Prognostic factors for cesarean section outcome of pregnant women with gestational diabetes mellitus: a systematic review and meta-analysis

Figures & data

Figure 1 The screening flow chart.

Table 1 Basic characteristics of included studies

	Year	Country	Funding	Conflict of interest	Time of research	Sample size	Prognostic factors	Exposed group (Mean±SD)			Nonexposed group (Mean±SD)
								Age	Weight (kg)	Gestation (weeks)	Age	Weight (kg)	Gestation (weeks)
Li 2010^Citation25	2010	China	○	○	2007.1~2009.12	48	Insulin pump	Range: 24~36	○	○	Range: 24~36	○	○
Feng 2017^Citation27	2017	China	○	○	2015.4~2015.9	162	Short-term fasting and water-deprivation	32.91±4.00	○	38.74±1.54	4.07±4.39	○	38.28±1.47
Wang 2017^Citation28	2017	China	○	○	2014.1~2016.2	110	Individual health education	○	○	○	○	○	○
Wang 2010^Citation16	2010	China	●^a	○	2009.2~2010.3	70	Fructose Injection	○	○	○	○	○	○
Zhao 2011^Citation24	2011	China	○	○	2011.3~2011.7	33	PCEA	29.7±3.7	76.7±6.3	○	30.1±4.1	77.2±6.2	○
Yu 2014^Citation17	2014	China	○	○	2011.5~2013.10	201	Fructose Injection	31.8±6.9	○	38.8±1.9	31.8±6.9	○	38.8±1.9
Chen 2015^Citation18	2015	China	○	○	2012.9~2013.9	140	Microwave treatment for postoperative wound	26.4±2.9	○	○	26.4±2.9	○	○
Han 2015^Citation22	2015	China	○	○	2012.2~2014.1	153	Psychological intervention	25.13±5.24	○	26.05±0.23	25.13±5.24	○	26.05±0.23
Li 2015^Citation23	2015	China	●^b	○	2014.1~2015.5	200	Psychological intervention	30.05±2.51	○	○	29.03±1.56	○	○
Yin 2015^Citation14	2015	China	○	○	2014.3~2015.3	54	Epidural anesthesia	28.1±5.4	○	37.9±5.1	29.0±5.4	○	38.5±5.4
Zhang 2015^Citation26	2015	China	○	○	2012.3~2013.12	99	Low dose sufentanil combined with bupivacaine VS bupivacaine	30.7±2.1	78.2±8.1	37.8±1.0	30.2±2.0	77.7±7.3	38.1±0.9
Yang 2017^Citation29	2017	China	○	○	2016.2~2017.6	120	Addition of once antibiotic	27.2±3.25	○	○	29.1±4.03	○	○

Notes: ○: Unreported; ●: reported; ^aLiaoning Natural Science Foundation Project (20042089), Liaoning Education Department Fund Project (20062013); ^bScience and Technology Research and Development Plan of Hebei province(132777208).

Abbreviation: PCEA, patient-controlled epidural analgesia.

Appendix 1 Effect evaluation results

Outcome	No. ofstudies	No. ofparticipants	Effect estimateRR/MD (95%CI)	P value
Insulin pump VS multiple subcutaneous injections of insulin
Blood glucose standard time (d)	1	48	MD: -5.30 (-5.78, -4.82)	<0.00001
Dose of insulin (U/d)	1	48	MD: -17.00 (-23.04, -10.96)	<0.00001
Surgical incision healing time /d	1	48	MD: -4.40 (-5.58, -3.22)	<0.00001
Fasting and water-deprivation: short-term VS long-term
Preoperative blood glucose (mmol/L)	1	162	MD: 0.84 (0.42, 1.26)	0.001
Postoperative blood glucose(mmol/L)	1	162	MD: 0.16 (-0.17, 0.49)	0.345
Incidence of nausea	1	162	RR: 2.98 (0.77, 11.51)	0.180
Incidence of vomiting	1	162	RR: 2.24 (0.38, 13.03)	0.647
Incidence of neonatal hypoglycemia	1	162	RR: 0.25 (0.03, 2.02)	0.302
Incidence of preoperative hypoglycemia	1	162	RR: 0.54 (0.18, 1.63)	0.264
Maternal anal discharge time(h)	1	162	MD: -0.04 (-0.25, 0.17)	0.692
Bleeding during childbirth (ml)	1	162	MD: -42.71 (-82.55, -2.86)	0.039
Neonatal Apgar scores at 1 min	1	162	MD: 0.03 (-0.18, 0.24)	0.918
Neonatal Apgar scores at 5 min	1	162	MD: -0.03 (-0.14, 0.08)	0.183
Postnatal blood glucose (mmol/L)	1	162	MD: 0.45 (0.03, 0.87)	0.038
Health education: individualization VS convention
Fasting blood glucose compliance rate	1	110	RR: 1.08 (0.86, 1.35)	>0.05
Glucose-target-rate at 2 o’clock	1	110	RR: 1.31 (1.04, 1.66)	<0.05
Glucose-target-rate at 0 o’cl	1	110	RR: 1.23 (1.01, 1.50)	<0.05
Nursing service satisfaction	1	110	MD: 6.51 (5.80, 7.22)	<0.01
Fructose Injection VS Glucose Injection + Insulin
Blood glucose level at 1.5~2h after infusion (mmol/L)	2	202	MD: -1.17 (-1.93, -0.41)	0.003
Blood glucose level at 3~4h after infusion (mmol/L)	2	202	MD: -0.99 (-1.61, -0.36)	0.002
Blood glucose level at 6h after infusion (mmol/L)	1	70	MD: -0.62 (-1.86, 0.61)	0.32
Insulin level at 1.5h after infusion (mU/L)	1	132	MD: -13.50 (-19.02, -7.98)	<0.00001
Insulin level at 3h after infusion (mU/L)	1	132	MD: -8.59 (-13.75, -3.43)	0.001
Blood uric acid level at 3h after infusion (μmol/L	1	132	MD: -8.00 (-34.96, 18.96)	0.56
Positive rate of urine carcass	2	202	RR: 1.14 (0.49, 2.64)	0.77
Positive rate of urine glucose	1	70	RR: 0.21 (0.01, 4.25)	0.31
PCEA VS PCIA
Blood glucose level at 3h after the onset of analgesia (mmol/L)	1	33	MD: 0.01 (-0.21, 0.23)	0.93
Blood glucose level at 3h after the onset of analgesia (mmol/L)	1	33	MD: -0.80 (-1.01, -0.59)	<0.00001
Blood glucose level at 12h after the onset of analgesia (mmol/L)	1	33	MD: -0.76 (-1.00, -0.52)	<0.00001
Blood glucose level at 24h after the onset of analgesia (mmol/L)	1	33	MD: -0.65 (-0.87, -0.43)	<0.00001
Blood glucose level at 36h after the onset of analgesia (mmol/L)	1	33	MD: -0.75 (-0.96, -0.54)	<0.00001
VAS score at 36h after the onset of analgesia (mmol/L)	1	33	MD: -0.04 (-0.31, 0.23)	0.77
VAS score at 6h after the onset of analgesia (mmol/L)	1	33	MD: -0.01 (-0.20, 0.18)	0.92
VAS score at 12h after the onset of analgesia (mmol/L)	1	33	MD: -0.02 (-0.24, 0.20)	0.86
VAS score at 24h after the onset of analgesia (mmol/L)	1	33	MD: -0.05 (-0.39, 0.29)	0.77
VAS score at 36h after the onset of analgesia (mmol/L)	1	33	MD: -0.04 (-0.35, 0.27)	0.80
Satisfaction rate of analgesic effect	1	33	RR: 1.00 (0.89, 1.12)	1.00
Vausea and vomiting	1	33	RR: 0.31 (0.01, 7.21)	0.47
Uroschesis	1	33	RR: 2.83 (0.12, 64.89)	0.51
Postoperative wound care: microwave treatment of VS routine care
Wound healing rate at first stage	1	140	RR: 1.15 (1.03, 1.29)	0.01
Psychological intervention (including music therapy) VS routine care
Systolic pressure immediately into the operating room (mmHg)	1	200	MD: -9.80 (-12.42, -7.18)	<0.00001
Systolic pressure after surgery into the operating room 30min (mmHg)	1	200	MD: -35.37 (-38.32, -32.42)	<0.00001
Intraoperative systolic pressure (mmHg)	1	153	MD: -22.63 (-27.24, -18.02)	<0.00001
Diastolic pressure immediately into the operating room (mmHg)	1	200	MD: -3.58 (-5.20, -1.96)	<0.00001
Diastolic pressure after surgery into the operating room 30min (mmHg)	1	200	MD: -7.58 (-9.62, -5.54)	<0.00001
Intraoperative diastolic pressure (mmHg)	1	153	MD: -10.61 (-14.65, -6.57)	<0.00001
Heart rate immediately into the operating room	1	200	MD: -0.86 (-2.69, 0.97)	0.36
Heart rate after surgery into the operating room 30min	1	200	MD: -8.89 (-10.52, -7.26)	<0.00001
Anxiety score immediately into the operating room	1	200	MD: -0.13 (-2.57, 2.31)	0.92
Anxiety score after surgery into the operating room 30min	1	200	MD: -2.22 (-3.55, -0.89)	0.001
Intro-operative hemorrhage (ml	1	153	MD: -62.39 (-78.31, -46.47)	<0.00001
Postoperative morbidity	1	153	RR: 0.35 (0.19, 0.64)	0.0008
Postoperative pains	1	153	RR: 0.73 (0.60, 0.89)	0.002
Postoperative normal feeding	1	153	RR: 1.07 (0.99, 1.16)	0.09
Epidural anesthesia vs general anesthesia
Blood glucose while skin cutting (mmol/L)	1	54	MD: 1.48 (1.31, 1.65)	<0.00001
Blood glucose while delivery of the fetus (mmol/L)	1	54	MD: 0.00 (-0.17, 0.17)	1.00
Blood glucose while delivery of placenta(mmol/L)	1	54	MD: -0.19 (-0.37, -0.01)	0.04
Blood glucose about 2 hours after delivery of the fetus (mmol/L)	1	54	MD: 0.90 (0.71, 1.09)	<0.00001
Blood glucose about 6 hours after delivery of the fetus (mmol/L)	1	54	MD: 1.11 (0.93, 1.29)	<0.00001
Apgar scores <7	1	54	RR: 0.20 (0.01, 3.98)	0.29
Combined spinal and epidural analgesia: low dose sufentanil combined with bupivacaine VS bupivacaine
Blood glucose while skin cutting (mmol/L)	1	66	MD: -1.45 (-1.61, -1.29)	<0.00001
Blood glucose while delivery of the fetus (mmol/L)	1	66	MD: 0.01 (-0.13, 0.15)	0.89
Blood glucose about 5 min after delivery of placenta (mmol/L)	1	66	MD: 0.23 (0.06, 0.40)	0.009
Blood glucose about 2 h after delivery of the fetus (mmol/L)	1	66	MD: -0.89 (-1.07, -0.71)	<0.00001
Mean arterial pressure at 1min after anesthesia (mmHg)	1	66	MD: 0.40 (-2.11, 2.91)	0.75
Mean arterial pressure at 2 min after anesthesia (mmHg)	1	66	MD: 1.40 (-1.62, 4.42)	0.36
Mean arterial pressure at 5 min after anesthesia (mmHg)	1	66	MD: 5.80 (3.12, 8.48)	<0.00001
Mean arterial pressure at 10 min after anesthesia (mmHg)	1	66	MD: 0.30 (-2.47, 3.07)	0.83
Mean arterial pressure at 20 min after anesthesia (mmHg)	1	66	MD: 1.90 (-1.10, 4.90)	0.21
Apgar score at 1 min	1	66	MD: 0.10 (-0.17, 0.37)	0.46
Apgar score at 5 min	1	66	MD: 0.10 (0.02, 0.18)	0.01
Additional an antibiotic once vs. 24-h antibiotic application
Marked effective rate	1	120	RR: 0.68 (0.48, 0.97)	<0.05
Effective rate	1	120	RR: 1.50 (0.97, 2.33)	>0.05
Inefficient rate	1	120	RR: 2.00 (0.38, 10.51)	>0.05
Total effective rate	1	120	RR: 0.97 (0.89, 1.05)	>0.05
WBC<12×10^9/L time (d)	1	120	MD: 0.50 (-0.02, 1.02)	>0.05
Body temperature (no fever and return to normal 48 h after surgery)	1	120	RR: 0.98 (0.93, 1.04)	>0.05
Class-A healing rate	1	120	RR: 0.97 (0.89, 1.05)	>0.05
Class-B healing rate	1	120	RR: 2.00 (0.38, 10.51)	>0.05
Class-C healing rate	1	120	-	>0.05

Notes: Bold values indicate statistical significance if the interval does not cross zero for continuous outcomes with MD, and cross one for dichotomous outcomes with RR. The bold values also mean the effect or difference was statistically significant.

Abbreviation: MD, mean difference.

Appendix 2 Summary of Evidence

Outcomes		No of participants(studies) Follow-up	Quality of the evidence(GRADE)	Relative effect (95% CI)	Anticipated absolute effects
					Risk with control group	Risk difference with observation group
Insulin pump VS multiple subcutaneous injections of insulin
Blood glucose standard time (d)		48 (1 RCT)	LOW ^1,2	-	-	MD 5.3 fewer (5.78 fewer to 4.82 fewer)
Dose of insulin (U/d)		48 (1 RCT)	LOW ^1,2	-	-	MD 17 fewer (23.04 fewer to 10.96 fewer)
Surgical incision healing time /d		48 (1 RCT)	LOW ^1,2	-	-	MD 4.4 fewer(5.58 fewer to 3.22 fewer)
Fasting and water-deprivation: short-term VS long-term
Preoperative blood glucose (mmol/L)		162 (1 RCT)	LOW ^1,2	-	-	MD 0.84 more (0.42 more to 1.26 more)
Postoperative blood glucose(mmol/L)		162 (1 RCT)	LOW ^1,5	-	-	MD 0.16 more(0.17 fewer to 0.49 more)
Incidence of nausea		162 (1 RCT)	LOW ^1,5	RR 2.98(0.77 to 11.51)	62 per 1,000	15 more per 1,000(61 fewer to 152 more)
Incidence of vomiting		162 (1 RCT)	LOW ^1,5	RR 2.24(0.38 to 13.03)	21 per 1,000	26 more per 1,000(13 fewer to 248 more)
Incidence of neonatal hypoglycemia		162 (1 RCT)	LOW ^1,5	RR 0.25 (0.03 to 2.02)	62 per 1,000	47 fewer per 1,000(60 fewer to 63 more)
Incidence of preoperative hypoglycemia		162 (1 RCT)	LOW ^1,5	RR 0.54 (0.18 to 1.63)	113 per 1,000	52 fewer per 1,000(93 fewer to 71 more)
Maternal anal discharge time(h)		162 (1 RCT)	LOW ^1,5	-	-	MD 0.04 fewer(0.25 fewer to 0.17 more)
Bleeding during childbirth (ml)		162 (1 RCT)	LOW ^1,2	-	-	MD 42.71 fewer(82.55 fewer to 2.86 fewer)
Neonatal Apgar scores at 1 min		162 (1 RCT)	LOW ^1,5	-	-	MD 0.03 more(0.18 fewer to 0.24 more)
Neonatal Apgar scores at 5 min		162 (1 RCT)	LOW ^1,5	-	-	MD 0.03 fewer(0.14 fewer to 0.08 more)
Postnatal blood glucose (mmol/L)		162 (1 RCT)	LOW ^1,5	-	-	MD 0.45 more(0.03 fewer to 0.87 more)
Health education: individualization VS convention
Fasting blood glucose compliance rate		110 (1 RCT)	LOW ^1,5	RR 1.08(0.86 to 1.35)	764 per 1,000	61 more per 1,000(107 fewer to 267 more)
Glucose-target-rate at 2 o’clock		110 (1 RCT)	LOW ^1,2	RR 1.31 (1.04 to 1.66)	836 per 1,000	259 more per 1,000 (33 more to 552 more)
Glucose-target-rate at 0 o’cl		110 (1 RCT)	LOW ^1,2	RR 1.23 (1.01 to 1.50)	873 per 1,000	201 more per 1,000 (9 more to 436 more)
Nursing service satisfaction		110 (1 RCT)	LOW ^1,2	-	-	MD 6.51 more (5.80 more to 7.22 more)
Fructose Injection vs. Glucose Injection + Insulin
Blood glucose level at 1.5~2 h after infusion (mmol/L)		202 (2 RCTs)	LOW ^2,3	-	-	MD 1.17 fewer (1.93 fewer to 0.41 fewer)
Blood glucose level at 3~4 h after infusion (mmol/L)		202 (2 RCTs)	LOW ^2,3	-	-	MD 0.99 fewer (1.61 fewer to 0.36 fewer)
Blood glucose level at 6h after infusion (mmol/L)		70 (1 RCT)	LOW ^4,5	-	-	MD 0.62 fewer(1.86 fewer to 0.61 more)
Insulin level at 1.5 h after infusion (mU/L)		132 (1 RCT)	LOW ^2,4	-		MD 13.5 fewer (19.02 fewer to 7.98 fewer)
Insulin level at 3 h after infusion (mU/L)		132 (1 RCT)	LOW ^2,4	-		MD 8.59 fewer (13.75 fewer to 3.43 fewer)
Blood uric acid level at 3 h after infusion (μmol/L)		132 (1 RCT)	LOW ^4,5	-		MD 8 fewer(34.96 fewer to 18.96 more)
Positive rate of urine carcass		202 (2 RCTs)	LOW ^3,5	OR 1.14(0.49 to 2.64)	129 per 1,000	15 more per 1,000(61 fewer to 152 more)
Positive rate of urine glucose		70 (1 RCT)	LOW ^1,5	RR 0.21(0.01 to 4.25)	56 per 1,000	44 fewer per 1,000(55 fewer to 181 more)
PCEA VS PCIA
Blood glucose level at 3 h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,5	-	-	MD 0.01 more(0.21 fewer to 0.23 more)
Blood glucose level at 3 h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,2	-	-	MD 0.8 fewer (1.01 fewer to 0.59 fewer)
Blood glucose level at 12h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,2	-	-	MD 0.76 fewer (1 fewer to 0.52 fewer)
Blood glucose level at 24h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,2	-		MD 0.65 fewer (0.87 fewer to 0.43 fewer)
Blood glucose level at 36h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,2	-	-	MD 0.75 fewer (0.96 fewer to 0.54 fewer)
VAS score at 36h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,5	-	-	MD 0.04 fewer(0.31 fewer to 0.23 more)
VAS score at 6h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,5	-		MD 0.01 fewer(0.2 fewer to 0.18 more)
VAS score at 12h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,5	-		MD 0.02 fewer(0.24 fewer to 0.2 more)
VAS score at 24h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,5	-		MD 0.05 fewer(0.39 fewer to 0.29 more)
VAS score at 36h after the onset of analgesia (mmol/L)		33 (1 RCT)	LOW ^1,5	-		MD 0.04 fewer(0.35 fewer to 0.27 more)
Satisfaction rate of analgesic effect		33 (1 RCT)	LOW ^1,5	RR 1.00(0.89 to 1.12)	1,000 per 1,000	0 fewer per 1,000(110 fewer to 120 more)
Vausea and vomiting		33 (1 RCT)	LOW ^1,5	RR 0.31(0.01 to 7.21)	63 per 1,000	43 fewer per 1,000(62 fewer to 388 more)
Uroschesis		33 (1 RCT)	LOW ^1,5	RR 2.83(0.12 to 64.89)	-	-
Postoperative wound care: microwave treatment of VS routine care
Wound healing rate at first stage		140 (1 RCT)	LOW ^1,2	RR 1.15 (1.03 to 1.29)	843 per 1,000	126 more per 1,000 (25 more to 244 more)
Psychological intervention (including music therapy) VS routine care
Systolic pressure immediately into the operating room (mmHg)		200 (1 RCT)	LOW ^2,6	-	-	MD 9.8 fewer (12.42 fewer to 7.18 fewer)
Systolic pressure after surgery into the operating room 30min (mmHg)		200 (1 RCT)	LOW ^2,6	-	-	MD 35.37 fewer (38.32 fewer to 32.42 fewer)
Intraoperative systolic pressure (mmHg)		153 (1 RCT)	LOW ^2,6	-	-	MD 22.63 fewer (27.24 fewer to 18.02 fewer)
Diastolic pressure immediately into the operating room (mmHg)		200 (1 RCT)	LOW ^2,6	-	-	MD 3.58 fewer (5.2 fewer to 1.96 fewer)
Diastolic pressure after surgery into the operating room 30min (mmHg)		200 (1 RCT)	LOW ^2,6	-	-	MD 7.58 fewer (9.62 fewer to 5.54 fewer)
Intraoperative diastolic pressure (mmHg)		153 (1 RCT)	LOW ^2,6	-	-	MD 10.61 fewer (14.65 fewer to 6.57 fewer)
Heart rate immediately into the operating room		200 (1 RCT)	LOW ^5,6	-	-	MD 0.86 fewer(2.69 fewer to 0.97 more)
Heart rate after surgery into the operating room 30min		200 (1 RCT)	LOW ^2,6	-	-	MD 8.89 fewer (10.52 fewer to 7.26 fewer)
Anxiety score immediately into the operating room		200 (1 RCT)	LOW ^5,6	-	-	MD 0.13 fewer(2.57 fewer to 2.31 more)
Anxiety score after surgery into the operating room 30min		200 (1 RCT)	LOW ^2,6	-	-	MD 2.22 fewer (3.55 fewer to 0.89 fewer)
Intro-operative hemorrhage (ml)		153 (1 RCT)	LOW ^2,6	-	-	MD 62.39 fewer (78.31 fewer to 46.47 fewer)
Postoperative pains		153 (1 RCT)	LOW ^2,6	RR 0.73 (0.60 to 0.89)	855 per 1,000	231 fewer per 1,000 (342 fewer to 94 fewer)
Postoperative normal feeding		153 (1 RCT)	LOW ^5,6	RR 1.07(0.99 to 1.16)	908 per 1,000	64 more per 1,000(9 fewer to 145 more)
Postoperative morbidity		153 (1 RCT)	LOW ^2,6	RR 0.35 (0.19 to 0.64)	408 per 1,000	265 fewer per 1,000 (330 fewer to 147 fewer)
Epidural anesthesia vs general anesthesia
Blood glucose while skin cutting (mmol/L)		54 (1 RCT)	LOW ^1,2	-	-	MD 1.48 higher (1.31 higher to 1.56 higher)
Blood glucose while delivery of the fetus (mmol/L)		54 (1 RCT)	LOW ^1,5	-	-	MD 0 (0.17 lower to 0.17 higher)
Blood glucose while delivery of placenta(mmol/L)		54 (1 RCT)	LOW ^1,2	-	-	MD 0.19 fewer (0.37 fewer to 0.1 fewer)
Blood glucose about 2 hours after delivery of the fetus (mmol/L)		54 (1 RCT)	LOW ^1,2	-	-	MD 0.9 higher (0.71 higher to 1.09 higher)
Blood glucose about 6 hours after delivery of the fetus (mmol/L)		54 (1 RCT)	LOW ^1,2	-	-	MD 1.11 higher (0.93 higher to 1.29 higher)
Apgar scores <7		54 (1 RCT)	LOW ^1,5	RR 0.20(0.01 to 3.98)	-	-
Combined spinal and epidural analgesia: low dose sufentanil combined with bupivacaine VS bupivacaine
Blood glucose while skin cutting (mmol/L)	66 (1 RCT)		LOW ^1,2	-	-	MD 1.45 fewer (1.61 fewer to 1.29 fewer)
Blood glucose while delivery of the fetus (mmol/L)	66 (1 RCT)		LOW ^1,5	-	-	MD 0.01 more(0.13 fewer to 0.15 more)
Blood glucose about 5min after delivery of placenta (mmol/L)	66 (1 RCT)		LOW ^1,2	-	-	MD 0.23 more (0.06 more to 0.4 more)
Blood glucose about 2 hours after delivery of the fetus (mmol/L)	66 (1 RCT)		LOW ^1,2	-	-	MD 0.89 fewer (1.07 fewer to 0.71 fewer)
Mean arterial pressure at 1min after anesthesia (mmHg)	66 (1 RCT)		LOW ^1,5	-	-	MD 0.4 more(2.11 fewer to 2.91 more)
Mean arterial pressure at 2min after anesthesia (mmHg)	66 (1 RCT)		LOW ^1,5	-	-	MD 1.4 more(1.62 fewer to 4.42 more)
Mean arterial pressure at 5min after anesthesia (mmHg)	66 (1 RCT)		LOW ^1,2	-	-	MD 5.8 more (3.12 more to 8.48 more)
Mean arterial pressure at 10min after anesthesia (mmHg)	66 (1 RCT)		LOW ^1,5	-	-	MD 0.3 more(2.47 fewer to 3.07 more)
Mean arterial pressure at 20min after anesthesia (mmHg)	66 (1 RCT)		LOW ^1,5	-	-	MD 1.9 more(1.1 fewer to 4.9 more)
Apgar score at 1min	66 (1 RCT)		LOW ^1,5	-	-	MD 0.1 more(0.17 fewer to 0.37 more)
Apgar score at 5mins	66 (1 RCT)		LOW ^1,2	-	-	MD 0.1 more (0.02 more to 0.18 more)
Additional an antibiotic once vs 24 hours antibiotic application
Marked effective rate	120 (1 RCT)		LOW ^1,2	RR 0.68 (0.48 to 0.97)	633 per 1,000	203 fewer per 1,000 (329 fewer to 19 fewer)
Effective rate	120 (1 RCT)		LOW ^1,5	RR 1.50(0.97 to 2.33)	333 per 1,000	167 more per 1,000(10 fewer to 443 more)
Inefficient rate	120 (1 RCT)		LOW ^1,5	RR 2.00(0.38 to 10.51)	33 per 1,000	33 more per 1,000(21 fewer to 317 more)
Total effective rate	120 (1 RCT)		LOW ^1,5	RR 0.97(0.89 to 1.05)	967 per 1,000	29 fewer per 1,000(106 fewer to 48 more)
WBC<12×10^9/L time (d)	120 (1 RCT)		LOW ^1,5	-	-	MD 0.50 more(0.02 fewer to 1.02 more)
Body temperature (no fever and return to normal 48 h after surgery)	120 (1 RCT)		LOW ^1,5	RR 0.98(0.93 to 1.04)	983 per 1,000	20 fewer per 1,000(69 fewer to 39 more)
Class-A healing rate	120 (1 RCT)		LOW ^1,5	RR 0.97(0.89 to 1.05)	967 per 1,000	29 fewer per 1,000(106 fewer to 48 more)
Class-B healing rate	120 (1 RCT)		LOW ^1,5	RR 2.00(0.38 to 10.51)	33 per 1,000	33 more per 1,000(21 fewer to 317 more)
Class-C healing rate	120 (1 RCT)		-	-	-	-
*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
GRADE Working Group grades of evidence: high quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Notes: ¹No random sequences were reported to generate and assign hidden methods, and no blindness was given to researchers, subjects, and outcome evaluators. ²The sample size is less than the optimal information sample size. ³None of the studies reported randomized generation and allocation of hidden methods, one of which did not blind the researchers and subjects. ⁴The method of generating and assigning hidden random numbers is not reported. ⁵The sample size is less than the optimal information sample size, and the confidence interval of the combined effect is across the invalid line. ⁶No evaluation of the outcome of the blind. The bold values mean the effect or difference was statistically significant.

Abbreviation: MD, mean difference.

Figure 2  Risk of bias graph.

Figure 3 Summary of risk ratio and quality of evidence of outcomes for the prognostic factors with the bubble diagram.

Abbreviation: PCEA, patient-controlled epidural analgesia.

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