Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections

David M Haas; Sarah Morgan; Karenrose Contreras

doi:10.1002/14651858.CD007892.pub5

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Figure 1

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Analysis 1.1

Comparison 1 Vaginal preparation versus control, Outcome 1 Post‐cesarean endometritis.

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Analysis 1.2

Comparison 1 Vaginal preparation versus control, Outcome 2 Postoperative fever.

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Analysis 1.3

Comparison 1 Vaginal preparation versus control, Outcome 3 Wound infection.

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Analysis 1.4

Comparison 1 Vaginal preparation versus control, Outcome 4 Any wound complication.

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Analysis 1.5

Comparison 1 Vaginal preparation versus control, Outcome 5 Composite wound complication or endometritis.

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Analysis 2.1

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 1 Post‐cesarean endometritis.

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Analysis 2.2

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 2 Postoperative fever.

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Analysis 2.3

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 3 Wound infection.

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Analysis 2.4

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 4 Any wound complication.

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Analysis 2.5

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 5 Composite wound complication or endometritis.

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Analysis 3.1

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 1 Post‐cesarean endometritis.

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Analysis 3.2

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 2 Postoperative fever.

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Analysis 3.3

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 3 Wound infection.

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Analysis 3.4

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 4 Any wound complication.

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Analysis 3.5

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 5 Composite wound complication or endometritis.

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Summary of findings for the main comparison. Vaginal preparation versus control for preventing postoperative infections

Vaginal preparation versus control for preventing postoperative infections
Population: Pregnant women who received a cesarean delivery Settings: A hospital in Iran, a hospital in Pakistan, hospitals in Turkey, and hospitals in USA Intervention: Vaginal preparation with povidone‐iodine solution versus control (saline vaginal wash; no vaginal cleansing)
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	Vaginal preparation versus control
Post‐cesarean endometritis	Study population		RR 0.45 (0.25 to 0.81)	2635 (7 studies)	⊕⊕⊝⊝ low^1,2
	83 per 1000	37 per 1000 (21 to 67)
	Moderate
	75 per 1000	34 per 1000 (19 to 61)
Postoperative fever	Study population		RR 0.9 (0.74 to 1.1)	2475 (6 studies)	⊕⊕⊕⊝ moderate¹
	141 per 1000	127 per 1000 (104 to 155)
	Moderate
	117 per 1000	105 per 1000 (87 to 129)
Wound infection	Study population		RR 0.86 (0.54 to 1.36)	2205 (6 studies)	⊕⊕⊝⊝ low^1,3
	33 per 1000	29 per 1000 (18 to 45)
	Moderate
	31 per 1000	27 per 1000 (17 to 42)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Most studies contributing data had design limitations. ² Statistical heterogeneity (I² = 55%). ³ Wide confidence interval crossing the line of no effect.

Summary of findings for the main comparison. Vaginal preparation versus control for preventing postoperative infections

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Comparison 1. Vaginal preparation versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐cesarean endometritis Show forest plot	7	2635	Risk Ratio (M‐H, Random, 95% CI)	0.45 [0.25, 0.81]

2 Postoperative fever Show forest plot	6	2475	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.74, 1.10]

3 Wound infection Show forest plot	6	2205	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.54, 1.36]

4 Any wound complication Show forest plot	2	729	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.37, 1.07]

5 Composite wound complication or endometritis Show forest plot	2	499	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.26, 0.82]

Comparison 1. Vaginal preparation versus control

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Comparison 2. Vaginal preparation versus control ‐ stratified by presence of labor

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐cesarean endometritis Show forest plot	3	1394	Risk Ratio (M‐H, Fixed, 95% CI)	0.70 [0.48, 1.02]

1.1 Women in labor	3	523	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.34, 0.95]
1.2 Women not in labor	3	871	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.52, 1.54]
2 Postoperative fever Show forest plot	2	965	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.59, 1.13]

2.1 Women in labor	2	307	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.42, 1.08]
2.2 Women not in labor	2	658	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.61, 1.49]
3 Wound infection Show forest plot	2	959	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.34, 1.34]

3.1 Women in labor	2	307	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.24, 2.21]
3.2 Women not in labor	2	652	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.27, 1.56]
4 Any wound complication Show forest plot	2	729	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.38, 1.09]

4.1 Women in labor	2	314	Risk Ratio (M‐H, Fixed, 95% CI)	0.77 [0.36, 1.61]
4.2 Women not in labor	2	415	Risk Ratio (M‐H, Fixed, 95% CI)	0.54 [0.25, 1.16]
5 Composite wound complication or endometritis Show forest plot	2	499	Risk Ratio (M‐H, Fixed, 95% CI)	0.47 [0.27, 0.85]

5.1 Women in labor	2	164	Risk Ratio (M‐H, Fixed, 95% CI)	0.34 [0.13, 0.87]
5.2 Women not in labor	2	335	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.29, 1.26]

Comparison 2. Vaginal preparation versus control ‐ stratified by presence of labor

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Comparison 3. Vaginal preparation versus control ‐ stratified by presence of ruptured membranes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐cesarean endometritis Show forest plot	3	1129	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.29, 0.70]

1.1 Women with ruptured membranes	3	272	Risk Ratio (M‐H, Fixed, 95% CI)	0.24 [0.10, 0.55]
1.2 Women with intact membranes	3	857	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.36, 1.06]
2 Postoperative fever Show forest plot	2	969	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.60, 1.14]

2.1 Women with ruptured membranes	2	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.34, 1.12]
2.2 Women with intact membranes	2	769	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.63, 1.36]
3 Wound infection Show forest plot	3	1129	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.49, 1.57]

3.1 Women with ruptured membranes	3	272	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.46, 3.20]
3.2 Women with intact membranes	3	857	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.35, 1.52]
4 Any wound complication Show forest plot	1	300	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.28, 1.44]

4.1 Women with ruptured membranes	1	76	Risk Ratio (M‐H, Fixed, 95% CI)	0.53 [0.15, 1.89]
4.2 Women with intact membranes	1	224	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.25, 2.10]
5 Composite wound complication or endometritis Show forest plot	2	500	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.27, 0.85]

5.1 Women with ruptured membranes	2	134	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.13, 1.13]
5.2 Women with intact membranes	2	366	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.26, 1.04]

Comparison 3. Vaginal preparation versus control ‐ stratified by presence of ruptured membranes

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