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Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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'Risk of bias. graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

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

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'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

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

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Funnel plot of comparison: 1 Maternal postpartum infectious morbidity, outcome: 1.1 Composite morbidity (as defined by trials).
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Figure 4

Funnel plot of comparison: 1 Maternal postpartum infectious morbidity, outcome: 1.1 Composite morbidity (as defined by trials).

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 1 Composite morbidity (as defined by trials).
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Analysis 1.1

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 1 Composite morbidity (as defined by trials).

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 2 Endomyometritis.
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Analysis 1.2

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 2 Endomyometritis.

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 3 Wound infection.
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Analysis 1.3

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 3 Wound infection.

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 4 UTI/cystitis/pyelonephritis.
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Analysis 1.4

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 4 UTI/cystitis/pyelonephritis.

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 5 Pelvic abscess.
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Analysis 1.5

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 5 Pelvic abscess.

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 6 Respiratory infection (pneumonia).
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Analysis 1.6

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 6 Respiratory infection (pneumonia).

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 7 Hospital length of stay (days).
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Analysis 1.7

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 7 Hospital length of stay (days).

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Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 8 Febrile Illness.
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Analysis 1.8

Comparison 1 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes), Outcome 8 Febrile Illness.

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 1 Sepsis.
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Analysis 2.1

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 1 Sepsis.

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 2 Neonatal sepsis work up.
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Analysis 2.2

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 2 Neonatal sepsis work up.

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 3 Infection with a resistant organism.
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Analysis 2.3

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 3 Infection with a resistant organism.

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 4 Infection (other).
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Analysis 2.4

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 4 Infection (other).

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 5 ICU admission.
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Analysis 2.5

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 5 ICU admission.

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 6 ICU length of stay (days).
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Analysis 2.6

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 6 ICU length of stay (days).

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 7 Neonatal antibiotic treatment.
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Analysis 2.7

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 7 Neonatal antibiotic treatment.

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Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 8 Fever.
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Analysis 2.8

Comparison 2 Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes), Outcome 8 Fever.

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Summary of findings for the main comparison. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping

Prophylactic antibiotics for preventing postpartum infectious morbidity in women and infants after cesarean delivery

Population: women undergoing cesarean delivery.
Settings: eight trials were conducted in developed countries: seven from US, one from Austria. Five trials were conducted in developing countries: two trials from India, one trial each from Egypt, South Africa and Turkey.
Intervention: prophylactic intravenous antibiotic administration for cesarean birth administered prior to skin incision versus after neonatal umbilical cord clamping.

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

Maternal and neonatal postpartum infectious morbidity

Maternal composite morbidity

Study population

RR 0.67
(0.54 to 0.82)

5041
(10 studies)

⊕⊕⊕⊕
high

85 per 1000

57 per 1000
(46 to 70)

Moderate

97 per 1000

65 per 1000
(52 to 80)

Maternal endomyometritis

Study population

RR 0.54
(0.36 to 0.79)

5041
(10 studies)

⊕⊕⊕⊕
high

28 per 1000

15 per 1000
(10 to 22)

Moderate

26 per 1000

14 per 1000
(9 to 21)

Maternal wound Infection

Study population

RR 0.59
(0.44 to 0.81)

5041
(10 studies)

⊕⊕⊕⊕
high

41 per 1000

24 per 1000
(17 to 33)

Moderate

51 per 1000

30 per 1000
(22 to 41)

Maternal UTI/cystitis/pyelonephritis

Study population

RR 1.02
(0.65 to 1.59)

4001
(8 studies)

⊕⊕⊕⊝
moderate1

18 per 1000

18 per 1000
(12 to 29)

Moderate

13 per 1000

13 per 1000
(8 to 21)

Maternal respiratory infection (pneumonia)

Study population

RR 2.3
(0.34 to 15.45)

1158
(2 studies)

⊕⊕⊝⊝
low2

2 per 1000

4 per 1000
(1 to 27)

Moderate

0 per 1000

0 per 1000
(0 to 0)

Neonatal sepsis

Study population

RR 0.76
(0.51 to 1.13)

2907
(5 studies)

⊕⊕⊕⊝
moderate1

37 per 1000

28 per 1000
(19 to 42)

Moderate

40 per 1000

30 per 1000
(20 to 45)

Neonatal ICU admission

Study population

RR 0.91
(0.74 to 1.13)

3708
(6 studies)

⊕⊕⊕⊕
high

86 per 1000

78 per 1000
(64 to 97)

Moderate

71 per 1000

65 per 1000
(53 to 80)

*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 Wide confidence interval crossing the line of no effect.
2 Wide confidence interval crossing the line of no effect, few events and small sample size.

Figuras y tablas -
Summary of findings for the main comparison. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping
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Comparison 1. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Composite morbidity (as defined by trials) Show forest plot

10

5041

Risk Ratio (M‐H, Fixed, 95% CI)

0.57 [0.45, 0.72]

1.1 Cephalosporin 1 g

5

2144

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.35, 0.86]

1.2 Cephalosporin 2 g

5

2897

Risk Ratio (M‐H, Fixed, 95% CI)

0.57 [0.43, 0.76]

2 Endomyometritis Show forest plot

10

5041

Risk Ratio (M‐H, Fixed, 95% CI)

0.54 [0.36, 0.79]

2.1 Cephalosporin 1 g

5

2144

Risk Ratio (M‐H, Fixed, 95% CI)

0.58 [0.30, 1.12]

2.2 Cephalosporin 2 g

5

2897

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.32, 0.83]

3 Wound infection Show forest plot

10

5041

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.44, 0.81]

3.1 Cephalosporin 1 g

5

2144

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.30, 1.01]

3.2 Cephalosporin 2 g

5

2897

Risk Ratio (M‐H, Fixed, 95% CI)

0.61 [0.43, 0.88]

4 UTI/cystitis/pyelonephritis Show forest plot

8

4001

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.65, 1.59]

5 Pelvic abscess Show forest plot

1

741

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.06, 15.97]

6 Respiratory infection (pneumonia) Show forest plot

4

1849

Risk Ratio (M‐H, Fixed, 95% CI)

2.30 [0.34, 15.45]

7 Hospital length of stay (days) Show forest plot

2

1342

Mean Difference (IV, Fixed, 95% CI)

‐0.17 [‐0.30, ‐0.04]

8 Febrile Illness Show forest plot

4

2650

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.63, 1.35]
Figuras y tablas -
Comparison 1. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (maternal outcomes)
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Comparison 2. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Sepsis Show forest plot

5

2907

Risk Ratio (M‐H, Fixed, 95% CI)

0.76 [0.51, 1.13]

2 Neonatal sepsis work up Show forest plot

4

1170

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.69, 1.23]

3 Infection with a resistant organism Show forest plot

1

379

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.12, 4.14]

4 Infection (other) Show forest plot

1

302

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.52, 1.64]

5 ICU admission Show forest plot

6

3708

Risk Ratio (M‐H, Fixed, 95% CI)

0.91 [0.74, 1.13]

6 ICU length of stay (days) Show forest plot

3

1731

Mean Difference (IV, Random, 95% CI)

‐0.07 [‐2.60, 2.46]

7 Neonatal antibiotic treatment Show forest plot

1

90

Risk Ratio (M‐H, Fixed, 95% CI)

0.84 [0.12, 5.68]

8 Fever Show forest plot

1

953

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.28, 1.62]
Figuras y tablas -
Comparison 2. Prophylactic intravenous antibiotics administered before cesarean incision versus after neonatal umbilical cord clamping (neonatal outcomes)
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