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with forceps or ventouse" /></a></div><div class="bkr_bib"><h1 id="_NBK596257_"><span itemprop="name">Evidence reviews for prophylactic antibiotics for birth with forceps or ventouse</span></h1><div class="subtitle">Intrapartum care</div><p><b>Evidence review J</b></p><p><i>NICE Guideline, No. 235</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2023 Sep</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-5395-0</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2023.</div></div><div class="bkr_clear"></div></div><div id="niceng235er10.s1"><h2 id="_niceng235er10_s1_">Prophylactic antibiotics for birth with forceps or ventouse</h2><div id="niceng235er10.s1.1"><h3>Review question</h3><p>What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</p><div id="niceng235er10.s1.1.1"><h4>Introduction</h4><p>Assisted vaginal births carry a higher risk of infection due to their invasive nature and the increase in vaginal examinations that are required, with evidence showing that there is an increased incidence of postnatal infections in women who have had a vaginal birth with forceps or ventouse. Prophylactic antibiotic use might prevent postnatal infections associated with assisted vaginal birth, however the effectiveness is unclear.</p><p>This review aims to find out whether administration of prophylactic antibiotics reduces the risk of infections related to assisted vaginal births with forceps or ventouse, and to determine if there are any negative effects on neonatal outcomes such as breastfeeding, and on the incidence of maternal adverse reactions.</p></div><div id="niceng235er10.s1.1.2"><h4>Summary of the protocol</h4><p>See <a class="figpopup" href="/books/NBK596257/table/niceng235er10.tab1/?report=objectonly" target="object" rid-figpopup="figniceng235er10tab1" rid-ob="figobniceng235er10tab1">Table 1</a> for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er10tab1"><a href="/books/NBK596257/table/niceng235er10.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er10tab1" rid-ob="figobniceng235er10tab1"><img class="small-thumb" src="/books/NBK596257/table/niceng235er10.tab1/?report=thumb" src-large="/books/NBK596257/table/niceng235er10.tab1/?report=previmg" alt="Table 1. Summary of the protocol (PICO table)." /></a><div class="icnblk_cntnt"><h4 id="niceng235er10.tab1"><a href="/books/NBK596257/table/niceng235er10.tab1/?report=objectonly" target="object" rid-ob="figobniceng235er10tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Summary of the protocol (PICO table). </p></div></div><p>For further details see the review protocol in <a href="#niceng235er10.appa">appendix A</a>.</p></div><div id="niceng235er10.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng235er10.appa">appendix A</a> and the <a href="/books/NBK596257/bin/NG235_Supplement_1_Methods.pdf">methods</a> document (supplementary document 1).</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p></div><div id="niceng235er10.s1.1.4"><h4>Effectiveness evidence</h4><div id="niceng235er10.s1.1.4.1"><h5>Included studies</h5><p>One Cochrane systematic review (<a class="bibr" href="#niceng235er10.s1.ref3" rid="niceng235er10.s1.ref3">Liabsuetrakul 2020</a>), which 2 included randomised controlled trials (RCTs) (<a class="bibr" href="#niceng235er10.s1.ref1" rid="niceng235er10.s1.ref1">Heitmann 1989</a> and <a class="bibr" href="#niceng235er10.s1.ref2" rid="niceng235er10.s1.ref2">Knight 2019</a>) was included in this review.</p><p>One RCT (<a class="bibr" href="#niceng235er10.s1.ref1" rid="niceng235er10.s1.ref1">Heitmann 1989</a>) compared prophylactic antibiotics given postnatally to no treatment. One RCT (<a class="bibr" href="#niceng235er10.s1.ref2" rid="niceng235er10.s1.ref2">Knight 2019</a>) compared prophylactic antibiotics given postnatally to placebo.</p><p>Studies were from the United Kingdom and the United States.</p><p>The included studies are summarised in <a class="figpopup" href="/books/NBK596257/table/niceng235er10.tab2/?report=objectonly" target="object" rid-figpopup="figniceng235er10tab2" rid-ob="figobniceng235er10tab2">Table 2</a>.</p><p>See the literature search strategy in <a href="#niceng235er10.appb">appendix B</a> and study selection flow chart in <a href="#niceng235er10.appc">appendix C</a>.</p></div><div id="niceng235er10.s1.1.4.2"><h5>Excluded studies</h5><p>Studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng235er10.appj">appendix J</a>.</p></div></div><div id="niceng235er10.s1.1.5"><h4>Summary of included studies</h4><p>Summaries of the studies that were included in this review are presented in <a class="figpopup" href="/books/NBK596257/table/niceng235er10.tab2/?report=objectonly" target="object" rid-figpopup="figniceng235er10tab2" rid-ob="figobniceng235er10tab2">Table 2</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er10tab2"><a href="/books/NBK596257/table/niceng235er10.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er10tab2" rid-ob="figobniceng235er10tab2"><img class="small-thumb" src="/books/NBK596257/table/niceng235er10.tab2/?report=thumb" src-large="/books/NBK596257/table/niceng235er10.tab2/?report=previmg" alt="Table 2. Summary of included studies." /></a><div class="icnblk_cntnt"><h4 id="niceng235er10.tab2"><a href="/books/NBK596257/table/niceng235er10.tab2/?report=objectonly" target="object" rid-ob="figobniceng235er10tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Summary of included studies. </p></div></div><p>See the full evidence tables in <a href="#niceng235er10.appd">appendix D</a>. No meta-analysis was conducted (and so there are no forest plots in <a href="#niceng235er10.appe">appendix E</a>).</p></div><div id="niceng235er10.s1.1.6"><h4>Summary of the evidence</h4><p>Prophylactic antibiotics were compared to either no treatment or placebo. All of the evidence used a single dose of antibiotics given intravenously (IV) after birth. All of the evidence included women who had undergone an assisted birth using forceps or vacuum, but the data were not available to analyse the 2 assistance methods separately. The antibiotic used was either cefotetan or co-amoxiclav.</p><p>Prophylactic antibiotics, using cefotetan, was compared to no treatment. The evidence showed an important benefit for cefotetan over no treatment for endometritis, with unknown follow-up period. The evidence was rated low quality for some concerns around bias, and some concerns around indirectness of the population.</p><p>Prophylactic antibiotics, using co-amoxiclav, was compared to placebo. The evidence showed an important benefit for co-amoxiclav over placebo in terms of infection at episiotomy or laceration site. The evidence showed no evidence of an important difference between groups for endometritis, systemic sepsis, maternal adverse reactions and perineal pain at 6 weeks. The evidence ranged from very low to moderate quality, with some concerns over indirectness and some concerns over imprecision around the estimate of the effect. Moderate quality evidence showed no important difference between groups for breastfeeding at 6 weeks, with some concerns around indirectness of the population.</p><p>No evidence was identified for long term neonatal outcomes, or antibiotic resistance.</p><p>See <a href="#niceng235er10.appf">appendix F</a> for full GRADE tables.</p></div><div id="niceng235er10.s1.1.7"><h4>Economic evidence</h4><div id="niceng235er10.s1.1.7.1"><h5>Included studies</h5><p>One economic study was identified which was relevant to this question (<a class="bibr" href="#niceng235er10.s1.ref4" rid="niceng235er10.s1.ref4">Knight 2019</a>).</p><p>See the literature search strategy in <a href="#niceng235er10.appb">appendix B</a> and economic study selection flow chart in <a href="#niceng235er10.appg">appendix G</a>.</p></div><div id="niceng235er10.s1.1.7.2"><h5>Excluded studies</h5><p>Economic studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng235er10.appj">appendix J</a>.</p></div></div><div id="niceng235er10.s1.1.8"><h4>Summary of included economic evidence</h4><p>See <a class="figpopup" href="/books/NBK596257/table/niceng235er10.tab3/?report=objectonly" target="object" rid-figpopup="figniceng235er10tab3" rid-ob="figobniceng235er10tab3">Table 3</a> for the economic evidence profile of the included study.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er10tab3"><a href="/books/NBK596257/table/niceng235er10.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er10tab3" rid-ob="figobniceng235er10tab3"><img class="small-thumb" src="/books/NBK596257/table/niceng235er10.tab3/?report=thumb" src-large="/books/NBK596257/table/niceng235er10.tab3/?report=previmg" alt="Table 3. Economic evidence profile of a systematic review of economic evaluations of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth." /></a><div class="icnblk_cntnt"><h4 id="niceng235er10.tab3"><a href="/books/NBK596257/table/niceng235er10.tab3/?report=objectonly" target="object" rid-ob="figobniceng235er10tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Economic evidence profile of a systematic review of economic evaluations of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth. </p></div></div></div><div id="niceng235er10.s1.1.9"><h4>Economic model</h4><p>No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.</p></div><div id="niceng235er10.s1.1.10"><h4>Unit costs</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er10tab4"><a href="/books/NBK596257/table/niceng235er10.tab4/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er10tab4" rid-ob="figobniceng235er10tab4"><img class="small-thumb" src="/books/NBK596257/table/niceng235er10.tab4/?report=thumb" src-large="/books/NBK596257/table/niceng235er10.tab4/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng235er10.tab4"><a href="/books/NBK596257/table/niceng235er10.tab4/?report=objectonly" target="object" rid-ob="figobniceng235er10tab4">Table</a></h4><p class="float-caption no_bottom_margin">BNF: British National Formulary; NHS: National Health Service; PSSRU: Personal Social Services Research Unit </p></div></div></div><div id="niceng235er10.s1.1.11"><h4>The committee’s discussion and interpretation of the evidence</h4><div id="niceng235er10.s1.1.11.1"><h5>The outcomes that matter most</h5><p>As the main aim following prophylactic use of antibiotics is a reduction in the risk of infection, the committee chose endometritis, infection at the perineal or vaginal episiotomy site, and sepsis following perineum infection or endometritis, as the critical outcomes for this review. They agreed that all 3 outcomes would provide information regarding the efficacy of prophylactic antibiotics at reducing the risk of local infections following assisted vaginal birth. They also agreed that this would provide information on whether antibiotics reduce the risk of any systematic infections that develop following local perineum infections or endometritis.</p><p>The committee also agreed to look at maternal adverse reactions as an important outcome, as it was necessary to consider any of the harms associated with antibiotic use. The committee also chose to include long term neonatal outcomes such as asthma and allergies. They discussed that antibiotics could have an effect on the neonatal immune system, if given immediately before birth, and also after birth if the woman is breastfeeding. They agreed this longer term outcome could provide an insight into the impact of antibiotic use in early neonatal life. The committee also wanted to find out whether prophylactic antibiotics had an impact on a breastfeeding rates at 6 weeks postnatal, as it would be key to inform women if antibiotics have an effect on breastfeeding. Perineal pain at 6 weeks was also an important outcome chosen by the committee as it affects the quality of a woman’s life. Antibiotic resistance was another outcome the committee chose as important due to emergence of bacteria with resistance to many different types of antibiotics.</p></div><div id="niceng235er10.s1.1.11.2"><h5>The quality of the evidence</h5><p>The quality of the evidence for outcomes was assessed with GRADE and was rated as moderate to low. All of the evidence was downgraded for indirectness as there was not enough information regarding non-cephalic presentations in the population. Some of the evidence was also downgraded for risk of bias, with some concerns around concealment of randomisation and not enough information to judge selective reporting. Most of the evidence was also downgraded for imprecision around the estimate of effect.</p></div><div id="niceng235er10.s1.1.11.3"><h5>Benefits and harms</h5><p>The committee discussed the evidence for prophylactic antibiotics use following vaginal birth with forceps or ventouse, which showed a benefit for prophylactic antibiotics at reducing the rates of endometritis and infected episiotomy/lacerations.</p><p>The committee discussed whether there were any adverse outcomes associated with prophylactic antibiotics. They agreed that the evidence suggested there was no difference in maternal adverse reactions or perineal pain at 6 weeks, and that there was evidence showing that there was no difference between groups on breastfeeding at 6 weeks. They agreed that the evidence supported the use of prophylactic antibiotics in terms of endometritis and infection at the episiotomy or laceration site, and did not lead to any harms. Births with forceps or ventouse have a higher chance of needing an episiotomy, so the committee discussed whether the source of infection is due to the instrument used or the episiotomy. Based on their personal experience and expertise, they noted that infections are usually due to the increased number of examinations needed for an assisted birth. Coupled with these factors, the committee agreed that the evidence supported a recommendation for prophylactic antibiotics following a birth with forceps or ventouse.</p><p>The committee considered the evidence to guide their recommendations for a specific antibiotic type. They discussed that cefotetan, as used in one of the studies showing a benefit for endometritis, is a second generation cephalosporin not currently used in the UK, and therefore they could not recommend this antibiotic specifically, but agreed that cefuroxime would be an equivalent available in the UK. The committee discussed that the evidence which used co-amoxiclav (a mixture of penicillin and clavulanic acid) was from the UK and would therefore be directly applicable to practice in the UK. They agreed with the reasons stated in the study for co-amoxiclav use, such as the wide spectrum of activity which is important considering contamination with bacteria around the perineum region. However, the committee discussed that co-amoxiclav used antenatally has an increased risk of necrotising enterocolitis to the neonate. They agreed that they would include in the recommendation that co-amoxiclav should be given postnatally to prevent this. The committee also included in their recommendation that the co-amoxiclav should be administered no more than 6 hours after cord clamping, as this was in line with the time of administration used in the study.</p><p>The committee also specified that the route of administration for the antibiotics should be IV, based on the evidence which had used this route. They discussed the availability of IV antibiotics across different birth places, and whether limiting to IV would have an impact on access. They agreed that this was unlikely to be an issue as assisted vaginal births only take place in settings where IV antibiotics are available (alongside midwifery units and obstetric units).</p><p>The committee recognised that co-amoxiclav may not be appropriate for all women: hospitals may have different antibiotic resistance profiles and some women may be allergic to penicillin, therefore they included that a local alternative could also be used.</p><p>The committee discussed that that the evidence only supported IV administration, but IV administration requires 2 trained staff to check and administer the antibiotic, therefore it may be preferable for oral antibiotics to be used. The committee wanted to know whether oral antibiotics would be effective as prophylaxis for postnatal infections. They agreed a research recommendation was necessary and made one to address this gap in evidence.</p></div><div id="niceng235er10.s1.1.11.4"><h5>Cost effectiveness and resource use</h5><p>One study (<a class="bibr" href="#niceng235er10.s1.ref2" rid="niceng235er10.s1.ref2">Knight 2019</a>) undertook a within trial cost analysis of prophylactic antibiotic for preventing postnatal infections in birth with forceps or ventouse. It found that overall, when compared to placebo, that antibiotics produced a mean cost saving of £52.60 per woman. This was driven by statistically significant reductions in GP visits, home visits by a midwife or nurse and outpatient hospital visits. An important limitation of this study was that the characteristics of women who returned the postal questionnaire, which captured data on resource use, differed systematically from those women who did not return the questionnaire. However, a sensitivity analysis involving imputation of missing data values reported a very similar mean cost saving £50.90. However, the cost analysis omitted staff costs to administer the antibiotic and all consumables apart from the drug cost. Therefore, the committee acknowledged that the cost saving was probably overstated by the analysis. However, given the “downstream” savings demonstrated by the cost analysis and improvements to health-related quality of life arising from lower infection rates, the committee considered that prophylactic antibiotics were likely to be cost-effective. According to NHS episode hospital statistics there are approximately 70,000 births with forceps or ventouse per annum (<a href="https://digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2020-21" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">https://digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2020-21</a>) and the committee reasoned that given this size of population and “downstream” savings in resource use, from reduced outpatient hospital visits and other contacts with healthcare professionals, that their recommendations were unlikely to have a significant resource impact.</p></div><div id="niceng235er10.s1.1.11.5"><h5>Other factors the committee took into account</h5><p>The committee discussed one of the specifications of the protocol regarding instrument type. They had hoped to find evidence to determine if the benefits of prophylaxis antibiotic were dependent on the type of instrument used (vacuum, forceps or sequential). In the absence of direct evidence to address this stratified analysis, the committee used a post-hoc analysis from the ANODE study (<a class="bibr" href="#niceng235er10.s1.ref2" rid="niceng235er10.s1.ref2">Knight 2019</a>) that looked at a composite measure of suspected and maternal infections, stratified by type of instrument used. The data for this outcome showed a benefit of prophylaxis antibiotics on forceps use and vacuum extraction. Although this outcome did not specifically meet the criteria of the protocol, as it could include other infections not related to instrumental birth, the committee agreed that it was useful for providing reassurance that in principle there are no differences in the benefits of antibiotics between types of instrument.</p></div></div><div id="niceng235er10.s1.1.12"><h4>Recommendations supported by this evidence review</h4><p>This evidence review supports recommendation 1.9.43 and a research recommendation.</p></div></div><div id="niceng235er10.s1.rl.r1"><h3>References – included studies</h3><ul class="simple-list"><div id="niceng235er10.s1.rl.r1.1"><h4>Effectiveness</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er10.s1.ref1"><p id="p-89">Heitmann 1989</p>Heitmann, J. A. and Benrubi, G. I. (1989) Efficacy of prophylactic antibiotics for the prevention of endomyometritis after forceps delivery. Southern medical journal
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82(8): 960–2 [<a href="https://pubmed.ncbi.nlm.nih.gov/2669154" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 2669154</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er10.s1.ref2"><p id="p-90">Knight 2019</p>Knight, Marian, Chiocchia, Virginia, Partlett, Christopher
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et al. (2019) Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial. Lancet (London, England)
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393(10189): 2395–2403 [<a href="/pmc/articles/PMC6584562/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6584562</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31097213" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31097213</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er10.s1.ref3"><p id="p-91">Liabsuetrakul 2020</p>Liabsuetrakul, Tippawan, Choobun, Thanapan, Peeyananjarassri, Krantarat
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et al. (2020) Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database of Systematic Reviews
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2020(3): cd004455 [<a href="/pmc/articles/PMC7096725/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7096725</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32215906" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32215906</span></a>]</div></p></li></ul></div><div id="niceng235er10.s1.rl.r1.2"><h4>Economic</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng235er10.s1.ref4"><p id="p-92">Knight 2019</p>Knight
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M, Chiocchia
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V, Partlett
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C, Rivero-Arias
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O, Hua
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X, Bowler
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U, et al. Intravenous co-amoxiclav to prevent infection after operative vaginal delivery: the ANODE RCT. Health Technology Assessment 2019;23(54) [<a href="/pmc/articles/PMC6801364/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6801364</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31590702" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31590702</span></a>]</div></p></li></ul></div></ul></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng235er10.appa"><h3>Appendix A. Review protocols</h3><p id="niceng235er10.appa.et1"><a href="/books/NBK596257/bin/niceng235er10-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 233K)</span></p></div><div id="niceng235er10.appb"><h3>Appendix B. Literature search strategies</h3><p id="niceng235er10.appb.et1"><a href="/books/NBK596257/bin/niceng235er10-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 199K)</span></p></div><div id="niceng235er10.appc"><h3>Appendix C. Effectiveness evidence study selection</h3><p id="niceng235er10.appc.et1"><a href="/books/NBK596257/bin/niceng235er10-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 191K)</span></p></div><div id="niceng235er10.appd"><h3>Appendix D. Evidence tables</h3><p id="niceng235er10.appd.et1"><a href="/books/NBK596257/bin/niceng235er10-appd-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Evidence tables for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 199K)</span></p></div><div id="niceng235er10.appe"><h3>Appendix E. Forest plots</h3><div id="niceng235er10.appe.s1"><h4>Forest plots for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</h4><p>This section includes forest plots only for outcomes that are meta-analysed. Outcomes from single studies are not presented here; the quality assessment for such outcomes is provided in the GRADE profiles in <a href="#niceng235er10.appf">appendix F</a>.</p></div></div><div id="niceng235er10.appf"><h3>Appendix F. GRADE tables</h3><p id="niceng235er10.appf.et1"><a href="/books/NBK596257/bin/niceng235er10-appf-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">GRADE tables for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 168K)</span></p></div><div id="niceng235er10.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng235er10.appg.et1"><a href="/books/NBK596257/bin/niceng235er10-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 180K)</span></p></div><div id="niceng235er10.apph"><h3>Appendix H. Economic evidence tables</h3><p id="niceng235er10.apph.et1"><a href="/books/NBK596257/bin/niceng235er10-apph-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Economic evidence tables for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 155K)</span></p></div><div id="niceng235er10.appi"><h3>Appendix I. Economic model</h3><div id="niceng235er10.appi.s1"><h4>Economic model for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</h4><p>No economic analysis was conducted for this review question.</p></div></div><div id="niceng235er10.appj"><h3>Appendix J. Excluded studies</h3><div id="niceng235er10.appj.s1"><h4>Excluded studies for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</h4></div><div id="niceng235er10.appj.s2"><h4>Excluded effectiveness studies</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er10appjtab1"><a href="/books/NBK596257/table/niceng235er10.appj.tab1/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er10appjtab1" rid-ob="figobniceng235er10appjtab1"><img class="small-thumb" src="/books/NBK596257/table/niceng235er10.appj.tab1/?report=thumb" src-large="/books/NBK596257/table/niceng235er10.appj.tab1/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng235er10.appj.tab1"><a href="/books/NBK596257/table/niceng235er10.appj.tab1/?report=objectonly" target="object" rid-ob="figobniceng235er10appjtab1">Table</a></h4><p class="float-caption no_bottom_margin">- Study design Abstract only. Full published results included</p></div></div></div><div id="niceng235er10.appj.s3"><h4>Excluded economic studies</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng235er10appjtab2"><a href="/books/NBK596257/table/niceng235er10.appj.tab2/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng235er10appjtab2" rid-ob="figobniceng235er10appjtab2"><img class="small-thumb" src="/books/NBK596257/table/niceng235er10.appj.tab2/?report=thumb" src-large="/books/NBK596257/table/niceng235er10.appj.tab2/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng235er10.appj.tab2"><a href="/books/NBK596257/table/niceng235er10.appj.tab2/?report=objectonly" target="object" rid-ob="figobniceng235er10appjtab2">Table</a></h4></div></div></div></div><div id="niceng235er10.appk"><h3>Appendix K. Research recommendations – full details</h3><p id="niceng235er10.appk.et1"><a href="/books/NBK596257/bin/niceng235er10-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Research recommendations for review question: What is the effectiveness of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth?</a><span class="small"> (PDF, 125K)</span></p></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Evidence reviews underpinning recommendation 1.9.43 and a research recommendation in the NICE guideline</p><p>These evidence reviews were developed by NICE</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="https://www.gov.wales/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2023.</div><div class="small"><span class="label">Bookshelf ID: NBK596257</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/37856640" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">37856640</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng235er10tab1"><div id="niceng235er10.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the protocol (PICO table)</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596257/table/niceng235er10.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er10.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng235er10.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng235er10.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Women in labour who are pregnant with a single baby, who go into labour at term (37 to 42 weeks of pregnancy) and who do not have any pre-existing medical conditions or antenatal conditions that predispose to a higher risk birth</div></li><li class="half_rhythm"><div>Women in labour whose baby has not been identified before labour to be at high risk of adverse outcome</div></li><li class="half_rhythm"><div>Singleton babies born at term (37 to 42 weeks of pregnancy) with no previously identified problems (for example congenital malformations, genetic anomalies, intrauterine growth restriction, placental problems)</div></li><li class="half_rhythm"><div>Women having an assisted vaginal birth (forceps or vacuum/suction birth) without evidence of an active infection or other conditions requiring antibiotics</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng235er10.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng235er10.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Prophylactic antibiotics given immediately before or as soon as possible after an assisted vaginal birth (forceps or vacuum birth)</td></tr><tr><th id="hd_b_niceng235er10.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng235er10.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Placebo</div></li><li class="half_rhythm"><div>Standard care (no antibiotics)</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng235er10.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcome</th><td headers="hd_b_niceng235er10.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p><b>Critical:</b>
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<ul><li class="half_rhythm"><div>Endometritis</div></li><li class="half_rhythm"><div>Infection at perineal/vaginal or episiotomy site (up till 6 weeks)</div></li><li class="half_rhythm"><div>Sepsis following perineum infection or endometritis</div></li></ul></p>
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<p><b>Important:</b>
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<ul><li class="half_rhythm"><div>Maternal adverse reaction to antibiotics</div></li><li class="half_rhythm"><div>Long-term neonatal outcomes (asthma, allergies)</div></li><li class="half_rhythm"><div>Breastfeeding at 6 weeks</div></li><li class="half_rhythm"><div>Perineal pain at 6 weeks</div></li><li class="half_rhythm"><div>Antibiotic resistance</div></li></ul></p>
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</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng235er10tab2"><div id="niceng235er10.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Summary of included studies</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596257/table/niceng235er10.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er10.tab2_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng235er10.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng235er10.tab2_1_1_1_2" colspan="2" rowspan="1" style="text-align:left;vertical-align:top;">Population</th><th id="hd_h_niceng235er10.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><th id="hd_h_niceng235er10.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><th id="hd_h_niceng235er10.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er10.tab2_1_1_1_1" rowspan="2" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng235er10.s1.ref3" rid="niceng235er10.s1.ref3">Liabsuetrakul 2020</a>
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</p>
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<p>Cochrane Systematic Review</p>
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<p>United Kingdom; United States</p>
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</td><td headers="hd_h_niceng235er10.tab2_1_1_1_2" rowspan="2" colspan="1" style="text-align:left;vertical-align:middle;">K=2</td><td headers="hd_h_niceng235er10.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<u><a class="bibr" href="#niceng235er10.s1.ref1" rid="niceng235er10.s1.ref1">Heitmann 1989</a>:</u>
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</p>
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<p>N=393 women undergoing forceps or vacuum birth</p>
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</td><td headers="hd_h_niceng235er10.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>2g of cefotetan (cephalosporin). Single dose, IV administration</p>
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<p>Given after cord-clamping.</p>
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</td><td headers="hd_h_niceng235er10.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">No treatment</td><td headers="hd_h_niceng235er10.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Endometritis</div></li></ul>
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</td></tr><tr><td headers="hd_h_niceng235er10.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<u><a class="bibr" href="#niceng235er10.s1.ref2" rid="niceng235er10.s1.ref2">Knight 2019</a>:</u>
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</p>
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<p>N= 3420 women undergoing forceps or vacuum birth</p>
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</td><td headers="hd_h_niceng235er10.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>1g Amoxicillin and 200mg clavulanic acid (co-amoxiclav). Single dose, IV administration.</p>
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<p>Given as soon as possible after birth (no more than 6 hours).</p>
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</td><td headers="hd_h_niceng235er10.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Placebo: 20ml IV sterile 0.9% saline within the same timeframe.</td><td headers="hd_h_niceng235er10.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Endometritis</div></li><li class="half_rhythm"><div>Infection at perineal/vagi nal episiotomy site</div></li><li class="half_rhythm"><div>Sepsis following perineum infection or endometritis</div></li><li class="half_rhythm"><div>Maternal adverse reaction to antibiotics</div></li><li class="half_rhythm"><div>Breastfeed at 6 weeks</div></li><li class="half_rhythm"><div>Perineal pain at 6 weeks</div></li></ul>
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</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">IV: intravenous</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng235er10tab3"><div id="niceng235er10.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Economic evidence profile of a systematic review of economic evaluations of prophylactic antibiotics for preventing postnatal infections in assisted vaginal birth</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596257/table/niceng235er10.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er10.tab3_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng235er10.tab3_1_1_1_1" rowspan="2" colspan="1" headers="hd_h_niceng235er10.tab3_1_1_1_1" style="text-align:left;vertical-align:bottom;">Study</th><th id="hd_h_niceng235er10.tab3_1_1_1_2" rowspan="2" colspan="1" headers="hd_h_niceng235er10.tab3_1_1_1_2" style="text-align:left;vertical-align:bottom;">Limitations</th><th id="hd_h_niceng235er10.tab3_1_1_1_3" rowspan="2" colspan="1" headers="hd_h_niceng235er10.tab3_1_1_1_3" style="text-align:left;vertical-align:bottom;">Applicability</th><th id="hd_h_niceng235er10.tab3_1_1_1_4" rowspan="2" colspan="1" headers="hd_h_niceng235er10.tab3_1_1_1_4" style="text-align:left;vertical-align:bottom;">Other comments</th><th id="hd_h_niceng235er10.tab3_1_1_1_5" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">Incremental</th><th id="hd_h_niceng235er10.tab3_1_1_1_6" rowspan="2" colspan="1" headers="hd_h_niceng235er10.tab3_1_1_1_6" style="text-align:left;vertical-align:bottom;">Uncertainty</th></tr><tr><th headers="hd_h_niceng235er10.tab3_1_1_1_5" id="hd_h_niceng235er10.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Costs</th><th headers="hd_h_niceng235er10.tab3_1_1_1_5" id="hd_h_niceng235er10.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Effect</th><th headers="hd_h_niceng235er10.tab3_1_1_1_5" id="hd_h_niceng235er10.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost effecti venss</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er10.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng235er10.s1.ref4" rid="niceng235er10.s1.ref4">Knight 2019</a>
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</p>
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<p>Prophylactic antibiot ic after operati ve birth versus placebo</p>
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</td><td headers="hd_h_niceng235er10.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Potentially serious limitations<sup>1</sup><sup>,</sup><sup>2</sup></td><td headers="hd_h_niceng235er10.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Directly applicable</td><td headers="hd_h_niceng235er10.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Cost analysis alongside a randomised controlled trial</td><td headers="hd_h_niceng235er10.tab3_1_1_1_5 hd_h_niceng235er10.tab3_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−£52</td><td headers="hd_h_niceng235er10.tab3_1_1_1_5 hd_h_niceng235er10.tab3_1_1_2_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">80 per 1000 fewer suspect ed or confirm ed infectio ns at 6 weeks post birth<sup>3</sup></td><td headers="hd_h_niceng235er10.tab3_1_1_1_5 hd_h_niceng235er10.tab3_1_1_2_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Domin ance</td><td headers="hd_h_niceng235er10.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>99% confidence intervals were reported for point estimates of mean difference in costs</p>
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<p>Sensitivity analysis was undertaken with imputation for missing data</p>
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</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>1</dt><dd><div id="niceng235er10.tab3_1"><p class="no_margin">Staffing and consumable costs were not included in the intervention costs.</p></div></dd></dl><dl class="bkr_refwrap"><dt>2</dt><dd><div id="niceng235er10.tab3_2"><p class="no_margin">There were statistically significant differences in the characteristics of the women who returned the postal questionnaire and those who did not.</p></div></dd></dl><dl class="bkr_refwrap"><dt>3</dt><dd><div id="niceng235er10.tab3_3"><p class="no_margin">Taken from the primary outcome of the study but not reported as part of the cost analysis</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng235er10tab4"><div id="niceng235er10.tab4" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596257/table/niceng235er10.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er10.tab4_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng235er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Resource</th><th id="hd_h_niceng235er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Unit costs</th><th id="hd_h_niceng235er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Source</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Co-amoxiclav 1000mg/200mg powder for solution for injection vials</td><td headers="hd_h_niceng235er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£1.06</td><td headers="hd_h_niceng235er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">BNF <a href="https://bnf.nice.org.uk/drugs/co-amoxiclav/medicinal-forms/#powder-for-solution-for-injection" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">https://bnf<wbr style="display:inline-block"></wbr>​.nice.org<wbr style="display:inline-block"></wbr>​.uk/drugs/co-forms/#powder-for-solution-for-injection</a> (accessed 21/06/2022)</td></tr><tr><td headers="hd_h_niceng235er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20ml sterile water</td><td headers="hd_h_niceng235er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.72</td><td headers="hd_h_niceng235er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">NHS Drugs Tariff (July 2022)</td></tr><tr><td headers="hd_h_niceng235er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20ml syringe</td><td headers="hd_h_niceng235er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.13</td><td headers="hd_h_niceng235er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><a href="https://www.medisave.co.uk/bd-discardittm-20ml-2-piece-eccentric-tip-syringe-box-of-100.html" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.medisave<wbr style="display:inline-block"></wbr>​.co.uk/bd-discardittm-20ml-2-piece-eccentric-tip-syringe-box-of-100.html</a> (accessed 19/07/2022)</td></tr><tr><td headers="hd_h_niceng235er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Drawing up needle</td><td headers="hd_h_niceng235er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.11</td><td headers="hd_h_niceng235er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><a href="https://www.medisave.co.uk/bd-blunt-fill-safety-draw-up-needle-18-g-red-40-mm-1-45-degr-qty100.html?gclid=Cj0KCQiAjc2QBhDgARIsAMc3SqRwZqK-ke3ULYIprmDFAt_Dc9aR0oMuZrNws704GeECKKs7fGV8K2gaAqUGEALw_wcB" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.medisave<wbr style="display:inline-block"></wbr>​.co.uk/bd-blunt-fill-safety-draw-up-needle-18-g-red-40-mm-1-45-degr-qty100<wbr style="display:inline-block"></wbr>​.html?gclid<wbr style="display:inline-block"></wbr>​=Cj0KCQiAjc2QBhDgARIsAMc3SqRwZqK-ke3ULYIprmDFAt<wbr style="display:inline-block"></wbr>​_Dc9aR0oMuZrNws704GeECKKs7fGV8K2gaAqUGEALw_wcB</a> (accessed 31/05/2022)</td></tr><tr><td headers="hd_h_niceng235er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Obstetrician<sup>a</sup></td><td headers="hd_h_niceng235er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£52 per hour</td><td headers="hd_h_niceng235er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU (2021)</td></tr><tr><td headers="hd_h_niceng235er10.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Midwife<sup>b</sup></td><td headers="hd_h_niceng235er10.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£51 per hour</td><td headers="hd_h_niceng235er10.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU (2021)</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">BNF: British National Formulary; NHS: National Health Service; PSSRU: Personal Social Services Research Unit</p></div></dd></dl><dl class="bkr_refwrap"><dt>a)</dt><dd><div id="niceng235er10.tab4_1"><p class="no_margin">Obstetrician prescribes antibiotic</p></div></dd></dl><dl class="bkr_refwrap"><dt>b)</dt><dd><div id="niceng235er10.tab4_2"><p class="no_margin">Midwives check and administer drug</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng235er10appjtab1"><div id="niceng235er10.appj.tab1" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596257/table/niceng235er10.appj.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er10.appj.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Reason</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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(2019) LB 3: Prophylactic antibiotics for the prevention of infection following operative vaginal delivery: the ANODE trial. American Journal of Obstetrics and Gynecology
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220(1supplement): 685
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>- Study design Abstract only.</p>
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<p>Full published results included</p>
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Berhan, Yifru; Kirba, Sisay; Gebre, Achamyelesh (2020) Still No Substantial Evidence to Use Prophylactic Antibiotic at Operative Vaginal Delivery: Systematic Review and Meta-Analysis. Obstetrics and gynecology international 2020: 1582653 [<a href="/pmc/articles/PMC7479451/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7479451</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32934656" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32934656</span></a>]
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>- Cochrane systematic review already included</p>
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<p>References checked and no additional studies included that were not included in the Cochrane systematic review included in this review</p>
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Buppasiri, P., Lumbiganon, P., Thinkhamrop, J.
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et al. (2005) Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth. The Cochrane database of systematic reviews: cd005125 [<a href="https://pubmed.ncbi.nlm.nih.gov/16235394" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16235394</span></a>]
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>- More recent version available</p>
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<p>Assessed under <a class="bibr" href="#niceng235er10.appj.ref4" rid="niceng235er10.appj.ref4">Buppasiri 2014</a></p>
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<a id="niceng235er10.appj.ref4"></a>Buppasiri, Pranom, Lumbiganon, Pisake, Thinkhamrop, Jadsada
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et al. (2014) Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth. Cochrane Database of Systematic Reviews
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2014(10): cd005125
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>- Population</p>
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<p>References checked, one included study does not meet the population as 65% of women had a spontaneous vaginal birth (only 35% had a forceps or vacuum assisted vaginal birth).</p>
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Knight, Marian (2020) Antibiotic prophylaxis after operative vaginal birth: the ANODE randomized controlled trial. Obstetrics, Gynaecology and Reproductive Medicine
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30(10): 326–327
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<p>- Study design</p>
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<p>Summary of a randomised trial already included (ANODE trial)</p>
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Knight, Marian, Chiocchia, Virginia, Partlett, Christopher
|
|
et al. (2019) Intravenous co-amoxiclav to prevent infection after operative vaginal delivery: the ANODE RCT. Health technology assessment (Winchester, England)
|
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23(54): 1–54 [<a href="/pmc/articles/PMC6801364/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6801364</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31590702" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31590702</span></a>]
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<p>- Study design</p>
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<p>Health Technology Assessment for the ANODE trial which has been included under Cochrane Systematic Review (<a class="bibr" href="#niceng235er10.s1.ref3" rid="niceng235er10.s1.ref3">Liabsuetrakul 2020</a>).</p>
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<p>Checked for secondary subgroup analysis, but nothing matching the protocol</p>
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Knight, Marian, Chiocchia, Virginia, Partlett, Christopher
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et al. (2019) Prophylactic Antibiotics in the Prevention of Infection After Operative Vaginal Delivery (ANODE): A Multicenter Randomized Controlled Trial. Obstetrical and Gynecological Survey
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74(11): 635–637 [<a href="/pmc/articles/PMC6584562/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6584562</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31097213" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31097213</span></a>]
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<p>- Study design</p>
|
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<p>Editorial comment</p>
|
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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Mohamed-Ahmed, Olaa; Hinshaw, Kim; Knight, Marian (2019) Operative vaginal delivery and post-partum infection. Best practice & research. Clinical obstetrics & gynaecology
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56: 93–106 [<a href="https://pubmed.ncbi.nlm.nih.gov/30992125" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30992125</span></a>]
|
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<p>- Study design</p>
|
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<p>Not a systematic review or randomised controlled trial. References checked and one relevant study has already been included under a Cochrane review</p>
|
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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van Schalkwyk, Julie, Money, Deborah M., Ogilvie, Gina
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et al. (2010) Antibiotic Prophylaxis in Obstetric Procedures. Journal of Obstetrics and Gynaecology Canada
|
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32(9): 878–884 [<a href="/pmc/articles/PMC7128122/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7128122</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/21050523" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 21050523</span></a>]
|
|
</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<p>- Study design</p>
|
|
<p>Not a systematic review or randomised controlled trial, however references checked. Cochrane systematic review identified, but a more recent one has been included in this review</p>
|
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</td></tr><tr><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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van Schalkwyk, Julie and Van Eyk, Nancy (2017) No. 247-Antibiotic Prophylaxis in Obstetric Procedures. Journal of Obstetrics and Gynaecology Canada
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39(9): e293–e299 [<a href="https://pubmed.ncbi.nlm.nih.gov/28859772" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28859772</span></a>]
|
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</td><td headers="hd_h_niceng235er10.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<p>- Study design</p>
|
|
<p>Not a systematic review or randomised controlled trial, however references checked.</p>
|
|
<p>Cochrane systematic review identified, but a more recent one has been included in this review</p>
|
|
</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng235er10appjtab2"><div id="niceng235er10.appj.tab2" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK596257/table/niceng235er10.appj.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng235er10.appj.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng235er10.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng235er10.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Reason</th></tr></thead><tbody><tr><td headers="hd_h_niceng235er10.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Owens, Sarah, Thayer, Sydney, Hersh, Alyssa R.
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et al. (2020) 118: Antibiotics at time of operative vaginal delivery: a cost-effectiveness analysis. American Journal of Obstetrics and Gynecology
|
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222(1supplement): 92
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</td><td headers="hd_h_niceng235er10.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">- Conference abstract</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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