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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 1

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

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

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

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 1 Woman's perception of pain relief in labour.
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Analysis 1.1

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 1 Woman's perception of pain relief in labour.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 2 Instrumental delivery.
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Analysis 1.2

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 2 Instrumental delivery.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 3 Caesarean section.
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Analysis 1.3

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 3 Caesarean section.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 4 Apgar score less than 7 at 5 minutes.
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Analysis 1.4

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 4 Apgar score less than 7 at 5 minutes.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 5 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good.
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Analysis 1.5

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 5 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 6 Long‐term backache.
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Analysis 1.6

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 6 Long‐term backache.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 7 Length of first stage of labour (minutes).
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Analysis 1.7

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 7 Length of first stage of labour (minutes).

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 8 Length of second stage of labour (minutes).
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Analysis 1.8

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 8 Length of second stage of labour (minutes).

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 9 Oxytocin augmentation.
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Analysis 1.9

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 9 Oxytocin augmentation.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 10 Caesarean section for fetal distress.
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Analysis 1.10

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 10 Caesarean section for fetal distress.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 11 Caesarean section for dystocia.
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Analysis 1.11

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 11 Caesarean section for dystocia.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 12 Time of administration of pain relief to time pain relief was satisfactory.
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Analysis 1.12

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 12 Time of administration of pain relief to time pain relief was satisfactory.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 13 Woman's perception of pain relief during first stage of labour.
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Analysis 1.13

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 13 Woman's perception of pain relief during first stage of labour.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 14 Woman's perception of pain relief during the second stage of labour.
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Analysis 1.14

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 14 Woman's perception of pain relief during the second stage of labour.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 15 Maternal satisfaction with childbirth experience.
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Analysis 1.15

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 15 Maternal satisfaction with childbirth experience.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 16 Perceived feeling of poor control in labour.
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Analysis 1.16

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 16 Perceived feeling of poor control in labour.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 17 Need for additional means of pain relief.
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Analysis 1.17

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 17 Need for additional means of pain relief.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 18 Maternal satisfaction with pain relief in labour ‐ continuous data.
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Analysis 1.18

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 18 Maternal satisfaction with pain relief in labour ‐ continuous data.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 19 Maternal hypotension as defined by trial authors.
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Analysis 1.19

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 19 Maternal hypotension as defined by trial authors.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 20 Postnatal depression (authors definition, on medication, or self‐reported).
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Analysis 1.20

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 20 Postnatal depression (authors definition, on medication, or self‐reported).

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 21 Motor blockade.
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Analysis 1.21

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 21 Motor blockade.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 22 Respiratory depression requiring oxygen administration.
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Analysis 1.22

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 22 Respiratory depression requiring oxygen administration.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 23 Headache.
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Analysis 1.23

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 23 Headache.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 24 Perineal trauma requiring suturing.
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Analysis 1.24

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 24 Perineal trauma requiring suturing.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 25 Nausea and vomiting.
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Analysis 1.25

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 25 Nausea and vomiting.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 26 Itch.
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Analysis 1.26

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 26 Itch.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 27 Fever > 38 degrees C.
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Analysis 1.27

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 27 Fever > 38 degrees C.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 28 Shivering.
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Analysis 1.28

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 28 Shivering.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 29 Drowsiness.
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Analysis 1.29

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 29 Drowsiness.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 30 Urinary retention.
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Analysis 1.30

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 30 Urinary retention.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 31 Cathetherisation during labour.
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Analysis 1.31

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 31 Cathetherisation during labour.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 32 Malposition.
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Analysis 1.32

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 32 Malposition.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 33 Surgical amniotomy.
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Analysis 1.33

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 33 Surgical amniotomy.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 34 Neonatal intensive care unit admission.
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Analysis 1.34

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 34 Neonatal intensive care unit admission.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 35 Acidosis defined by cord arterial pH < 7.2 at delivery.
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Analysis 1.35

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 35 Acidosis defined by cord arterial pH < 7.2 at delivery.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 36 Acidosis defined by cord arterial pH < 7.15.
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Analysis 1.36

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 36 Acidosis defined by cord arterial pH < 7.15.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 37 Naloxone administration.
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Analysis 1.37

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 37 Naloxone administration.

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 38 Meconium staining of liquor.
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Analysis 1.38

Comparison 1 Epidural versus non‐epidural analgesia in labour, Outcome 38 Meconium staining of liquor.

Comparison 6 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for allocation concealment, Outcome 1 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good.
Figuras y tablas -
Analysis 6.1

Comparison 6 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for allocation concealment, Outcome 1 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good.

Comparison 6 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for allocation concealment, Outcome 2 Need for additional means of pain relief.
Figuras y tablas -
Analysis 6.2

Comparison 6 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for allocation concealment, Outcome 2 Need for additional means of pain relief.

Comparison 7 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for incomplete outcome data, Outcome 1 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good.
Figuras y tablas -
Analysis 7.1

Comparison 7 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for incomplete outcome data, Outcome 1 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good.

Comparison 7 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for incomplete outcome data, Outcome 2 Need for additional means of pain relief.
Figuras y tablas -
Analysis 7.2

Comparison 7 Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for incomplete outcome data, Outcome 2 Need for additional means of pain relief.

Comparison 1. Epidural versus non‐epidural analgesia in labour

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Woman's perception of pain relief in labour Show forest plot

3

1166

Mean Difference (IV, Random, 95% CI)

‐3.36 [‐5.41, ‐1.31]

2 Instrumental delivery Show forest plot

23

7935

Risk Ratio (M‐H, Fixed, 95% CI)

1.42 [1.28, 1.57]

3 Caesarean section Show forest plot

27

8417

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.97, 1.25]

4 Apgar score less than 7 at 5 minutes Show forest plot

18

6898

Risk Ratio (M‐H, Fixed, 95% CI)

0.80 [0.54, 1.20]

5 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good Show forest plot

7

2929

Risk Ratio (M‐H, Random, 95% CI)

1.31 [0.84, 2.05]

6 Long‐term backache Show forest plot

3

1806

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.86, 1.07]

7 Length of first stage of labour (minutes) Show forest plot

11

2981

Mean Difference (IV, Random, 95% CI)

18.51 [‐12.91, 49.92]

8 Length of second stage of labour (minutes) Show forest plot

13

4233

Mean Difference (IV, Random, 95% CI)

13.66 [6.67, 20.66]

9 Oxytocin augmentation Show forest plot

13

5815

Risk Ratio (M‐H, Random, 95% CI)

1.19 [1.03, 1.39]

10 Caesarean section for fetal distress Show forest plot

11

4816

Risk Ratio (M‐H, Fixed, 95% CI)

1.43 [1.03, 1.97]

11 Caesarean section for dystocia Show forest plot

12

5001

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.73, 1.12]

12 Time of administration of pain relief to time pain relief was satisfactory Show forest plot

1

82

Mean Difference (IV, Fixed, 95% CI)

‐6.70 [‐8.02, ‐5.38]

13 Woman's perception of pain relief during first stage of labour Show forest plot

4

589

Mean Difference (IV, Random, 95% CI)

‐16.35 [‐25.11, ‐7.58]

14 Woman's perception of pain relief during the second stage of labour Show forest plot

3

559

Mean Difference (IV, Random, 95% CI)

‐25.29 [‐40.48, ‐10.11]

15 Maternal satisfaction with childbirth experience Show forest plot

1

332

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.87, 1.03]

16 Perceived feeling of poor control in labour Show forest plot

1

344

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.62, 2.21]

17 Need for additional means of pain relief Show forest plot

15

6019

Risk Ratio (M‐H, Random, 95% CI)

0.05 [0.02, 0.17]

18 Maternal satisfaction with pain relief in labour ‐ continuous data Show forest plot

2

272

Std. Mean Difference (IV, Random, 95% CI)

0.10 [‐0.49, 0.70]

19 Maternal hypotension as defined by trial authors Show forest plot

8

2789

Risk Ratio (M‐H, Random, 95% CI)

18.23 [5.09, 65.35]

20 Postnatal depression (authors definition, on medication, or self‐reported) Show forest plot

1

313

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.38, 1.05]

21 Motor blockade Show forest plot

3

322

Risk Ratio (M‐H, Random, 95% CI)

31.67 [4.33, 231.51]

22 Respiratory depression requiring oxygen administration Show forest plot

1

122

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

23 Headache Show forest plot

3

1198

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.81, 1.15]

24 Perineal trauma requiring suturing Show forest plot

1

369

Risk Ratio (M‐H, Fixed, 95% CI)

1.05 [0.93, 1.18]

25 Nausea and vomiting Show forest plot

12

3187

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.72, 1.27]

26 Itch Show forest plot

3

230

Risk Ratio (M‐H, Fixed, 95% CI)

1.46 [0.51, 4.16]

27 Fever > 38 degrees C Show forest plot

6

2741

Risk Ratio (M‐H, Fixed, 95% CI)

3.34 [2.63, 4.23]

28 Shivering Show forest plot

1

20

Risk Ratio (M‐H, Fixed, 95% CI)

5.0 [0.27, 92.62]

29 Drowsiness Show forest plot

4

641

Risk Ratio (M‐H, Random, 95% CI)

0.55 [0.07, 4.26]

30 Urinary retention Show forest plot

3

283

Risk Ratio (M‐H, Fixed, 95% CI)

17.05 [4.82, 60.39]

31 Cathetherisation during labour Show forest plot

2

1103

Risk Ratio (M‐H, Random, 95% CI)

1.81 [0.44, 7.46]

32 Malposition Show forest plot

4

673

Risk Ratio (M‐H, Fixed, 95% CI)

1.40 [0.98, 1.99]

33 Surgical amniotomy Show forest plot

2

211

Risk Ratio (M‐H, Random, 95% CI)

1.03 [0.74, 1.43]

34 Neonatal intensive care unit admission Show forest plot

7

3125

Risk Ratio (M‐H, Fixed, 95% CI)

1.19 [0.94, 1.50]

35 Acidosis defined by cord arterial pH < 7.2 at delivery Show forest plot

7

3643

Risk Ratio (M‐H, Fixed, 95% CI)

0.80 [0.68, 0.94]

36 Acidosis defined by cord arterial pH < 7.15 Show forest plot

2

382

Risk Ratio (M‐H, Fixed, 95% CI)

0.95 [0.50, 1.79]

37 Naloxone administration Show forest plot

10

2645

Risk Ratio (M‐H, Fixed, 95% CI)

0.15 [0.10, 0.23]

38 Meconium staining of liquor Show forest plot

5

2295

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.84, 1.21]

Figuras y tablas -
Comparison 1. Epidural versus non‐epidural analgesia in labour
Comparison 6. Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for allocation concealment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good Show forest plot

4

2330

Risk Ratio (M‐H, Random, 95% CI)

1.39 [0.68, 2.80]

2 Need for additional means of pain relief Show forest plot

10

4156

Risk Ratio (M‐H, Random, 95% CI)

0.05 [0.01, 0.27]

Figuras y tablas -
Comparison 6. Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for allocation concealment
Comparison 7. Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for incomplete outcome data

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Maternal satisfaction with pain relief in labour ‐ proportion rating excellent or very good Show forest plot

3

923

Risk Ratio (M‐H, Random, 95% CI)

1.23 [0.97, 1.55]

2 Need for additional means of pain relief Show forest plot

8

3707

Risk Ratio (M‐H, Random, 95% CI)

0.10 [0.03, 0.33]

Figuras y tablas -
Comparison 7. Sensitivity analysis of primary outcomes based on exclusion of studies with high or unclear risk of bias for incomplete outcome data