | "Computer‐generated randomization codes" |
| Allocation concealment (selection bias) | Low risk | "Codes contained in sealed, sequentially numbered envelopes" |
| Blinding of participants and personnel (performance bias) | Low risk | "Double blind"; "two identical syringes"; investigators and women were blinded to the contents of the syringes |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: none (although there was insufficient cord blood to measure pH in 1 neonate) |
| Selective reporting (reporting bias) | Low risk | Appears to report all |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 104 participants Inclusion criteria: ASA I‐II, age > 18 years, term singleton pregnancy, elective caesarean under spinal anaesthesia Exclusion criteria: pre‐existing or gestational hypertension, abnormality of fetus, onset of uterine contraction, coagulopathy, thrombocytopenia, cerebrovascular or cardiovascular disease, any contraindication to the use of spinal anaesthesia, height > 180 cm or < 140 cm, weight > 100 kg or < 50 kg Setting: Hong Kong, China | |
| Interventions | Prophylactic glycopyrrolate versus control Group 1: single IV bolus of glycopyrrolate 4μg/kg diluted in saline to 2 mL administered at commencement of spinal injection Group 2: single IV bolus 2 mL saline placebo administered at commencement of spinal injection All women received standardised aspiration prophylaxis, standardised monitoring, standardised positioning, standardised cannulation, a standardised spinal anaesthetic technique and dose, and standardised crystalloid coload. BP maintained using infusion of phenylephrine 100 μg/mL using a computer controlled closed‐loop feedback infusion. | |
| Outcomes | Maternal: total dose and median rate of phenylephrine infusion, total amount of IV fluid given, number of episodes of hypotension, nausea and vomiting Neonatal: Apgar scores, umbilical cord gases | |
| Notes | Hypotension was defined as SBP < 80% of baseline. Hypertension was defined as SBP > 120% of baseline. Bradycardia was defined as heart rate < 50 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random codes |
| Allocation concealment (selection bias) | Low risk | Sealed opaque sequentially numbered envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Yes, both blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Blinded |
| Incomplete outcome data (attrition bias) | Low risk | Group 1 – 5 excluded due to severe shivering, infusion tubing fault, computer cable fault Group 2 – 6 excluded due to severe shivering, infusion tubing fault |
| Selective reporting (reporting bias) | Low risk | Appears all reported |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 54 women Inclusion criteria: ASA I‐II status women, between 20 to 40 years, undergoing elective caesarean Exclusion criteria: women with BMI > 30 kg/m², anaemia (Hb < 10 g/dL), history of neurological or psychiatric diseases Setting: Japan | |
| Interventions | Colloid preload versus colloid coload versus crystalloid alone Group 1: colloid preload: after Ringer's lactate was started at a rate of 5 mL/kg, this was changed to HES 6% (molecular weight 70 kDa, degree of substitution 0.5) and infusion rate was increased to 15 mL/kg for 10 min before spinal anaesthesia. Infusion rate was returned to Ringer's lactate at 5 mL/kg Group 2: colloid coload: after Ringer's lactate was started at a rate of 5 mL/kg, this was changed to HES 6% (molecular weight 70 kDa, degree of substitution 0.5) and infusion rate was increased to 15 mL/kg for 10 min after spinal anaesthesia. Infusion rate was returned to Ringer's lactate at 5 mL/kg Group 3: crystalloid alone: Ringer's lactate at 5 mL/kg All women received standardised leg wrapping, no sedative premedication, and a standardised spinal anaesthetic technique and dose. Hypotension requiring intervention was managed with IV bolus of 4 mg of ephedrine to maintain BP at 80% of baseline. Bradycardia was managed with IV atropine 0.5 mg. | |
| Outcomes | Maternal: hypotension; need for ephedrine; BP; bradycardia Neonatal: pH, BE, Apgar scores | |
| Notes | Hypotension was defined as a decrease in SBP < 80% baseline Bradycardia was defined as heart rate < 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Random number tables |
| Allocation concealment (selection bias) | Unclear risk | No method of allocation concealment reported |
| Blinding of participants and personnel (performance bias) | Low risk | "Double‐blind"; "both the patient and the researcher who recorded the data were blinded as to the type of colloid loading" |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes were reported (except for nausea/vomiting) |
| Other bias | Unclear risk | Similar baseline characteristics except that women in the HES coload group had lower mean BMI |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 168 women Inclusion criteria: age > 18 years, ASA I‐II, term singleton pregnancy, elective caesarean delivery under spinal anaesthesia Exclusion criteria: diabetes mellitus other than gestational diabetes, hypertension, BMI > 40 kg/m², complicated pregnancy, allergy to study drugs, long QT syndrome, contraindications to spinal anaesthesia Setting: Thailand | |
| Interventions | Ondansetron versus ephedrine versus control Group 1: ephedrine 10 mg IV Group 2: ondansetron 8 mg IV Group 3: normal saline IV Above interventions were diluted in 10 mL 0.9% saline and administered immediately after spinal anaesthesia. All women received the same aspiration prophylaxis, monitoring, crystalloid preload, anaesthetic technique and dose. If hypotension developed, women received ephedrine 5‐10 mg or noradrenalin 4‐8 μg IV (choice of agent was up to the attending anaesthetist). Bradycardia was treated with IV atropine 0.6 mg. | |
| Outcomes | Maternal: hypotension, nausea and vomiting, incidence of vasopressor and dose of vasopressor used Neonatal: Apgar scores | |
| Notes | Hypotension defined as decrease in SBP > 20% of baseline or SBP < 90 mmHg. Bradycardia defined as heart rate < 50 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation table |
| Allocation concealment (selection bias) | Low risk | Sealed envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Blinded |
| Incomplete outcome data (attrition bias) | Low risk | Only 2 women were excluded due to protocol violations |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I, elective CS under spinal anaesthesia Exclusion criteria: gestational age < 37 weeks, multiple gestation, fetal distress, pre‐eclampsia, cardiovascular disease, diabetes Setting: South Korea | |
| Interventions | Comparison of crystalloid preload versus coload Group 1: rapid infusion of 15 mL/kg Hartmann's preloading Group 2: rapid infusion of 15 mL/kg Hartmann's just after intrathecal injection All women had same monitoring, IV access, spinal anaesthetic technique and dose. Hypotension treated with 5 mg IV ephedrine. | |
| Outcomes | Maternal: incidence of hypotension, nausea and vomiting Neonatal: Apgar scores at 1 min and 5 min, umbilical cord gases | |
| Notes | Hypotension defined as a decrease of SBP > 20% from baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random allocation (block randomisation, block size 4) |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Low risk | Not blinded, but unlikely to have affected incidence of hypotension |
| Blinding of outcome assessment (detection bias) | Low risk | Not blinded, but unlikely to have affected incidence of hypotension |
| Incomplete outcome data (attrition bias) | Low risk | Group 1: 1 woman excluded due to surgical delay by other operation Group 2: 1 woman excluded due to inadequate spinal anaesthesia |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 28 women Inclusion criteria: healthy parturients at term scheduled for elective CS due to disproportion or breech presentation | |
| Interventions | Prophylactic ephedrine + crystalloid preload versus crystalloid preload alone Group 1: 750 mL isotonic saline plus 20 mL/kg preload Group 2: 750 mL isotonic saline plus 500 mL preload followed by ephedrine bolus (0.15 mg/kg) and ephedrine infusion (0.4 mg/kg/h); ephedrine commenced after spinal anaesthetic All women received standardised positioning, and a standardised spinal anaesthetic technique and dose followed by standardised surgical positioning. | |
| Outcomes | Maternal: hypotension; BP; level of block; induction to incision/incision to birth times; ephedrine dose Neonatal: umbilical pH; Apgar scores | |
| Notes | Hypotension was defined as > 10 mmHg decrease in MAP (reported only as dose of ephedrine) | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Apgar scores were blinded – no further details |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: 2/28 women were excluded due to technical difficulties with the ephedrine infusion pump and the Dinamap respectively |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 128 women Inclusion criteria: ASA I, elective caesarean under spinal anaesthesia Exclusion criteria: patient refusal to participate, contraindication to spinal anaesthesia, age < 20 or > 45 years, BMI > 30 kg/m², history of allergy or side effects to ondansetron Setting: Spain | |
| Interventions | Comparison of different doses of prophylactic ondansetron with placebo Group 1: placebo 0.9% saline 10 mL Group 2: 2 mg ondansetron with 0.9% saline to total volume of 10 mL Group 3: 4 mg ondansetron with 0.9% saline to total volume of 10 mL Group 4: 8 mg ondansetron with 0.9% saline to total volume of 10 mL The above 10 mL preparation was injected IV over 60 s, 5 min before the spinal anaesthesia was performed All women received the same IV cannulation, monitoring, spinal anaesthetic technique with dose adjusted according to height, and 8 mL/kg of colloid coloading Hypotension was treated with IV ephedrine 10 mg, or phenylephrine 50 μg if maternal heart rate > 95 beat/min Bradycardia was treated with IV atropine 0.01 mg/kg | |
| Outcomes | Maternal: incidence of hypotension, adverse effects, need for atropine or ephedrine or phenylephrine | |
| Notes | Hypotension defined as SBP < 75% of baseline Bradycardia was defined as heart rate < 45 beat/min | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Randomised by local statistical department |
| Allocation concealment (selection bias) | Low risk | Ondansetron/placebo syringes were prepared by the anaesthetic nurse with no label indicating the group allocation |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Double‐blinded |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 62 women Inclusion criteria: ASA physical status 1 and 2, term singleton pregnancy undergoing elective CS under spinal anaesthesia Exclusion criteria: pre‐existing or pregnancy‐induced hypertension, women with cardiac, renal or other end‐organ disease, women in active labour, placenta praevia, contraindications to neuraxial block, emergency delivery Setting: Tunisia | |
| Interventions | Crystalloid preload versus control Group 1: rapid preload infusion of 20 mL/kg Ringer's lactate, 15 min before the spinal block Group 2: no preload All women received a standardised spinal anaesthetic technique and dose with standardised surgical positioning. Hypotension (requiring intervention) was treated immediately with rapid fluid infusion and ephedrine 6 mg IV and repeated whenever necessary. | |
| Outcomes | Maternal: hypotension; nausea; vomiting; pruritus; dizziness; time to hypotension; heart rate Neonatal: Apgar at 1 min and 5 min | |
| Notes | Hypotension was defined as 20% or more fall below the pre‐induction level, or systolic pressure < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomly assigned"; no further details given |
| Allocation concealment (selection bias) | Unclear risk | "Sealed envelope" |
| Blinding of participants and personnel (performance bias) | Low risk | An independent investigator who recorded all variables was blinded to the anaesthetic technique used (however the paper did not report how this blinding was achieved) |
| Blinding of outcome assessment (detection bias) | Low risk | As above; plus Apgar score was assessed by a paediatrician who was unaware of group assignment |
| Incomplete outcome data (attrition bias) | Low risk | 2/62 – 1 from each group (both due to inadequate sensory level (< T6)) |
| Selective reporting (reporting bias) | Unclear risk | Some maternal outcomes not reported completely; only 1 neonatal outcome reported |
| Other bias | Unclear risk | Similar baseline characteristics |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 150 women Inclusion criteria: absence of any systemic illness or fetal pathology, undergoing CS under spinal anaesthesia | |
| Interventions | Crystalloid preload versus colloid preload versus crystalloid preload + prophylactic ephedrine versus colloid preload + prophylactic ephedrine Group1: Ringer's lactate IV 1000 mL Group 2: Ringer's lactate IV 1000 mL + ephedrine 15 mg Group 3: Ringer's lactate IV 1000 mL + ephedrine 30 mg Group 4: gelatine 500 mL solution Group 5: gelatine 500 mL + ephedrine 15 mg Group 6: gelatine 500 mL + ephedrine 30 mg Unclear whether standardised spinal anaesthetic technique and dose Hypotension treated with additional Ringer's lactate infusions while hypotensive periods longer than 3 min were treated with 5 mg ephedrine IV | |
| Outcomes | Maternal: hypotension; heart rate; nausea; vomiting; vasopressor requirement Neonatal: stated that there were no significant differences in neonatal outcomes, but these outcomes were not described | |
| Notes | Hypotension defined as < 20% of baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not stated |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Unclear risk | Not apparent, but not well reported |
| Other bias | High risk | Variable dose of local anaesthetic used for spinal anaesthesia |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: healthy term women awaiting elective caesarean under spinal anaesthesia | |
| Interventions | Colloid preload versus crystalloid preload Group 1: HES preload, 1000 mL over 15 min Group 2: Ringer's lactate preload, 1500 mL over 15 min All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; heart rate; Doppler measures; ephedrine use | |
| Notes | Hypotension was defined as 20% reduction in SBP | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Methods not described |
| Allocation concealment (selection bias) | Unclear risk | Methods not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Double blind" – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: none reported but losses unlikely |
| Selective reporting (reporting bias) | Unclear risk | Not apparent, but not well reported |
| Other bias | Unclear risk | Not apparent, but not well reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: ASA I‐II women aged 18‐45 having elective LSCS under spinal anaesthesia No exclusion criteria mentioned in abstract Setting: Greece | |
| Interventions | Pre‐spinal anaesthesia IM ephedrine versus delayed IV ephedrine Group 1: ephedrine IM 37.5 mg 15 min before spinal Group 2: ephedrine 15 mg IV 2 min after spinal anaesthesia All women received a standardised crystalloid preload followed by a standardised spinal anaesthetic technique and dose | |
| Outcomes | Maternal: incidence/severity of hypotension | |
| Notes | Hypotension classified as "mild" (decrease of 20% from baseline) or "severe" (decrease of < 30% from baseline) | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Double‐randomised" but no details as to how |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | High risk | Unable to be blinded |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 22 women Inclusion criteria: healthy women undergoing elective CS at term, indications being breech presentation, contracted pelvis or previous CS Exclusion criteria: multiple gestation, fetal and maternal complications and contraindications to spinal anaesthesia, active labour | |
| Interventions | Colloid preload versus crystalloid preload Group 1: 500 mL 6% HES prior to spinal anaesthesia Group 2: 1000 mL Ringer's lactate prior to spinal anaesthesia All women received standardised aspiration prophylaxis, standardised crystalloid coload, standardised spinal anaesthetic and dose, and standardised surgical positioning. | |
| Outcomes | Maternal: hypotension; data expressed as mean (SD) rather than discrete incidence of hypotension; heart rate; CVP; haematocrit; ANP; endothelin‐1 (ET‐1) assays (central and peripheral); blood loss Neonatal: birthweight; umbilical arterial ANP; ET‐1 assays; pH (expressed as mean (SEM)) | |
| Notes | Hypotension defined as SBP < 90 mmHg or less than 80% of baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Methods not described |
| Allocation concealment (selection bias) | Unclear risk | Methods not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 32 women Inclusion criteria: healthy pregnant women undergoing elective caesarean at term (38 to 40 weeks' gestation) with spinal anaesthesia Exclusion criteria: women in labour, hypertension, diabetes, platelet counts < 100,000 mm3, prolonged thromboplastin time, fetal distress, cardiac or pulmonary disease, any medical illness, or a known history of drug abuse | |
| Interventions | Prophylactic angiotensin versus prophylactic ephedrine versus control Group 1: angiotensin II (1000 ng/mL in 0.9% sodium chloride) Group 2: ephedrine (1 mg/mL) Group 3: control (no prophylactic intervention) All women received a standardised crystalloid preload and a standardised spinal anaesthetic technique with slight variation in spinal anaesthetic doses. | |
| Outcomes | Maternal: hypotension (defined as decrease of > 30% from baseline); arterial BP (mean and SD); Neonatal: Apgar scores at 1 min and 5 min (mean and SD); pH < 7.2; umbilical artery pH (mean and SD); umbilical venous pH (mean and SD); pCO2; BE | |
| Notes | Hypotension was defined as a decrease in BP of > 30% from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | "Randomised" but method otherwise not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not stated |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: 2/32 – 1 woman in the control group with a fetal death; 1 woman (group not specified) gave birth before her scheduled procedure |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: healthy women undergoing elective caesarean Exclusion criteria: women with symptoms or signs of labour, prematurity (< 37 weeks' gestation), multiple pregnancy, hypertension, pre‐eclampsia, obesity, intrauterine growth retardation, fetal distress or any other factor contraindicating a standard spinal anaesthetic technique Setting: UK | |
| Interventions | Left lateral versus left lateral tilt Group 1: full left lateral after spinal Group 2: 15 degree left lateral table tilt from supine after spinal Women remained in the study position for 15 min after spinal anaesthesia; women in the left lateral group were then turned into the 15 degree tilt position. All women received a standardised crystalloid preload, a standardised spinal anaesthetic technique and dose, and 6 mg ephedrine IV immediately after insertion of spinal anaesthetic. | |
| Outcomes | Maternal: hypotension; block height; ephedrine dose; nausea; vomiting; bradycardia; maximum percentage decrease in arm SAP; maximum percentage decrease in leg SAP; fetal heart traces Neonatal: Apgar scores (presented as means and ranges); venous cord gases (presented as means only); arterial cord gases (presented as means only) | |
| Notes | Hypotension was defined as SAP of either less than 100 mmHg or less than 80% of baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Stratified by cephalic or breech presentation (separate random‐number lists) |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelopes prepared in advance by a third party |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not stated |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: 2/60 – 1 from each group: in 1 woman, the anaesthetist was unable to site the spinal in the lateral position and the spinal was subsequently successfully inserted in the sitting position; another withdrawal (from the lateral group) was due to inadequate spread of spinal blockade |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: non‐labouring ASA I and II women having non‐urgent CS Exclusion criteria: obesity (weight over 115 kg), height less than 152 cm, diabetes, pregnancy‐induced hypertension, chronic hypertension, heart disease, multiple gestation and age less than 18 or more than 40 years | |
| Interventions | Colloid + crystalloid preload versus crystalloid preload Group 1: 500 mL 6% hetastarch administered prior to induction of spinal anaesthesia Group 2: 1000 mL Ringer's lactate administered prior to induction of spinal anaesthesia All women received a standardised crystalloid infusion after the study drug, a standardised spinal anaesthetic technique and dose, and ephedrine 10 mg IV. | |
| Outcomes | Maternal: hypotension; heart rate; block height; ephedrine dose; nausea and/or vomiting; additional IV fluid prior to birth. Neonatal: Apgar scores < 7; umbilical arterial and venous blood gas (expressed as mean and SD); pH (expressed as mean and SD). | |
| Notes | Hypotension was defined as SBP less than 100 mmHg and less than 80% of baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Low risk | Women and providers blinded – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 105 patients undergoing elective caesarean section Inclusion criteria: term singleton pregnancies, not in labour, elective caesarean, appropriate for spinal anaesthesia Exclusion criteria: pre‐eclampsia, weight > 110 kg, < 150 cm tall, allergy to HES, known fetal abnormalities, contraindication for spinal anaesthesia, sensitive block height that exceeded T4, haemodynamic instability caused by a surgical complication, failed spinal anaesthesia Setting: Tunisia | |
| Interventions | HES vs crystalloid preload Group 1: 500 mL of 6% HES 130/0.4 Group 2: 1500 mL of 9% normal saline solution Both groups received bolus 30 min prior to spinal anaesthesia Both groups received rescue ephedrine | |
| Outcomes | Maternal: hypotension; heart rate; dose of ephedrine; nausea and vomiting Neonatal: umbilical blood pH; Apgar at 1 min and 5 min | |
| Notes | Hypotension defined as a 20% drop in systolic blood pressure from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated |
| Allocation concealment (selection bias) | Unclear risk | Not stated |
| Blinding of participants and personnel (performance bias) | High risk | Not blinded |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not blinded |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Low risk | Most expected outcomes reported |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 20 women Inclusion criteria: healthy parturients undergoing elective CS, term, singleton pregnancies, cephalic presentation, not more than 90 kg Exclusion criteria: medical or obstetric complications or evidence of placental dysfunction | |
| Interventions | Crystalloid preload: comparison of different rates of infusion Group 1: plasmalyte‐L 20 mL/kg infused over 20 min prior to spinal anaesthesia Group 2: plasmalyte‐L 20 mL/kg infused over 10 min prior to spinal anaesthesia All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; heart rate; CVP; spinal to birth time; uterine incision to birth time; block height at 5 min; ephedrine dose Neonatal: Apgar scores (minus colour) at 2 and 5 min; umbilical arterial and venous blood gas and pH (data incomplete) | |
| Notes | Hypotension was defined as SBP less than 100 mmHg and less than 80% of baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women Inclusion criteria: ASA I parturients undergoing elective repeat CS with uncomplicated singleton pregnancy and weight less than 90 kg at term Exclusion criteria: not specified | |
| Interventions | Lower leg compression versus leg elevation versus control Group 1: legs horizontal but wrapped from toe to mid‐thigh with rubber Esmarch bandages with preservation of pedal pulses Group 2: legs elevated on 4 pillows at 30 degrees to horizontal Group 3: control – neither wrapped nor raised All women received a standardised crystalloid preload and a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; diastolic BP; heart rate; onset of hypotension; ephedrine dose; spinal to birth time; uterine incision to birth time Neonatal: umbilical arterial and venous blood gas; pH < 7.25; Apgar scores minus colour at 2 min and 5 min | |
| Notes | Hypotension defined as defined as SBP less than 100 mmHg and less than 80% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: 3/100 – 2 women had an inadequate block and 1 woman had a high block (groups not specified) |
| Selective reporting (reporting bias) | Unclear risk | Not apparent |
| Other bias | Unclear risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 56 women Inclusion criteria: ASA I, age 20‐40, elective LSCS Exclusion criteria: contraindications to SAB, patient refusal, unstable haemodynamics, coagulopathy, history of hypersensitivity to ondansetron or local anaesthetic agents, hypertensive disorders of pregnancy, cardiovascular insufficiency, receiving selective serotonin reuptake inhibitors or migraine medications Setting: India | |
| Interventions | Pretreatment with ondansetron versus placebo Group 1: IV ondansetron 4 mg diluted in 10 mL of normal saline given over 1 min, 5 min before spinal anaesthesia Group 2: 10 mL of normal saline IV given over 1 min, 5 min before spinal anaesthesia | |
| Outcomes | Maternal: hypotension, decrease in BP, decrease in heart rate, nausea and vomiting Neonatal: none | |
| Notes | Hypotension: SBP < 90 mmHg or DBP < 60 mmHg Bradycardia: heart rate < 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation chart |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Low risk | Blinded anaesthetist assessing outcomes |
| Incomplete outcome data (attrition bias) | Low risk | Not apparent |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: healthy women awaiting elective caesarean under spinal anaesthesia | |
| Interventions | Colloid vs crystalloid preload Group 1: HES 6% w/v 500 mL Group 2: HES 6% w/v 1000 mL Group 3: Hartmann's solution 1500 mL All women were placed in the left lateral position and fluid was then preloaded over 15 min. All women received a standardised anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; heart rate; BP; ephedrine use Neonatal: cord gases | |
| Notes | Hypotension defined as 20% reduction in SBP | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | "Double blind" – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | "Double blind" – no further details |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Unclear risk | Not apparent, but not well reported |
| Other bias | Unclear risk | Not apparent, but not well reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: non‐labouring ASA class I and II women scheduled for elective caesarean Exclusion criteria: obesity (> 115 kg), height > 152 cm, diabetes, pregnancy‐induced hypertension, chronic hypertension, heart disease, multiple gestation, breech presentation, age < 18 or > 40 and SBP < 100 mmHg Setting: Lebanon | |
| Interventions | Colloid v crystalloid preload Group 1: HES 10%, 500 mL Group 2: Ringer's lactate 1000 mL All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; block height; ephedrine dose; heart rate; BP; nausea; vomiting Neonatal: Apgar scores; venous and arterial blood gases | |
| Notes | Hypotension was defined as SBP < 80% baseline or < 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Randomisation method not described |
| Allocation concealment (selection bias) | Unclear risk | "Drawing shuffled sealed envelopes" |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: nurses placed a brown paper bag over the IV solution to conceal its identity from the anaesthetist |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Unclear risk | Not apparent |
| Other bias | Unclear risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 183 women Inclusion criteria: non‐labouring women, > 37 weeks' gestation, ASA I or II scheduled for elective caesarean Exclusion criteria: pregnancy‐induced hypertension, chronic hypertension, multiple gestation, known fetal compromise, diabetes mellitus, polyhydramnios, weight > 100 kg, major systematic disease, anaemia (haemoglobin concentration < 10 g/dL), or clotting diathesis Setting: Lebanon | |
| Interventions | Colloid preload versus colloid coload Group 1: colloid preload: preload of 500 mL HES (6% HES 130/0.4), administered by gravity at a wide open rate over 15‐20 min before spinal anaesthesia Group 2: colloid coload: coload of 500 mL of HES (6% HES 130/0.4) administered using a pressure infusion system at the maximum possible rate, commenced at the time of identification of CSF All women received a standardised spinal anaesthetic technique and dose, a standardised crystalloid infusion after spinal anaesthetic, and a standardised oxytocin regimen after delivery. Hypotension requiring intervention was managed with 6 mg IV bolus of ephedrine if heart rate < 90 bpm or 0.1 mg phenylephrine IV bolus if heart rate > 90 bpm. | |
| Outcomes | Maternal: hypotension; minimum SBP; maximum heart rate; time to hypotension; ephedrine dose; phenylephrine dose; nausea and/or vomiting; metoclopramide administration; total Ringer's lactate; duration of infusion; duration of surgery; sensory block level; duration of anaesthesia Neonatal: birthweight; Apgar score; umbilical vein pH, pO2, pCO2, BE; umbilical artery pH, pO2, pCO2, BE | |
| Notes | Hypotension was defined as the administration of at least 1 dose of vasopressor. Severe hypotension was defined as SBP < 80 mmHg. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated table of random numbers |
| Allocation concealment (selection bias) | Unclear risk | "Randomised" – no further details provided |
| Blinding of participants and personnel (performance bias) | Low risk | Woman, anaesthetist performing the spinal block, collecting the data and treating adverse effects, and the paediatrician assessing neonatal outcomes were all unaware of group allocation. The infusion bag was prepared and hidden behind a drape and administered by a nurse who was not involved in anaesthetic management (and who decided when the woman should sit up for spinal anaesthesia). To maintain blinding, this occurred after completion of colloid administration in the preload group (lasting ~15‐20 min) or 15‐20 min from starting the Ringer's lactate in the coload group. |
| Blinding of outcome assessment (detection bias) | Low risk | See above |
| Incomplete outcome data (attrition bias) | Low risk | 5/183 women were excluded after randomisation due to protocol violations (2 from the preload group and 3 from the coload group) |
| Selective reporting (reporting bias) | Unclear risk | Most expected outcomes reported but some (all neonatal outcomes) not reported in a form that could be used in this review (e.g. medians, and average for Apgar scores) |
| Other bias | Low risk | No apparent risk of other sources of bias |
| Study characteristics | ||
| Methods | Randomised, quasi‐experimental observational cohort study | |
| Participants | 60 patients Exclusion criteria: pregnancy‐induced high BP, high‐risk pregnancy, fetal distress, moderate to severe anaemia, patient refusal, infection at site of injection, bleeding diathesis, severe hypovolaemia, elevated intracranial pressure, spine deformity and patients with major systemic illness Setting: India | |
| Interventions | Crystalloid versus colloid preload Group 1: 20 mL/kg Ringer's lactate preloading over 20 min just prior to SAB Group 2: 10 mL/kg HES 130/0.4 (up to a max 500 mL) preloading over 20 min just prior to SAB | |
| Outcomes | Maternal: haemodynamics/observations, urine output, duration of surgery, uterine incision‐delivery time, SAB complications, "undesirable effects" from HES including "anaphylactoid" reactions, pruritis, bleeding Neonatal: Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as a fall in SAP > 30% of baseline or SAP < 90 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not reported |
| Other bias | Unclear risk | Not reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 60 women Inclusion criteria: singleton uncomplicated pregnancy, ASA I‐II, elective caesarean under spinal anaesthesia Setting: unknown | |
| Interventions | Leg wrapping versus no leg wrapping Group 1: no leg wrapping Group 2: leg wrapping with crepe bandage (15 cm width, 4 m stretched length) from ankle to mid‐thigh level over both legs. During wrapping, lower extremities were lifted at a 45 degree angle Crepe bandages were wrapped tightly enough that the woman felt the tightness, yet it was comfortable and not painful. All patients had their legs wrapped by the same person in 3 min to eliminate bias introduced by method or altered force of wrapping. Legs were hidden to ensure blinding. All women received the same aspiration prophylaxis, monitoring, 20 mL/kg IV Ringer's lactate fluid preloading over 15‐20 min prior to spinal anaesthesia, spinal anaesthetic technique and dose. Hypotension was treated with 50 μg IV phenylephrine bolus and an increase in rate of IV fluid infusion. | |
| Outcomes | Maternal: incidence of hypotension | |
| Notes | Hypotension was defined as a fall in SBP to < 90 mHg. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Generation of random sequence not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Low risk | Personnel blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Personnel blinded |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: primiparous, full‐term parturients, aged 18‐40 years, ASA I, scheduled for elective CS Exclusion criteria: refusal of regional anaesthesia, contraindications to spinal anaesthesia, fetal abnormalities, known allergy to any of the drugs used in the study, pregnancy‐induced hypertension or parturients with SBP > 140 mmHg, history of diabetes mellitus, cardiovascular or cerebrovascular and any chronic diseases Setting: India | |
| Interventions | Ephedrine versus control Group 1: 1 mL 5 mg ephedrine IV immediately after SAB Group 2: 1 mL 0.9% NaCl IV immediately after SAB All women received standardised monitoring, standardised crystalloid IV fluid, standardised spinal anaesthetic technique and dose. Treatment of hypotension involved rapid infusion of Ringer's lactate and 5 mg IV ephedrine. Bradycardia treated with 0.6 mg IV atropine sulfate. | |
| Outcomes | Maternal: incidence of hypotension, reactive hypertension, number of patients requiring rescue ephedrine, total dose of rescue ephedrine (mg), bradycardia, nausea/vomiting, average time to delivery Neonatal: Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as a decrease in SBP of > 20% Bradycardia was defined as heart rate < 60 bpm Reactive hypertension: SBP > 140 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation |
| Allocation concealment (selection bias) | Unclear risk | Not mentioned |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blinded. Study solution prepared by person not involved in the study |
| Blinding of outcome assessment (detection bias) | Low risk | Study staff recorded outcomes |
| Incomplete outcome data (attrition bias) | Low risk | All patients completed protocol |
| Selective reporting (reporting bias) | Low risk | Not evident |
| Other bias | Unclear risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: ASA I or II parturients undergoing elective CS at term Exclusion criteria: history of cardiovascular disease or contraindication to spinal, body weight > 90 kg and/or thigh circumference > 62 cm | |
| Interventions | Lower limb compression versus control Group 1: TED stockings applied 1 hour preoperatively from toes to mid‐thigh according to manufacturer's guidelines Group 2: no compression All women received standardised crystalloid preload, standardised spinal anaesthetic technique with dose adjusted according to subject's height. | |
| Outcomes | Maternal: hypotension; diastolic BP and MAP; heart rate; SpO2 Neonatal: Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as a SBP < 90 mmHg or a decrease in SBP more than 20% from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not mentioned |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not mentioned |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up not stated |
| Selective reporting (reporting bias) | Unclear risk | Not apparent |
| Other bias | Unclear risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 75 women Inclusion criteria: healthy women (55 of whom had experienced at least 1 previous birth) undergoing elective CS during spinal anaesthesia Exclusion criteria: history of nausea and vomiting associated with previous surgery or anaesthesia; nausea or vomiting within 24 h prior to caesarean, history of diabetes mellitus, or morbid obesity | |
| Interventions | Acupressure versus metoclopramide versus placebo Group 1: acupressure bands + 2 mL IV saline Group 2: placebo wrist bands + 10 mg metoclopramide Group 3: placebo wrist bands + 2 mL IV saline Acupressure defined as pressure on the Neiguan (P6) acupuncture points of the wrist. All women received a standardised preload of 1500‐2000 mL Ringer's lactate in addition to a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; nausea (score > 2); vomiting; anxiety Neonatal: Apgar score < 7 at 5 min | |
| Notes | Hypotension was defined as a decrease in SBP more than 20% from baseline or < 100 mmHg. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | "Envelope system" – no further details |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: wrist bands were placed bilaterally by an anaesthetist not directly involved in the women's care. The acupressure bands were lightly covered with gauze and tapes so they could not be distinguished from the placebo bands. |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women Inclusion criteria: ASA I‐II, elective CS under SAB Exclusion criteria: contraindication to SAB, peripartum bleeding > 1 L, multiple gestation, polyhydramnios, gestation < 37 weeks, any patient considered at high risk of DVT Setting: India | |
| Interventions | Mechanical lower limb compression versus control Group 1: mechanical pump with thigh‐level cuff applied to lower limbs in all subjects and switched on Group 2: mechanical pump with thigh‐level cuff applied to lower limbs in all subjects but not switched on All women received standardised aspiration prophylaxis, standardised monitoring, standardised spinal anaesthetic technique and dose, standardised crystalloid coloading and maintenance, standardised positioning and standardised oxytocic administration. Hypotension was treated with IV ephedrine 6 mg, repeated every 3 min as needed. | |
| Outcomes | Maternal: BP, heart rate, SpO2 recorded every 3 min for 1 h. Total volume of IV fluid given, total ephedrine dose Neonatal: Apgar scores | |
| Notes | Hypotension defined as a decrease in SBP > 20% baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelope |
| Blinding of participants and personnel (performance bias) | Low risk | Anaethetist caring for women during caesarean blinded. Possible that blinding may have been broken |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Group 1 – 3 women excluded due to pregnancy‐induced hypertension Group 2 – 5 women excluded due to pregnancy‐induced hypertension |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women Inclusion criteria: ASA I or II women undergoing elective CS | |
| Interventions | Lower limb compression versus control Group 1: TED stockings applied before arrival in theatre and lower limb sequential compression device inflated immediately after spinal injection Group 2: no mechanical prophylaxis All women received a standardised spinal anaesthetic technique with dose adjusted according to subject's height. Hypotension was managed with a standardised ephedrine regimen. | |
| Outcomes | Maternal: hypotension; systolic, diastolic and mean BP; level of sensory block; ephedrine requirement; time to first episode of hypotension Neonatal: Apgar scores at 1 min and 5 min (expressed as n with score < 9); umbilical artery pH (expressed as mean (SD)) | |
| Notes | Hypotension defined as SBP < 100 mmHg or fall of > 20% from baseline Lack of blinding acknowledged Protocol violations acknowledged | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | High risk | Neither participants nor investigators blinded |
| Blinding of outcome assessment (detection bias) | High risk | As above |
| Incomplete outcome data (attrition bias) | High risk | Losses to follow‐up: no dropouts but 46/100 protocol violations (ephedrine administered in error on 17 occasions (9 intervention, 8 control), ephedrine omitted in error on 29 occasions (10 intervention, 19 control) |
| Selective reporting (reporting bias) | Unclear risk | Not apparent |
| Other bias | Unclear risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 210 women Inclusion criteria: elective caesarean, ASA I‐II, singleton pregnancy Exclusion criteria: age < 19 or > 40 years, height < 150 or > 185 cm, weight < 60 or > 100 kg, BMI > 40 kg/m², chronic or pregnancy‐induced hypertension, baseline SBP < 100 or > 140 mmHg, diabetes mellitus, cardiovascular, cerebrovascular or renal disease, haemoglobin < 100g/L, patients in labour, any contraindication to spinal anaesthesia, preterm (< 37 weeks gestation), multiple pregnancy, polyhydramnios or known fetal abnormalities Setting: Egypt | |
| Interventions | Colloid preload versus crystalloid coload Group 1: colloid preload – 6% HES 130/0.4 in 0.9% sodium chloride 500 mL within 15 min before induction of spinal anaesthesia Group 2: crystalloid coload – 1000 mL of Ringer's acetate using a pressuriser as rapidly as possible starting at time of intrathecal injection All women received IV cannulation, routine monitoring, a standardised crystalloid infusion after administration of study solution, a standardised spinal anaesthetic technique and dose. Hypotension was treated with IV ephedrine 5 mg bolus. Severe hypotension was treated with 10 mg IV ephedrine. Bradycardia was treated with IV atropine 0.5 mg. | |
| Outcomes | Maternal: hypotension, bradycardia, nausea and vomiting Neonatal: Apgar scores at 1 min and 5 min and umbilical cord gases | |
| Notes | Hypotension defined as SBP < 80% baseline or < 90 mmHg Severe hypotension: SBP < 80 mmHg Maternal bradycardia defined as heart rate < 50 bpm | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random numbers |
| Allocation concealment (selection bias) | Low risk | Sequentially numbered opaque sealed envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blinded. Anaesthetists, women, and neonatologists blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Double‐blinded. Outcomes recorded by anaesthetists and neonatologists |
| Incomplete outcome data (attrition bias) | Low risk | 5 patients excluded due to failed spinal or protocol violation |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 22 women Inclusion criteria: healthy women with uncomplicated singleton pregnancies at 36‐40 weeks' gestation, not in labour, undergoing elective caesarean under spinal anaesthesia | |
| Interventions | Crystalloid: high versus low volume preload Group 1: 15 mL/kg Ringer's lactate Group 2: 150 mL Ringer's lactate All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; ephedrine dose Neonatal: pulsatility indices; pH (mean and SD); Apgar score at 1 min, 5 min, and 10 min (mean and SD); NACS | |
| Notes | Hypotension was defined as decrease in SBP of more than 20% from baseline. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Low risk | Adequate: drawing of sealed consecutive opaque sealed envelopes a day before surgery |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not stated |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: not stated but losses unlikely |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 91 women Inclusion criteria: elective CS Exclusion criteria: diabetes, chronic hypertension, gestational hypertension, pre‐eclampsia, cardiac disease, patients with long QT syndrome and known contraindications to spinal anaesthesia Setting: USA | |
| Interventions | Ondansetron versus control Group 1: received 8 mg ondansetron diluted in 10 mL in 0.9% NaCl Group 2: received 10 mL of 0.9% NaCl Study drug was administered over a period of 5 min whilst in sitting position, prior to SAB. All women received standardised aspiration prophylaxis, standardised colloid preload, standardised crystalloid maintenance fluid, standardised monitoring, standardised spinal anaesthetic technique and dose, standardised positioning. Hypotension was managed with boluses of 100 μg of phenylephrine administered incrementally until SBP > 90 mmHg. Bradycardia was managed with 0.4 mg atropine or 0.2 mg glycopyrrolate. | |
| Outcomes | Maternal: incidence of hypotension, incidence of bradycardia, amount of vasopressor and anticholinergic agents given, pruritus, nausea and vomiting, extent of sensory block, estimated blood loss, total fluid administered Neonatal: Apgar scores | |
| Notes | Hypotension was defined as SBP < 90 mmHg or 20% drop in SBP from baseline. Bradycardia was defined as heart rate < 60 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation |
| Allocation concealment (selection bias) | Unclear risk | Not clear |
| Blinding of participants and personnel (performance bias) | Low risk | Drugs prepared by pharmacist |
| Blinding of outcome assessment (detection bias) | Low risk | All research personnel were blinded. |
| Incomplete outcome data (attrition bias) | Low risk | Group 1: 4 excluded (3 due to protocol violation, 1 due to failed SAB) Group 2: 1 excluded (due to protocol violation) |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | None evident |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: scheduled for elective CS Exclusion criteria: contraindications to spinal anaesthesia, fetal or maternal pathology and known allergy to the drugs being administered | |
| Interventions | Ephedrine versus control Group 1: ephedrine IV 8 mg Group 2: placebo (saline) Study drugs were given at the same time as spinal anaesthetic. All women received a preload of 10 mL/kg Ringer's lactate, a prophylactic dose of 8 mg of ephedrine prior to intrathecal injection, a standardised spinal anaesthetic technique and dose, and standardised positioning for surgery. | |
| Outcomes | Maternal: hypotension; dose of local anaesthetic; level of block; surgical time; BP; heart rate; nausea; vomiting; total ephedrine dose; postdural puncture headache Neonatal: Apgar score at 1 min and 5 min | |
| Notes | Hypotension was defined as decrease in SBP of 20% or more. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Double‐blind but details not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Double‐blind but details not reported |
| Incomplete outcome data (attrition bias) | Low risk | Not apparent |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 80 women Inclusion criteria: ASA I, elective caesarean, primipara, term pregnancy Exclusion criteria: emesis gravidarum, contraindication to spinal anaesthesia (patient refusal, unstable haemodynamic, and coagulation abnormalities), chronic hypertension or pre‐eclampsia, morbid obesity, and/or any study drugs allergy Setting: Tunisia | |
| Interventions | Prophylactic ondansetron versus control Group 1: 4 mg IV ondansetron in 10 mL saline, 5 min before spinal puncture Group 2: 10 mL saline, 5 min before spinal puncture All women received the same monitoring, standardised crystalloid preload before spinal anaesthesia, spinal anaesthetic technique and dose. Hypotension was treated with 100 mL crystalloid and 6 mg ephedrine IV. Bradycardia was treated with fluids and ephedrine up to 25 mg, If did not resolve within 30 s of treatment, IV atropine 0.5 mg IV given every 30 s until resolution | |
| Outcomes | Maternal: incidence of hypotension, nausea and vomiting Neonatal: Apgar scores, umbilical cord gases | |
| Notes | Hypotension was defined as a decrease from baseline > 20% in systolic pressure. Bradycardia was defined as 30% drop in heart rate or < 45 bpm. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Random sequence generated by website: www.random.org |
| Allocation concealment (selection bias) | Low risk | Anaesthetic nurse prepared solution according to group allocation on above website |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blinded |
| Blinding of outcome assessment (detection bias) | Low risk | Double‐blinded |
| Incomplete outcome data (attrition bias) | Low risk | No data loss |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: ASA I and II women not in labour undergoing elective caesarean for term uncomplicated singleton pregnancies, taking only prenatal vitamins and weighing less than 100 kg Exclusion criteria: women with cardiac, pulmonary or renal diseases, or systemic diseases that could influence haemodynamic responses, including pre‐eclampsia, hypertension and diabetes; if women were taking or had a history of taking any medications that could influence haemodynamic responses, including magnesium sulphate, terbutaline or beta‐blockers | |
| Interventions | Ephedrine versus control Group 1: ephedrine 2 mL IV (10 mg) given simultaneously with spinal anaesthetic Group 2: saline 2 mL IV given simultaneously with spinal anaesthetic All women received a standardised crystalloid preload and a standardised spinal anaesthetic technique and dose, followed by standardised surgical positioning. Hypotension was treated with 10 mg IV doses of ephedrine. | |
| Outcomes | Maternal: hypotension; MAP; heart rate; tachycardia (ephedrine group only); hypertension (ephedrine group only); systemic vascular resistance index; stroke index; cardiac index Neonatal: Apgar score < 8 at 5 min | |
| Notes | Hypotension was defined as 20% decrease in MAP | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelopes |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: double‐blind – Apgar scored by a paediatrician blinded to the study – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 30 women Inclusion criteria: healthy women at term undergoing elective CS under spinal anaesthesia Exclusion criteria: active labour, rupture of amniotic membranes, chronic or pregnancy‐induced hypertension, insulin‐dependent diabetes mellitus, multiple gestation, oligohydramnios and preoperative diagnosis of small for gestational age fetus | |
| Interventions | Ephedrine infusion versus ephedrine bolus Group 1: ephedrine infusion IV 5 mg/min commenced immediately after intrathecal injection Group 2: control – ephedrine bolus 10 mg administered if hypotension developed All women received standardised positioning, standardised crystalloid preload, a standardised spinal anaesthetic technique with the dose adjusted according to subject's height. | |
| Outcomes | Maternal: hypotension); nausea and vomiting; BP; heart rate; arterial blood | |
| Notes | Hypotension defined as 20% decrease from baseline (measured prior to fluid preload) | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Sealed envelopes |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not stated |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 100 women (60 non‐labouring women scheduled for elective caesarean and 40 labouring women for emergency caesarean) Exclusion criteria: women with placenta praevia, abruptio placenta; toxaemia | |
| Interventions | Ephedrine (various doses) versus control Group1: ephedrine 5 mg Group 2: ephedrine 10 mg Group 3: no ephedrine Ephedrine was administered with the spinal. All women received a standardised preload of 1000 mL Ringer's lactate, a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; SAP | |
| Notes | Hypotension was defined as SAP lower than 80 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Methods not described |
| Allocation concealment (selection bias) | Unclear risk | Methods not describe |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not stated |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 36 women Inclusion criteria: healthy full‐term parturients scheduled for elective caesarean during spinal anaesthesia | |
| Interventions | Colloid preload versus crystalloid preload Group 1: 500 mL HES 6% Group 2: 1000 mL HES 6% Group 3: 1500 mL Ringer's lactate All solutions were infused over 30 min before injection of spinal anaesthesia. All women received a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; blood volume; cardiac output | |
| Notes | Hypotension defined as defined as decrease in SBP to less than 100 mmHg and less than 80% of baseline value | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Randomisation by random envelope method |
| Allocation concealment (selection bias) | High risk | No allocation concealment. Infusion bottle shape different between study groups |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Not apparent, but not well reported |
| Other bias | Unclear risk | Not apparent, but not well reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 20 women Inclusion criteria: healthy women scheduled for elective caesarean during spinal anaesthesia | |
| Interventions | Prophylactic ephedrine versus prophylactic phenylephrine Group 1: 40 mg ephedrine Group 2: 250 µg phenylephrine All women were given Ringer's lactate at a rate of 100 mL/hour immediately after ephedrine or phenylephrine. All women received a standardised spinal anaesthetic technique and dose followed by standardised surgical positioning. | |
| Outcomes | Maternal: hypotension; cardiac output | |
| Notes | Hypotension defined as a drop in SBP of > 20% and < 100 torr | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Methods not described |
| Allocation concealment (selection bias) | Unclear risk | Methods not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding: "in a double‐blind fashion" – no further details |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Not reported |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 90 women Inclusion criteria: ASA I/II, singleton uncomplicated pregnancy at full term gestation undergoing elective CS under spinal anaesthesia Exclusion criteria: significant co‐existing disease such as pre‐eclampsia and hepato‐renal disease, pregnancy pre‐induced hypertension, being in active labour or requiring emergency CS, any contraindication to regional anaesthesia such as local infection or bleeding disorders Setting: Turkey | |
| Interventions | Rapid crystalloid coload versus rapid colloid coload versus slow crystalloid coload Group 1: 1000 mL Ringer's lactate at maximum rate Group 2: 1000 mL 6% HES at maximum rate Group 3: 1000 mL Ringer's lactate at minimum rate All fluids were commenced immediately after induction of spinal anaesthesia. All women received standardised fasting regimen, standardised monitoring, standardised cannulation, standardised crystalloid coload (10 mL/kg/hour) via a separate cannula, standardised spinal anaesthetic technique and dose, standardised positioning, standardised oxygen therapy. Hypotension was treated with IV ephedrine 10 mg. If heart rate was < 50 bpm, 0.5 mg atropine was administered IV. | |
| Outcomes | Maternal: incidence of hypotension, total fluid volumes, ephedrine requirements, bradycardia, hypoxaemia, excessive sedation, pruritis, dizziness, nausea and vomiting Neonatal: umbilical artery pH/PaO2/PaCO2/HCO3‐, Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as SBP < 80% of baseline (prenatal) or < 90 mmHg. Bradycardia was defined as heart rate < 50 bpm. Hypoxaemia was defined as SpO2 < 95%. | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated randomisation |
| Allocation concealment (selection bias) | Low risk | Fluid in non‐transparent bag |
| Blinding of participants and personnel (performance bias) | Low risk | Double‐blind |
| Blinding of outcome assessment (detection bias) | Low risk | Assessors blinded to patient group. "Demographic data (age, height, weight, parity and gravity) and duration of surgery were noted by an observer blinded to the treatment group. Systolic and diastolic blood pressures (SBP, DBP), heart rate and peripheral oxygen saturation (SpO2) were recorded by an anaesthetist blinded to the patient group." |
| Incomplete outcome data (attrition bias) | Low risk | No losses to follow‐up |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | None identified |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: non‐labouring ASA I/II undergoing elective CS Exclusion criteria: patients aged < 18 years or > 40 years, weighing > 100 kg, height < 152 cm, associated diabetes mellitus, pregnancy‐induced hypertension, chronic hypertension, heart disease, multiple gestation, breech presentation, SBP < 100 mmHg, patients who had received IV fluids prior to surgery Setting: India | |
| Interventions | Crystalloid preload versus colloid preload Group 1 crystalloid preload: 1000 mL Ringer's lactate Group 2 colloid preload: 500 mL 6% hetastarch Fluids were administered 30 min prior to surgery. All women received standardised aspiration prophylaxis, standardised cannulation, standardised monitoring, standardised spinal anaesthetic technique and dose, standardised positioning, standardised oxygen therapy. Hypotension was managed with IV boluses of 5 mg of ephedrine, repeated every 2 min as required. | |
| Outcomes | Maternal: incidence of hypotension, nausea/vomiting, interval between spinal injection and delivery Neonatal: Apgar scores | |
| Notes | Hypotension was defined as SBP < 100 mmHg and < 80% baseline BP | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not specified |
| Allocation concealment (selection bias) | Unclear risk | Not specified |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not specified |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not specified |
| Incomplete outcome data (attrition bias) | Low risk | No evidence of losses to follow‐up |
| Selective reporting (reporting bias) | Low risk | Not evident |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 50 women Inclusion criteria: singleton pregnancy, ASA I or II, presenting for elective caesarean at term Exclusion criteria: height < 152 cm, multiple pregnancy, pregnancy‐induced hypertension, placenta praevia, diabetes mellitus, maternal refusal, clotting disorder, fixed cardiac output disease, pre‐existing neurological disease, local and systemic sepsis, and allergy to local anaesthetics | |
| Interventions | Glycopyrrolate versus control Group 1: glycopyrrolate 200 µg Group 2: saline (placebo) All women received the study drug with a standardised crystalloid preload (15 mL/kg). All women received a standardised spinal anaesthetic technique and dose followed by standardised surgical positioning. | |
| Outcomes | Maternal: hypotension; nausea; nausea severity score; nausea episodes per woman; vomiting; ephedrine dose; heart rate; duration of operation; time to block; blood loss Neonatal: birthweight; Apgar score | |
| Notes | Hypotension defined as decrease in SAP 20% or more from baseline or absolute decrease to less than 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: "double‐blind"; "both glycopyrrolate and saline were given as 1 mL of clear fluid and therefore the participant and researcher were blinded to the randomization" |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | Losses to follow‐up: 1 woman in the glycopyrrolate group refused subarachnoid anaesthesia after the study drug had been given |
| Selective reporting (reporting bias) | Low risk | Not apparent |
| Other bias | Low risk | Not apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 150 women Inclusion criteria: primiparous, single fetus, elective caesarean, age 18‐35 years, 37‐40 weeks gestation, ASA I‐II, normal prenatal exam, normal liver and renal function, normal fetal screening, no medical history of heart or lung disease Setting: China | |
| Interventions | Comparison of different doses of prophylactic ondansetron versus control 5 min prior to spinal anaesthesia, women were given (all diluted to 5 mL with physiological saline): Group 1: 5 mL physiological saline Group 2: 2 mg ondansetron Group 3: 4 mg ondansetron Group 4: 6 mg ondansetron Group 5: 8 mg ondansetron All women received no premedication, routine monitoring, cannulation, a standardised crystalloid coload, and a standardised spinal anaesthetic technique and dose Treatment of hypotension consisted of administration of IV bolus of 100 μg phenylephrine | |
| Outcomes | Maternal: hypotension, treatment for hypotension/bradycardia, nausea and vomiting Neonatal: cord gases, Apgar score at 1 min and 5 min | |
| Notes | Hypotension defined as systolic pressure < 80% of baseline | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated codes |
| Allocation concealment (selection bias) | Unclear risk | Not mentioned |
| Blinding of participants and personnel (performance bias) | Low risk | Ondansetron and saline solutions were prepared by an anaesthetist who was blinded to this study. |
| Blinding of outcome assessment (detection bias) | Low risk | As above |
| Incomplete outcome data (attrition bias) | Low risk | None reported |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 66 women Inclusion criteria: primiparous, singleton pregnancy, elective caesarean, age 18‐35, 37‐42 weeks' gestation, ASA I‐II, normal prenatal examinations, normal renal and liver function, no medical history of heart or lung disease, no fetal abnormalities Exclusion criteria: hypertension, cardiovascular or cerebrovascular disease, placenta praevia, abnormal fetal development, contraindications to spinal anaesthesia, endocrine disorders, recent administration of 5‐HT reuptake inhibitors or drugs for treatment of migraines Setting: China | |
| Interventions | Prophylactic ondansetron versus control 5 min prior to spinal anaesthesia: Group 1: 4 mg IV ondansetron (diluted to 5 mL with physiological saline) Group 2: 5 mL IV physiological saline All women received the same standardised monitoring, cannulation, spinal anaesthetic technique and dose, standardised crystalloid coload and postdelivery oxytocin If hypotension occurred, 100 μg IV phenylephrine was administered, and repeated every 2 min as required until SBP > 80% baseline If bradycardia occurred, 0.5 mg IV atropine was administered If SpO2 < 95%, mask assisted O2 inhalation was given at 3 L/min If nausea or vomiting occurred, 12.5 mg IV promethazine was administered If intractable pain, assisted anaesthetics were added or GA performed and patient was excluded | |
| Outcomes | Maternal: incidence of hypotension, bradycardia, nausea and vomiting, peak block height, total consumption of phenylephrine Neonatal: umbilical cord gases, Apgar scores at 1 min and 5 min | |
| Notes | Hypotension was defined as maternal SBP < 80% baseline Bradycardia was defined as heart rate < 50 bpm Hypertension was defined as SBP > 140 mmHg or DBP > 90 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated |
| Allocation concealment (selection bias) | Low risk | Opaque, sealed, sequentially numbered envelopes |
| Blinding of participants and personnel (performance bias) | Low risk | Study drugs prepared by anaesthetist not directly involved in the patient scare or assessment. Solutions were in syringes of similar appearance, labelled study drug |
| Blinding of outcome assessment (detection bias) | Low risk | As above, anaesthetist was blinded |
| Incomplete outcome data (attrition bias) | Low risk | Group 1: 1 woman excluded from BP analysis due to intractable shivering preventing BP measurement, 2 women excluded from blood gas analysis due to insufficient samples Group 2: 1 woman completely excluded due to failed spinal anaesthesia, 2 women excluded from blood gas analysis because of insufficient samples |
| Selective reporting (reporting bias) | Low risk | None apparent |
| Other bias | Low risk | None apparent. Grant from Wuxi Municipal Health Bureau |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 40 women Inclusion criteria: parturients receiving spinal anaesthesia for elective CS Exclusion criteria: impalpable lumbar spines, baseline BP > 150/90, coagulopathy, sepsis, hypovolaemia | |
| Interventions | Ephedrine versus control Group 1: ephedrine 37.5 mg IM in 1.5 mL saline administered prior to spinal anaesthesia Group 2: placebo 1.5 mL saline IM in deltoid muscle administered prior to spinal anaesthesia All women received a standardised crystalloid preload, and a standardised spinal anaesthetic technique and dose. | |
| Outcomes | Maternal: hypotension; hypertension; heart rate Neonatal: Apgar scores at 5 min; umbilical vein pH (expressed as mean and SD) | |
| Notes | Hypotension was defined as a decrease in SBP < 100 mmHg OR > 70% baseline Hypertension was defined as SBP > 30% above baseline, but no intervention reported | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Unclear risk | Blinding not stated |
| Blinding of outcome assessment (detection bias) | Unclear risk | Blinding not state |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 70 women Inclusion criteria: pregnant women (ASA I or II) undergoing elective CS | |
| Interventions | Glucose versus crystalloid preload Group 1: glucose 5% IV Group 2: normal saline IV Administered at 125 mL/h prior to spinal anaesthesia Unclear whether all women received the same anaesthetic technique and dose | |
| Outcomes | Maternal: hypotension; total study solution received; total IV preload; glucose levels Neonatal: Apgar scores; umbilical cord gases | |
| Notes | Hypotension was defined as SBP > 20% decrease | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Method not described |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: study solutions "were enclosed in an opaque bag to maintain blinding"; "double‐blind" |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: not stated |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | High risk | Variable dose of local anaesthetic used for spinal anaesthesia |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 120 women Inclusion criteria: ASA I‐II singleton pregnancy, able to speak English, undergoing elective CS Exclusion criteria: morbid obesity, glucose intolerance, taking vasoactive medication or that known to alter glucose metabolism | |
| Interventions | Comparison of dextrose 5% versus normal saline as a crystalloid preload Group 1: dextrose 5% in normal saline at 125 mL/h IV for 2 hours before surgery Group 2: normal saline at same rate All women received a standardised crystalloid preload after the study drug (normal saline 15 mL/kg) followed by a standardised anaesthetic technique and dose, and standardised surgical positioning | |
| Outcomes | Maternal: hypotension; serial blood glucose measurements; preoperative fasting time; total fluid volume administered; block height; spinal‐birth time Neonatal: Apgar scores at 1 min, 5 min, and 10 min; umbilical venous and arterial blood gas; pH; lactate and glucose (generally expressed as mean (SD)) | |
| Notes | Hypotension defined as a decrease in SBP > 20% or BP less than 100 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated table |
| Allocation concealment (selection bias) | Unclear risk | Method not described |
| Blinding of participants and personnel (performance bias) | Low risk | Blinding: intervention solutions in opaque bags – participants, anaesthetist and investigator unaware of allocation |
| Blinding of outcome assessment (detection bias) | Unclear risk | As above |
| Incomplete outcome data (attrition bias) | Unclear risk | Losses to follow‐up: 1 participant was excluded from saline only group due to incomplete maternal data; and neonatal data were incomplete due to technical problems with umbilical cord blood analysis |
| Selective reporting (reporting bias) | Unclear risk | Unclear reporting |
| Other bias | Unclear risk | Unclear reporting |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 30 women Inclusion criteria: healthy women undergoing elective CS under spinal anaesthesia at term Setting: Japan | |
| Interventions | Dopamine versus control Group 1: dopamine continuous infusion 5 µg/kg/min Group 2: non‐dopamine infusion All women received a preload of 1000 mL of Ringer's lactate All women received a variable anaesthetic technique (L2‐3 or L3‐4) with variable 0.3% dibucaine doses (1.6‐2.0 mL) | |
| Outcomes | Maternal: hypotension; BP; heart rate Neonatal: Apgar scores | |
| Notes | Hypotension was defined as 90% or less of baseline BP | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Not reported |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not apparent, but not well reported |
| Other bias | Unclear risk | Not apparent, but not well reported |
| Study characteristics | ||
| Methods | RCT | |
| Participants | 67 women Inclusion criteria: without toxaemia, undergoing caesarean under spinal anaesthesia Setting: Japan | |
| Interventions | Colloid preload versus crystalloid preload Group 1: HES starch 1% dextrose (n = 32) Group 2: Ringer's lactate (n = 35) For all women IV infusion was commenced at arrival in the operating room and continued until delivery All women received a standardised spinal anaesthetic technique with dose adjusted according to subject's height, and standardised surgical positioning | |
| Outcomes | Maternal: pain; time from incision to birth; hypotension; ephedrine dose; duration of hypotension; level of block; blood loss Neonatal: Apgar score; birthweight; blood pH; pO2; pCO2; BE; blood sugar; haemoglobin | |
| Notes | Hypotension was defined as SBP < 90 mmHg | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | Not reported |
| Allocation concealment (selection bias) | Unclear risk | Not reported |
| Blinding of participants and personnel (performance bias) | Unclear risk | Not reported |
| Blinding of outcome assessment (detection bias) | Unclear risk | Paediatricians blinded for Apgar scores |
| Incomplete outcome data (attrition bias) | Unclear risk | Not reported |
| Selective reporting (reporting bias) | Unclear risk | Not apparent, but not well reported |
| Other bias | Unclear risk | Not apparent, but not well reported |
ANP: atrial natriuretic peptide; ASA: American Society of Anesthesiologists Classification; BE: base excess; BMI: body mass index; BP: blood pressure; bpm: beats per minute; cc: cubic centimetre, equivalent to 1 mL; CS: caesarean section; CSE: combined spinal‐epidural; CSF: cerebrospinal fluid; CTG: cardiotocography; CVP: central venous pressure; DBP: diastolic blood pressure; DVT: deep vein thrombosis; ET‐1: enothelin‐1; GA: general anaesthetic; HES: hydroxyethyl starch; IDC: in‐dwelling catheter (urinary catheter); IVT: intravascular transfusion; IM: intramuscular; IV: intravenous; LSCS: lower segment caesarean section; MAP: mean arterial pressure; NACS: neurologic and adaptive capacity score; NICU: neonatal intensive care unit; NS: normal saline; pO2 : partial pressure of oxygen; pCO2 : partial pressure of carbon dioxide; RCT: randomised controlled trial; SAB: sub‐arachnoid block; SAP: systolic arterial pressure; SBP: systolic blood pressure; SCD: sequential compression device; SD: standard deviation; SEM: standard error of mean; SpO2/SaO2 : oximetry; SST: supine stress test; TED: thromboembolic deterrent; w/v: weight/volume; 0.9% NaCl/ 0.9% NS: 0.9% sodium chloride, normal saline.
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
| Examines effect on combined spinal‐epidural (not spinal anaesthesia alone) | |
| Prevention of hypotension was not a study outcome, instead it examined effect of the interventions on restoration of BP. Aim was treatment not prophylaxis | |
| Inadequate information on number of women allocated to each group | |
| Intervention aimed to treat hypotension not prevent | |
| Investigated prevention of hypotension resulting from combined spinal‐epidural anaesthesia | |
| Intervention aimed to treat hypotension not prevent | |
| Combined spinal‐epidurals performed | |
| Investigated treatment, rather than prevention, of hypotension | |
| Inadequate reporting of study method. It is unclear if patients received spinal versus epidural versus combined spinal‐epidural | |
| Phenylephrine and ephedrine used to maintain systolic arterial pressure (treating hypotension) | |
| Anaesthetic regimen differed between groups | |
| Investigated treatment, rather than prevention, of hypotension | |
| Combined spinal epidural anaesthesia performed | |
| Quasi‐randomised study | |
| Intervention aimed to treat hypotension not prevent | |
| Pharmacological treatment of maternal hypotension was studied. Prophylaxis was not studied | |
| Comparison of different anaesthetic techniques | |
| Ephedrine or ethylphenylephrine (etilfrine) were used for treating, not preventing, hypotension | |
| Compared different spinal techniques – intervention was adding clonidine or fentanyl to bupivacaine | |
| Incidence of hypotension not reported | |
| Phenylephrine, ephedrine or mephentermine were used for treating, not preventing hypotension | |
| Participants received epidural, not spinal anaesthesia | |
| Participants underwent combined epidural‐spinal anaesthesia | |
| Compared different spinal anaesthetic techniques – different rates of anaesthetic administration | |
| Dose of the anaesthetic into spinal was not standardised between the study groups (low dose versus high dose). Comparisons between different anaesthetics techniques not included in this review | |
| Compared different spinal anaesthetic techniques – different doses of local anaesthetic. | |
| Incidence of hypotension not reported | |
| Combined spinal‐epidurals performed | |
| Compared different spinal anaesthetic techniques – intervention compared 2 different needles | |
| Metaraminol was used to maintain BP | |
| Phenylephrine or metaraminol were used for treating, not preventing, hypotension | |
| Not a prospective randomised controlled trial (control group was retrospectively collected from case notes). Also incidence of hypotension not reported. | |
| This study evaluated different anaesthetic techniques – hyperbaric bupivacaine alone versus sequential subarachnoid injection of plain bupivacaine followed by hyperbaric bupivacaine | |
| Investigation of effect of fluid preload on neonatal acid‐base status (not maternal hypotension) | |
| Comparison of different anaesthetic techniques | |
| Compared different spinal anaesthetic techniques – intervention was volume of anaesthetic | |
| Dopamine was used for treating, not preventing, hypotension | |
| Investigated prevention of hypotension for combined spinal‐epidural anaesthesia for caesarean section | |
| Phenylephrine and ephedrine used to maintain systolic arterial pressure (treating hypotension) | |
| Phenylephrine and ephedrine used to maintain systolic arterial pressure (treating hypotension) | |
| Intervention aimed to treat hypotension not prevent | |
| Combined spinal‐epidurals performed | |
| Inadequate data. This study investigates both the prevention and management of hypotension using a infusion which is commenced prior to spinal injection and then titrated according to BP using a predetermined algorithm. It is the initial prevention of hypotension (prior to titration of the vasopressor infusion) that this Cochrane review examines, however, this is impossible to examine based on the published data in this paper. | |
| Not randomised (allocated according to BP levels) | |
| Intervention aimed to treat hypotension not prevent | |
| Treatment rather than prevention | |
| Ephedrine or saline used to maintain systolic arterial pressure (treating hypotension) | |
| Investigated treatment, rather than prevention, of hypotension. Also incidence of hypotension was not reported | |
| Investigated treatment of hypotension, not prevention of hypotension | |
| Phenylephrine and ephedrine used to maintain systolic arterial pressure (treating hypotension) | |
| Incidence of hypotension not reported | |
| Investigated prevention of hypotension following combined spinal‐epidural anaesthesia (not spinal anaesthesia alone) | |
| Inadequate data on specific numbers for incidence of hypotension in each group | |
| Techniques to prevent incidence of hypotension following spinal anaesthesia for caesarean section not investigated | |
| Combined spinal‐epidural anaesthesia performed | |
| Incidence of hypotension not reported | |
| Inadequate data. The number of participants in each study group was not reported. | |
| Study not adequately controlled with respect to fluid administration. Methods to prevent maternal hypotension was not a study outcome | |
| Treatment, not prevention, of hypotension | |
| Compared different spinal anaesthetic techniques – 2 doses of bupivacaine | |
| Combined spinal‐epidural anaesthesia performed | |
| Intervention was early identification of signs of hypotension so that women received prompt treatment | |
| Treatment, rather than prevention, of hypotension | |
| Participants not randomised ('sequential allocation') | |
| Investigated different anaesthetic techniques in prevention of maternal hypotension | |
| Incidence of hypotension not reported | |
| Investigated different doses of levobupivacaine into a combined spinal‐epidural anaesthetic | |
| Only women who developed hypotension were randomised | |
| Ephedrine or phenylephrine were used to treat, not prevent, hypotension | |
| Women given combined spinal epidural anaesthesia | |
| No mention of randomisation | |
| BP 'maintained', thus not prevention | |
| Different anaesthetic agent doses for spinal anaesthesia were compared | |
| Quasi‐randomised trial | |
| Investigated treatment of hypotension; no definition of hypotension; no evidence of randomisation | |
| Combined spinal‐epidurals performed | |
| Investigated treatment of hypotension, not prevention | |
| Studied the effect of the rate of injection of bupivacaine on haemodynamic changes in elective caesarean | |
| Hypotension treated not prevented ‐ ephedrine manually regulated to keep BP in normal range | |
| 2 different anaesthetics used ‐ not a randomised trial | |
| BP was maintained by ephedrine infusion as well as treated according to rescue criteria for hypotension | |
| Maintenance, not prevention of hypotension | |
| Interventions were differing needle orientations | |
| Comparison of different anaesthetic techniques | |
| Inadequate data – incidence of hypotension following spinal anaesthesia was not reported | |
| Investigated methods of preventing oxytocin induced hypotension by co‐administration of phenylephrine. Preventing of spinal anaesthesia induced hypotension was not investigated. | |
| BP 'maintained', thus not prevention | |
| Epidural anaesthesia used | |
| Despite adequate definition of hypotension, any fall in BP was treated with ephedrine boluses – not prevention | |
| BP 'maintained', thus not prevention | |
| Combined spinal epidural anaesthesia performed | |
| Different anaesthetic techniques compared | |
| Incidence of hypotension not reported | |
| Combined spinal‐epidurals performed | |
| Treatment rather than prevention of spinal hypotension was investigated | |
| Different anaesthetic techniques investigated | |
| Intervention aimed to treat hypotension, not prevent | |
| Combined spinal‐epidurals performed | |
| Comparison of pressors used to treat hypotension, not prevention | |
| Incidence of hypotension not reported | |
| Intervention aimed to treat hypotension not prevent. | |
| Investigated prevention of hypotension in combined spinal‐epidural anaesthesia | |
| Prevention of hypotension was not investigated | |
| Combined spinal‐epidural anaesthesia performed | |
| Combined spinal‐epidural anaesthesia performed | |
| Ephedrine and/or fluid used to maintain BP | |
| Epidural anaesthesia used | |
| Treatment, rather than prevention, of hypotension | |
| Intervention aimed to treat hypotension not prevent | |
| Study meets criteria for inclusion but unable to interpret data/results presented in paper. Attempted to contact to resolve but no response. | |
| Anaesthetist made decision of whether women had general anaesthetic or spinal anaesthesia. Different anaesthetic techniques used therefore excluded | |
| Group allocation was not reported. It was not reported to be a "randomised" study | |
| Combined spinal‐epidural anaesthesia performed | |
| Combined spinal‐epidurals performed | |
| Prevention of hypotension following spinal anaesthesia was not investigated. | |
| This study investigates different spinal anaesthetic doses (i.e. reduction in bupivacaine dose) effect on incidence of hypotension | |
| Combined spinal‐epidurals performed | |
| Investigated treatment of hypotension | |
| Unclear how many women were allocated to each study group | |
| This RCT was included in comparison 7 (colloid versus crystalloid) in the Cyna 2017 updated review. However, this study has since been retracted by the Saudi Journal of Anaesthesia and we have now reclassified this study from included to excluded. | |
| Dose‐finding comparison between ephedrine and phenylephrine, not a randomised trial | |
| Investigated treatment rather than prevention of hypotension | |
| Treatment, rather than prevention, of hypotension | |
| Investigates effect of speed of spinal local anaesthetic injection on incidence of hypotension | |
| Different anaesthetic agent doses for spinal anaesthesia were compared | |
| Comparison of pressors used to maintain BP, not used for prevention | |
| Phenylephrine and ephedrine were used for treating, not preventing, hypotension | |
| Investigated 2 different types of local anaesthetic used in intrathecal injection and their effects on the incidence of hypotension | |
| Comparison of different anaesthetic regimens | |
| Combined spinal‐epidural anaesthesia performed | |
| Treatment, rather than prevention, of hypotension | |
| Metaraminol was used for treating, not preventing, hypotension | |
| Metaraminol was used for treating, not preventing, hypotension | |
| Metaraminol was used for treating, not preventing, hypotension | |
| Thresholds of systolic arterial pressure randomised rather than prophylactic interventions | |
| Phenylephrine was used to maintain systolic arterial pressure (treating hypotension) | |
| Treatment, not prevention | |
| Treatment, not prevention | |
| Phenylephrine and ephedrine were used to maintain systolic arterial pressure (treating hypotension) | |
| Methods to maintain maternal BP was investigated, not methods to prevent hypotension | |
| Methods to maintain maternal BP was investigated, not methods to prevent hypotension | |
| Investigated treatment of hypotension | |
| Results not reported for all women who were randomised (5 emergency caesareans not reported in the groups to which they were randomised) | |
| Crystalloids used for maintaining BP | |
| Incidence of hypotension not reported | |
| This study investigates the efficacy of vasopressors in treatment (not prevention) of postspinal hypotension. | |
| Incidence of hypotension not reported | |
| Combined spinal‐epidural anaesthesia performed | |
| Incidence of hypotension not reported | |
| Anaesthetic techniques varied among participants: spinal anaesthetic is not controlled and position of patient variable (variable bupivicaine dose according to height of patient, ± fentanyl, positioned in supine or side‐lying for SAB). | |
| Study was uncontrolled with respect to haemodynamics – "...ephedrine and additional fluid were given at the discretion of the anesthesiologist ... to maintain a systolic BP > 100 mmHg or 80% of baseline" | |
| Combined spinal‐epidural anaesthesia conducted, not spinal anaesthesia alone | |
| Despite adequate definition of hypotension, rescue ephedrine was also given for nausea and hypotension was not reported | |
| Phenylephrine and ephedrine were used to treat, not prevent, hypotension | |
| Incidence of hypotension not reported | |
| Combined spinal epidurals performed | |
| Different anaesthetic agents for spinal anaesthesia were compared | |
| Different anaesthetic techniques compared | |
| Study not adequately controlled – BP maintained within 20% of preoperative value of baseline by adjusting infusion rate of ephedrine in Hartmann's solution | |
| Investigated treatment of hypotension | |
| Intervention aimed to manage hypotension not prevent | |
| This study investigated the efficacy of prophylactic ephedrine given soon after spinal block compared to those women who were given treatment boluses of ephedrine only after they developed hypotension | |
| Number of women allocated to each study group not reported | |
| Intervention was using different doses of anaesthetic | |
| Quasi‐randomised study | |
| Unclear definition of hypotension | |
| Combined spinal‐epidurals performed | |
| Combined spinal‐epidurals performed | |
| Prevention of oxytocin‐induced hypotension rather than prevention of spinal‐induced hypotension | |
| Combined spinal‐epidurals performed | |
| Number of women allocated to each study group not reported | |
| Combined spinal epidurals performed | |
| Investigated effects of intrathecal midazolam in addition to bupivacaine on post‐spinal hypotension | |
| Combined spinal‐epidurals performed | |
| Intervention aimed to treat hypotension not prevent | |
| Comparison of injection rates of spinal anaesthetic | |
| Investigated the effect of different doses of bupivacaine‐fentanyl on postspinal hypotension | |
| Investigated treatment not prevention of hypotension in women having spinal anaesthesia for caesarean section | |
| Epidurals performed | |
| Not reported as a randomised study | |
| Techniques to treat, rather than prevent, hypotension | |
| Compared different anaesthetic doses/regimens | |
| Compared fast and slow injection rates; no mention of randomisation | |
| Investigated effect of plain bupivacaine versus lower dose bupivacaine with fentanyl on the incidence of hypotension | |
| Investigated treatment, not prevention of hypotension | |
| Techniques to treat, rather than prevent, hypotension | |
| Not randomised – allocation was sequential | |
| Combined spinal‐epidurals performed | |
| Investigated the effect of differing rates of phenylephrine infusions (used for the treatment of maternal hypotension) on the incidence of maternal reactive hypertension | |
| Compared different spinal anaesthetic techniques – spinal given in different positions | |
| Investigated the effect of preloading with lactated or bicarbonate Ringer's solutions on fetal acid base balance. Maternal BP was not reported | |
| Treatment, not prevention | |
| Combined spinal‐epidurals performed | |
| Not a randomised controlled trial | |
| Phenylephrine dose finding study, not randomised trial | |
| Combined spinal‐epidural performed; compared different anaesthetic techniques | |
| Different doses of spinal local anaesthetic compared | |
| Not prophylaxis – arterial BP was maintained at 90% to 100% of baseline values | |
| Thresholds of systolic arterial pressure randomised rather than prophylactic interventions | |
| Given as treatment not prophylaxis | |
| Treatment given as baby was born | |
| Compared different spinal anaesthetic techniques – different doses of anaesthetics | |
| Incidence of hypotension not reported | |
| Incidence of hypotension not reported | |
| The method by which hypotension was treated was not clearly reported, and potentially inconsistent between study participants | |
| Investigated CSE technique | |
| Combined spinal‐epidurals performed | |
| Study not adequately controlled – BP maintained at 90% – 100% of baseline by adjusting infusions of intervention pressor | |
| Treatment, rather than prevention, of hypotension | |
| Treatment, rather than prevention, of hypotension | |
| Intervention aimed to treat hypotension not prevent | |
| Combined spinal epidurals performed | |
| Comparison of different spinal anaesthetic techniques | |
| Incidence of hypotension not reported | |
| No mention of randomisation of study participants. 'Control group' included 5 parturients having vaginal birth | |
| Combined spinal epidurals performed | |
| Combined spinal epidurals performed | |
| Not a randomised trial. This study aimed to determine the median effective volume of crystalloid in preventing hypotension in women undergoing caesarean delivery with spinal anaesthesia. | |
| Combined spinal‐epidural anaesthesia performed | |
| Intervention aimed to treat hypotension not prevent | |
| Combined spinal‐epidurals performed | |
| Variable bupivicaine dosing was used: "The amount of 0.5% bupivacaine hyperbaric solution to be administered was adjusted to aim for a level of anaesthesia of T4, at 2.5ml, with reference to the weight of the patient." | |
| Incidence of hypotension not reported | |
| Intervention aimed to treat hypotension not prevent | |
| Combined spinal‐epidurals performed | |
| Investigated effect of hyperbaric, isobaric and combinations of bupivacaine for spinal anaesthesia | |
| Comparison of pressors to treat, not prevent, hypotension | |
| Only randomised women at high risk of developing hypotension | |
| Combined spinal‐epidurals performed |
BP: blood pressure; CSE: combined spinal‐epidural; SBP: systolic blood pressure.
Characteristics of studies awaiting classification [ordered by study ID]
| Methods | RCT |
| Participants | Women undergoing caesarean section Inclusion criteria: aged 20‐40 years, ASA physical status I and II, single pregnancy, elective caesarean, gestational age ≥ 37 weeks Exclusion criteria: hypovolaemia, deformity of spinal column, increase of intracranial pressure, coagulopathy, infection of skin or soft tissue and dissatisfaction of patient |
| Interventions | Atropine versus ephedrine versus phenylephrine Group 1: 0.5 mg atropine (IV) before spinal anaesthesia (single dose) Group 2: 5 mg ephedrine before spinal anaesthesia (single dose) Group 3: 100 µg phenylephrine (mucosal) before spinal anaesthesia (single dose) All women receive 500 mL Ringer's lactate before spinal anaesthesia |
| Outcomes | Maternal: blood pressure; heart rate; oxygen saturation Neonatal: — |
| Notes | Full report published in 2012, in Arabic, abstract is in English Awaiting translation |
| Methods | RCT |
| Participants | 80 women undergoing caesarean section Inclusion criteria: absence of uterine activity or fetal risk Exclusion criteria: not specified |
| Interventions | Ephedrine vs phenylephrine after spinal block Group 1: IV bolus of 0.1 mg/kg plus continuous infusion at a rate of 0.5 mg/kg/h Group 2: IV bolus of 0.5 µg/kg plus continuous infusion at a rate of 1.5 µg/kg/min |
| Outcomes | Maternal: hypotension; hypertension; bradycardia Neonatal: umbilical cord blood parameters (pH, pCO2, HCO3); Apgar scores |
| Notes | Original article in Spanish Only abstract in English Awaiting translation; unclear if this intervention is for treatment or prevention of hypotension |
| Methods | RCT |
| Participants | 100 pregnant women undergoing elective caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Phenylephrine vs ephedrine post spinal anaesthesia Group 1: 100 μg bolus dose Group 2. 10 mg bolus dose |
| Outcomes | Maternal: heart rate; BP Neonatal: umbilical cord blood gases |
| Notes | Original article in Arabic Only abstract in English Awaiting translation |
| Methods | RCT |
| Participants | 40 women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Ephedrine versus phenylephrine Group 1: 5 mg/min ephedrine infusions Group 2: 100 μg/min phenylephrine infusions |
| Outcomes | Maternal: incidence of hypotension; incidence of hypertension; duration of infusion; spinal delivery Neonatal: fetal acidosis |
| Notes | Unclear whether intervention is for treatment or prevention of hypotension – first author contacted 26/06/2017, awaiting response. |
| Methods | RCT |
| Participants | 120 women undergoing elective caesarean section Inclusion criteria: ASA I and II Exclusion criteria: not specified |
| Interventions | HES vs normal saline Group 1: 500 mg of HES 130/0.4 (Voluven (R)) Group 2: 500 mL normal saline Both groups received ephedrine for hypotension |
| Outcomes | Maternal: hypotension; ephedrine requirement and consumption; nausea and vomiting; headache Neonatal: Apgar scores; umbilical blood gases |
| Notes | Original version in French Only abstract available in English Awaiting translation |
| Methods | RCT |
| Participants | 105 women undergoing elective caesarean section |
| Interventions | Group 1: received a 1‐mg/min ephedrine infusion from the time of injection of the spinal solution until uterine incision Group 2: received a 9‐mg ephedrine bolus at the time of injection of the spinal solution. Group 3: received no prophylactic ephedrine |
| Outcomes | Maternal: time of hypotension; volume of rescue fluid; dose of rescue ephedrine Neonatal: Apgar scores |
| Notes | If SBP fell below IBP, a 250‐mL rescue bolus of normal saline and ephedrine 6 mg were given. If, after 2 min the SBP was still < IBP, a further 6‐mg bolus of ephedrine was given. If, after a further 2 min, the SBP remained < IBP, another 250‐mL bolus of saline with ephedrine 6 mg was given. This 4‐min cycle would be repeated until the SBP was > IBP. The study continued until uterine incision. Abstract only. Unclear whether intervention is for treatment or prevention of hypotension – first author's institution contacted 26 June 2017, awaiting response |
| Methods | RCT |
| Participants | 40 women undergoing elective caesarean section |
| Interventions | Ephedrine vs placebo Group 1: ephedrine 30 mg Group 2: placebo Identical capsules taken by mouth 1 h before institution of the spinal anaesthetic. All participants then received Hartmann's solution 15 mL/kg before subarachnoid injection of 0.5% heavy bupivacaine 2.5 mL and diamorphine 0.25 mg, using a 25‐gauge pencil‐point needle with the patient in the sitting position on the operation table |
| Outcomes | Maternal: — Neonatal: — |
| Notes | Women were given bolus injections of rescue ephedrine 6 mg on each occasion their systolic blood pressure was less than 80% of that recorded before the spinal injection. Abstract only. Insufficient information to assess risk of bias – unable to find contact details of author |
| Methods | RCT |
| Participants | 112 women undergoing elective caesarean section Inclusion criteria: ASA I and II Exclusion criteria: not specified |
| Interventions | HES prior to spinal anaesthesia vs HES after spinal anaesthesia Both groups received 500 mg of 6% HES Both groups received rescue dose of combined ephedrine 5 mg/mL with phenylephrine 25 µg/mL |
| Outcomes | Maternal: hypotension; vVasopressor consumption Neonatal: not specified |
| Notes | Original article in Arabic Only abstract available in English Awaiting translation |
| Methods | RCT |
| Participants | 26 women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: age < 18 years, non‐elective CS, BMI > 40 kg/m², hypertension, multiple pregnancy, high‐risk patients, sepsis, insulin – dependent diabetes mellitus, spinal block level > T5, ongoing epidural anaesthesia |
| Interventions | Intermittent pneumatic compression system (IPCS) versus control Group 1: IPCS applied to legs Group 2: crystalloid cohydration with 0.9% saline 500 mL (given to women in both groups) |
| Outcomes | Maternal: diastolic, mean and diastolic arterial pressure; umbilical cord blood gas values; phenylephrine boluses and total dose; haemoglobin levels Neonatal: Apgar scores at 1 min and 5 min |
| Notes | Abstract only; unclear whether intervention is for treatment or prevention of hypotension – unable to find contact details of authors |
| Methods | Not known |
| Participants | Women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Coload with colloid versus crystalloid solutions Group 1: 500 mL of Ringer's lactate Group 2: 1000 mL of Ringer's lactate Group 3: 500 mL of 6% hydroxyethyl starch All solutions given over 15 minutes immediately following intrathecal administration of hyperbaric bupivacaine 12 µg with fentanyl 15 mg and morphine 150 µg. |
| Outcomes | Maternal: hypotension; heart rate; stroke volume; cardiac index; systemic vascular resistance Neonatal: — |
| Notes | Abstract only. Insufficient information to assess risk of bias – first author contacted 26 June 2017, awaiting response |
| Methods | RCT |
| Participants | 21 women undergoing elective caesarean section Inclusion criteria: ASA I Exclusion criteria: not specified |
| Interventions | Crystalloid 20 min vs crystalloid 10 min prior to spinal Both groups received 20 mL/kg |
| Outcomes | Maternal: CVP; hypotension Neonatal: not specified |
| Notes | Original article in Korean Only abstract available in English Awaiting translation |
| Methods | RCT |
| Participants | 92 women undergoing caesarean section Inclusion criteria: undergoing spinal anesthesia for emergency cesarean delivery indicated due to acute fetal compromise Exclusion criteria: not specified |
| Interventions | Ephedrine versus phenylephrine Group 1: received prophylactic infusions of ephedrine at the rate of 2.5 mg/min Group 2: received prophylactic infusions of phenylephrine at the rate of 30 µg/min |
| Outcomes | Maternal: systolic blood pressure; umbilical artery pH; need for immediate resuscitation; haemodynamics; intra‐operative nausea/vomiting Neonatal: cord blood gases; incidence of fetal acidosis; Apgar score |
| Notes | Abstract only. Unclear whether intervention is for treatment or prevention of hypotension – first author contacted 26/06/2017, awaiting response. |
| Methods | RCT |
| Participants | 900 women undergoing elective caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Ephedrine vs phenylephrine vs ephedrine plus phenylephrine Group 1: ephedrine 2 mg/min infusion with 6 mg bolus Group 2: phenylephrine 33.3 µg/min infusion with 50 µg bolus Group 3: ephedrine plus phenylephrine combined at half the infusion doses and bolus |
| Outcomes | Maternal: number of boluses given; hypotension; bradycardia Neonatal: umbilical blood gas; Apgar score |
| Notes | Original article in Korean Only abstract available in English Awaiting translation; unclear if intervention is for treatment or prevention |
| Methods | RCT |
| Participants | A non‐specified number of women undergoing elective caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Left 15 degrees tilt vs uterine displacement by hand Ephedrine (4 mg IV) administered in either case for hypotension, nausea or vomiting Group 1: following spinal injection patients turn to 15 degrees left lateral supine position Group 2: following spinal injection patient had uterine displacement by hand |
| Outcomes | Maternal: arm systolic BP; leg systolic BP; mean ephedrine requirement Neonatal: Apgar scores; umbilical artery pH |
| Notes | Original article in Japanese Only abstract available in English Awaiting translation |
| Methods | RCT |
| Participants | 102 women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: fetal distress, severe comorbidities, urgent caesarean section for any cause |
| Interventions | Ringer's lactate versus balanced Ringer's solution |
| Outcomes | Maternal: mean arterial pressure; heart rate; oxygen saturation Neonatal: — |
| Notes | Abstract only. Unclear if intervention is treatment or prevention of hypotension – unable to find contact details of authors |
| Methods | RCT |
| Participants | 38 women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Ringer's lactate versus albumin solution Group 1: 50 mL/kg of Ringer's lactate before spinal anaesthesia with 12 mg of bupivacaine Group 2: 15 mL/kg of 5% albumin solution before spinal anaesthesia with 12 mg of bupivacaine |
| Outcomes | Maternal: mean arterial pressure; umbilical cord blood gases; arterial natriuretic peptide; cardiac output Neonatal: Apgar scores; fetal biochemical profiles |
| Notes | Abstract only. Insufficient information to assess risk of bias – unable to find contact details of authors |
| Methods | Not known |
| Participants | 45 women undergoing caesarean section Inclusion criteria: not clear Exclusion criteria: not clear |
| Interventions | Prehydration versus Wrapping of legs Group 1: prehydration with 10 mL/kg Group 2: prehydration with 10 mL/kg and wrapping of the legs Group 3: prehydration with 5 mL/kg and wrapping of the legs |
| Outcomes | Maternal: incidence of hypotension; systolic arterial pressure Neonatal: — |
| Notes | Full report is in Chinese while the abstract is in English Awaiting translation |
| Methods | RCT |
| Participants | Women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Colloid versus crystalloid versus combination of both preloads Group 1: 500 mL of Ringer's lactate, preload, before spinal anaesthesia Group 2: 500 mL of 6% pentastarch, preload, before spinal anaesthesia Group 3: combination of 250 mL of 6% pentastarch and 750 mL of Ringer's lactate intravenous fluid preload, before spinal anaesthesia |
| Outcomes | Maternal: hypotension Neonatal: not specified |
| Notes | Abstract only. Insufficient information to assess risk of bias – first author contacted 26/06/2017, awaiting response. |
| Methods | RCT |
| Participants | 62 women undergoing caesarean section Inclusion criteria: women with ASA I status Exclusion criteria: not specified |
| Interventions | Colloid versus control Group 1: preloading with 500 mL of a gelatine modified fluid (Gelofusine 4%) over 10 min before spinal anaesthesia Group 2: no preload |
| Outcomes | Maternal: systolic arterial blood pressure; incidence of nausea and vomiting; allergic reactions Neonatal: Apgar scores at 1 min and 5 minutes; cord blood gases |
| Notes | Abstract only. Insufficient information to assess risk of bias – unable to find contact details for authors. |
| Methods | RCT |
| Participants | 40 women undergoing caesarean section Inclusion criteria: full‐term pregnant women of ASA grade I and II, posted for cesarean section Exclusion criteria: not specified |
| Interventions | Phenylephrine versus colloids (hydroxyethyl starch) Group 1: women received phenylephrine at 60 µg/min for 2 min unless SBP was > 120% of baseline immediately after intrathecal injection Group 2: women received rapid colloid infusion (12 mL/kg of hydroxyethyl starch 6%) immediately after intrathecal injection |
| Outcomes | Maternal: blood pressure; fall in BP below 80% of baseline; umbilical artery pH Neonatal: — |
| Notes | Abstract only. Unclear if intervention is for treatment or prevention of hypotension – first author's institution contacted 26 June 2017, awaiting response |
| Methods | RCT |
| Participants | 32 patients undergoing caesarean delivery Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Phenylephrine vs ephedrine Both groups received drug after spinal Group 1: phenylephrine continuous infusion – details not specified in abstract Group 2: ephedrine continuous infusion – details not specified in abstract |
| Outcomes | Maternal: block height; haemodynamic changes Neonatal: umbilical artery pH |
| Notes | Original article in Japanese Only abstract available in English Awaiting translation; unclear if intervention is for treatment or prevention of hypotension |
| Methods | RCT |
| Participants | 300 women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Combination of 2 interventions Group 1: crystalloid and colloid: Ringer's lactate (15 mL/kg) and Hemaxel (7ml/kg) – both given before spinal anaesthesia (SA) Group 2: crystalloid and ephedrine: Ringer's lactate (15 mL/kg) given before SA and ephedrine 15 mg IV, after SA Group 3: crystalloid and bandage: Ringer's lactate (15 mL/kg) and lower limb bandage Group 4: colloid and ephedrine: hydroxyethyl starch (7ml/kg) given before SA, and ephedrine 15 mg IV, after SA Group 5: colloid and bandage: hydroxyethyl starch (7ml/kg) given before SA, and lower limb bandage Group 6: ephedrine and bandage: ephedrine 15 mg, IV after SA, and lower limb bandage |
| Outcomes | Maternal: pulse rate; systolic blood pressure Neonatal: Apgar score; neurological and adaptive capacity score (NACS) |
| Notes | Abstract only. Insufficient information to assess risk of bias – first author contacted 26 June 2017, awaiting response |
| Methods | RCT |
| Participants | 68 women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Hip flexion versus no flexion Immediately after the administration of subarachnoid injection, women were placed in Fowler's position (30 degree raised head and shoulders, 15 degree lateral tilt) Group 1: hip flexed at 45 degree for 5 minutes Group 2: legs were straight |
| Outcomes | Maternal: systolic arterial pressure; incidence of hypotension Neonatal: Apgar scores |
| Notes | Brief communication only. Insufficient information to assess risk of bias – first author contacted 26 June 2017, email bounced, unable to find other contact |
| Methods | RCT |
| Participants | 60 women undergoing caesarean section Inclusion criteria: ASA physical status I and II Exclusion criteria: pregnancy‐induced hypertension; pre‐eclampsia or eclampsia; illegal drug use; fetal distress; nausea and vomiting; maternal coagulopathy; high/low blood pressure; diabetes |
| Interventions | All women in both the groups received 15‐20 mL/kg Ringer's lactate 20‐30 minutes prior to subarachnoid block (SAB), left uterine displacement (LUD), and ephedrine as needed Group 1: TED compression prior to fluid loading and SAB, and fluids Group 2: TED compression and foam wedge that elevates leg to 30 degree within 5 minutes following SAB prior to fluid loading and SAB, and fluids Group 3: received only fluids |
| Outcomes | Maternal: incidence of hypotension; blood loss Neonatal: not specified |
| Notes | Abstract only. Insufficient information to assess risk of bias – unable to find contact details. |
| Methods | RCT |
| Participants | 32 women undergoing caesarean section Inclusion criteria: not specified Exclusion criteria: not specified |
| Interventions | Ephedrine versus phenylephrine versus combination of both infusions |
| Outcomes | Maternal: systolic blood pressure; pulse rate; systolic vascular resistance index; cardiac index; stroke volume index; nausea and vomiting scores; total fluid intake; phenylephrine rescues; umbilical vein pH Neonatal: Apgar scores |
| Notes | Full report is available in Korean Awaiting translation. Unclear if intervention is for treatment or prevention of hypotension. |
BMI: body mass index; BP: blood pressure; CVP: central venous pressure; HES: hydroxyethyl starch solution; IBP: invasive blood pressure; IM: intramuscular; IV: intravenous; RCT: randomised controlled trial; SAB: sub‐arachnoid block; TED: thromboembolic deterrent.
Characteristics of ongoing studies [ordered by study ID]
| Study name | Prevention of maternal hypotension during elective caesarean section performed with spinal anaesthesia, through intermittent pneumatic compression system in the lower extremities |
| Methods | RCT |
| Participants | Inclusion criteria: age > 18 years; elective caesarean section Exclusion criteria: emergency caesarean; epidural anaesthesia; caesarean section of multiple pregnancies; obstetric pathology (pre‐eclampsia, eclampsia, HELLP syndrome (haemolysis elevated liver enzymes low platelet count), small‐for‐gestational age, preterm (< 32 weeks); valvular heart disease; hypertension; sepsis; BMI > 40 kg/m²; insulin dependent diabetes mellitus; block level achieved with spinal anaesthesia > T5; patients that cannot meet the study protocol |
| Interventions | Phenylephrine infusion vs phenylephrine infusion with intermittent pneumatic compression |
| Outcomes | Maternal: vasopressor dose required; effectiveness of intermittent pneumatic compression system to decrease requirement of vasopressors Neonatal: not specified |
| Starting date | — |
| Contact information | — |
| Notes | Information obtained from trial registry |
BMI: body mass index; RCT: randomised controlled trial.
Data and analyses
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Women with hypotension requiring intervention Show forest plot | 5 | 370 | Risk Ratio (M‐H, Random, 95% CI) | 0.84 [0.72, 0.98] |
| Analysis 1.1  Comparison 1: Crystalloid vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 1.2 Nausea and/or vomiting Show forest plot | 1 | 69 | Risk Ratio (M‐H, Random, 95% CI) | 0.19 [0.01, 3.91] |
| Analysis 1.2  Comparison 1: Crystalloid vs control, Outcome 2: Nausea and/or vomiting | ||||
| 1.3 Anaphylaxis Show forest plot | 1 | 69 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 1.3  Comparison 1: Crystalloid vs control, Outcome 3: Anaphylaxis | ||||
| 1.4 Apgar < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 1.4  Comparison 1: Crystalloid vs control, Outcome 4: Apgar < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Women with hypotension requiring intervention Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 0.86 [0.45, 1.64] |
| Analysis 2.1  Comparison 2: Crystalloid: rapid infusion vs slow infusion, Outcome 1: Women with hypotension requiring intervention | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 3.1 Women with hypotension requiring intervention Show forest plot | 3 | 192 | Risk Ratio (M‐H, Random, 95% CI) | 0.55 [0.29, 1.02] |
| Analysis 3.1  Comparison 3: Crystalloid: high vs low preload volume, Outcome 1: Women with hypotension requiring intervention | ||||
| 3.1.1 15 mL/kg crystalloid | 2 | 67 | Risk Ratio (M‐H, Random, 95% CI) | 0.56 [0.33, 0.96] |
| 3.1.2 20 mL/kg crystalloid | 2 | 125 | Risk Ratio (M‐H, Random, 95% CI) | 0.51 [0.11, 2.44] |
| 3.2 Nausea and/or vomiting Show forest plot | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.40, 3.62] |
| Analysis 3.2  Comparison 3: Crystalloid: high vs low preload volume, Outcome 2: Nausea and/or vomiting | ||||
| 3.3 Apgar < 8 at 5 min Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 3.3  Comparison 3: Crystalloid: high vs low preload volume, Outcome 3: Apgar < 8 at 5 min | ||||
| 3.3.1 15 mL/kg crystalloid | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 3.3.2 20 mL/kg crystalloid | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 4.1 Women with hypotension requiring intervention Show forest plot | 5 | 384 | Risk Ratio (M‐H, Random, 95% CI) | 0.70 [0.59, 0.83] |
| Analysis 4.1  Comparison 4: Crystalloid: rapid coload vs preload, Outcome 1: Women with hypotension requiring intervention | ||||
| 4.2 Hypertension requiring intervention Show forest plot | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.67 [0.42, 6.60] |
| Analysis 4.2  Comparison 4: Crystalloid: rapid coload vs preload, Outcome 2: Hypertension requiring intervention | ||||
| 4.3 Women with bradycardia Show forest plot | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.43 [0.59, 3.45] |
| Analysis 4.3  Comparison 4: Crystalloid: rapid coload vs preload, Outcome 3: Women with bradycardia | ||||
| 4.4 Women with nausea or vomiting Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 4.4  Comparison 4: Crystalloid: rapid coload vs preload, Outcome 4: Women with nausea or vomiting | ||||
| 4.4.1 Women with nausea | 3 | 210 | Risk Ratio (M‐H, Random, 95% CI) | 1.98 [1.26, 3.12] |
| 4.4.2 Women with vomiting | 2 | 160 | Risk Ratio (M‐H, Random, 95% CI) | 2.33 [0.98, 5.58] |
| 4.5 Neonates with acidosis (pH < 7.2) Show forest plot | 2 | 110 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 4.5  Comparison 4: Crystalloid: rapid coload vs preload, Outcome 5: Neonates with acidosis (pH < 7.2) | ||||
| 4.6 Apgar < 8 at 5 min Show forest plot | 3 | 210 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 4.6  Comparison 4: Crystalloid: rapid coload vs preload, Outcome 6: Apgar < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 5.1 Women with hypotension requiring intervention Show forest plot | 1 | 113 | Risk Ratio (M‐H, Random, 95% CI) | 1.03 [0.65, 1.62] |
| Analysis 5.1  Comparison 5: Crystalloid: warm vs cold, Outcome 1: Women with hypotension requiring intervention | ||||
| 5.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 5.2  Comparison 5: Crystalloid: warm vs cold, Outcome 2: Women with nausea and/or vomiting | ||||
| 5.2.1 Nausea | 1 | 113 | Risk Ratio (M‐H, Random, 95% CI) | 1.64 [0.97, 2.76] |
| 5.2.2 Vomiting | 1 | 113 | Risk Ratio (M‐H, Random, 95% CI) | 2.95 [0.12, 70.87] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 6.1 Women with hypotension requiring intervention Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 6.1  Comparison 6: Crystalloid vs another crystalloid, Outcome 1: Women with hypotension requiring intervention | ||||
| 6.1.1 Dextrose + saline vs saline | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | 0.88 [0.68, 1.14] |
| 6.1.2 Glucose vs saline | 1 | 70 | Risk Ratio (M‐H, Random, 95% CI) | 1.05 [0.74, 1.48] |
| 6.1.3 Ringer's lactate vs saline | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.17 [0.65, 2.09] |
| 6.2 Neonates with acidosis: Ringer's lactate vs saline Show forest plot | 1 | 60 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| Analysis 6.2  Comparison 6: Crystalloid vs another crystalloid, Outcome 2: Neonates with acidosis: Ringer's lactate vs saline | ||||
| 6.3 Neonates with acidosis: dextrose vs saline Show forest plot | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.39, 3.72] |
| Analysis 6.3  Comparison 6: Crystalloid vs another crystalloid, Outcome 3: Neonates with acidosis: dextrose vs saline | ||||
| 6.4 Neonates with Apgar score < 7 at 5 min Show forest plot | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 6.4  Comparison 6: Crystalloid vs another crystalloid, Outcome 4: Neonates with Apgar score < 7 at 5 min | ||||
| 6.5 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| Analysis 6.5  Comparison 6: Crystalloid vs another crystalloid, Outcome 5: Neonates with Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 7.1 Women with hypotension requiring intervention Show forest plot | 27 | 2009 | Risk Ratio (M‐H, Random, 95% CI) | 0.69 [0.58, 0.81] |
| Analysis 7.1  Comparison 7: Colloid vs crystalloid, Outcome 1: Women with hypotension requiring intervention | ||||
| 7.2 Women with hypertension requiring intervention Show forest plot | 3 | 327 | Risk Ratio (M‐H, Random, 95% CI) | 0.64 [0.09, 4.46] |
| Analysis 7.2  Comparison 7: Colloid vs crystalloid, Outcome 2: Women with hypertension requiring intervention | ||||
| 7.3 Women with cardiac dysrhythmia Show forest plot | 6 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 7.3  Comparison 7: Colloid vs crystalloid, Outcome 3: Women with cardiac dysrhythmia | ||||
| 7.3.1 Tachycardia | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.10 [0.79, 1.53] |
| 7.3.2 Bradycardia | 5 | 413 | Risk Ratio (M‐H, Random, 95% CI) | 0.98 [0.54, 1.78] |
| 7.4 Women with nausea and/or vomiting Show forest plot | 15 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 7.4  Comparison 7: Colloid vs crystalloid, Outcome 4: Women with nausea and/or vomiting | ||||
| 7.4.1 Nausea and/or vomiting | 14 | 1058 | Risk Ratio (M‐H, Random, 95% CI) | 0.89 [0.66, 1.19] |
| 7.4.2 Nausea | 5 | 390 | Risk Ratio (M‐H, Random, 95% CI) | 1.10 [0.77, 1.58] |
| 7.4.3 Vomiting | 4 | 320 | Risk Ratio (M‐H, Random, 95% CI) | 1.35 [0.55, 3.27] |
| 7.5 Neonates with acidosis (pH < 7.2) Show forest plot | 6 | 678 | Risk Ratio (M‐H, Random, 95% CI) | 0.83 [0.15, 4.52] |
| Analysis 7.5  Comparison 7: Colloid vs crystalloid, Outcome 5: Neonates with acidosis (pH < 7.2) | ||||
| 7.6 Neonates: Apgar score Show forest plot | 12 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 7.6  Comparison 7: Colloid vs crystalloid, Outcome 6: Neonates: Apgar score | ||||
| 7.6.1 Apgar < 7 at 5 min | 2 | 127 | Risk Ratio (M‐H, Random, 95% CI) | 0.16 [0.01, 2.90] |
| 7.6.2 Apgar < 8 at 5 min | 10 | 730 | Risk Ratio (M‐H, Random, 95% CI) | 0.24 [0.03, 2.05] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 8.1 Women with hypotension requiring intervention Show forest plot | 5 | 426 | Risk Ratio (M‐H, Random, 95% CI) | 0.40 [0.16, 0.96] |
| Analysis 8.1  Comparison 8: Colloid vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 8.2 Women with bradycardia Show forest plot | 1 | 54 | Risk Ratio (M‐H, Random, 95% CI) | 7.70 [0.46, 127.78] |
| Analysis 8.2  Comparison 8: Colloid vs control, Outcome 2: Women with bradycardia | ||||
| 8.3 Women with nausea and/or vomiting Show forest plot | 2 | 245 | Risk Ratio (M‐H, Random, 95% CI) | 1.65 [0.75, 3.64] |
| Analysis 8.3  Comparison 8: Colloid vs control, Outcome 3: Women with nausea and/or vomiting | ||||
| 8.4 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 205 | Risk Ratio (M‐H, Random, 95% CI) | 1.24 [0.34, 4.48] |
| Analysis 8.4  Comparison 8: Colloid vs control, Outcome 4: Neonates with acidosis (pH < 7.2) | ||||
| 8.5 Neonates with Apgar score < 7 at 5 min Show forest plot | 4 | 221 | Risk Ratio (M‐H, Random, 95% CI) | 0.07 [0.00, 1.24] |
| Analysis 8.5  Comparison 8: Colloid vs control, Outcome 5: Neonates with Apgar score < 7 at 5 min | ||||
| 8.6 Neonatal Apgar < 8 at 5 min Show forest plot | 1 | 205 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 8.6  Comparison 8: Colloid vs control, Outcome 6: Neonatal Apgar < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 9.1 Women with hypotension requiring intervention Show forest plot | 3 | 134 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.27, 2.08] |
| Analysis 9.1  Comparison 9: Colloid: different volumes, Outcome 1: Women with hypotension requiring intervention | ||||
| 9.2 Apgar < 9 at 5 min Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 9.2  Comparison 9: Colloid: different volumes, Outcome 2: Apgar < 9 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 10.1 Women with hypotension requiring intervention Show forest plot | 4 | 320 | Risk Ratio (M‐H, Random, 95% CI) | 0.93 [0.78, 1.10] |
| Analysis 10.1  Comparison 10: Colloid preload vs colloid coload, Outcome 1: Women with hypotension requiring intervention | ||||
| 10.2 Women with cardiac dysrhythmia Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 10.2  Comparison 10: Colloid preload vs colloid coload, Outcome 2: Women with cardiac dysrhythmia | ||||
| 10.2.1 Bradycardia | 2 | 82 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.20, 2.88] |
| 10.2.2 Tachycardia | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 10.3 Women with nausea and/or vomiting Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 10.3  Comparison 10: Colloid preload vs colloid coload, Outcome 3: Women with nausea and/or vomiting | ||||
| 10.3.1 Nausea and/or vomiting | 1 | 178 | Risk Ratio (M‐H, Random, 95% CI) | 0.92 [0.63, 1.35] |
| 10.3.2 Nausea | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.15, 6.51] |
| 10.3.3 Vomiting | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 10.4 Women with anaphylaxis Show forest plot | 1 | 178 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 10.4  Comparison 10: Colloid preload vs colloid coload, Outcome 4: Women with anaphylaxis | ||||
| 10.5 Neonates with Apgar score < 7 at 5 min Show forest plot | 1 | 36 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 10.5  Comparison 10: Colloid preload vs colloid coload, Outcome 5: Neonates with Apgar score < 7 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 11.1 Women with hypotension requiring intervention Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 11.1  Comparison 11: Colloid + crystalloid vs another colloid + crystalloid, Outcome 1: Women with hypotension requiring intervention | ||||
| 11.1.1 Albumin or dextrose vs dextrose | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | 0.13 [0.01, 2.30] |
| 11.1.2 Unbalanced vs balanced hydroxyethyl starch | 1 | 51 | Risk Ratio (M‐H, Random, 95% CI) | 1.04 [0.78, 1.39] |
| 11.2 Neonates: Apgar score < 7 Show forest plot | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | 0.13 [0.01, 2.30] |
| Analysis 11.2  Comparison 11: Colloid + crystalloid vs another colloid + crystalloid, Outcome 2: Neonates: Apgar score < 7 | ||||
| 11.2.1 Albumin or dextrose vs dextrose | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | 0.13 [0.01, 2.30] |
| 11.3 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 51 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 11.3  Comparison 11: Colloid + crystalloid vs another colloid + crystalloid, Outcome 3: Neonates with Apgar score < 8 at 5 min | ||||
| 11.3.1 Unbalanced vs balanced hydroxyethyl starch | 1 | 51 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 12.1 Women with hypotension requiring intervention Show forest plot | 22 | 1401 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.53, 0.80] |
| Analysis 12.1  Comparison 12: Ephedrine vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 12.2 Women with hypertension requiring intervention Show forest plot | 7 | 520 | Risk Ratio (M‐H, Random, 95% CI) | 1.61 [1.00, 2.61] |
| Analysis 12.2  Comparison 12: Ephedrine vs control, Outcome 2: Women with hypertension requiring intervention | ||||
| 12.3 Women with cardiac arrhythmia Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 12.3  Comparison 12: Ephedrine vs control, Outcome 3: Women with cardiac arrhythmia | ||||
| 12.3.1 Tachycardia | 2 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 1.12 [0.74, 1.70] |
| 12.3.2 Bradycardia | 2 | 103 | Risk Ratio (M‐H, Random, 95% CI) | 14.46 [0.87, 241.09] |
| 12.4 Women with nausea and/or vomiting Show forest plot | 13 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 12.4  Comparison 12: Ephedrine vs control, Outcome 4: Women with nausea and/or vomiting | ||||
| 12.4.1 Nausea and/or vomiting | 5 | 219 | Risk Ratio (M‐H, Random, 95% CI) | 0.71 [0.22, 2.34] |
| 12.4.2 Nausea | 8 | 620 | Risk Ratio (M‐H, Random, 95% CI) | 0.68 [0.48, 0.96] |
| 12.4.3 Vomiting | 6 | 516 | Risk Ratio (M‐H, Random, 95% CI) | 0.68 [0.44, 1.07] |
| 12.5 Neonates with acidosis (pH < 7.2) Show forest plot | 9 | 576 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.67, 2.49] |
| Analysis 12.5  Comparison 12: Ephedrine vs control, Outcome 5: Neonates with acidosis (pH < 7.2) | ||||
| 12.6 Neonates: Apgar score Show forest plot | 14 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 12.6  Comparison 12: Ephedrine vs control, Outcome 6: Neonates: Apgar score | ||||
| 12.6.1 Apgar < 8 at 5 min | 10 | 579 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 12.6.2 Apgar < 7 at 5 min | 4 | 263 | Risk Ratio (M‐H, Random, 95% CI) | 1.14 [0.34, 3.81] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 13.1 Women with hypotension requiring intervention Show forest plot | 9 | 613 | Risk Ratio (M‐H, Random, 95% CI) | 0.60 [0.47, 0.78] |
| Analysis 13.1  Comparison 13: Ephedrine vs crystalloid, Outcome 1: Women with hypotension requiring intervention | ||||
| 13.2 Women with hypertension requiring intervention Show forest plot | 3 | 280 | Risk Ratio (M‐H, Random, 95% CI) | 1.10 [0.37, 3.28] |
| Analysis 13.2  Comparison 13: Ephedrine vs crystalloid, Outcome 2: Women with hypertension requiring intervention | ||||
| 13.3 Women with bradycardia Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.33 [0.01, 7.99] |
| Analysis 13.3  Comparison 13: Ephedrine vs crystalloid, Outcome 3: Women with bradycardia | ||||
| 13.4 Women with nausea and/or vomiting Show forest plot | 5 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 13.4  Comparison 13: Ephedrine vs crystalloid, Outcome 4: Women with nausea and/or vomiting | ||||
| 13.4.1 Nausea and/or vomiting | 2 | 146 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.48, 2.08] |
| 13.4.2 Nausea | 3 | 220 | Risk Ratio (M‐H, Random, 95% CI) | 0.54 [0.31, 0.93] |
| 13.4.3 Vomiting | 3 | 220 | Risk Ratio (M‐H, Random, 95% CI) | 0.57 [0.31, 1.05] |
| 13.5 Women with impaired consciousness Show forest plot | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.40 [0.09, 1.86] |
| Analysis 13.5  Comparison 13: Ephedrine vs crystalloid, Outcome 5: Women with impaired consciousness | ||||
| 13.6 Neonates with acidosis (pH < 7.2) Show forest plot | 2 | 218 | Risk Ratio (M‐H, Random, 95% CI) | 1.41 [0.48, 4.15] |
| Analysis 13.6  Comparison 13: Ephedrine vs crystalloid, Outcome 6: Neonates with acidosis (pH < 7.2) | ||||
| 13.7 Neonatal Apgar score Show forest plot | 5 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 13.7  Comparison 13: Ephedrine vs crystalloid, Outcome 7: Neonatal Apgar score | ||||
| 13.7.1 Apgar < 8 at 5 min | 4 | 226 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.13, 71.92] |
| 13.7.2 Apgar < 7 at 5 min | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 14.1 Women with hypotension requiring intervention Show forest plot | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.38, 1.12] |
| Analysis 14.1  Comparison 14: Ephedrine + crystalloid vs colloid, Outcome 1: Women with hypotension requiring intervention | ||||
| 14.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 14.2  Comparison 14: Ephedrine + crystalloid vs colloid, Outcome 2: Women with nausea and/or vomiting | ||||
| 14.2.1 Nausea | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.42 [0.22, 0.81] |
| 14.2.2 Vomiting | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.17 [0.04, 0.77] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 15.1 Women with hypotension requiring intervention Show forest plot | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.39 [0.21, 0.74] |
| Analysis 15.1  Comparison 15: Ephedrine + colloid vs crystalloid, Outcome 1: Women with hypotension requiring intervention | ||||
| 15.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 15.2  Comparison 15: Ephedrine + colloid vs crystalloid, Outcome 2: Women with nausea and/or vomiting | ||||
| 15.2.1 Nausea | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.27 [0.11, 0.65] |
| 15.2.2 Vomiting | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.09, 1.55] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 16.1 Women with hypotension requiring intervention Show forest plot | 8 | 401 | Risk Ratio (M‐H, Random, 95% CI) | 0.92 [0.71, 1.18] |
| Analysis 16.1  Comparison 16: Ephedrine vs phenylephrine, Outcome 1: Women with hypotension requiring intervention | ||||
| 16.2 Women with hypertension requiring intervention Show forest plot | 2 | 118 | Risk Ratio (M‐H, Random, 95% CI) | 1.72 [0.71, 4.16] |
| Analysis 16.2  Comparison 16: Ephedrine vs phenylephrine, Outcome 2: Women with hypertension requiring intervention | ||||
| 16.3 Cardiac dysrhythmia Show forest plot | 5 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 16.3  Comparison 16: Ephedrine vs phenylephrine, Outcome 3: Cardiac dysrhythmia | ||||
| 16.3.1 Bradycardia | 5 | 304 | Risk Ratio (M‐H, Random, 95% CI) | 0.37 [0.21, 0.64] |
| 16.3.2 Tachycardia | 1 | 57 | Risk Ratio (M‐H, Random, 95% CI) | 2.22 [0.44, 11.18] |
| 16.4 Women with nausea and/or vomiting Show forest plot | 4 | 204 | Risk Ratio (M‐H, Random, 95% CI) | 0.76 [0.39, 1.49] |
| Analysis 16.4  Comparison 16: Ephedrine vs phenylephrine, Outcome 4: Women with nausea and/or vomiting | ||||
| 16.5 Neonates with acidosis (pH < 7.2) Show forest plot | 3 | 175 | Risk Ratio (M‐H, Random, 95% CI) | 0.89 [0.07, 12.00] |
| Analysis 16.5  Comparison 16: Ephedrine vs phenylephrine, Outcome 5: Neonates with acidosis (pH < 7.2) | ||||
| 16.6 Neonates with Apgar score < 8 at 5 min Show forest plot | 6 | 321 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 16.6  Comparison 16: Ephedrine vs phenylephrine, Outcome 6: Neonates with Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 17.1 Women with hypotension requiring intervention Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 17.1  Comparison 17: Ephedrine vs angiotensin, Outcome 1: Women with hypotension requiring intervention | ||||
| 17.2 Women with nausea and/or vomiting Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.14, 65.90] |
| Analysis 17.2  Comparison 17: Ephedrine vs angiotensin, Outcome 2: Women with nausea and/or vomiting | ||||
| 17.3 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 9.00 [0.55, 147.95] |
| Analysis 17.3  Comparison 17: Ephedrine vs angiotensin, Outcome 3: Neonates with acidosis (pH < 7.2) | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 18.1 Women with hypotension requiring intervention Show forest plot | 2 | 160 | Risk Ratio (M‐H, Random, 95% CI) | 0.53 [0.36, 0.79] |
| Analysis 18.1  Comparison 18: Ephedrine vs colloid, Outcome 1: Women with hypotension requiring intervention | ||||
| 18.2 Women with hypertension requiring intervention Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.00 [0.32, 27.87] |
| Analysis 18.2  Comparison 18: Ephedrine vs colloid, Outcome 2: Women with hypertension requiring intervention | ||||
| 18.3 Women with bradycardia Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| Analysis 18.3  Comparison 18: Ephedrine vs colloid, Outcome 3: Women with bradycardia | ||||
| 18.4 Women with nausea and vomiting Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 18.4  Comparison 18: Ephedrine vs colloid, Outcome 4: Women with nausea and vomiting | ||||
| 18.4.1 Women with nausea and/or vomiting | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 5.00 [0.25, 101.58] |
| 18.4.2 Women with nausea | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.22 [0.05, 0.94] |
| 18.4.3 Women with vomiting | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.14 [0.01, 2.65] |
| 18.5 5 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| Analysis 18.5  Comparison 18: Ephedrine vs colloid, Outcome 5: 5 Neonates with acidosis (pH < 7.2) | ||||
| 18.6 Apgar score < 8 at 5 min Show forest plot | 2 | 160 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.13, 71.92] |
| Analysis 18.6  Comparison 18: Ephedrine vs colloid, Outcome 6: Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 19.1 Women with hypotension requiring intervention Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 1.56 [0.50, 4.89] |
| Analysis 19.1  Comparison 19: Ephedrine vs metaraminol, Outcome 1: Women with hypotension requiring intervention | ||||
| 19.2 Women with hypertension requiring intervention Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 0.62 [0.26, 1.47] |
| Analysis 19.2  Comparison 19: Ephedrine vs metaraminol, Outcome 2: Women with hypertension requiring intervention | ||||
| 19.3 Women with bradycardia Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 19.3  Comparison 19: Ephedrine vs metaraminol, Outcome 3: Women with bradycardia | ||||
| 19.4 Women with nausea and/or vomiting Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 7.26 [0.39, 134.01] |
| Analysis 19.4  Comparison 19: Ephedrine vs metaraminol, Outcome 4: Women with nausea and/or vomiting | ||||
| 19.5 5 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 19.5  Comparison 19: Ephedrine vs metaraminol, Outcome 5: 5 Neonates with acidosis (pH < 7.2) | ||||
| 19.6 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 19.6  Comparison 19: Ephedrine vs metaraminol, Outcome 6: Neonatal Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 20.1 Women with hypotension requiring intervention Show forest plot | 6 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 20.1  Comparison 20: Ephedrine: different doses, Outcome 1: Women with hypotension requiring intervention | ||||
| 20.1.1 5 mg vs 10 mg | 2 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.05 [0.65, 1.69] |
| 20.1.2 6 mg vs 12 mg | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 1.83 [0.83, 4.04] |
| 20.1.3 5 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.94, 4.27] |
| 20.1.4 10 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.83 [0.84, 3.99] |
| 20.1.5 10 mg vs 20 mg | 2 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.06 [0.80, 1.39] |
| 20.1.6 10 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.43 [1.30, 4.54] |
| 20.1.7 15 mg vs 30 mg | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 2.11 [1.06, 4.21] |
| 20.1.8 20 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.29 [1.21, 4.32] |
| 20.2 Women with hypertension requiring intervention Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 20.2  Comparison 20: Ephedrine: different doses, Outcome 2: Women with hypertension requiring intervention | ||||
| 20.2.1 5 mg vs 10 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.44, 3.30] |
| 20.2.2 5 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.23, 1.07] |
| 20.2.3 10 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.42 [0.18, 0.96] |
| 20.2.4 10 mg vs 20 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.03, 1.56] |
| 20.2.5 10 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.02, 0.80] |
| 20.2.6 20 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.56 [0.23, 1.37] |
| 20.3 Women with nausea and/or vomiting Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 20.3  Comparison 20: Ephedrine: different doses, Outcome 3: Women with nausea and/or vomiting | ||||
| 20.3.1 6 mg vs 12 mg (nausea and/or vomiting) | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.38, 1.74] |
| 20.3.2 5 mg vs 10 mg (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.34, 26.45] |
| 20.3.3 5 mg vs 15 mg (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.50 [0.28, 8.04] |
| 20.3.4 10 mg vs 15 mg (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.05, 5.08] |
| 20.3.5 5 mg vs 10 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.83, 4.81] |
| 20.3.6 5 mg vs 15 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.50 [0.94, 6.66] |
| 20.3.7 10 mg vs 15 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.25 [0.39, 3.99] |
| 20.3.8 10 mg vs 20 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.69 [0.39, 1.24] |
| 20.3.9 10 mg vs 30 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.80 [0.73, 4.43] |
| 20.3.10 15 mg vs 30 mg (nausea) | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.43 [0.59, 3.45] |
| 20.3.11 20 mg vs 30 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.60 [1.14, 5.93] |
| 20.3.12 15 mg vs 30 mg (vomiting) | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.12, 3.82] |
| 20.4 Neonates with acidosis (pH < 7.2) Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 20.4  Comparison 20: Ephedrine: different doses, Outcome 4: Neonates with acidosis (pH < 7.2) | ||||
| 20.4.1 5 mg vs 10 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.01, 3.92] |
| 20.4.2 5 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.33 [0.01, 7.72] |
| 20.4.3 6 mg vs 12 mg | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.31 [0.01, 7.16] |
| 20.4.4 10 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.20, 20.33] |
| 20.4.5 10 mg vs 20 mg | 1 | 39 | Risk Ratio (M‐H, Random, 95% CI) | 0.59 [0.24, 1.50] |
| 20.4.6 10 mg vs 30 mg | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | 1.12 [0.36, 3.55] |
| 20.4.7 20 mg vs 30 mg | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | 1.89 [0.69, 5.21] |
| 20.5 Neonatal Apgar score at 5 min Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 20.5  Comparison 20: Ephedrine: different doses, Outcome 5: Neonatal Apgar score at 5 min | ||||
| 20.5.1 6 mg vs 12 mg (Apgar < 7) | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.31 [0.01, 7.16] |
| 20.5.2 5 mg vs 10 mg (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.3 5 mg vs 15 mg (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.4 10 mg vs 15 mg (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.5 10 mg vs 20 mg (Apgar < 7) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.6 10 mg vs 30 mg (Apgar < 7) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.7 20 mg vs 30 mg (Apgar < 7) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.8 10 mg vs 20 mg (Apgar < 8) | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 21.1 Women with hypotension requiring intervention Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 21.1  Comparison 21: Ephedrine: different rates, Outcome 1: Women with hypotension requiring intervention | ||||
| 21.1.1 Bolus + infusion vs infusion | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 3.50 [1.26, 9.72] |
| 21.1.2 0.5 mg/min vs 1 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.65, 2.29] |
| 21.1.3 0.5 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.57 [0.77, 3.22] |
| 21.1.4 0.5 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.65, 2.29] |
| 21.1.5 1 mg/min vs 2 mg/min | 3 | 107 | Risk Ratio (M‐H, Random, 95% CI) | 1.24 [0.83, 1.84] |
| 21.1.6 1 mg/min vs 3 to 4 mg/min | 2 | 99 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.81, 2.05] |
| 21.1.7 2 mg/min vs 3 to 4 mg/min | 2 | 239 | Risk Ratio (M‐H, Random, 95% CI) | 1.21 [0.60, 2.43] |
| 21.2 Women with hypertension requiring intervention Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 21.2  Comparison 21: Ephedrine: different rates, Outcome 2: Women with hypertension requiring intervention | ||||
| 21.2.1 Bolus + infusion vs infusion | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.39, 2.59] |
| 21.2.2 0.5 mg/min vs 1 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 5.00 [0.26, 98.00] |
| 21.2.3 0.5 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.12, 3.57] |
| 21.2.4 0.5 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.05, 0.80] |
| 21.2.5 1 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.14 [0.01, 2.60] |
| 21.2.6 1 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.05 [0.00, 0.76] |
| 21.2.7 2 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.30 [0.10, 0.93] |
| 21.3 Women with bradycardia Show forest plot | 1 | 19 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 21.3  Comparison 21: Ephedrine: different rates, Outcome 3: Women with bradycardia | ||||
| 21.3.1 1 mg/min vs 2 mg/min | 1 | 19 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.4 Women with nausea and/or vomiting Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 21.4  Comparison 21: Ephedrine: different rates, Outcome 4: Women with nausea and/or vomiting | ||||
| 21.4.1 Bolus + infusion vs infusion (nausea) | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.83 [0.75, 4.48] |
| 21.4.2 0.5 mg/min vs 1 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.60, 2.77] |
| 21.4.3 0.5 mg/min vs 2 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.50 [0.66, 3.43] |
| 21.4.4 0.5 mg/min vs 4 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.60, 2.77] |
| 21.4.5 1 mg/min vs 2 mg/min (nausea) | 2 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 2.19 [0.30, 15.85] |
| 21.4.6 1 mg/min vs 4 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.43, 2.33] |
| 21.4.7 2 mg/min vs 4 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.86 [0.35, 2.10] |
| 21.4.8 Bolus + infusion vs infusion (vomiting) | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.67 [0.43, 6.51] |
| 21.4.9 0.5 mg/min vs 1 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.12, 3.57] |
| 21.4.10 0.5 mg/min vs 2 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.20, 20.33] |
| 21.4.11 0.5 mg/min vs 4 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.20, 20.33] |
| 21.4.12 1 mg/min vs 2 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.34, 26.45] |
| 21.4.13 1 mg/min vs 4 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.34, 26.45] |
| 21.4.14 2 mg/min vs 4 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.07, 14.90] |
| 21.4.15 1 mg/min vs 2 mg/min (nausea or vomiting) | 1 | 19 | Risk Ratio (M‐H, Random, 95% CI) | 8.18 [0.50, 133.66] |
| 21.5 Neonates with acidosis (pH < 7.2) Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 21.5  Comparison 21: Ephedrine: different rates, Outcome 5: Neonates with acidosis (pH < 7.2) | ||||
| 21.5.1 Bolus + infusion vs infusion | 1 | 78 | Risk Ratio (M‐H, Random, 95% CI) | 1.66 [0.53, 5.23] |
| 21.5.2 0.5 mg/min vs 1 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.33 [0.04, 2.94] |
| 21.5.3 0.5 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.13, 69.52] |
| 21.5.4 0.5 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.25 [0.03, 2.05] |
| 21.5.5 1 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 7.00 [0.38, 127.32] |
| 21.5.6 1 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.19, 2.93] |
| 21.5.7 2 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 1.94] |
| 21.6 Neonatal Apgar score at 5 min Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 21.6  Comparison 21: Ephedrine: different rates, Outcome 6: Neonatal Apgar score at 5 min | ||||
| 21.6.1 Bolus + infusion vs infusion (Apgar < 7) | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.2 0.5 mg/min vs 1 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.3 0.5 mg/min vs 2 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.4 0.5 mg/min vs 4 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.5 1 mg/min vs 2 mg/min (Apgar < 8) | 2 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.6 1 mg/min vs 4 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.7 2 mg/min vs 4 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 22.1 Women with hypotension requiring intervention Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 22.1  Comparison 22: Ephedrine: oral vs IM or IV, Outcome 1: Women with hypotension requiring intervention | ||||
| 22.1.1 Oral vs IM | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.95, 9.48] |
| 22.1.2 Oral vs IV | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 19.00 [1.18, 305.88] |
| 22.2 Women with hypertension requiring intervention Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 22.2  Comparison 22: Ephedrine: oral vs IM or IV, Outcome 2: Women with hypertension requiring intervention | ||||
| 22.2.1 Oral vs IM | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 22.2.2 Oral vs IV | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 22.3 Women with nausea and vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 22.3  Comparison 22: Ephedrine: oral vs IM or IV, Outcome 3: Women with nausea and vomiting | ||||
| 22.3.1 Oral vs IM | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.33 [0.34, 5.21] |
| 22.3.2 Oral vs IV | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 9.00 [0.52, 156.91] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 23.1 Women with hypotension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.43, 1.30] |
| Analysis 23.1  Comparison 23: Ephedrine: IM vs IV, Outcome 1: Women with hypotension requiring intervention | ||||
| 23.2 Women with hypertension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 23.2  Comparison 23: Ephedrine: IM vs IV, Outcome 2: Women with hypertension requiring intervention | ||||
| 23.3 Apgar < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 23.3  Comparison 23: Ephedrine: IM vs IV, Outcome 3: Apgar < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 24.1 Women with hypotension requiring intervention Show forest plot | 5 | 280 | Risk Ratio (M‐H, Random, 95% CI) | 0.45 [0.26, 0.80] |
| Analysis 24.1  Comparison 24: Phenylephrine vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 24.2 Women with cardiac dysrhythmia Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 24.2  Comparison 24: Phenylephrine vs control, Outcome 2: Women with cardiac dysrhythmia | ||||
| 24.2.1 Tachycardia | 1 | 56 | Risk Ratio (M‐H, Random, 95% CI) | 0.87 [0.13, 5.73] |
| 24.2.2 Bradycardia | 3 | 180 | Risk Ratio (M‐H, Random, 95% CI) | 3.23 [0.17, 61.85] |
| 24.3 Women with nausea and/or vomiting Show forest plot | 3 | 180 | Risk Ratio (M‐H, Random, 95% CI) | 0.70 [0.16, 2.98] |
| Analysis 24.3  Comparison 24: Phenylephrine vs control, Outcome 3: Women with nausea and/or vomiting | ||||
| 24.4 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 49 | Risk Ratio (M‐H, Random, 95% CI) | 0.96 [0.06, 14.50] |
| Analysis 24.4  Comparison 24: Phenylephrine vs control, Outcome 4: Neonates with acidosis (pH < 7.2) | ||||
| 24.5 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 24.5  Comparison 24: Phenylephrine vs control, Outcome 5: Neonates with Apgar < 7 at 5 min | ||||
| 24.6 Neonates with Apgar < 8 at 5 min Show forest plot | 2 | 96 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 24.6  Comparison 24: Phenylephrine vs control, Outcome 6: Neonates with Apgar < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 25.1 Women with hypotension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.19, 20.90] |
| Analysis 25.1  Comparison 25: Phenylephrine vs mephentermine, Outcome 1: Women with hypotension requiring intervention | ||||
| 25.2 Women with hypertension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 17.00 [1.03, 281.91] |
| Analysis 25.2  Comparison 25: Phenylephrine vs mephentermine, Outcome 2: Women with hypertension requiring intervention | ||||
| 25.3 Cardiac dysrhythmia Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 25.3  Comparison 25: Phenylephrine vs mephentermine, Outcome 3: Cardiac dysrhythmia | ||||
| 25.3.1 Bradycardia | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 15.00 [0.89, 251.42] |
| 25.4 Nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 25.4  Comparison 25: Phenylephrine vs mephentermine, Outcome 4: Nausea and/or vomiting | ||||
| 25.4.1 Nausea | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.01, 4.00] |
| 25.4.2 Vomiting | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.07, 15.26] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 26.1 Women with hypotension requiring intervention Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | 0.84 [0.23, 3.06] |
| Analysis 26.1  Comparison 26: Phenylephrine vs metaraminol, Outcome 1: Women with hypotension requiring intervention | ||||
| 26.2 Women with hypertension requiring intervention Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | 0.25 [0.08, 0.83] |
| Analysis 26.2  Comparison 26: Phenylephrine vs metaraminol, Outcome 2: Women with hypertension requiring intervention | ||||
| 26.3 Women with bradycardia Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 26.3  Comparison 26: Phenylephrine vs metaraminol, Outcome 3: Women with bradycardia | ||||
| 26.4 Women with nausea and/or vomiting Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 26.4  Comparison 26: Phenylephrine vs metaraminol, Outcome 4: Women with nausea and/or vomiting | ||||
| 26.5 Neonatal pH < 7.2 Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 26.5  Comparison 26: Phenylephrine vs metaraminol, Outcome 5: Neonatal pH < 7.2 | ||||
| 26.6 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 26.6  Comparison 26: Phenylephrine vs metaraminol, Outcome 6: Neonatal Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 27.1 Women with hypotension requiring intervention Show forest plot | 1 | 76 | Risk Ratio (M‐H, Random, 95% CI) | 0.73 [0.46, 1.15] |
| Analysis 27.1  Comparison 27: Phenylephrine vs leg compression, Outcome 1: Women with hypotension requiring intervention | ||||
| 27.2 Women with bradycardia Show forest plot | 1 | 76 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.05, 5.28] |
| Analysis 27.2  Comparison 27: Phenylephrine vs leg compression, Outcome 2: Women with bradycardia | ||||
| 27.3 Women with nausea and/or vomiting Show forest plot | 1 | 76 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.32, 3.17] |
| Analysis 27.3  Comparison 27: Phenylephrine vs leg compression, Outcome 3: Women with nausea and/or vomiting | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 28.1 Women with hypotension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.40 [0.50, 3.92] |
| Analysis 28.1  Comparison 28: Phenylephrine: infusion vs bolus, Outcome 1: Women with hypotension requiring intervention | ||||
| 28.2 Women with cardiac dysrhythmia Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.59, 2.51] |
| Analysis 28.2  Comparison 28: Phenylephrine: infusion vs bolus, Outcome 2: Women with cardiac dysrhythmia | ||||
| 28.2.1 Bradycardia | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.59, 2.51] |
| 28.3 Women with nausea/vomiting Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.45 [0.18, 1.15] |
| Analysis 28.3  Comparison 28: Phenylephrine: infusion vs bolus, Outcome 3: Women with nausea/vomiting | ||||
| 28.4 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 28.4  Comparison 28: Phenylephrine: infusion vs bolus, Outcome 4: Neonatal Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 29.1 Women with hypotension requiring intervention Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 8.17 [1.04, 64.30] |
| Analysis 29.1  Comparison 29: Phenylephrine: different doses, Outcome 1: Women with hypotension requiring intervention | ||||
| 29.1.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 8.17 [1.04, 64.30] |
| 29.2 Women with hypertension requiring intervention Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.23 [0.05, 1.02] |
| Analysis 29.2  Comparison 29: Phenylephrine: different doses, Outcome 2: Women with hypertension requiring intervention | ||||
| 29.2.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.23 [0.05, 1.02] |
| 29.3 Women with cardiac dysrhythmia Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 0.80] |
| Analysis 29.3  Comparison 29: Phenylephrine: different doses, Outcome 3: Women with cardiac dysrhythmia | ||||
| 29.3.1 Bradycardia: 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 0.80] |
| 29.4 Women with nausea and/or vomiting Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 3.50 [0.37, 32.67] |
| Analysis 29.4  Comparison 29: Phenylephrine: different doses, Outcome 4: Women with nausea and/or vomiting | ||||
| 29.4.1 Nausea and vomiting: 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 3.50 [0.37, 32.67] |
| 29.5 Neonatal cord blood pH < 7.2 Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 29.5  Comparison 29: Phenylephrine: different doses, Outcome 5: Neonatal cord blood pH < 7.2 | ||||
| 29.5.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 29.6 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 29.6  Comparison 29: Phenylephrine: different doses, Outcome 6: Neonatal Apgar score < 8 at 5 min | ||||
| 29.6.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 30.1 Women with hypotension requiring intervention Show forest plot | 2 | 142 | Risk Ratio (M‐H, Random, 95% CI) | 0.63 [0.21, 1.91] |
| Analysis 30.1  Comparison 30: Glycopyrrolate vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 30.2 Women with hypertension requiring intervention Show forest plot | 1 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 2.67 [1.31, 5.43] |
| Analysis 30.2  Comparison 30: Glycopyrrolate vs control, Outcome 2: Women with hypertension requiring intervention | ||||
| 30.3 Women with bradycardia Show forest plot | 1 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 0.21 [0.01, 4.32] |
| Analysis 30.3  Comparison 30: Glycopyrrolate vs control, Outcome 3: Women with bradycardia | ||||
| 30.4 Women with nausea and/or vomiting Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 30.4  Comparison 30: Glycopyrrolate vs control, Outcome 4: Women with nausea and/or vomiting | ||||
| 30.4.1 Nausea or vomiting | 1 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 2.49 [0.69, 9.04] |
| 30.4.2 Nausea | 1 | 49 | Risk Ratio (M‐H, Random, 95% CI) | 0.61 [0.36, 1.06] |
| 30.4.3 Vomiting | 1 | 49 | Risk Ratio (M‐H, Random, 95% CI) | 0.52 [0.10, 2.59] |
| 30.5 Neonates with Apgar score < 8 at 5 min Show forest plot | 2 | 142 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 30.5  Comparison 30: Glycopyrrolate vs control, Outcome 5: Neonates with Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 31.1 Women with hypotension requiring intervention Show forest plot | 8 | 740 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.54, 0.83] |
| Analysis 31.1  Comparison 31: Ondansetron vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 31.1.1 2 mg vs control | 2 | 79 | Risk Ratio (M‐H, Random, 95% CI) | 0.90 [0.51, 1.58] |
| 31.1.2 4 mg vs control | 5 | 277 | Risk Ratio (M‐H, Random, 95% CI) | 0.46 [0.34, 0.63] |
| 31.1.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | 0.48 [0.22, 1.03] |
| 31.1.4 8 mg vs control | 5 | 346 | Risk Ratio (M‐H, Random, 95% CI) | 0.85 [0.70, 1.03] |
| 31.2 Women with bradycardia Show forest plot | 8 | 740 | Risk Ratio (M‐H, Random, 95% CI) | 0.49 [0.28, 0.87] |
| Analysis 31.2  Comparison 31: Ondansetron vs control, Outcome 2: Women with bradycardia | ||||
| 31.2.1 2 mg vs control | 2 | 79 | Risk Ratio (M‐H, Random, 95% CI) | 0.23 [0.02, 3.29] |
| 31.2.2 4 mg vs control | 5 | 277 | Risk Ratio (M‐H, Random, 95% CI) | 0.33 [0.16, 0.71] |
| 31.2.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.2.4 8 mg vs control | 5 | 346 | Risk Ratio (M‐H, Random, 95% CI) | 0.94 [0.38, 2.37] |
| 31.3 Women with nausea or vomiting Show forest plot | 7 | 653 | Risk Ratio (M‐H, Random, 95% CI) | 0.35 [0.24, 0.51] |
| Analysis 31.3  Comparison 31: Ondansetron vs control, Outcome 3: Women with nausea or vomiting | ||||
| 31.3.1 2 mg vs control | 2 | 79 | Risk Ratio (M‐H, Random, 95% CI) | 0.54 [0.18, 1.59] |
| 31.3.2 4 mg vs control | 5 | 277 | Risk Ratio (M‐H, Random, 95% CI) | 0.32 [0.17, 0.60] |
| 31.3.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | 0.09 [0.01, 0.74] |
| 31.3.4 8 mg vs control | 4 | 259 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.19, 0.76] |
| 31.4 Women with anaphylaxis Show forest plot | 1 | 150 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 31.4  Comparison 31: Ondansetron vs control, Outcome 4: Women with anaphylaxis | ||||
| 31.4.1 2 mg vs control | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.4.2 4 mg vs control | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.4.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.4.4 8 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5 Neonatal Apgar score < 8 at 5 min Show forest plot | 3 | 284 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 31.5  Comparison 31: Ondansetron vs control, Outcome 5: Neonatal Apgar score < 8 at 5 min | ||||
| 31.5.1 2 mg vs control | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5.2 4 mg vs control | 2 | 102 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5.4 8 mg vs control | 2 | 107 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.6 Neonatal pH < 7.2 Show forest plot | 2 | 134 | Risk Ratio (M‐H, Random, 95% CI) | 0.48 [0.05, 5.09] |
| Analysis 31.6  Comparison 31: Ondansetron vs control, Outcome 6: Neonatal pH < 7.2 | ||||
| 31.6.1 4 mg vs control | 1 | 65 | Risk Ratio (M‐H, Random, 95% CI) | 0.48 [0.05, 5.09] |
| 31.6.2 8 mg vs control | 1 | 69 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 32.1 Women with hypotension requiring intervention Show forest plot | 1 | 112 | Risk Ratio (M‐H, Random, 95% CI) | 1.07 [0.76, 1.49] |
| Analysis 32.1  Comparison 32: Ondansetron vs ephedrine, Outcome 1: Women with hypotension requiring intervention | ||||
| 32.2 Women with bradycardia Show forest plot | 1 | 112 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.12, 72.10] |
| Analysis 32.2  Comparison 32: Ondansetron vs ephedrine, Outcome 2: Women with bradycardia | ||||
| 32.3 Women with nausea and/or vomiting Show forest plot | 1 | 112 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.10, 1.34] |
| Analysis 32.3  Comparison 32: Ondansetron vs ephedrine, Outcome 3: Women with nausea and/or vomiting | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 33.1 Women with hypotension requiring intervention Show forest plot | 1 | 200 | Risk Ratio (M‐H, Random, 95% CI) | 0.05 [0.02, 0.14] |
| Analysis 33.1  Comparison 33: Granisetron vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 34.1 Women with hypotension requiring intervention Show forest plot | 1 | 105 | Risk Ratio (M‐H, Random, 95% CI) | 0.79 [0.62, 1.01] |
| Analysis 34.1  Comparison 34: Ketamine vs saline, Outcome 1: Women with hypotension requiring intervention | ||||
| 34.1.1 0.25 mg/kg IV ketamine | 1 | 52 | Risk Ratio (M‐H, Random, 95% CI) | 0.83 [0.61, 1.14] |
| 34.1.2 0.5 mg/kg IV ketamine | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 0.73 [0.50, 1.07] |
| 34.2 Women with nausea and/or vomiting Show forest plot | 1 | 105 | Risk Ratio (M‐H, Random, 95% CI) | 0.79 [0.50, 1.25] |
| Analysis 34.2  Comparison 34: Ketamine vs saline, Outcome 2: Women with nausea and/or vomiting | ||||
| 34.2.1 0.25 mg/kg IV ketamine | 1 | 52 | Risk Ratio (M‐H, Random, 95% CI) | 0.91 [0.48, 1.71] |
| 34.2.2 0.5 mg/kg IV ketamine | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 0.69 [0.36, 1.31] |
| 34.3 Apgar score < 8 at 5 min Show forest plot | 1 | 105 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 34.3  Comparison 34: Ketamine vs saline, Outcome 3: Apgar score < 8 at 5 min | ||||
| 34.3.1 0.25 mg/kg IV ketamine | 1 | 52 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 34.3.2 0.5 mg/kg IV ketamine | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 35.1 Women with hypotension requiring intervention Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 0.09 [0.01, 1.45] |
| Analysis 35.1  Comparison 35: Angiotensin vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 35.2 Women with nausea and/or vomiting Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.01, 3.70] |
| Analysis 35.2  Comparison 35: Angiotensin vs control, Outcome 2: Women with nausea and/or vomiting | ||||
| 35.3 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 35.3  Comparison 35: Angiotensin vs control, Outcome 3: Neonates with acidosis (pH < 7.2) | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 36.1 Women with hypotension requiring intervention Show forest plot | 1 | 30 | Risk Ratio (M‐H, Random, 95% CI) | 0.05 [0.00, 0.75] |
| Analysis 36.1  Comparison 36: Dopamine vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 36.2 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 30 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 36.2  Comparison 36: Dopamine vs control, Outcome 2: Neonatal Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 37.1 Women with hypotension requiring intervention Show forest plot | 11 | 705 | Risk Ratio (M‐H, Random, 95% CI) | 0.61 [0.47, 0.78] |
| Analysis 37.1  Comparison 37: Lower limb compression vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| 37.2 Women with bradycardia Show forest plot | 1 | 74 | Risk Ratio (M‐H, Random, 95% CI) | 0.63 [0.11, 3.56] |
| Analysis 37.2  Comparison 37: Lower limb compression vs control, Outcome 2: Women with bradycardia | ||||
| 37.3 Women with nausea and/or vomiting Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 37.3  Comparison 37: Lower limb compression vs control, Outcome 3: Women with nausea and/or vomiting | ||||
| 37.3.1 Women with nausea and/or vomiting | 4 | 276 | Risk Ratio (M‐H, Random, 95% CI) | 0.42 [0.14, 1.27] |
| 37.3.2 Women with nausea | 1 | 92 | Risk Ratio (M‐H, Random, 95% CI) | 1.44 [0.25, 8.20] |
| 37.3.3 Women with vomiting | 1 | 92 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 37.4 Neonates with Apgar score < 8 at 5 min Show forest plot | 3 | 130 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 37.4  Comparison 37: Lower limb compression vs control, Outcome 4: Neonates with Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 38.1 Women with hypotension requiring intervention Show forest plot | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 0.85 [0.53, 1.37] |
| Analysis 38.1  Comparison 38: Wedge vs supine, Outcome 1: Women with hypotension requiring intervention | ||||
| 38.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 38.2  Comparison 38: Wedge vs supine, Outcome 2: Women with nausea and/or vomiting | ||||
| 38.2.1 Women with nausea | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 0.27 [0.12, 0.60] |
| 38.2.2 Women with vomiting | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 2.00] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 39.1 Women with hypotension requiring intervention Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.71 [0.47, 1.06] |
| Analysis 39.1  Comparison 39: Head‐up tilt vs horizontal, Outcome 1: Women with hypotension requiring intervention | ||||
| 39.2 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 39.2  Comparison 39: Head‐up tilt vs horizontal, Outcome 2: Neonates with Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 40.1 Women with hypotension requiring intervention Show forest plot | 1 | 34 | Risk Ratio (M‐H, Random, 95% CI) | 1.07 [0.81, 1.42] |
| Analysis 40.1  Comparison 40: Head‐down tilt vs horizontal, Outcome 1: Women with hypotension requiring intervention | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 41.1 Women with hypotension requiring intervention Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.92 [0.57, 1.49] |
| Analysis 41.1  Comparison 41: Crawford's wedge vs manual uterine displacement, Outcome 1: Women with hypotension requiring intervention | ||||
| 41.2 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 41.2  Comparison 41: Crawford's wedge vs manual uterine displacement, Outcome 2: Neonates with Apgar score < 8 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 42.1 Women with hypotension requiring intervention Show forest plot | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.58, 1.12] |
| Analysis 42.1  Comparison 42: Supine vs sitting, Outcome 1: Women with hypotension requiring intervention | ||||
| 42.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 42.2  Comparison 42: Supine vs sitting, Outcome 2: Women with nausea and/or vomiting | ||||
| 42.2.1 Nausea | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.40, 1.07] |
| 42.2.2 Vomiting | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.02, 9.01] |
| 42.3 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 42.3  Comparison 42: Supine vs sitting, Outcome 3: Neonates with acidosis (pH < 7.2) | ||||
| 42.4 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 42.4  Comparison 42: Supine vs sitting, Outcome 4: Neonates with Apgar < 7 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 43.1 Women requiring intervention for hypotension Show forest plot | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | 0.71 [0.41, 1.21] |
| Analysis 43.1  Comparison 43: Walking vs lying, Outcome 1: Women requiring intervention for hypotension | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 44.1 Women with hypotension requiring intervention Show forest plot | 2 | 126 | Risk Ratio (M‐H, Random, 95% CI) | 0.91 [0.75, 1.09] |
| Analysis 44.1  Comparison 44: Lateral vs supine wedged position, Outcome 1: Women with hypotension requiring intervention | ||||
| 44.2 Women with cardiac dysrhythmia requiring intervention Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.05, 5.08] |
| Analysis 44.2  Comparison 44: Lateral vs supine wedged position, Outcome 2: Women with cardiac dysrhythmia requiring intervention | ||||
| 44.3 Neonates admitted to neonatal intensive care unit Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 44.3  Comparison 44: Lateral vs supine wedged position, Outcome 3: Neonates admitted to neonatal intensive care unit | ||||
| 44.4 Women with nausea Show forest plot | 1 | 86 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.45, 1.48] |
| Analysis 44.4  Comparison 44: Lateral vs supine wedged position, Outcome 4: Women with nausea | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 45.1 Women with hypotension requiring intervention Show forest plot | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.80, 1.79] |
| Analysis 45.1  Comparison 45: Left lateral vs left lateral tilt, Outcome 1: Women with hypotension requiring intervention | ||||
| 45.2 Women with cardiac dysrhythmia requiring intervention Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 45.2  Comparison 45: Left lateral vs left lateral tilt, Outcome 2: Women with cardiac dysrhythmia requiring intervention | ||||
| 45.2.1 Bradycardia | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 0.10 [0.01, 1.68] |
| 45.3 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 45.3  Comparison 45: Left lateral vs left lateral tilt, Outcome 3: Women with nausea and/or vomiting | ||||
| 45.3.1 Nausea: 15 degree tilt | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 0.45 [0.18, 1.11] |
| 45.3.2 Vomiting: 15 degree tilt | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 0.15 [0.01, 2.83] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 46.1 Women with hypotension requiring intervention Show forest plot | 1 | 90 | Risk Ratio (M‐H, Random, 95% CI) | 0.63 [0.49, 0.80] |
| Analysis 46.1  Comparison 46: Left lateral tilt vs left manual uterine displacement, Outcome 1: Women with hypotension requiring intervention | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 47.1 Women with hypotension requiring intervention Show forest plot | 1 | 63 | Risk Ratio (M‐H, Random, 95% CI) | 0.73 [0.42, 1.26] |
| Analysis 47.1  Comparison 47: Leg elevation vs control, Outcome 1: Women with hypotension requiring intervention | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 48.1 Women with hypotension requiring intervention Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.84 [0.58, 1.22] |
| Analysis 48.1  Comparison 48: Acupressure vs placebo, Outcome 1: Women with hypotension requiring intervention | ||||
| 48.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 48.2  Comparison 48: Acupressure vs placebo, Outcome 2: Women with nausea and/or vomiting | ||||
| 48.2.1 Nausea | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.32 [0.15, 0.66] |
| 48.2.2 Vomiting | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.14, 1.78] |
| 48.3 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 48.3  Comparison 48: Acupressure vs placebo, Outcome 3: Neonates with Apgar < 7 at 5 min | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 49.1 Women with hypotension requiring intervention Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.94 [0.63, 1.40] |
| Analysis 49.1  Comparison 49: Acupressure vs metoclopramide, Outcome 1: Women with hypotension requiring intervention | ||||
| 49.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Analysis 49.2  Comparison 49: Acupressure vs metoclopramide, Outcome 2: Women with nausea and/or vomiting | ||||
| 49.2.1 Nausea | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 1.50 [0.48, 4.68] |
| 49.2.2 Vomiting | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.33, 26.92] |
| 49.3 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Analysis 49.3  Comparison 49: Acupressure vs metoclopramide, Outcome 3: Neonates with Apgar < 7 at 5 min | ||||
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Funnel plot of comparison: 7 Colloid vs crystalloid, outcome: 7.1 Women with hypotension requiring intervention.
Funnel plot of comparison: 13 Ephedrine vs control, outcome: 13.1 Women with hypotension requiring intervention.
Funnel plot of comparison: 47 Lower limb compression vs control, outcome: 47.1 Women with hypotension requiring intervention.
Comparison 1: Crystalloid vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 1: Crystalloid vs control, Outcome 2: Nausea and/or vomiting
Comparison 1: Crystalloid vs control, Outcome 3: Anaphylaxis
Comparison 1: Crystalloid vs control, Outcome 4: Apgar < 8 at 5 min
Comparison 2: Crystalloid: rapid infusion vs slow infusion, Outcome 1: Women with hypotension requiring intervention
Comparison 3: Crystalloid: high vs low preload volume, Outcome 1: Women with hypotension requiring intervention
Comparison 3: Crystalloid: high vs low preload volume, Outcome 2: Nausea and/or vomiting
Comparison 3: Crystalloid: high vs low preload volume, Outcome 3: Apgar < 8 at 5 min
Comparison 4: Crystalloid: rapid coload vs preload, Outcome 1: Women with hypotension requiring intervention
Comparison 4: Crystalloid: rapid coload vs preload, Outcome 2: Hypertension requiring intervention
Comparison 4: Crystalloid: rapid coload vs preload, Outcome 3: Women with bradycardia
Comparison 4: Crystalloid: rapid coload vs preload, Outcome 4: Women with nausea or vomiting
Comparison 4: Crystalloid: rapid coload vs preload, Outcome 5: Neonates with acidosis (pH < 7.2)
Comparison 4: Crystalloid: rapid coload vs preload, Outcome 6: Apgar < 8 at 5 min
Comparison 5: Crystalloid: warm vs cold, Outcome 1: Women with hypotension requiring intervention
Comparison 5: Crystalloid: warm vs cold, Outcome 2: Women with nausea and/or vomiting
Comparison 6: Crystalloid vs another crystalloid, Outcome 1: Women with hypotension requiring intervention
Comparison 6: Crystalloid vs another crystalloid, Outcome 2: Neonates with acidosis: Ringer's lactate vs saline
Comparison 6: Crystalloid vs another crystalloid, Outcome 3: Neonates with acidosis: dextrose vs saline
Comparison 6: Crystalloid vs another crystalloid, Outcome 4: Neonates with Apgar score < 7 at 5 min
Comparison 6: Crystalloid vs another crystalloid, Outcome 5: Neonates with Apgar score < 8 at 5 min
Comparison 7: Colloid vs crystalloid, Outcome 1: Women with hypotension requiring intervention
Comparison 7: Colloid vs crystalloid, Outcome 2: Women with hypertension requiring intervention
Comparison 7: Colloid vs crystalloid, Outcome 3: Women with cardiac dysrhythmia
Comparison 7: Colloid vs crystalloid, Outcome 4: Women with nausea and/or vomiting
Comparison 7: Colloid vs crystalloid, Outcome 5: Neonates with acidosis (pH < 7.2)
Comparison 7: Colloid vs crystalloid, Outcome 6: Neonates: Apgar score
Comparison 8: Colloid vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 8: Colloid vs control, Outcome 2: Women with bradycardia
Comparison 8: Colloid vs control, Outcome 3: Women with nausea and/or vomiting
Comparison 8: Colloid vs control, Outcome 4: Neonates with acidosis (pH < 7.2)
Comparison 8: Colloid vs control, Outcome 5: Neonates with Apgar score < 7 at 5 min
Comparison 8: Colloid vs control, Outcome 6: Neonatal Apgar < 8 at 5 min
Comparison 9: Colloid: different volumes, Outcome 1: Women with hypotension requiring intervention
Comparison 9: Colloid: different volumes, Outcome 2: Apgar < 9 at 5 min
Comparison 10: Colloid preload vs colloid coload, Outcome 1: Women with hypotension requiring intervention
Comparison 10: Colloid preload vs colloid coload, Outcome 2: Women with cardiac dysrhythmia
Comparison 10: Colloid preload vs colloid coload, Outcome 3: Women with nausea and/or vomiting
Comparison 10: Colloid preload vs colloid coload, Outcome 4: Women with anaphylaxis
Comparison 10: Colloid preload vs colloid coload, Outcome 5: Neonates with Apgar score < 7 at 5 min
Comparison 11: Colloid + crystalloid vs another colloid + crystalloid, Outcome 1: Women with hypotension requiring intervention
Comparison 11: Colloid + crystalloid vs another colloid + crystalloid, Outcome 2: Neonates: Apgar score < 7
Comparison 11: Colloid + crystalloid vs another colloid + crystalloid, Outcome 3: Neonates with Apgar score < 8 at 5 min
Comparison 12: Ephedrine vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 12: Ephedrine vs control, Outcome 2: Women with hypertension requiring intervention
Comparison 12: Ephedrine vs control, Outcome 3: Women with cardiac arrhythmia
Comparison 12: Ephedrine vs control, Outcome 4: Women with nausea and/or vomiting
Comparison 12: Ephedrine vs control, Outcome 5: Neonates with acidosis (pH < 7.2)
Comparison 12: Ephedrine vs control, Outcome 6: Neonates: Apgar score
Comparison 13: Ephedrine vs crystalloid, Outcome 1: Women with hypotension requiring intervention
Comparison 13: Ephedrine vs crystalloid, Outcome 2: Women with hypertension requiring intervention
Comparison 13: Ephedrine vs crystalloid, Outcome 3: Women with bradycardia
Comparison 13: Ephedrine vs crystalloid, Outcome 4: Women with nausea and/or vomiting
Comparison 13: Ephedrine vs crystalloid, Outcome 5: Women with impaired consciousness
Comparison 13: Ephedrine vs crystalloid, Outcome 6: Neonates with acidosis (pH < 7.2)
Comparison 13: Ephedrine vs crystalloid, Outcome 7: Neonatal Apgar score
Comparison 14: Ephedrine + crystalloid vs colloid, Outcome 1: Women with hypotension requiring intervention
Comparison 14: Ephedrine + crystalloid vs colloid, Outcome 2: Women with nausea and/or vomiting
Comparison 15: Ephedrine + colloid vs crystalloid, Outcome 1: Women with hypotension requiring intervention
Comparison 15: Ephedrine + colloid vs crystalloid, Outcome 2: Women with nausea and/or vomiting
Comparison 16: Ephedrine vs phenylephrine, Outcome 1: Women with hypotension requiring intervention
Comparison 16: Ephedrine vs phenylephrine, Outcome 2: Women with hypertension requiring intervention
Comparison 16: Ephedrine vs phenylephrine, Outcome 3: Cardiac dysrhythmia
Comparison 16: Ephedrine vs phenylephrine, Outcome 4: Women with nausea and/or vomiting
Comparison 16: Ephedrine vs phenylephrine, Outcome 5: Neonates with acidosis (pH < 7.2)
Comparison 16: Ephedrine vs phenylephrine, Outcome 6: Neonates with Apgar score < 8 at 5 min
Comparison 17: Ephedrine vs angiotensin, Outcome 1: Women with hypotension requiring intervention
Comparison 17: Ephedrine vs angiotensin, Outcome 2: Women with nausea and/or vomiting
Comparison 17: Ephedrine vs angiotensin, Outcome 3: Neonates with acidosis (pH < 7.2)
Comparison 18: Ephedrine vs colloid, Outcome 1: Women with hypotension requiring intervention
Comparison 18: Ephedrine vs colloid, Outcome 2: Women with hypertension requiring intervention
Comparison 18: Ephedrine vs colloid, Outcome 3: Women with bradycardia
Comparison 18: Ephedrine vs colloid, Outcome 4: Women with nausea and vomiting
Comparison 18: Ephedrine vs colloid, Outcome 5: 5 Neonates with acidosis (pH < 7.2)
Comparison 18: Ephedrine vs colloid, Outcome 6: Apgar score < 8 at 5 min
Comparison 19: Ephedrine vs metaraminol, Outcome 1: Women with hypotension requiring intervention
Comparison 19: Ephedrine vs metaraminol, Outcome 2: Women with hypertension requiring intervention
Comparison 19: Ephedrine vs metaraminol, Outcome 3: Women with bradycardia
Comparison 19: Ephedrine vs metaraminol, Outcome 4: Women with nausea and/or vomiting
Comparison 19: Ephedrine vs metaraminol, Outcome 5: 5 Neonates with acidosis (pH < 7.2)
Comparison 19: Ephedrine vs metaraminol, Outcome 6: Neonatal Apgar score < 8 at 5 min
Comparison 20: Ephedrine: different doses, Outcome 1: Women with hypotension requiring intervention
Comparison 20: Ephedrine: different doses, Outcome 2: Women with hypertension requiring intervention
Comparison 20: Ephedrine: different doses, Outcome 3: Women with nausea and/or vomiting
Comparison 20: Ephedrine: different doses, Outcome 4: Neonates with acidosis (pH < 7.2)
Comparison 20: Ephedrine: different doses, Outcome 5: Neonatal Apgar score at 5 min
Comparison 21: Ephedrine: different rates, Outcome 1: Women with hypotension requiring intervention
Comparison 21: Ephedrine: different rates, Outcome 2: Women with hypertension requiring intervention
Comparison 21: Ephedrine: different rates, Outcome 3: Women with bradycardia
Comparison 21: Ephedrine: different rates, Outcome 4: Women with nausea and/or vomiting
Comparison 21: Ephedrine: different rates, Outcome 5: Neonates with acidosis (pH < 7.2)
Comparison 21: Ephedrine: different rates, Outcome 6: Neonatal Apgar score at 5 min
Comparison 22: Ephedrine: oral vs IM or IV, Outcome 1: Women with hypotension requiring intervention
Comparison 22: Ephedrine: oral vs IM or IV, Outcome 2: Women with hypertension requiring intervention
Comparison 22: Ephedrine: oral vs IM or IV, Outcome 3: Women with nausea and vomiting
Comparison 23: Ephedrine: IM vs IV, Outcome 1: Women with hypotension requiring intervention
Comparison 23: Ephedrine: IM vs IV, Outcome 2: Women with hypertension requiring intervention
Comparison 23: Ephedrine: IM vs IV, Outcome 3: Apgar < 8 at 5 min
Comparison 24: Phenylephrine vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 24: Phenylephrine vs control, Outcome 2: Women with cardiac dysrhythmia
Comparison 24: Phenylephrine vs control, Outcome 3: Women with nausea and/or vomiting
Comparison 24: Phenylephrine vs control, Outcome 4: Neonates with acidosis (pH < 7.2)
Comparison 24: Phenylephrine vs control, Outcome 5: Neonates with Apgar < 7 at 5 min
Comparison 24: Phenylephrine vs control, Outcome 6: Neonates with Apgar < 8 at 5 min
Comparison 25: Phenylephrine vs mephentermine, Outcome 1: Women with hypotension requiring intervention
Comparison 25: Phenylephrine vs mephentermine, Outcome 2: Women with hypertension requiring intervention
Comparison 25: Phenylephrine vs mephentermine, Outcome 3: Cardiac dysrhythmia
Comparison 25: Phenylephrine vs mephentermine, Outcome 4: Nausea and/or vomiting
Comparison 26: Phenylephrine vs metaraminol, Outcome 1: Women with hypotension requiring intervention
Comparison 26: Phenylephrine vs metaraminol, Outcome 2: Women with hypertension requiring intervention
Comparison 26: Phenylephrine vs metaraminol, Outcome 3: Women with bradycardia
Comparison 26: Phenylephrine vs metaraminol, Outcome 4: Women with nausea and/or vomiting
Comparison 26: Phenylephrine vs metaraminol, Outcome 5: Neonatal pH < 7.2
Comparison 26: Phenylephrine vs metaraminol, Outcome 6: Neonatal Apgar score < 8 at 5 min
Comparison 27: Phenylephrine vs leg compression, Outcome 1: Women with hypotension requiring intervention
Comparison 27: Phenylephrine vs leg compression, Outcome 2: Women with bradycardia
Comparison 27: Phenylephrine vs leg compression, Outcome 3: Women with nausea and/or vomiting
Comparison 28: Phenylephrine: infusion vs bolus, Outcome 1: Women with hypotension requiring intervention
Comparison 28: Phenylephrine: infusion vs bolus, Outcome 2: Women with cardiac dysrhythmia
Comparison 28: Phenylephrine: infusion vs bolus, Outcome 3: Women with nausea/vomiting
Comparison 28: Phenylephrine: infusion vs bolus, Outcome 4: Neonatal Apgar score < 8 at 5 min
Comparison 29: Phenylephrine: different doses, Outcome 1: Women with hypotension requiring intervention
Comparison 29: Phenylephrine: different doses, Outcome 2: Women with hypertension requiring intervention
Comparison 29: Phenylephrine: different doses, Outcome 3: Women with cardiac dysrhythmia
Comparison 29: Phenylephrine: different doses, Outcome 4: Women with nausea and/or vomiting
Comparison 29: Phenylephrine: different doses, Outcome 5: Neonatal cord blood pH < 7.2
Comparison 29: Phenylephrine: different doses, Outcome 6: Neonatal Apgar score < 8 at 5 min
Comparison 30: Glycopyrrolate vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 30: Glycopyrrolate vs control, Outcome 2: Women with hypertension requiring intervention
Comparison 30: Glycopyrrolate vs control, Outcome 3: Women with bradycardia
Comparison 30: Glycopyrrolate vs control, Outcome 4: Women with nausea and/or vomiting
Comparison 30: Glycopyrrolate vs control, Outcome 5: Neonates with Apgar score < 8 at 5 min
Comparison 31: Ondansetron vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 31: Ondansetron vs control, Outcome 2: Women with bradycardia
Comparison 31: Ondansetron vs control, Outcome 3: Women with nausea or vomiting
Comparison 31: Ondansetron vs control, Outcome 4: Women with anaphylaxis
Comparison 31: Ondansetron vs control, Outcome 5: Neonatal Apgar score < 8 at 5 min
Comparison 31: Ondansetron vs control, Outcome 6: Neonatal pH < 7.2
Comparison 32: Ondansetron vs ephedrine, Outcome 1: Women with hypotension requiring intervention
Comparison 32: Ondansetron vs ephedrine, Outcome 2: Women with bradycardia
Comparison 32: Ondansetron vs ephedrine, Outcome 3: Women with nausea and/or vomiting
Comparison 33: Granisetron vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 34: Ketamine vs saline, Outcome 1: Women with hypotension requiring intervention
Comparison 34: Ketamine vs saline, Outcome 2: Women with nausea and/or vomiting
Comparison 34: Ketamine vs saline, Outcome 3: Apgar score < 8 at 5 min
Comparison 35: Angiotensin vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 35: Angiotensin vs control, Outcome 2: Women with nausea and/or vomiting
Comparison 35: Angiotensin vs control, Outcome 3: Neonates with acidosis (pH < 7.2)
Comparison 36: Dopamine vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 36: Dopamine vs control, Outcome 2: Neonatal Apgar score < 8 at 5 min
Comparison 37: Lower limb compression vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 37: Lower limb compression vs control, Outcome 2: Women with bradycardia
Comparison 37: Lower limb compression vs control, Outcome 3: Women with nausea and/or vomiting
Comparison 37: Lower limb compression vs control, Outcome 4: Neonates with Apgar score < 8 at 5 min
Comparison 38: Wedge vs supine, Outcome 1: Women with hypotension requiring intervention
Comparison 38: Wedge vs supine, Outcome 2: Women with nausea and/or vomiting
Comparison 39: Head‐up tilt vs horizontal, Outcome 1: Women with hypotension requiring intervention
Comparison 39: Head‐up tilt vs horizontal, Outcome 2: Neonates with Apgar score < 8 at 5 min
Comparison 40: Head‐down tilt vs horizontal, Outcome 1: Women with hypotension requiring intervention
Comparison 41: Crawford's wedge vs manual uterine displacement, Outcome 1: Women with hypotension requiring intervention
Comparison 41: Crawford's wedge vs manual uterine displacement, Outcome 2: Neonates with Apgar score < 8 at 5 min
Comparison 42: Supine vs sitting, Outcome 1: Women with hypotension requiring intervention
Comparison 42: Supine vs sitting, Outcome 2: Women with nausea and/or vomiting
Comparison 42: Supine vs sitting, Outcome 3: Neonates with acidosis (pH < 7.2)
Comparison 42: Supine vs sitting, Outcome 4: Neonates with Apgar < 7 at 5 min
Comparison 43: Walking vs lying, Outcome 1: Women requiring intervention for hypotension
Comparison 44: Lateral vs supine wedged position, Outcome 1: Women with hypotension requiring intervention
Comparison 44: Lateral vs supine wedged position, Outcome 2: Women with cardiac dysrhythmia requiring intervention
Comparison 44: Lateral vs supine wedged position, Outcome 3: Neonates admitted to neonatal intensive care unit
Comparison 44: Lateral vs supine wedged position, Outcome 4: Women with nausea
Comparison 45: Left lateral vs left lateral tilt, Outcome 1: Women with hypotension requiring intervention
Comparison 45: Left lateral vs left lateral tilt, Outcome 2: Women with cardiac dysrhythmia requiring intervention
Comparison 45: Left lateral vs left lateral tilt, Outcome 3: Women with nausea and/or vomiting
Comparison 46: Left lateral tilt vs left manual uterine displacement, Outcome 1: Women with hypotension requiring intervention
Comparison 47: Leg elevation vs control, Outcome 1: Women with hypotension requiring intervention
Comparison 48: Acupressure vs placebo, Outcome 1: Women with hypotension requiring intervention
Comparison 48: Acupressure vs placebo, Outcome 2: Women with nausea and/or vomiting
Comparison 48: Acupressure vs placebo, Outcome 3: Neonates with Apgar < 7 at 5 min
Comparison 49: Acupressure vs metoclopramide, Outcome 1: Women with hypotension requiring intervention
Comparison 49: Acupressure vs metoclopramide, Outcome 2: Women with nausea and/or vomiting
Comparison 49: Acupressure vs metoclopramide, Outcome 3: Neonates with Apgar < 7 at 5 min
| Techniques for preventing hypotension during spinal anaesthesia for caesarean section | |||||
| Patient or population: women having spinal anaesthesia for caesarean section Setting: hospital (inpatient) Outcome: maternal hypotension requiring intervention | |||||
| Comparisons | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | |
|---|---|---|---|---|---|
| Risk with control | Risk with Intervention | ||||
| Crystalloid vs control | Control | Crystalloid | average RR 0.84 | 370 | ⊕⊕⊝⊝ |
| 535 per 1000 | 449 per 1000 | ||||
| Colloid vs crystalloid | Crystalloid | Colloid | average RR 0.68 (0.58 to 0.80) | 2105 | ⊕⊝⊝⊝ |
| 586 per 1000 | 398 per 1000 | ||||
| Ephedrine vs phenylephrine | Phenylephrine | Ephedrine | average RR 0.92 | 401 | ⊕⊝⊝⊝ |
| 465 per 1000 | 428 per 1000 | ||||
| Ondansetron vs control | Control | Ondansetron | average RR 0.67 | 740 | ⊕⊕⊝⊝ |
| 579 per 1000 | 388 per 1000 | ||||
| Lower limb compression vs control | Control | Lower limb compression | average RR 0.61 | 705 | ⊕⊝⊝⊝ |
| 663 per 1000 | 404 per 1000 | ||||
| Walking vs lying | Lying | Walking | RR 0.71 (0.41 to 1.21) | 37 (1 RCT) | ⊕⊝⊝⊝ Very lowf,g |
| 706 per 1000 | 501 per 1000 | ||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence | |||||
| aInclusion criteria not representative of wider population (e.g. only elective caesarean sections) (−1). | |||||
| Crystalloid versus control for preventing hypotension during spinal anaesthesia for caesarean section | |||||
| Patient or population: women having spinal anaesthesia for caesarean section | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | |
|---|---|---|---|---|---|
| Risk with control | Risk with crystalloid | ||||
| Maternal hypotension requiring intervention | Study population | RR 0.84 | 370 | ⊕⊕⊝⊝ | |
| 535 per 1000 | 449 per 1000 | ||||
| Maternal hypertension requiring intervention | No studies reported this outcome. | ||||
| Maternal bradycardia requiring intervention | No studies reported this outcome. | ||||
| Maternal nausea and/or vomiting | Study population | RR 0.19 (0.01 to 3.91) | 69 (1 RCT) | ⊕⊝⊝⊝ Very lowa,c | |
| 59 per 1000 | 11 per 1000 (1 to 230) | ||||
| Neonatal acidosis as defined by cord or neonatal blood with a pH < 7.2 | No studies reported this outcome. | ||||
| Neonatal Apgar score < 8 at 5 minutes | Study population | Not estimable | 60 | ⊕⊕⊝⊝ | |
| 0 per 1000 | 0 per 1000 | ||||
| Admission to neonatal intensive care unit | No studies reported this outcome. | ||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. | |||||
| aOnly elective caesarean sections included (−1). | |||||
| Colloid versus crystalloid for preventing hypotension during spinal anaesthesia for caesarean section | |||||
| Patient or population: women having spinal anaesthesia for caesarean section | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | |
|---|---|---|---|---|---|
| Risk with crystalloid | Risk with colloid | ||||
| Maternal hypotension requiring intervention | Study population | RR 0.69 (0.58 to 0.81) | 2009 | ⊕⊝⊝⊝ | |
| 595 per 1000 | 411 per 1000 | ||||
| Maternal hypertension requiring intervention | Study population | RR 0.64 | 327 | ⊕⊝⊝⊝ | |
| 55 per 1000 | 35 per 1000 | ||||
| Maternal bradycardia requiring intervention | Study population | RR 0.98 | 413 | ⊕⊝⊝⊝ | |
| 87 per 1000 | 86 per 1000 | ||||
| Maternal nausea and/or vomiting | Study population | RR 0.89 | 1058 | ⊕⊝⊝⊝ | |
| 230 per 1000 | 205 per 1000 | ||||
| Neonatal acidosis as defined by cord or neonatal blood with a pH < 7.2 | Study population | RR 0.83 | 678 | ⊕⊝⊝⊝ | |
| 26 per 1000 | 21 per 1000 | ||||
| Neonatal Apgar score < 8 at 5 minutes | Study population | RR 0.24 | 730 | ⊕⊝⊝⊝ | |
| 10 per 1000 | 3 per 1000 | ||||
| Admission to neonatal intensive care unit | No studies reported this outcome. | ||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. | |||||
| aDowngraded one level for serious risk of bias (due to unclear risk of selection bias in most included studies) (−1). | |||||
| Ephedrine versus phenylephrine for preventing hypotension during spinal anaesthesia for caesarean section | ||||||
| Patient or population: women having spinal anaesthesia for caesarean section | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Risk with phenylephrine | Risk with ephedrine | |||||
| Maternal hypotension requiring intervention | Study population | RR 0.92 | 401 | ⊕⊝⊝⊝ | — | |
| 465 per 1000 | 428 per 1000 | |||||
| Maternal hypertension requiring intervention | Study population | RR 1.72 | 118 | ⊕⊕⊝⊝ | — | |
| 113 per 1000 | 194 per 1000 | |||||
| Maternal bradycardia requiring intervention | Study population | RR 0.37 | 304 | ⊕⊕⊝⊝ | — | |
| 243 per 1000 | 90 per 1000 | |||||
| Maternal nausea and/or vomiting | Study population | RR 0.76 | 204 | ⊕⊝⊝⊝ | — | |
| 216 per 1000 | 164 per 1000 | |||||
| Neonatal acidosis as defined by cord or neonatal blood with a pH < 7.2 | Study population | RR 0.89 | 175 | ⊕⊕⊝⊝ | — | |
| 11 per 1000 | 10 per 1000 | |||||
| Neonatal Apgar score < 8 at 5 minutes | Study population | Not estimable | 321 | ⊕⊕⊝⊝ | No events observed in any studies. Relative effect could not be estimated. | |
| Not pooled | Not pooled | |||||
| Admission to neonatal intensive care unit | No studies reported this outcome. | |||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. | ||||||
| aSubstantial heterogeneity (−1). | ||||||
| Ondansetron versus saline placebo for preventing hypotension during spinal anaesthesia for caesarean section | |||||
| Patient or population: women having spinal anaesthesia for caesarean section | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | |
|---|---|---|---|---|---|
| Risk with control | Risk with ondansetron | ||||
| Maternal hypotension requiring intervention | Study population | RR 0.67 | 740 | ⊕⊕⊝⊝ | |
| 579 per 1000 | 388 per 1000 | ||||
| Maternal hypertension requiring intervention | No studies reported this outcome. | ||||
| Maternal bradycardia requiring intervention | Study population | RR 0.49 | 740 | ⊕⊕⊝⊝ | |
| 100 per 1000 | 49 per 1000 | ||||
| Maternal nausea and/or vomiting | Study population | RR 0.35 | 653 | ⊕⊕⊝⊝ | |
| 296 per 1000 | 103 per 1000 | ||||
| Neonatal Apgar score < 8 at 5 minutes | Study population | Not estimable | 284 | ⊕⊕⊝⊝ | |
| Not pooled | Not pooled | ||||
| Neonatal acidosis as defined by cord or neonatal blood with a pH < 7.2 | Study population | RR 0.48 | 134 | ⊕⊕⊝⊝ | |
| 30 per 1000 | 15 per 1000 | ||||
| Admission to neonatal care unit | No studies reported this outcome. | ||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. | |||||
| a Inclusion criteria not representative of wider population (e.g. elective caesarean section only) (−1). | |||||
| Leg compression versus control for preventing hypotension during spinal anaesthesia for caesarean section | ||||||
| Patient or population: women having spinal anaesthesia for caesarean section | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | Comments | |
|---|---|---|---|---|---|---|
| Risk with control | Risk with lower limb compression | |||||
| Maternal hypotension requiring intervention | Study population | RR 0.61 | 705 | ⊕⊝⊝⊝ | — | |
| 663 per 1000 | 404 per 1000 | |||||
| Maternal hypertension requiring intervention | No studies reported this outcome. | |||||
| Maternal bradycardia requiring intervention | Study population | RR 0.63 (0.11 to 3.56) | 74 (1 RCTs) | ⊕⊝⊝⊝ | — | |
| 83 per 1000 | 53 per 1000 (9 to 297) | |||||
| Maternal nausea and/or vomiting | Study population | RR 0.42 | 276 | ⊕⊝⊝⊝ | — | |
| 162 per 1000 | 68 per 1000 | |||||
| Neonatal acidosis as defined by cord or neonatal blood with a pH < 7.2 | No studies reported this outcome. | |||||
| Neonatal Apgar score < 8 at 5 minutes | Study population | Not estimable | 130 | ⊕⊝⊝⊝ | No events observed in any studies. Relative effect could not be estimated. | |
| Not pooled | Not pooled | |||||
| Admission to neonatal intensive care unit | No studies reported this outcome. | |||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | ||||||
| GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. | ||||||
| aDowngraded one level for serious risk of bias (due to unclear risk of selection bias in the majority of included studies (−1). | ||||||
| Walking versus lying for reducing risk of maternal hypotension during spinal anaesthesia for caesarean section | |||||
| Patient or population: women having spinal anaesthesia for caesarean section | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | № of participants | Quality of the evidence | |
|---|---|---|---|---|---|
| Risk with lying | Risk with walking | ||||
| Maternal hypotension requiring intervention | Study population | RR 0.71 | 37 | ⊕⊝⊝⊝ | |
| 706 per 1000 | 501 per 1000 | ||||
| Maternal hypertension requiring intervention | No studies reported this outcome. | ||||
| Maternal bradycardia requiring intervention | No studies reported this outcome. | ||||
| Maternal nausea and/or vomiting | No studies reported this outcome. | ||||
| Neonatal acidosis as defined by cord or neonatal blood with a pH < 7.2 | No studies reported this outcome. | ||||
| Neonal Apgar score < 8 at 5 minutes | No studies reported this outcome. | ||||
| Admission to neonatal intensive care unit | No studies reported this outcome. | ||||
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). | |||||
| GRADE Working Group grades of evidence | |||||
| aParticipants and anaesthetists not blinded in 1 study with 100% weight in analysis (−1). | |||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1.1 Women with hypotension requiring intervention Show forest plot | 5 | 370 | Risk Ratio (M‐H, Random, 95% CI) | 0.84 [0.72, 0.98] |
| 1.2 Nausea and/or vomiting Show forest plot | 1 | 69 | Risk Ratio (M‐H, Random, 95% CI) | 0.19 [0.01, 3.91] |
| 1.3 Anaphylaxis Show forest plot | 1 | 69 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 1.4 Apgar < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 2.1 Women with hypotension requiring intervention Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 0.86 [0.45, 1.64] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 3.1 Women with hypotension requiring intervention Show forest plot | 3 | 192 | Risk Ratio (M‐H, Random, 95% CI) | 0.55 [0.29, 1.02] |
| 3.1.1 15 mL/kg crystalloid | 2 | 67 | Risk Ratio (M‐H, Random, 95% CI) | 0.56 [0.33, 0.96] |
| 3.1.2 20 mL/kg crystalloid | 2 | 125 | Risk Ratio (M‐H, Random, 95% CI) | 0.51 [0.11, 2.44] |
| 3.2 Nausea and/or vomiting Show forest plot | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.40, 3.62] |
| 3.3 Apgar < 8 at 5 min Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 3.3.1 15 mL/kg crystalloid | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 3.3.2 20 mL/kg crystalloid | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 4.1 Women with hypotension requiring intervention Show forest plot | 5 | 384 | Risk Ratio (M‐H, Random, 95% CI) | 0.70 [0.59, 0.83] |
| 4.2 Hypertension requiring intervention Show forest plot | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.67 [0.42, 6.60] |
| 4.3 Women with bradycardia Show forest plot | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.43 [0.59, 3.45] |
| 4.4 Women with nausea or vomiting Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 4.4.1 Women with nausea | 3 | 210 | Risk Ratio (M‐H, Random, 95% CI) | 1.98 [1.26, 3.12] |
| 4.4.2 Women with vomiting | 2 | 160 | Risk Ratio (M‐H, Random, 95% CI) | 2.33 [0.98, 5.58] |
| 4.5 Neonates with acidosis (pH < 7.2) Show forest plot | 2 | 110 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 4.6 Apgar < 8 at 5 min Show forest plot | 3 | 210 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 5.1 Women with hypotension requiring intervention Show forest plot | 1 | 113 | Risk Ratio (M‐H, Random, 95% CI) | 1.03 [0.65, 1.62] |
| 5.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 5.2.1 Nausea | 1 | 113 | Risk Ratio (M‐H, Random, 95% CI) | 1.64 [0.97, 2.76] |
| 5.2.2 Vomiting | 1 | 113 | Risk Ratio (M‐H, Random, 95% CI) | 2.95 [0.12, 70.87] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 6.1 Women with hypotension requiring intervention Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 6.1.1 Dextrose + saline vs saline | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | 0.88 [0.68, 1.14] |
| 6.1.2 Glucose vs saline | 1 | 70 | Risk Ratio (M‐H, Random, 95% CI) | 1.05 [0.74, 1.48] |
| 6.1.3 Ringer's lactate vs saline | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.17 [0.65, 2.09] |
| 6.2 Neonates with acidosis: Ringer's lactate vs saline Show forest plot | 1 | 60 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| 6.3 Neonates with acidosis: dextrose vs saline Show forest plot | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.39, 3.72] |
| 6.4 Neonates with Apgar score < 7 at 5 min Show forest plot | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 6.5 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 7.1 Women with hypotension requiring intervention Show forest plot | 27 | 2009 | Risk Ratio (M‐H, Random, 95% CI) | 0.69 [0.58, 0.81] |
| 7.2 Women with hypertension requiring intervention Show forest plot | 3 | 327 | Risk Ratio (M‐H, Random, 95% CI) | 0.64 [0.09, 4.46] |
| 7.3 Women with cardiac dysrhythmia Show forest plot | 6 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 7.3.1 Tachycardia | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.10 [0.79, 1.53] |
| 7.3.2 Bradycardia | 5 | 413 | Risk Ratio (M‐H, Random, 95% CI) | 0.98 [0.54, 1.78] |
| 7.4 Women with nausea and/or vomiting Show forest plot | 15 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 7.4.1 Nausea and/or vomiting | 14 | 1058 | Risk Ratio (M‐H, Random, 95% CI) | 0.89 [0.66, 1.19] |
| 7.4.2 Nausea | 5 | 390 | Risk Ratio (M‐H, Random, 95% CI) | 1.10 [0.77, 1.58] |
| 7.4.3 Vomiting | 4 | 320 | Risk Ratio (M‐H, Random, 95% CI) | 1.35 [0.55, 3.27] |
| 7.5 Neonates with acidosis (pH < 7.2) Show forest plot | 6 | 678 | Risk Ratio (M‐H, Random, 95% CI) | 0.83 [0.15, 4.52] |
| 7.6 Neonates: Apgar score Show forest plot | 12 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 7.6.1 Apgar < 7 at 5 min | 2 | 127 | Risk Ratio (M‐H, Random, 95% CI) | 0.16 [0.01, 2.90] |
| 7.6.2 Apgar < 8 at 5 min | 10 | 730 | Risk Ratio (M‐H, Random, 95% CI) | 0.24 [0.03, 2.05] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 8.1 Women with hypotension requiring intervention Show forest plot | 5 | 426 | Risk Ratio (M‐H, Random, 95% CI) | 0.40 [0.16, 0.96] |
| 8.2 Women with bradycardia Show forest plot | 1 | 54 | Risk Ratio (M‐H, Random, 95% CI) | 7.70 [0.46, 127.78] |
| 8.3 Women with nausea and/or vomiting Show forest plot | 2 | 245 | Risk Ratio (M‐H, Random, 95% CI) | 1.65 [0.75, 3.64] |
| 8.4 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 205 | Risk Ratio (M‐H, Random, 95% CI) | 1.24 [0.34, 4.48] |
| 8.5 Neonates with Apgar score < 7 at 5 min Show forest plot | 4 | 221 | Risk Ratio (M‐H, Random, 95% CI) | 0.07 [0.00, 1.24] |
| 8.6 Neonatal Apgar < 8 at 5 min Show forest plot | 1 | 205 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 9.1 Women with hypotension requiring intervention Show forest plot | 3 | 134 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.27, 2.08] |
| 9.2 Apgar < 9 at 5 min Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 10.1 Women with hypotension requiring intervention Show forest plot | 4 | 320 | Risk Ratio (M‐H, Random, 95% CI) | 0.93 [0.78, 1.10] |
| 10.2 Women with cardiac dysrhythmia Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 10.2.1 Bradycardia | 2 | 82 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.20, 2.88] |
| 10.2.2 Tachycardia | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 10.3 Women with nausea and/or vomiting Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 10.3.1 Nausea and/or vomiting | 1 | 178 | Risk Ratio (M‐H, Random, 95% CI) | 0.92 [0.63, 1.35] |
| 10.3.2 Nausea | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.15, 6.51] |
| 10.3.3 Vomiting | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 10.4 Women with anaphylaxis Show forest plot | 1 | 178 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 10.5 Neonates with Apgar score < 7 at 5 min Show forest plot | 1 | 36 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 11.1 Women with hypotension requiring intervention Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 11.1.1 Albumin or dextrose vs dextrose | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | 0.13 [0.01, 2.30] |
| 11.1.2 Unbalanced vs balanced hydroxyethyl starch | 1 | 51 | Risk Ratio (M‐H, Random, 95% CI) | 1.04 [0.78, 1.39] |
| 11.2 Neonates: Apgar score < 7 Show forest plot | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | 0.13 [0.01, 2.30] |
| 11.2.1 Albumin or dextrose vs dextrose | 1 | 45 | Risk Ratio (M‐H, Random, 95% CI) | 0.13 [0.01, 2.30] |
| 11.3 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 51 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 11.3.1 Unbalanced vs balanced hydroxyethyl starch | 1 | 51 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 12.1 Women with hypotension requiring intervention Show forest plot | 22 | 1401 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.53, 0.80] |
| 12.2 Women with hypertension requiring intervention Show forest plot | 7 | 520 | Risk Ratio (M‐H, Random, 95% CI) | 1.61 [1.00, 2.61] |
| 12.3 Women with cardiac arrhythmia Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 12.3.1 Tachycardia | 2 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 1.12 [0.74, 1.70] |
| 12.3.2 Bradycardia | 2 | 103 | Risk Ratio (M‐H, Random, 95% CI) | 14.46 [0.87, 241.09] |
| 12.4 Women with nausea and/or vomiting Show forest plot | 13 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 12.4.1 Nausea and/or vomiting | 5 | 219 | Risk Ratio (M‐H, Random, 95% CI) | 0.71 [0.22, 2.34] |
| 12.4.2 Nausea | 8 | 620 | Risk Ratio (M‐H, Random, 95% CI) | 0.68 [0.48, 0.96] |
| 12.4.3 Vomiting | 6 | 516 | Risk Ratio (M‐H, Random, 95% CI) | 0.68 [0.44, 1.07] |
| 12.5 Neonates with acidosis (pH < 7.2) Show forest plot | 9 | 576 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.67, 2.49] |
| 12.6 Neonates: Apgar score Show forest plot | 14 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 12.6.1 Apgar < 8 at 5 min | 10 | 579 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 12.6.2 Apgar < 7 at 5 min | 4 | 263 | Risk Ratio (M‐H, Random, 95% CI) | 1.14 [0.34, 3.81] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 13.1 Women with hypotension requiring intervention Show forest plot | 9 | 613 | Risk Ratio (M‐H, Random, 95% CI) | 0.60 [0.47, 0.78] |
| 13.2 Women with hypertension requiring intervention Show forest plot | 3 | 280 | Risk Ratio (M‐H, Random, 95% CI) | 1.10 [0.37, 3.28] |
| 13.3 Women with bradycardia Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.33 [0.01, 7.99] |
| 13.4 Women with nausea and/or vomiting Show forest plot | 5 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 13.4.1 Nausea and/or vomiting | 2 | 146 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.48, 2.08] |
| 13.4.2 Nausea | 3 | 220 | Risk Ratio (M‐H, Random, 95% CI) | 0.54 [0.31, 0.93] |
| 13.4.3 Vomiting | 3 | 220 | Risk Ratio (M‐H, Random, 95% CI) | 0.57 [0.31, 1.05] |
| 13.5 Women with impaired consciousness Show forest plot | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.40 [0.09, 1.86] |
| 13.6 Neonates with acidosis (pH < 7.2) Show forest plot | 2 | 218 | Risk Ratio (M‐H, Random, 95% CI) | 1.41 [0.48, 4.15] |
| 13.7 Neonatal Apgar score Show forest plot | 5 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 13.7.1 Apgar < 8 at 5 min | 4 | 226 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.13, 71.92] |
| 13.7.2 Apgar < 7 at 5 min | 1 | 120 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 14.1 Women with hypotension requiring intervention Show forest plot | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.38, 1.12] |
| 14.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 14.2.1 Nausea | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.42 [0.22, 0.81] |
| 14.2.2 Vomiting | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.17 [0.04, 0.77] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 15.1 Women with hypotension requiring intervention Show forest plot | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.39 [0.21, 0.74] |
| 15.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 15.2.1 Nausea | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.27 [0.11, 0.65] |
| 15.2.2 Vomiting | 1 | 75 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.09, 1.55] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 16.1 Women with hypotension requiring intervention Show forest plot | 8 | 401 | Risk Ratio (M‐H, Random, 95% CI) | 0.92 [0.71, 1.18] |
| 16.2 Women with hypertension requiring intervention Show forest plot | 2 | 118 | Risk Ratio (M‐H, Random, 95% CI) | 1.72 [0.71, 4.16] |
| 16.3 Cardiac dysrhythmia Show forest plot | 5 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 16.3.1 Bradycardia | 5 | 304 | Risk Ratio (M‐H, Random, 95% CI) | 0.37 [0.21, 0.64] |
| 16.3.2 Tachycardia | 1 | 57 | Risk Ratio (M‐H, Random, 95% CI) | 2.22 [0.44, 11.18] |
| 16.4 Women with nausea and/or vomiting Show forest plot | 4 | 204 | Risk Ratio (M‐H, Random, 95% CI) | 0.76 [0.39, 1.49] |
| 16.5 Neonates with acidosis (pH < 7.2) Show forest plot | 3 | 175 | Risk Ratio (M‐H, Random, 95% CI) | 0.89 [0.07, 12.00] |
| 16.6 Neonates with Apgar score < 8 at 5 min Show forest plot | 6 | 321 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 17.1 Women with hypotension requiring intervention Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 17.2 Women with nausea and/or vomiting Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.14, 65.90] |
| 17.3 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 9.00 [0.55, 147.95] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 18.1 Women with hypotension requiring intervention Show forest plot | 2 | 160 | Risk Ratio (M‐H, Random, 95% CI) | 0.53 [0.36, 0.79] |
| 18.2 Women with hypertension requiring intervention Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | 3.00 [0.32, 27.87] |
| 18.3 Women with bradycardia Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| 18.4 Women with nausea and vomiting Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 18.4.1 Women with nausea and/or vomiting | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 5.00 [0.25, 101.58] |
| 18.4.2 Women with nausea | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.22 [0.05, 0.94] |
| 18.4.3 Women with vomiting | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.14 [0.01, 2.65] |
| 18.5 5 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 100 | Risk Ratio (M‐H, Fixed, 95% CI) | Not estimable |
| 18.6 Apgar score < 8 at 5 min Show forest plot | 2 | 160 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.13, 71.92] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 19.1 Women with hypotension requiring intervention Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 1.56 [0.50, 4.89] |
| 19.2 Women with hypertension requiring intervention Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 0.62 [0.26, 1.47] |
| 19.3 Women with bradycardia Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 19.4 Women with nausea and/or vomiting Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 7.26 [0.39, 134.01] |
| 19.5 5 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 19.6 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 20.1 Women with hypotension requiring intervention Show forest plot | 6 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 20.1.1 5 mg vs 10 mg | 2 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.05 [0.65, 1.69] |
| 20.1.2 6 mg vs 12 mg | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 1.83 [0.83, 4.04] |
| 20.1.3 5 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.94, 4.27] |
| 20.1.4 10 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.83 [0.84, 3.99] |
| 20.1.5 10 mg vs 20 mg | 2 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.06 [0.80, 1.39] |
| 20.1.6 10 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.43 [1.30, 4.54] |
| 20.1.7 15 mg vs 30 mg | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 2.11 [1.06, 4.21] |
| 20.1.8 20 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.29 [1.21, 4.32] |
| 20.2 Women with hypertension requiring intervention Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 20.2.1 5 mg vs 10 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.44, 3.30] |
| 20.2.2 5 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.23, 1.07] |
| 20.2.3 10 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.42 [0.18, 0.96] |
| 20.2.4 10 mg vs 20 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.03, 1.56] |
| 20.2.5 10 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.02, 0.80] |
| 20.2.6 20 mg vs 30 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.56 [0.23, 1.37] |
| 20.3 Women with nausea and/or vomiting Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 20.3.1 6 mg vs 12 mg (nausea and/or vomiting) | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.38, 1.74] |
| 20.3.2 5 mg vs 10 mg (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.34, 26.45] |
| 20.3.3 5 mg vs 15 mg (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.50 [0.28, 8.04] |
| 20.3.4 10 mg vs 15 mg (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.05, 5.08] |
| 20.3.5 5 mg vs 10 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.83, 4.81] |
| 20.3.6 5 mg vs 15 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.50 [0.94, 6.66] |
| 20.3.7 10 mg vs 15 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.25 [0.39, 3.99] |
| 20.3.8 10 mg vs 20 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.69 [0.39, 1.24] |
| 20.3.9 10 mg vs 30 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.80 [0.73, 4.43] |
| 20.3.10 15 mg vs 30 mg (nausea) | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 1.43 [0.59, 3.45] |
| 20.3.11 20 mg vs 30 mg (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.60 [1.14, 5.93] |
| 20.3.12 15 mg vs 30 mg (vomiting) | 1 | 100 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.12, 3.82] |
| 20.4 Neonates with acidosis (pH < 7.2) Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 20.4.1 5 mg vs 10 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.01, 3.92] |
| 20.4.2 5 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.33 [0.01, 7.72] |
| 20.4.3 6 mg vs 12 mg | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.31 [0.01, 7.16] |
| 20.4.4 10 mg vs 15 mg | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.20, 20.33] |
| 20.4.5 10 mg vs 20 mg | 1 | 39 | Risk Ratio (M‐H, Random, 95% CI) | 0.59 [0.24, 1.50] |
| 20.4.6 10 mg vs 30 mg | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | 1.12 [0.36, 3.55] |
| 20.4.7 20 mg vs 30 mg | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | 1.89 [0.69, 5.21] |
| 20.5 Neonatal Apgar score at 5 min Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 20.5.1 6 mg vs 12 mg (Apgar < 7) | 1 | 46 | Risk Ratio (M‐H, Random, 95% CI) | 0.31 [0.01, 7.16] |
| 20.5.2 5 mg vs 10 mg (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.3 5 mg vs 15 mg (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.4 10 mg vs 15 mg (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.5 10 mg vs 20 mg (Apgar < 7) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.6 10 mg vs 30 mg (Apgar < 7) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.7 20 mg vs 30 mg (Apgar < 7) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 20.5.8 10 mg vs 20 mg (Apgar < 8) | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 21.1 Women with hypotension requiring intervention Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 21.1.1 Bolus + infusion vs infusion | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 3.50 [1.26, 9.72] |
| 21.1.2 0.5 mg/min vs 1 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.65, 2.29] |
| 21.1.3 0.5 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.57 [0.77, 3.22] |
| 21.1.4 0.5 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.65, 2.29] |
| 21.1.5 1 mg/min vs 2 mg/min | 3 | 107 | Risk Ratio (M‐H, Random, 95% CI) | 1.24 [0.83, 1.84] |
| 21.1.6 1 mg/min vs 3 to 4 mg/min | 2 | 99 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.81, 2.05] |
| 21.1.7 2 mg/min vs 3 to 4 mg/min | 2 | 239 | Risk Ratio (M‐H, Random, 95% CI) | 1.21 [0.60, 2.43] |
| 21.2 Women with hypertension requiring intervention Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 21.2.1 Bolus + infusion vs infusion | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.39, 2.59] |
| 21.2.2 0.5 mg/min vs 1 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 5.00 [0.26, 98.00] |
| 21.2.3 0.5 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.12, 3.57] |
| 21.2.4 0.5 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.05, 0.80] |
| 21.2.5 1 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.14 [0.01, 2.60] |
| 21.2.6 1 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.05 [0.00, 0.76] |
| 21.2.7 2 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.30 [0.10, 0.93] |
| 21.3 Women with bradycardia Show forest plot | 1 | 19 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.3.1 1 mg/min vs 2 mg/min | 1 | 19 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.4 Women with nausea and/or vomiting Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 21.4.1 Bolus + infusion vs infusion (nausea) | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.83 [0.75, 4.48] |
| 21.4.2 0.5 mg/min vs 1 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.60, 2.77] |
| 21.4.3 0.5 mg/min vs 2 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.50 [0.66, 3.43] |
| 21.4.4 0.5 mg/min vs 4 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.29 [0.60, 2.77] |
| 21.4.5 1 mg/min vs 2 mg/min (nausea) | 2 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 2.19 [0.30, 15.85] |
| 21.4.6 1 mg/min vs 4 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.43, 2.33] |
| 21.4.7 2 mg/min vs 4 mg/min (nausea) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.86 [0.35, 2.10] |
| 21.4.8 Bolus + infusion vs infusion (vomiting) | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 1.67 [0.43, 6.51] |
| 21.4.9 0.5 mg/min vs 1 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.12, 3.57] |
| 21.4.10 0.5 mg/min vs 2 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.20, 20.33] |
| 21.4.11 0.5 mg/min vs 4 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.20, 20.33] |
| 21.4.12 1 mg/min vs 2 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.34, 26.45] |
| 21.4.13 1 mg/min vs 4 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.34, 26.45] |
| 21.4.14 2 mg/min vs 4 mg/min (vomiting) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.07, 14.90] |
| 21.4.15 1 mg/min vs 2 mg/min (nausea or vomiting) | 1 | 19 | Risk Ratio (M‐H, Random, 95% CI) | 8.18 [0.50, 133.66] |
| 21.5 Neonates with acidosis (pH < 7.2) Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 21.5.1 Bolus + infusion vs infusion | 1 | 78 | Risk Ratio (M‐H, Random, 95% CI) | 1.66 [0.53, 5.23] |
| 21.5.2 0.5 mg/min vs 1 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.33 [0.04, 2.94] |
| 21.5.3 0.5 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.13, 69.52] |
| 21.5.4 0.5 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.25 [0.03, 2.05] |
| 21.5.5 1 mg/min vs 2 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 7.00 [0.38, 127.32] |
| 21.5.6 1 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.19, 2.93] |
| 21.5.7 2 mg/min vs 4 mg/min | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 1.94] |
| 21.6 Neonatal Apgar score at 5 min Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 21.6.1 Bolus + infusion vs infusion (Apgar < 7) | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.2 0.5 mg/min vs 1 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.3 0.5 mg/min vs 2 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.4 0.5 mg/min vs 4 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.5 1 mg/min vs 2 mg/min (Apgar < 8) | 2 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.6 1 mg/min vs 4 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 21.6.7 2 mg/min vs 4 mg/min (Apgar < 8) | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 22.1 Women with hypotension requiring intervention Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 22.1.1 Oral vs IM | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.95, 9.48] |
| 22.1.2 Oral vs IV | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 19.00 [1.18, 305.88] |
| 22.2 Women with hypertension requiring intervention Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 22.2.1 Oral vs IM | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 22.2.2 Oral vs IV | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 22.3 Women with nausea and vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 22.3.1 Oral vs IM | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 1.33 [0.34, 5.21] |
| 22.3.2 Oral vs IV | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 9.00 [0.52, 156.91] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 23.1 Women with hypotension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.75 [0.43, 1.30] |
| 23.2 Women with hypertension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 23.3 Apgar < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 24.1 Women with hypotension requiring intervention Show forest plot | 5 | 280 | Risk Ratio (M‐H, Random, 95% CI) | 0.45 [0.26, 0.80] |
| 24.2 Women with cardiac dysrhythmia Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 24.2.1 Tachycardia | 1 | 56 | Risk Ratio (M‐H, Random, 95% CI) | 0.87 [0.13, 5.73] |
| 24.2.2 Bradycardia | 3 | 180 | Risk Ratio (M‐H, Random, 95% CI) | 3.23 [0.17, 61.85] |
| 24.3 Women with nausea and/or vomiting Show forest plot | 3 | 180 | Risk Ratio (M‐H, Random, 95% CI) | 0.70 [0.16, 2.98] |
| 24.4 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 49 | Risk Ratio (M‐H, Random, 95% CI) | 0.96 [0.06, 14.50] |
| 24.5 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 24.6 Neonates with Apgar < 8 at 5 min Show forest plot | 2 | 96 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 25.1 Women with hypotension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 2.00 [0.19, 20.90] |
| 25.2 Women with hypertension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 17.00 [1.03, 281.91] |
| 25.3 Cardiac dysrhythmia Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 25.3.1 Bradycardia | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 15.00 [0.89, 251.42] |
| 25.4 Nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 25.4.1 Nausea | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.01, 4.00] |
| 25.4.2 Vomiting | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.07, 15.26] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 26.1 Women with hypotension requiring intervention Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | 0.84 [0.23, 3.06] |
| 26.2 Women with hypertension requiring intervention Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | 0.25 [0.08, 0.83] |
| 26.3 Women with bradycardia Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 26.4 Women with nausea and/or vomiting Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 26.5 Neonatal pH < 7.2 Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 26.6 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 59 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 27.1 Women with hypotension requiring intervention Show forest plot | 1 | 76 | Risk Ratio (M‐H, Random, 95% CI) | 0.73 [0.46, 1.15] |
| 27.2 Women with bradycardia Show forest plot | 1 | 76 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.05, 5.28] |
| 27.3 Women with nausea and/or vomiting Show forest plot | 1 | 76 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.32, 3.17] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 28.1 Women with hypotension requiring intervention Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.40 [0.50, 3.92] |
| 28.2 Women with cardiac dysrhythmia Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.59, 2.51] |
| 28.2.1 Bradycardia | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 1.22 [0.59, 2.51] |
| 28.3 Women with nausea/vomiting Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | 0.45 [0.18, 1.15] |
| 28.4 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 60 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 29.1 Women with hypotension requiring intervention Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 8.17 [1.04, 64.30] |
| 29.1.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 8.17 [1.04, 64.30] |
| 29.2 Women with hypertension requiring intervention Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.23 [0.05, 1.02] |
| 29.2.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.23 [0.05, 1.02] |
| 29.3 Women with cardiac dysrhythmia Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 0.80] |
| 29.3.1 Bradycardia: 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 0.80] |
| 29.4 Women with nausea and/or vomiting Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 3.50 [0.37, 32.67] |
| 29.4.1 Nausea and vomiting: 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | 3.50 [0.37, 32.67] |
| 29.5 Neonatal cord blood pH < 7.2 Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 29.5.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 29.6 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 29.6.1 50 μg/mL vs 100 μg/mL | 1 | 117 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 30.1 Women with hypotension requiring intervention Show forest plot | 2 | 142 | Risk Ratio (M‐H, Random, 95% CI) | 0.63 [0.21, 1.91] |
| 30.2 Women with hypertension requiring intervention Show forest plot | 1 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 2.67 [1.31, 5.43] |
| 30.3 Women with bradycardia Show forest plot | 1 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 0.21 [0.01, 4.32] |
| 30.4 Women with nausea and/or vomiting Show forest plot | 2 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 30.4.1 Nausea or vomiting | 1 | 93 | Risk Ratio (M‐H, Random, 95% CI) | 2.49 [0.69, 9.04] |
| 30.4.2 Nausea | 1 | 49 | Risk Ratio (M‐H, Random, 95% CI) | 0.61 [0.36, 1.06] |
| 30.4.3 Vomiting | 1 | 49 | Risk Ratio (M‐H, Random, 95% CI) | 0.52 [0.10, 2.59] |
| 30.5 Neonates with Apgar score < 8 at 5 min Show forest plot | 2 | 142 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 31.1 Women with hypotension requiring intervention Show forest plot | 8 | 740 | Risk Ratio (M‐H, Random, 95% CI) | 0.67 [0.54, 0.83] |
| 31.1.1 2 mg vs control | 2 | 79 | Risk Ratio (M‐H, Random, 95% CI) | 0.90 [0.51, 1.58] |
| 31.1.2 4 mg vs control | 5 | 277 | Risk Ratio (M‐H, Random, 95% CI) | 0.46 [0.34, 0.63] |
| 31.1.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | 0.48 [0.22, 1.03] |
| 31.1.4 8 mg vs control | 5 | 346 | Risk Ratio (M‐H, Random, 95% CI) | 0.85 [0.70, 1.03] |
| 31.2 Women with bradycardia Show forest plot | 8 | 740 | Risk Ratio (M‐H, Random, 95% CI) | 0.49 [0.28, 0.87] |
| 31.2.1 2 mg vs control | 2 | 79 | Risk Ratio (M‐H, Random, 95% CI) | 0.23 [0.02, 3.29] |
| 31.2.2 4 mg vs control | 5 | 277 | Risk Ratio (M‐H, Random, 95% CI) | 0.33 [0.16, 0.71] |
| 31.2.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.2.4 8 mg vs control | 5 | 346 | Risk Ratio (M‐H, Random, 95% CI) | 0.94 [0.38, 2.37] |
| 31.3 Women with nausea or vomiting Show forest plot | 7 | 653 | Risk Ratio (M‐H, Random, 95% CI) | 0.35 [0.24, 0.51] |
| 31.3.1 2 mg vs control | 2 | 79 | Risk Ratio (M‐H, Random, 95% CI) | 0.54 [0.18, 1.59] |
| 31.3.2 4 mg vs control | 5 | 277 | Risk Ratio (M‐H, Random, 95% CI) | 0.32 [0.17, 0.60] |
| 31.3.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | 0.09 [0.01, 0.74] |
| 31.3.4 8 mg vs control | 4 | 259 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.19, 0.76] |
| 31.4 Women with anaphylaxis Show forest plot | 1 | 150 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.4.1 2 mg vs control | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.4.2 4 mg vs control | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.4.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.4.4 8 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5 Neonatal Apgar score < 8 at 5 min Show forest plot | 3 | 284 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5.1 2 mg vs control | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5.2 4 mg vs control | 2 | 102 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5.3 6 mg vs control | 1 | 38 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.5.4 8 mg vs control | 2 | 107 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 31.6 Neonatal pH < 7.2 Show forest plot | 2 | 134 | Risk Ratio (M‐H, Random, 95% CI) | 0.48 [0.05, 5.09] |
| 31.6.1 4 mg vs control | 1 | 65 | Risk Ratio (M‐H, Random, 95% CI) | 0.48 [0.05, 5.09] |
| 31.6.2 8 mg vs control | 1 | 69 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 32.1 Women with hypotension requiring intervention Show forest plot | 1 | 112 | Risk Ratio (M‐H, Random, 95% CI) | 1.07 [0.76, 1.49] |
| 32.2 Women with bradycardia Show forest plot | 1 | 112 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.12, 72.10] |
| 32.3 Women with nausea and/or vomiting Show forest plot | 1 | 112 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.10, 1.34] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 33.1 Women with hypotension requiring intervention Show forest plot | 1 | 200 | Risk Ratio (M‐H, Random, 95% CI) | 0.05 [0.02, 0.14] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 34.1 Women with hypotension requiring intervention Show forest plot | 1 | 105 | Risk Ratio (M‐H, Random, 95% CI) | 0.79 [0.62, 1.01] |
| 34.1.1 0.25 mg/kg IV ketamine | 1 | 52 | Risk Ratio (M‐H, Random, 95% CI) | 0.83 [0.61, 1.14] |
| 34.1.2 0.5 mg/kg IV ketamine | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 0.73 [0.50, 1.07] |
| 34.2 Women with nausea and/or vomiting Show forest plot | 1 | 105 | Risk Ratio (M‐H, Random, 95% CI) | 0.79 [0.50, 1.25] |
| 34.2.1 0.25 mg/kg IV ketamine | 1 | 52 | Risk Ratio (M‐H, Random, 95% CI) | 0.91 [0.48, 1.71] |
| 34.2.2 0.5 mg/kg IV ketamine | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | 0.69 [0.36, 1.31] |
| 34.3 Apgar score < 8 at 5 min Show forest plot | 1 | 105 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 34.3.1 0.25 mg/kg IV ketamine | 1 | 52 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 34.3.2 0.5 mg/kg IV ketamine | 1 | 53 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 35.1 Women with hypotension requiring intervention Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 0.09 [0.01, 1.45] |
| 35.2 Women with nausea and/or vomiting Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | 0.20 [0.01, 3.70] |
| 35.3 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 20 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 36.1 Women with hypotension requiring intervention Show forest plot | 1 | 30 | Risk Ratio (M‐H, Random, 95% CI) | 0.05 [0.00, 0.75] |
| 36.2 Neonatal Apgar score < 8 at 5 min Show forest plot | 1 | 30 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 37.1 Women with hypotension requiring intervention Show forest plot | 11 | 705 | Risk Ratio (M‐H, Random, 95% CI) | 0.61 [0.47, 0.78] |
| 37.2 Women with bradycardia Show forest plot | 1 | 74 | Risk Ratio (M‐H, Random, 95% CI) | 0.63 [0.11, 3.56] |
| 37.3 Women with nausea and/or vomiting Show forest plot | 4 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 37.3.1 Women with nausea and/or vomiting | 4 | 276 | Risk Ratio (M‐H, Random, 95% CI) | 0.42 [0.14, 1.27] |
| 37.3.2 Women with nausea | 1 | 92 | Risk Ratio (M‐H, Random, 95% CI) | 1.44 [0.25, 8.20] |
| 37.3.3 Women with vomiting | 1 | 92 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 37.4 Neonates with Apgar score < 8 at 5 min Show forest plot | 3 | 130 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 38.1 Women with hypotension requiring intervention Show forest plot | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 0.85 [0.53, 1.37] |
| 38.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 38.2.1 Women with nausea | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 0.27 [0.12, 0.60] |
| 38.2.2 Women with vomiting | 1 | 80 | Risk Ratio (M‐H, Random, 95% CI) | 0.11 [0.01, 2.00] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 39.1 Women with hypotension requiring intervention Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.71 [0.47, 1.06] |
| 39.2 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 40.1 Women with hypotension requiring intervention Show forest plot | 1 | 34 | Risk Ratio (M‐H, Random, 95% CI) | 1.07 [0.81, 1.42] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 41.1 Women with hypotension requiring intervention Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.92 [0.57, 1.49] |
| 41.2 Neonates with Apgar score < 8 at 5 min Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 42.1 Women with hypotension requiring intervention Show forest plot | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.58, 1.12] |
| 42.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 42.2.1 Nausea | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | 0.65 [0.40, 1.07] |
| 42.2.2 Vomiting | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.02, 9.01] |
| 42.3 Neonates with acidosis (pH < 7.2) Show forest plot | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 42.4 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 98 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 43.1 Women requiring intervention for hypotension Show forest plot | 1 | 37 | Risk Ratio (M‐H, Random, 95% CI) | 0.71 [0.41, 1.21] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 44.1 Women with hypotension requiring intervention Show forest plot | 2 | 126 | Risk Ratio (M‐H, Random, 95% CI) | 0.91 [0.75, 1.09] |
| 44.2 Women with cardiac dysrhythmia requiring intervention Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.05, 5.08] |
| 44.3 Neonates admitted to neonatal intensive care unit Show forest plot | 1 | 40 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| 44.4 Women with nausea Show forest plot | 1 | 86 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.45, 1.48] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 45.1 Women with hypotension requiring intervention Show forest plot | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 1.20 [0.80, 1.79] |
| 45.2 Women with cardiac dysrhythmia requiring intervention Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 45.2.1 Bradycardia | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 0.10 [0.01, 1.68] |
| 45.3 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 45.3.1 Nausea: 15 degree tilt | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 0.45 [0.18, 1.11] |
| 45.3.2 Vomiting: 15 degree tilt | 1 | 58 | Risk Ratio (M‐H, Random, 95% CI) | 0.15 [0.01, 2.83] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 46.1 Women with hypotension requiring intervention Show forest plot | 1 | 90 | Risk Ratio (M‐H, Random, 95% CI) | 0.63 [0.49, 0.80] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 47.1 Women with hypotension requiring intervention Show forest plot | 1 | 63 | Risk Ratio (M‐H, Random, 95% CI) | 0.73 [0.42, 1.26] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 48.1 Women with hypotension requiring intervention Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.84 [0.58, 1.22] |
| 48.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 48.2.1 Nausea | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.32 [0.15, 0.66] |
| 48.2.2 Vomiting | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.50 [0.14, 1.78] |
| 48.3 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 49.1 Women with hypotension requiring intervention Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 0.94 [0.63, 1.40] |
| 49.2 Women with nausea and/or vomiting Show forest plot | 1 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 49.2.1 Nausea | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 1.50 [0.48, 4.68] |
| 49.2.2 Vomiting | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | 3.00 [0.33, 26.92] |
| 49.3 Neonates with Apgar < 7 at 5 min Show forest plot | 1 | 50 | Risk Ratio (M‐H, Random, 95% CI) | Not estimable |
