Can Clean Delivery Kits Prevent Infections? Lessons from Traditional Birth Attendants in Nigeria.

Background: In resource-poor settings, perinatal infections contribute significantly to maternal and neonatal deaths, and the use of clean delivery kits (CDKs) has been proposed as a tool to reduce the risk of infection-related deaths. This study aims to assess the acceptability and effectiveness of CDKs in preventing infections in deliveries attended by traditional birth attendants (TBAs) in Abeokuta, Nigeria. Methods: The study was a cluster-randomized trial with 67 birth centres/clusters, 453 births/mothers, and 457 babies randomized to intervention or control arms; intervention involved supplementation of delivery with JANMA CDKs. Interviews were conducted at the birth homes, and the primary outcomes were neonatal infection and puerperal fever. The association between infection and perinatal risk factors was tested using the Chi-square and Fisher's exact tests. Results: CDKs were well accepted by TBAs. The incidence of puerperal fever and neonatal infection was 1.1% and 11.2%, respectively. Concurrent infection was found in 1 (0.22%) of the mother-neonate pair. There was no significant association between any of the sociodemographic factors and infection for both mothers and neonates. PROM and prolonged labour were significantly associated with puerperal infection. All mothers with puerperal fever were from the control group. Compared to the control group, the relative risk of puerperal infection and neonatal infection in the intervention group was 0.08 (0.004 -1.35, p = 0.079) and 0.64 (0.37 to 1.1, p = 0.10), respectively. Conclusion: CDKs hold promising results in attenuating maternal infections in resource-poor settings. Larger studies with greater statistical power are required to establish statistically reliable information.

Exploring terminology for puerperal sepsis and its symptoms in urban Karachi, Pakistan to improve communication, care-seeking, and illness recognition.

Puerperal sepsis is an important cause of maternal morbidity and mortality in developing countries. Awareness of local terminology for its signs and symptoms may improve communication about this illness, what actions to take when symptoms appear, timely care seeking, and clinical outcomes. This formative research aimed to improve recognition and management of postpartum sepsis in Pakistan by eliciting local terms used for postpartum illnesses and symptoms. We conducted 32 in-depth interviews with recently delivered women, their relatives, traditional birth attendants, and health care providers to explore postpartum experiences. Terms for symptoms and illness are used interchangeably (i.e. bukhar, the Urdu word for fever), many variations exist for the same term, and gradations of severity for each term as not associated with different types of illnesses. The lack of a designated term for postpartum sepsis in Urdu delays care-seeking and proper diagnosis, particularly at the community level. Ideally, a common lexicon for symptoms and postpartum sepsis would be developed but this may not be feasible or appropriate given the nature of the Urdu language and local understandings of postpartum illness. These insights can inform how we approach educational campaigns, the development of clinical algorithms that focus on symptoms, and counselling protocols.

Pre-Caesarean Section Vaginal Preparation with Chlorhexidine Solution in Preventing Puerperal Infectious Morbidities: A Randomized Controlled Trial.

BACKGROUND: Globally, peripartum or puerperal infections account for about one tenth of maternal mortality, most of which occur in low income countries. Therefore, vaginal preparation with an antiseptic prior to a caesarean delivery could be considered an additional measure to prevent subsequent infectious morbidities. OBJECTIVES: To evaluate vaginal preparation with 0.3% chlorhexidine solution in the prevention of endometritis, surgical site infection and post-operative fever following emergency caesarean section. METHODS: This prospective randomized controlled trial (RCT) was conducted among 240 participants planned for emergency caesarean sections (CS) at term in the University of Medical Sciences Teaching Hospital Complex, Ondo State, Nigeria. Participants were randomised into either group "A" (study) or "B" (control). The former had vaginal preparation with 0.3% chlorhexidine gluconate immediately after anaesthesia while the latter received normal saline. Participants were followed up post-operatively during which clinical features of puerperal infectious morbidities were observed for each during admission as well as 8th and 14th days after delivery. RESULTS: The rate and risk of endometritis were significantly lower in the study group compared to the control; 5.0% versus 13.3%, respectively (chi squared =5.004; p=0.042, RR = 0.38; 95% CI = 0.15-0.94; p = 0.042; RRR = 0.62). Post-operative fever and surgical site infection, were also lower in the study group compared to the controls, but the difference was not statistically significant. CONCLUSION: When compared to placebo, pre-caesarean section vaginal preparation with 0.3% chlorhexidine solution significantly reduced only the rate and risk of post-operative endometritis among infectious morbidities.

CONTEXTE: À l'échelle mondiale, infections péripartum ou puerpérales représentent environ un dixième de la mortalité maternelle, dont la plupart se produisent dans les pays à faible revenu. Par conséquent, la préparation vaginale avec un antiseptique avant un accouchement par césarienne pourrait être considéré comme un mesure supplémentaire pour prévenir les morbidités infectieuses subséquentes. OBJECTIFS: Évaluer la préparation vaginale avec 0.3%solution de chlorhexidine dans la prévention de l'endométrite, site chirurgical infection et fièvre postopératoire après une césarienne d'urgence section. MÉTHODES: Cet essai prospectif randomisé contrôlé (ECR)a été menée auprès de 240 participants prévus pour une urgence césariennes (CS) à terme à l'Université des sciences médicales Complexe hospitalier universitaire, État d'Ondo, Nigéria. Les participants étaient randomisé dans le groupe "A" (étude) ou "B" (témoin). Celui-là avait une préparation vaginale avec 0.3 % de gluconate de chlorhexidine immédiatement après l'anesthésie alors que ce dernier a reçu une solution saline normale. Les participants ont été suivis postopératoirement au cours desquels des caractéristiques de morbidité infectieuse puerpérale ont été observées pour chaquelors de l'admission ainsi que les 8ème et 14ème jours après la livraison. RÉSULTATS: Le taux et le risque d'endométrite étaient significativement plus faibles dans le groupe d'étude par rapport au groupe témoin; 5.0 % contre 13.3 %, respectivement (chi carré =5.004; p=0.042, RR = 0.38; 95% CI = 0.15­0.94; p = 0.042; RRR = 0.62). Fièvre postopératoire et infection du site chirurgical, étaient également plus faibles dans le groupe d'étude par rapport aux témoins, mais lela différence n'était pas statistiquement significative. CONCLUSION: Par rapport au placebo, pré-césarienne préparation vaginale avec une solution de chlorhexidine à 0.3% significativement réduit uniquement le taux et le risque d'endométrite postopératoire chez morbidités infectieuses. Mots-clés: Chlorhexidine, Préparation Vaginale, Infection Puerpéral emorbidité, Césarienne, Endométrite, Fièvre Postopératoire, Infection Du Site Chirurgical.

Impact of local terminology on the design of a community-based diagnostic and management algorithm for postpartum sepsis: findings of formative research.

BACKGROUND: Postpartum sepsis is one of the leading causes of maternal mortality and morbidity in developing countries. This formative research elicits local terms used for postpartum illnesses and symptoms of postpartum sepsis with the aim of improving postpartum diagnosis and management in Pakistan. METHODS: We conducted 34 in-depth interviews with recently delivered women (RDW), traditional birth attendants (TBAs), healthcare providers and family members of RDW from rural Sindh to explore local Sindhi terms used to describe postpartum sepsis and related symptoms. During interviews, all participants were asked to orally free list common symptoms of postpartum illnesses; those who were aware of the concept were asked to free list possible symptoms of postpartum sepsis. The responses were recorded by the interviewer. Free listing data were analyzed for frequency and salience. RESULTS: Most participants, including TBAs, were not familiar with the concept of postpartum sepsis as a distinct disease or of a local term denoting the concept. Almost all could identify and report symptoms related to postpartum sepsis in the local language. Only physicians were able to recognize the term postpartum sepsis and related symptoms. Multiple local terms were used for a particular symptom; still others were used to denote gradations of severity. 'Bukhar' (fever) was the most commonly named symptom although it was often considered a normal part of puerperium. Many postpartum illnesses were related to the highly non-specific local term 'kamzori' (weakness). CONCLUSIONS: Better awareness about local terminology used in rural areas related to postpartum sepsis could improve communication, care-seeking patterns, diagnosis and management.

Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections.

OBJECTIVES: Gestational IDA has been linked to adverse maternal and neonatal outcomes, but the impact of iron supplementation on outcome measures remains unclear. Our objective was to assess the effects of gestational IDA on pregnancy outcomes and compare outcomes in pregnancies treated with either oral or intravenous iron supplementation. METHODS: We evaluated maternal and neonatal outcomes in 215 pregnancies complicated with gestational IDA (Hb<100 g/L) and delivered in our tertiary unit between January 2016 and October 2018. All pregnancies from the same period served as a reference group (n=11,545). 163 anemic mothers received oral iron supplementation, and 52 mothers received intravenous iron supplementation. RESULTS: Gestational IDA was associated with an increased risk of preterm birth (10.2% vs. 6.1%, p=0.009) and fetal growth restriction (FGR) (1.9% vs. 0.3%, p=0.006). The gestational IDA group that received intravenous iron supplementation had a greater increase in Hb levels compared to those who received oral medication (18.0 g/L vs. 10.0 g/L, p<0.001), but no statistically significant differences in maternal and neonatal outcomes were detected. CONCLUSIONS: Compared to the reference group, prematurity, FGR, postpartum infections, and extended hospital stays were more common among mothers with gestational IDA, causing an additional burden on the families and the healthcare system.

Mortality Synopsis Among Women of Reproductive Age Group in Nigeria: A Hospital-Based Study.

PURPOSE: Identification of health problems of women of reproductive age, using a reliable mortality data, is essential in evading preventable female deaths. This study aimed at investigating mortality profile of women of reproductive age group in Nigeria. MATERIALS AND METHODS: This is a descriptive, retrospective study involving women of reproductive age group of 15-49 years that died at DELSUTH from 1st January 2016 to 31st December 2018. The age, date of death and cause of death were retrieved from the hospital records and subsequently analyzed using SPSS version 21. RESULTS: One hundred and eighty-seven eligible deaths were encountered in this study, constituting 17.5% of all deaths in the hospital. Twenty four (12.8%) cases were of maternal etiology while 163 (87.2%) were of non-maternal causes. Non-communicable disease, communicable disease and external injuries accounted for 100 (53.5%), 44 (23.5%) and 19 (10.2%) deaths among the non-maternal causes. The mean age and the peak age group are 34.4 years and the 4th decade respectively. The leading specified non-maternal causes of death (in descending order) are AIDS/TB, cerebrovascular accidents (CVA), breast cancer, road traffic accident (RTA), diabetes, perioperative death and sepsis while the leading maternal causes of death are abortion, postpartum hemorrhage, eclampsia and puerperal sepsis. CONCLUSION: Most deaths affecting WRAG are preventable, with non-maternal causes in excess of maternal causes. There is need for holistic life-long interventional policies and strategies that will address the health need of these women, using evidence-based research findings.

Endometritis: Nontraditional Therapies.

Endometritis is characterized by inflammation of the endometrial lining of the uterus and is a leading cause of subfertility in broodmares. When traditional therapies fall short, nonconventional means can be used either to supplement or in lieu of customary practices to manage endometritis. This article reviews alternative therapies available for use in broodmare practice and provides anecdotal and scientific evidence supporting their use.

Early post parturient changes in milk acute phase proteins.

The periparturient period is one of the most critical periods in the productive life of a dairy cow, and is the period when dairy cows are most susceptible to developing new intramammary infections (IMI) leading to mastitis. Acute phase proteins (APP) such as haptoglobin (Hp), mammary associated serum amyloid A3 (M-SAA3) and C-reactive protein (CRP) have been detected in milk during mastitis but their presence in colostrum and milk in the immediate postpartum period has had limited investigation. The hypothesis was tested that APP are a constituent of colostrum and milk during this period. Enzyme linked immunosorbent assays (ELISAs) were used to determine each APP's concentration in colostrum and milk collected daily from the first to tenth day following calving in 22 Holstein-Friesian dairy cows. Haptoglobin was assessed in individual quarters and composite milk samples while M-SAA3 and CRP concentration were determined in composite milk samples. Change in Hp in relation to the high abundance proteins during the transition from colostrum to milk were evaluated by 1 and 2 dimension electrophoresis and western blot. In 80% of the cows all APPs were detected in colostrum on the first day following parturition at moderately high levels but gradually decreased to minimal values in the milk by the 6th day after calving. The remaining cows (20%) showed different patterns in the daily milk APP concentrations and when an elevated level is detected could reflect the presence of IMI. Demonstration that APP are present in colostrum and milk following parturition but fall to low levels within 4 days means that elevated APP after this time could be biomarkers of post parturient mastitis allowing early intervention to reduce disease on dairy farms.

Perineal wound infections: an audit.

An audit was completed by an NHS trust to determine the rate of perineal trauma amongst vaginal births and to assess the rate of perineal wound infections. The audit results confirmed a higher than average rate of perineal wound infections amongst women who had an instrumental birth. The trust decided to separate the contents of the delivery packs into two separate packs--one pack for birth and one pack for suturing--and developed a back-to-basics update session that was delivered to staff working within the maternity setting. A re-audit the following year confirmed that these measures had worked and the overall perineal wound infection rate reduced within the trust.

Acupuncture and postpartum pyogenic sacroiliitis: a case report.

INTRODUCTION: Pyogenic sacroiliitis, a rare form of septic arthritis, occurs in patients following trauma, intravenous drug use, genitourinary infections and pregnancy. Here we report a rare case where both acupuncture and pregnancy served as predisposing risk factors to the development of this infection. CASE PRESENTATION: A 33-year-old white woman received several sessions of acupuncture treatment during her gestation at the site of her sacroiliac joint for sciatica; she developed biopsy-confirmed sacroiliitis with methicillin-sensitive Staphylococcus aureus during the immediate postpartum period. The diagnosis, medical management and treatment course are described. CONCLUSIONS: Low back and pelvic pain are common conditions during pregnancy and postpartum. Acupuncture is a common modality of medication-free treatment used by many patients. Recognition of the potential complications of such therapies can lead to early diagnosis, accurate treatment, decreased morbidity and increased chances for a successful outcome.

Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal.

BACKGROUND: Globally, puerperal sepsis accounts for an estimated 8-12% of maternal deaths, but evidence is lacking on the extent to which clean delivery practices could improve maternal survival. We used data from the control arms of four cluster-randomised controlled trials conducted in rural India, Bangladesh and Nepal, to examine associations between clean delivery kit use and hand washing by the birth attendant with maternal mortality among home deliveries. METHODS: We tested associations between clean delivery practices and maternal deaths, using a pooled dataset for 40,602 home births across sites in the three countries. Cross-sectional data were analysed by fitting logistic regression models with and without multiple imputation, and confounders were selected a priori using causal directed acyclic graphs. The robustness of estimates was investigated through sensitivity analyses. RESULTS: Hand washing was associated with a 49% reduction in the odds of maternal mortality after adjusting for confounding factors (adjusted odds ratio (AOR) 0.51, 95% CI 0.28-0.93). The sensitivity analysis testing the missing at random assumption for the multiple imputation, as well as the sensitivity analysis accounting for possible misclassification bias in the use of clean delivery practices, indicated that the association between hand washing and maternal death had been over estimated. Clean delivery kit use was not associated with a maternal death (AOR 1.26, 95% CI 0.62-2.56). CONCLUSIONS: Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported.

Postparturient disorders and backfat loss in tropical sows associated with parity, farrowing duration and type of antibiotic.

The present study investigated the incidence of postparturient disorders and backfat loss in primiparous and multiparous sows under tropical climates in relation to duration of farrowing and type of antibiotic used postpartum. In total, 81 sows (42 primiparous and 39 multiparous sows) were included. The sows were categorised according to the duration of farrowing into three groups: <2 (n = 58), 2-4 (n = 19) and >4 h (n = 4). According to the antibiotic used postpartum, the sows were divided into two groups: group I (enrofloxacin type 1, n = 36) and group II (enrofloxacin type 2, n = 45). Rectal temperature, the presence of abnormal vaginal discharge, the occurrence of postpartum dysgalactia syndrome (PDS) and the sows' appetite were determined at days 0, 1, 2 and 3 postpartum. Backfat thickness was measured before farrowing and at 21 days postpartum. The mean duration of farrowing was 114.5 ± 60.2 min. Stillborn piglets in the sows with a long duration of farrowing (>4 h, mean 287.9 min) was higher than in sows with a short duration (<2 h, mean 85.5 min) of farrowing (29.2 and 7.9 %, P = 0.044). Primiparous sows lost more backfat during lactation than multiparous sows (15.7 and 4.8 %, P = 0.004). The incidence of abnormal vaginal discharge (P = 0.046) and PDS (P = 0.057) was less frequent in group II than in group I sows. In conclusion, primiparous sows and sows with a long duration of farrowing had a high risk of postparturient disorders. The type of antibiotic had an effect on the incidence of abnormal vaginal discharge and PDS in sows.

Caesarean wound care for midwives.

With a rise in caesarean births there is a rise in wound care management issues for midwives and the potential for surgical site infections (SSIs). The burden of SSIs include increases in maternal mortality, morbidity, length of hospital stay and cost. Sepsis is currently the leading cause of maternal mortality, with 50 per cent of the women who died from sepsis having had a caesarean birth (Centre for Maternal and Child Enquiries (CMACE) 2011). Wound management and the prevention of sepsis are therefore issues of great concern to midwives. This article considers the incidence of wound infections and presents the guidance available to help address this problem.

Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia.

BACKGROUND: Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia. METHODS: We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010. RESULTS: There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%). CONCLUSION: Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (EmOC) facilities in the Zone. Our study found that only three basic and two comprehensive EmOC service qualifying facilities serve this large population which is below the UN's minimum recommendation. The utilization of the existing facilities for delivery was also low, which is clearly inadequate to reduce maternal deaths to the MDG target.

Frequency and treatment of methicillin resistant Staphylococcus aureus in obstetric and gynaecological sepsis.

OBJECTIVE: To perform culture and sensitivity for pathogens causing puerperal and postoperative wound sepsis and determine the frequency of Methicillin Resistant Staphylococcus aureus (MRSA) in such infections. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Obstetrics and Gynaecology Ward, Jinnah Postgraduate Medical Centre, Karachi, from December 2008 to May 2010. METHODOLOGY: All patients presenting with puerperal sepsis or postoperative wound infection were enrolled. Pus was collected for culture and sensitivity using standard technique. Two samples were taken from each patient; one before starting the treatment and one at the end of treatment. Ames transport medium was used. Empirical treatment with triple regimen (Ampicillin, Metronidazole and Gentamicin) was started immediately to cover Gram positive as well as negative bacteria in addition to anaerobic infection. After receiving the sensitivity report, antimicrobial agent were changed accordingly. Samples from ward and theater staff and environment were also taken to look for possible mode of transmission. Data was recorded on a proforma. Discrete variables are expressed as percentages. RESULTS: Staphylococcus aureus was the most frequent organism isolated in 34.6% cases. Methicillin sensitive Staphylococcus aureus was seen in 20% cases and methicillin resistant Staphylococcus aureus was seen in 14.6%. Out of these 14.6% MRSA, (17) 77% was associated with puerperal sepsis and rest (5) 23% was associated with postoperative wound infection. It showed best sensitivity to vancomycin. CONCLUSION: Staphylococcus aureus and E. coli were common causative agent of postoperative infections and puerperal sepsis.

Enemas during labour.

BACKGROUND: Although the use of enemas during labour usually reflects the preference of the attending healthcare provider, enemas may cause discomfort for women. OBJECTIVES: To assess the effects of enemas applied during the first stage of labour on maternal and neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013), the Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effectiveness (The Cochrane Library 2013, Issue 5), PubMed (1966 to 31 May 2013), LILACS (31 May 2013), the Search Portal of the International Clinical Trials Registry Platform (ICTRP) (31 May 2013), Health Technology Assessment Program, UK (31 May 2013), Medical Research Council, UK (31 May 2013), The Wellcome Trust, UK (31 May 2013) and reference lists of retrieved articles. SELECTION CRITERIA: Randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion. MAIN RESULTS: Four RCTs (1917 women) met the inclusion criteria. One study was judged as having a low risk of bias. In the meta-analysis we conducted of two trials, we found no significant difference in infection rates for puerperal women (two RCTs; 594 women; risk ratio (RR) 0.66, 95% confidence (CI) 0.42 to 1.04). No significant differences were found in neonatal umbilical infection rates (two RCTs; 592 women; RR 3.16, 95% CI 0.50 to 19.82; I(2) 0%. In addition, meta-analysis of two studies found that there were no significant differences in the degree of perineal tear between groups. Finally, meta-analysis of two trials found no significant differences in the mean duration of labour. AUTHORS' CONCLUSIONS: The evidence provided by the four included RCTs shows that enemas do not have a significant beneficial effect on infection rates such as perineal wound infection or other neonatal infections and women's satisfaction. These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged.

Causes of puerperal and neonatal sepsis in resource-constrained settings and advocacy for an integrated community-based postnatal approach.

BACKGROUND: Puerperal sepsis and neonatal sepsis are important causes of mortality and morbidity in low-income countries. OBJECTIVES: To help improve global guidelines on postpartum care by reviewing existing data on microbiologic causes of sepsis among mothers, newborns, and mother-newborn pairs. SEARCH STRATEGY: An extensive literature review of peer-reviewed publications from resource-constrained settings was conducted using PubMed. SELECTION CRITERIA: Primary research studies containing microbiologic data on puerperal sepsis or combined maternal and neonatal sepsis published since 1980. DATA COLLECTION AND ANALYSIS: Study characteristics and results were analyzed. Data regarding causative microorganisms were tabulated and discussed in the main text. MAIN RESULTS: Diagnostic evaluation of microorganisms causing puerperal sepsis was difficult, with few studies linking microorganisms causing infection in individual mother-newborn pairs. The most frequent microorganisms associated with puerperal sepsis were Neisseria gonorrhoeae and Chlamydia trachomatis. The most frequent microorganisms associated with neonatal sepsis were Escherichia coli, Staphylococcus aureus, and Klebsiella species. CONCLUSIONS: Management tools for community-based care of mothers with puerperal sepsis-including early detection, initiation of broad-spectrum antibiotic treatment, and timely referral-should be added to those currently in use for neonatal sepsis. Further research is required to address acceptability, feasibility, and impact of community-based presumptive treatment.

Enemas during labour.

BACKGROUND: Although the use of enemas during labour usually reflects the preference of the attending healthcare provider, enemas may cause discomfort for women. OBJECTIVES: To assess the effects of enemas applied during the first stage of labour on maternal and neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 May 2012), the Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effectiveness (The Cochrane Library 2012, Issue 5), PubMed (1966 to 17 May 2012), LILACS (17 May 2012), the Search Portal of the International Clinical Trials Registry Platform (ICTRP) (17 May 2012), Health Technology Assessment Program, UK (17 May 2012), Medical Research Council, UK (17 May 2012), The Wellcome Trust, UK (17 May 2012) and reference lists of retrieved articles. SELECTION CRITERIA: Randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion.  MAIN RESULTS: Four RCTs (1917 women) met the inclusion criteria. One study was judged as having a low risk of bias. In the meta-analysis we conducted of two trials, we found no significant difference in infection rates for puerperal women (two RCTs; 594 women; risk ratio (RR) 0.66, 95% confidence (CI) 0.42 to 1.04). No significant differences were found in neonatal umbilical infection rates (two RCTs; 592 women; RR 3.16, 95% CI 0.50 to 19.82; I² 0%. In addition, meta-analysis of two studies found that there were no significant differences in the degree of perineal tear between groups. Finally, meta-analysis of two trials found no significant differences in the mean duration of labour. AUTHORS' CONCLUSIONS: The evidence provided by the four included RCTs shows that enemas do not have a significant beneficial effect on infection rates such as perineal wound infection or other neonatal infections and women's satisfaction. These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged.