Parenteral opioids for maternal pain management in labour

Lesley A Smith; Ethel Burns; Anna Cuthbert

doi:10.1002/14651858.CD007396.pub3

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Analysis 1.1

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 1 Maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes).

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Analysis 1.2

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 2 Maternal pain score or pain measured in labour (described as good or fair after 1 hour).

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Analysis 1.3

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 3 Maternal pain score or pain measured in labour (reduction in VAS of at least 40 mm after 30 minutes).

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Analysis 1.4

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 4 Additional analgesia required.

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Analysis 1.5

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 5 Epidural.

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Analysis 1.6

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 6 Nausea and vomiting.

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Analysis 1.7

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 7 Maternal sleepiness.

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Analysis 1.8

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 8 Assisted vaginal delivery.

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Analysis 1.9

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 9 Caesarean section.

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Analysis 1.10

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 10 Neonatal resuscitation.

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Analysis 1.11

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 11 Low Apgar score (≤ 7) at 1 and 5 minutes.

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Analysis 1.12

Comparison 1 IM pethidine 50 mg/100 mg versus placebo, Outcome 12 Admission to NICU.

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Analysis 2.1

Comparison 2 IM pentazocine versus placebo, Outcome 1 Maternal pain score measured during labour.

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Analysis 2.2

Comparison 2 IM pentazocine versus placebo, Outcome 2 Nausea and vomiting.

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Analysis 2.3

Comparison 2 IM pentazocine versus placebo, Outcome 3 Caesarean section.

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Analysis 2.4

Comparison 2 IM pentazocine versus placebo, Outcome 4 Assisted vaginal birth.

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Analysis 3.1

Comparison 3 IM tramadol versus no treatment, Outcome 1 Maternal satisfaction with analgesia (Analgesic effect described as satisfactory (not clear when measured)).

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Analysis 4.1

Comparison 4 IM meptazinol versus pethidine, Outcome 1 Maternal pain score or pain measured in labour (Maternal pain relief poor or none (3‐5 PN)).

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Analysis 4.2

Comparison 4 IM meptazinol versus pethidine, Outcome 2 Maternal pain score or pain measured in labour (Pain intensity 4 or 5 on 5‐point scale (1 hour)).

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Analysis 4.3

Comparison 4 IM meptazinol versus pethidine, Outcome 3 Additional analgesia required.

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Analysis 4.4

Comparison 4 IM meptazinol versus pethidine, Outcome 4 Epidural.

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Analysis 4.5

Comparison 4 IM meptazinol versus pethidine, Outcome 5 Maternal sleepiness.

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Analysis 4.6

Comparison 4 IM meptazinol versus pethidine, Outcome 6 Nausea and vomiting.

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Analysis 4.7

Comparison 4 IM meptazinol versus pethidine, Outcome 7 Caesarean section.

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Analysis 4.8

Comparison 4 IM meptazinol versus pethidine, Outcome 8 Assisted vaginal birth.

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Analysis 4.9

Comparison 4 IM meptazinol versus pethidine, Outcome 9 Breastfeeding at discharge (problems).

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Analysis 4.10

Comparison 4 IM meptazinol versus pethidine, Outcome 10 Fetal heart rate changes (decelerations).

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Analysis 4.11

Comparison 4 IM meptazinol versus pethidine, Outcome 11 Naloxone administration.

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Analysis 4.12

Comparison 4 IM meptazinol versus pethidine, Outcome 12 Neonatal resuscitation (by gestation).

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Analysis 4.13

Comparison 4 IM meptazinol versus pethidine, Outcome 13 Neonatal resuscitation.

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Analysis 4.14

Comparison 4 IM meptazinol versus pethidine, Outcome 14 Apgar score ≤ 7 at 1 minute.

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Analysis 4.15

Comparison 4 IM meptazinol versus pethidine, Outcome 15 Apgar score ≤ 7 at 5 minutes.

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Analysis 4.16

Comparison 4 IM meptazinol versus pethidine, Outcome 16 Admission to NICU.

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Analysis 5.1

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 1 Maternal satisfaction with analgesia in labour measured during the postnatal period (Global assessment of pain relief at 24 hours).

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Analysis 5.2

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 2 Maternal pain score or pain measured in labour (Pain intensity at 1 hour (moderate or severe)).

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Analysis 5.3

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 3 Additonal analgesia required.

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Analysis 5.4

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 4 Epidural.

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Analysis 5.5

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 5 Maternal sleepiness during labour.

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Analysis 5.6

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 6 Vomiting in labour.

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Analysis 5.7

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 7 Caesarean section.

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Analysis 5.8

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 8 Assisted vaginal birth.

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Analysis 5.9

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 9 Neonatal resuscitation.

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Analysis 5.10

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 10 Apgar < 7 at 1 minute.

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Analysis 5.11

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 11 Apgar < 7 at 5 minutes.

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Analysis 5.12

Comparison 5 IM diamorphine + prochlorperazine versus pethidine + prochlorperazine, Outcome 12 Admission to NICU.

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Analysis 6.1

Comparison 6 IM tramadol versus pethidine, Outcome 1 Maternal pain score or pain measured in labour (Pain intensity: women with poor pain relief).

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Analysis 6.2

Comparison 6 IM tramadol versus pethidine, Outcome 2 Additional analgesia required.

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Analysis 6.3

Comparison 6 IM tramadol versus pethidine, Outcome 3 Maternal sleepiness in labour.

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Analysis 6.4

Comparison 6 IM tramadol versus pethidine, Outcome 4 Nausea and vomiting in labour.

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Analysis 6.5

Comparison 6 IM tramadol versus pethidine, Outcome 5 Caesarean section.

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Analysis 6.6

Comparison 6 IM tramadol versus pethidine, Outcome 6 Assisted vaginal birth.

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Analysis 6.7

Comparison 6 IM tramadol versus pethidine, Outcome 7 Neonatal resuscitation.

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Analysis 6.8

Comparison 6 IM tramadol versus pethidine, Outcome 8 Apgar scores ≤ 7 at 1 and 5 minutes.

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Analysis 6.9

Comparison 6 IM tramadol versus pethidine, Outcome 9 Neonatal respiratory distress.

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Analysis 6.10

Comparison 6 IM tramadol versus pethidine, Outcome 10 Admission to NICU.

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Analysis 7.1

Comparison 7 IM tramadol + triflupromazine versus pethidine + triflupromazine, Outcome 1 Maternal sleepiness in labour.

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Analysis 7.2

Comparison 7 IM tramadol + triflupromazine versus pethidine + triflupromazine, Outcome 2 Nausea and vomiting in labour.

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Analysis 8.1

Comparison 8 IM dihydrocodeine 50 mg versus pethidine 100 mg, Outcome 1 Maternal pain score or pain measured in labour (Maternal pain relief poor at 1 hour).

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Analysis 8.2

Comparison 8 IM dihydrocodeine 50 mg versus pethidine 100 mg, Outcome 2 Maternal sleepiness in labour.

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Analysis 8.3

Comparison 8 IM dihydrocodeine 50 mg versus pethidine 100 mg, Outcome 3 Nausea and vomiting in labour.

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Analysis 8.4

Comparison 8 IM dihydrocodeine 50 mg versus pethidine 100 mg, Outcome 4 Apgar ≤ 7 at 1 minute.

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Analysis 9.1

Comparison 9 IM pentazocine versus pethidine, Outcome 1 Maternal satisfaction with analgesia measured during labour (Pain relief (good or very good) at delivery).

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Analysis 9.2

Comparison 9 IM pentazocine versus pethidine, Outcome 2 Maternal pain score or pain measured in labour (Pain relief poor (partial, none or worse)).

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Analysis 9.3

Comparison 9 IM pentazocine versus pethidine, Outcome 3 Additional analgesia required.

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Analysis 9.4

Comparison 9 IM pentazocine versus pethidine, Outcome 4 Maternal sleepiness in labour.

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Analysis 9.5

Comparison 9 IM pentazocine versus pethidine, Outcome 5 Nausea and vomiting in labour.

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Analysis 9.6

Comparison 9 IM pentazocine versus pethidine, Outcome 6 Assisted vaginal birth.

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Analysis 9.7

Comparison 9 IM pentazocine versus pethidine, Outcome 7 Naloxone administration.

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Analysis 9.8

Comparison 9 IM pentazocine versus pethidine, Outcome 8 Apgar score ≤ 7 at 1 minute.

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Analysis 9.9

Comparison 9 IM pentazocine versus pethidine, Outcome 9 Apgar score ≤ 7 at 5 minutes.

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Analysis 10.1

Comparison 10 IM nalbuphine versus pethidine, Outcome 1 Maternal satisfaction with analgesia measured during the postnatal period (numbers dissatisfied).

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Analysis 10.2

Comparison 10 IM nalbuphine versus pethidine, Outcome 2 Maternal satisfaction with analgesia measured during labour (Pain free).

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Analysis 10.3

Comparison 10 IM nalbuphine versus pethidine, Outcome 3 Maternal pain score or pain measured in labour (Pain intensity at 30 minutes: women with severe pain).

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Analysis 10.4

Comparison 10 IM nalbuphine versus pethidine, Outcome 4 Maternal pain score or pain measured in labour (VAS at 60 minutes (at peak of contraction)).

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Analysis 10.5

Comparison 10 IM nalbuphine versus pethidine, Outcome 5 Additional analgesia required.

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Analysis 10.6

Comparison 10 IM nalbuphine versus pethidine, Outcome 6 Epidural.

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Analysis 10.7

Comparison 10 IM nalbuphine versus pethidine, Outcome 7 Maternal sleepiness in labour.

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Analysis 10.8

Comparison 10 IM nalbuphine versus pethidine, Outcome 8 Nausea and vomiting in labour.

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Analysis 10.9

Comparison 10 IM nalbuphine versus pethidine, Outcome 9 Caesarean section.

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Analysis 10.10

Comparison 10 IM nalbuphine versus pethidine, Outcome 10 Assisted vaginal birth.

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Analysis 10.11

Comparison 10 IM nalbuphine versus pethidine, Outcome 11 Naloxone administration.

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Analysis 10.12

Comparison 10 IM nalbuphine versus pethidine, Outcome 12 Apgar score ≤ 7 at 1 and 5 minutes.

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Analysis 10.13

Comparison 10 IM nalbuphine versus pethidine, Outcome 13 Admission to NICU.

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Analysis 10.14

Comparison 10 IM nalbuphine versus pethidine, Outcome 14 Neonatal neurobehavioural (Scanlon) 2‐4 hours PN.

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Analysis 11.1

Comparison 11 IM phenazocine versus pethidine, Outcome 1 Epidural.

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Analysis 11.2

Comparison 11 IM phenazocine versus pethidine, Outcome 2 Vomiting.

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Analysis 12.1

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 1 Maternal satisfaction with analgesia (number of women satisfied or very satisfied).

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Analysis 12.2

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 2 Maternal satisfaction with analgesia measured during labour or during the postnatal period (Pain relief described as poor).

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Analysis 12.3

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 3 Maternal pain score or pain measured in labour (pain relief at 30 mins).

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Analysis 12.4

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 4 Maternal pain score or pain measured in labour (pain relief at 60 mins).

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Analysis 12.5

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 5 Additional analgesia required.

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Analysis 12.6

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 6 Maternal sleepiness.

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Analysis 12.7

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 7 Nausea and vomiting.

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Analysis 12.8

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 8 Caesarean section.

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Analysis 12.9

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 9 Assisted vaginal birth.

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Analysis 12.10

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 10 Naloxone administration.

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Analysis 12.11

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 11 Neonatal resuscitation.

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Analysis 12.12

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 12 Apgar < 7 at 1 minute.

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Analysis 12.13

Comparison 12 IM diamorphine/morphine versus pethidine, Outcome 13 Admission to NICU.

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Analysis 13.1

Comparison 13 IM butorphanol versus pethidine, Outcome 1 Additional analgesia required.

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Analysis 13.2

Comparison 13 IM butorphanol versus pethidine, Outcome 2 Nausea.

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Analysis 13.3

Comparison 13 IM butorphanol versus pethidine, Outcome 3 Vomiting.

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Analysis 13.4

Comparison 13 IM butorphanol versus pethidine, Outcome 4 Neonatal resuscitation.

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Analysis 13.5

Comparison 13 IM butorphanol versus pethidine, Outcome 5 Naloxone administration (neonatal).

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Analysis 14.1

Comparison 14 IM Avacan® versus IM pentazocine, Outcome 1 Additional analgesia required ‐ Entonox.

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Analysis 14.2

Comparison 14 IM Avacan® versus IM pentazocine, Outcome 2 Additional analgesia required ‐ pudendal‐paracervical block.

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Analysis 14.3

Comparison 14 IM Avacan® versus IM pentazocine, Outcome 3 Caesarean section.

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Analysis 14.4

Comparison 14 IM Avacan® versus IM pentazocine, Outcome 4 Low Apgar score (< 7) "at birth".

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Analysis 15.1

Comparison 15 IM pentazocine versus IM Pethilorfan®, Outcome 1 Maternal pain score measured during labour (Pain relief (women NOT obtaining pain relief) at 1 hour).

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Analysis 15.2

Comparison 15 IM pentazocine versus IM Pethilorfan®, Outcome 2 Additional analgesia required.

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Analysis 15.3

Comparison 15 IM pentazocine versus IM Pethilorfan®, Outcome 3 Assisted vaginal birth.

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Analysis 15.4

Comparison 15 IM pentazocine versus IM Pethilorfan®, Outcome 4 Apgar < 8 at 1 minute (non pre‐specified).

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Analysis 15.5

Comparison 15 IM pentazocine versus IM Pethilorfan®, Outcome 5 Apgar < 8 at 5 minutes (non pre‐specified).

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Analysis 16.1

Comparison 16 IM pentazocine versus complementary and alternate medicine (CAM), Outcome 1 Maternal pain score measured during labour.

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Analysis 16.2

Comparison 16 IM pentazocine versus complementary and alternate medicine (CAM), Outcome 2 Nausea and vomiting.

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Analysis 16.3

Comparison 16 IM pentazocine versus complementary and alternate medicine (CAM), Outcome 3 Caesarean section.

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Analysis 16.4

Comparison 16 IM pentazocine versus complementary and alternate medicine (CAM), Outcome 4 Assisted vaginal delivery.

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Analysis 17.1

Comparison 17 IM pentazocine versus IM tramadol, Outcome 1 Maternal satisfaction with analgesia measured during labour (pain relief after 30 mins).

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Analysis 17.2

Comparison 17 IM pentazocine versus IM tramadol, Outcome 2 Maternal satisfaction with analgesia measured during labour (pain after 60 mins).

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Analysis 17.3

Comparison 17 IM pentazocine versus IM tramadol, Outcome 3 Maternal pain score or pain measured in labour (moderate or severe at 30 mins).

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Analysis 17.4

Comparison 17 IM pentazocine versus IM tramadol, Outcome 4 Maternal pain score or pain measured in labour (moderate or severe at 60 mins).

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Analysis 17.5

Comparison 17 IM pentazocine versus IM tramadol, Outcome 5 Maternal sleepiness during labour.

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Analysis 17.6

Comparison 17 IM pentazocine versus IM tramadol, Outcome 6 Nausea and vomiting.

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Analysis 17.7

Comparison 17 IM pentazocine versus IM tramadol, Outcome 7 Caesarean section.

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Analysis 17.8

Comparison 17 IM pentazocine versus IM tramadol, Outcome 8 Assisted vaginal delivery.

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Analysis 17.9

Comparison 17 IM pentazocine versus IM tramadol, Outcome 9 Apgar score < 7 at 1 minute.

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Analysis 17.10

Comparison 17 IM pentazocine versus IM tramadol, Outcome 10 Apgar score < 7 at 5 minutes.

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Analysis 17.11

Comparison 17 IM pentazocine versus IM tramadol, Outcome 11 Admission to NICU.

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Analysis 18.1

Comparison 18 IM pethidine versus Entonox, Outcome 1 Maternal pain score or pain measured in labour (after 30 mins).

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Analysis 18.2

Comparison 18 IM pethidine versus Entonox, Outcome 2 Maternal pain score or pain measured in labour (after 60 mins).

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Analysis 19.1

Comparison 19 IV pethidine versus placebo, Outcome 1 Maternal pain score or pain measured in labour (Pain score 30 mins post analgesia).

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Analysis 19.2

Comparison 19 IV pethidine versus placebo, Outcome 2 Nausea and vomiting.

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Analysis 19.3

Comparison 19 IV pethidine versus placebo, Outcome 3 Caesarean section.

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Analysis 19.4

Comparison 19 IV pethidine versus placebo, Outcome 4 Assisted vaginal birth.

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Analysis 19.5

Comparison 19 IV pethidine versus placebo, Outcome 5 Admission to NICU.

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Analysis 20.1

Comparison 20 IV fentanyl versus no treatment, Outcome 1 Maternal pain score or pain measured in labour (Pain score 1 hour post‐analgesia).

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Analysis 20.2

Comparison 20 IV fentanyl versus no treatment, Outcome 2 Maternal pain score or pain measured in labour (Pain intensity (Severe) after 1 hour).

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Analysis 20.3

Comparison 20 IV fentanyl versus no treatment, Outcome 3 Caesarean section.

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Analysis 21.1

Comparison 21 IV fentanyl versus IV pethidine, Outcome 1 Maternal pain score or pain measured in labour (Pain score 1 hour after drug administration).

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Analysis 21.2

Comparison 21 IV fentanyl versus IV pethidine, Outcome 2 Mean doses of analgesia (non pre‐specified).

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Analysis 21.3

Comparison 21 IV fentanyl versus IV pethidine, Outcome 3 Maternal sleepiness in labour (sedation).

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Analysis 21.4

Comparison 21 IV fentanyl versus IV pethidine, Outcome 4 Nausea and/or vomiting.

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Analysis 21.5

Comparison 21 IV fentanyl versus IV pethidine, Outcome 5 Anti‐emetic required (non pre‐specified).

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Analysis 21.6

Comparison 21 IV fentanyl versus IV pethidine, Outcome 6 Caesarean section.

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Analysis 21.7

Comparison 21 IV fentanyl versus IV pethidine, Outcome 7 Naloxone administered.

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Analysis 21.8

Comparison 21 IV fentanyl versus IV pethidine, Outcome 8 Babies requiring resuscitation/ventilatory support.

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Analysis 21.9

Comparison 21 IV fentanyl versus IV pethidine, Outcome 9 Apgar score < 7 at 1 minute.

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Analysis 21.10

Comparison 21 IV fentanyl versus IV pethidine, Outcome 10 Apgar score < 7 at 5 minutes.

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Analysis 21.11

Comparison 21 IV fentanyl versus IV pethidine, Outcome 11 Neurobehavioural score (1 ‐ 2 hours after delivery).

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Analysis 21.12

Comparison 21 IV fentanyl versus IV pethidine, Outcome 12 Neurobehavioural score (2 hours ‐ 24 hours).

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Analysis 22.1

Comparison 22 IV nalbuphine versus IV pethidine, Outcome 1 Caesarean section.

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Analysis 22.2

Comparison 22 IV nalbuphine versus IV pethidine, Outcome 2 Apgar score < 7 at 1 minute.

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Analysis 22.3

Comparison 22 IV nalbuphine versus IV pethidine, Outcome 3 Apgar score < 7 at 5 minutes.

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Analysis 23.1

Comparison 23 IV phenazocine versus IV pethidine, Outcome 1 Maternal satisfaction with analgesia measured during labour (women with fair or poor relief).

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Analysis 23.2

Comparison 23 IV phenazocine versus IV pethidine, Outcome 2 Nausea with vomiting.

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Analysis 23.3

Comparison 23 IV phenazocine versus IV pethidine, Outcome 3 Perinatal death.

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Analysis 23.4

Comparison 23 IV phenazocine versus IV pethidine, Outcome 4 Apgar score < 7 at 1 minute.

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Analysis 24.1

Comparison 24 IV butorphanol versus IV pethidine, Outcome 1 Maternal pain score or pain measured in labour (Pain relief score).

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Analysis 24.2

Comparison 24 IV butorphanol versus IV pethidine, Outcome 2 Maternal pain score or pain measured in labour (Pain score (1 hour after drug administration)).

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Analysis 24.3

Comparison 24 IV butorphanol versus IV pethidine, Outcome 3 Additional analgesia required.

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Analysis 24.4

Comparison 24 IV butorphanol versus IV pethidine, Outcome 4 Epidural.

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Analysis 24.5

Comparison 24 IV butorphanol versus IV pethidine, Outcome 5 Nausea and/or vomiting.

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Analysis 24.6

Comparison 24 IV butorphanol versus IV pethidine, Outcome 6 Caesarean section.

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Analysis 24.7

Comparison 24 IV butorphanol versus IV pethidine, Outcome 7 Assisted vaginal birth.

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Analysis 24.8

Comparison 24 IV butorphanol versus IV pethidine, Outcome 8 Apgar score < 7 at 1 minute.

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Analysis 24.9

Comparison 24 IV butorphanol versus IV pethidine, Outcome 9 Apgar score < 7 at 5 minutes.

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Analysis 25.1

Comparison 25 IV morphine versus IV pethidine, Outcome 1 Maternal satisfaction with analgesia (assessed 3 days postpartum).

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Analysis 25.2

Comparison 25 IV morphine versus IV pethidine, Outcome 2 Additional analgesia required.

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Analysis 25.3

Comparison 25 IV morphine versus IV pethidine, Outcome 3 Nausea and vomiting.

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Analysis 25.4

Comparison 25 IV morphine versus IV pethidine, Outcome 4 Caesarean section.

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Analysis 26.1

Comparison 26 IV Nisentil versus IV pethidine, Outcome 1 Nausea and vomiting.

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Analysis 26.2

Comparison 26 IV Nisentil versus IV pethidine, Outcome 2 Neonatal resuscitation/ventilatory support.

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Analysis 27.1

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 1 Additional analgesia required.

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Analysis 27.2

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 2 Epidural.

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Analysis 27.3

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 3 Matenal sleepiness (required tactile rousing).

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Analysis 27.4

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 4 Caesarean section.

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Analysis 27.5

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 5 Naloxone required.

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Analysis 27.6

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 6 Neonatal resuscitation (Babies requiring ventilatory support).

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Analysis 27.7

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 7 Apgar score < 7 at 5 minutes.

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Analysis 27.8

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 8 Newborn neurobehavioural score at 2‐4 hours.

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Analysis 27.9

Comparison 27 IV fentanyl versus IV butorphanol, Outcome 9 Newborn neurobehavioural score at 24‐36 hours.

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Analysis 28.1

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 1 Maternal pan score or pain measured in labour.

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Analysis 28.2

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 2 Maternal pan score or pain measured in labour (rated as good one day after birth).

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Analysis 28.3

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 3 Epidural.

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Analysis 28.4

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 4 Nausea and vomiting.

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Analysis 28.5

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 5 Maternal sleepiness during labour (Sedation).

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Analysis 28.6

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 6 Caesarean section.

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Analysis 28.7

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 7 Breastfeeding at discharge.

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Analysis 28.8

Comparison 28 PCA pentazocine versus PCA pethidine, Outcome 8 Apgar score < 7 at 5 minutes.

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Analysis 29.1

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 1 Maternal pain score in labour.

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Analysis 29.2

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 2 Additional analgesia required.

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Analysis 29.3

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 3 Epidural.

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Analysis 29.4

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 4 Maternal sleepiness during labour.

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Analysis 29.5

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 5 Nausea and vomiting.

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Analysis 29.6

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 6 Caesarean section.

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Analysis 29.7

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 7 Assisted vaginal birth.

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Analysis 29.8

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 8 Satisfaction with childbirth experience.

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Analysis 29.9

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 9 Naloxone administered.

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Analysis 29.10

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 10 Apgar score < 7 at 5 minutes.

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Analysis 29.11

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 11 Admission to NICU.

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Analysis 29.12

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 12 Newborn neurobehavioural score (15 minutes post delivery).

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Analysis 29.13

Comparison 29 PCA remifentanil versus PCA pethidine, Outcome 13 Newborn neurobehavioural score (2 hours post delivery).

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Analysis 30.1

Comparison 30 PCA nalbuphine versus PCA pethidine, Outcome 1 Maternal satisfaction with analgesia in labour measured during the postnatal period (rated good or excellent).

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Analysis 30.2

Comparison 30 PCA nalbuphine versus PCA pethidine, Outcome 2 Maternal satisfaction with analgesia in labour measured during the postnatal period (Would use the same pain relief again).

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Analysis 30.3

Comparison 30 PCA nalbuphine versus PCA pethidine, Outcome 3 Maternal pain score or pain measured in labour.

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Analysis 30.4

Comparison 30 PCA nalbuphine versus PCA pethidine, Outcome 4 Additional analgesia required.

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Analysis 30.5

Comparison 30 PCA nalbuphine versus PCA pethidine, Outcome 5 Nausea and vomiting.

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Analysis 30.6

Comparison 30 PCA nalbuphine versus PCA pethidine, Outcome 6 Apgar score < 7 at 5 minutes.

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Analysis 31.1

Comparison 31 PCA fentanyl versus PCA alfentanil, Outcome 1 Maternal satisfaction with analgesia in labour measured during the postnatal period (described as adequate).

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Analysis 31.2

Comparison 31 PCA fentanyl versus PCA alfentanil, Outcome 2 Maternal pain score or pain measured in labour (Pain score at 4‐6 cm cervical dilatation).

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Analysis 31.3

Comparison 31 PCA fentanyl versus PCA alfentanil, Outcome 3 Nausea.

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Analysis 31.4

Comparison 31 PCA fentanyl versus PCA alfentanil, Outcome 4 Caesarean section.

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Analysis 31.5

Comparison 31 PCA fentanyl versus PCA alfentanil, Outcome 5 Naloxone required.

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Analysis 32.1

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 1 Maternla pain score measured in labour.

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Analysis 32.2

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 2 Epidural.

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Analysis 32.3

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 3 Maternal sleepiness during labour.

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Analysis 32.4

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 4 Nausea and vomiting.

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Analysis 32.5

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 5 Caesarean section.

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Analysis 32.6

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 6 Assisted vaginal birth.

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Analysis 32.7

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 7 Newborn neurobehavioural score (15 minutes post delivery).

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Analysis 32.8

Comparison 32 PCA fentanyl versus PCA pethidine, Outcome 8 Newborn neurobehavioural score (2 hours post delivery).

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Analysis 33.1

Comparison 33 PCA (IM) meptazinol versus PCA (IM) pethidine, Outcome 1 Maternal pain score or pain measured in labour (measured 1 day after delivery).

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Analysis 33.2

Comparison 33 PCA (IM) meptazinol versus PCA (IM) pethidine, Outcome 2 Satisfied with mode of administration (PCA IM) (non pre‐specified).

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Analysis 33.3

Comparison 33 PCA (IM) meptazinol versus PCA (IM) pethidine, Outcome 3 Epidural.

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Analysis 33.4

Comparison 33 PCA (IM) meptazinol versus PCA (IM) pethidine, Outcome 4 Maternal sleepiness in labour (Drowsiness score in labour rated 1 day after delivery).

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Analysis 33.5

Comparison 33 PCA (IM) meptazinol versus PCA (IM) pethidine, Outcome 5 Nausea (score in labour rated 1 day after delivery).

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Analysis 33.6

Comparison 33 PCA (IM) meptazinol versus PCA (IM) pethidine, Outcome 6 Naloxone administered.

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Analysis 34.1

Comparison 34 Opioids versus TENS, Outcome 1 Maternal satisfaction with analgesia measured post delivery (rated as good).

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Analysis 34.2

Comparison 34 Opioids versus TENS, Outcome 2 Maternal pain score measured during labour.

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Analysis 34.3

Comparison 34 Opioids versus TENS, Outcome 3 Maternal pain score in labour.

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Analysis 34.4

Comparison 34 Opioids versus TENS, Outcome 4 Maternal sleepiness during labour (Drowsiness).

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Analysis 34.5

Comparison 34 Opioids versus TENS, Outcome 5 Nausea and vomiting.

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Analysis 34.6

Comparison 34 Opioids versus TENS, Outcome 6 Caesarean section.

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Analysis 34.7

Comparison 34 Opioids versus TENS, Outcome 7 Assisted vaginal birth.

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Analysis 34.8

Comparison 34 Opioids versus TENS, Outcome 8 Fetal heart rate changes in labour (Fetal distress).

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Summary of findings for the main comparison. IM pethidine compared to placebo for pain management in labour

IM pethidine compared to placebo for pain management for women in labour
Patient or population: women in labour Setting: hospital settings in South Africa and Hong Kong Intervention: IM pethidine 50 mg/100 mg Comparison: placebo
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
	Risk with IM pethidine 50 mg/100 mg	Risk with placebo
Maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes)	Study population		RR 7.00 (0.38 to 128.87)	50 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 2}
	0 per 1000 (0 to 0)	0 per 1000
Maternal pain score or pain measured in labour (described as good or fair after 1 hour)	Study population		RR 1.75 (1.24 to 2.47)	116 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 3}
	724 per 1000 (513 to 1000)	414 per 1000
Maternal pain score or pain measured in labour (reduction in VAS of at least 40 mm after 30 minutes)	Study population		RR 25.00 (1.56 to 400.54)	50 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 4}
	0 per 1000 (0 to 0)	0 per 1000
Additional analgesia required (epidural, pethidine and Entonox)	Study population		RR 0.71 (0.54 to 0.94)	50 (1 RCT)	⊕⊕⊝⊝ LOW ^{1 3}
	682 per 1000 (518 to 902)	960 per 1000
Epidural	Study population		RR 0.50 (0.14 to 1.78)	50 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^{1 2}
	120 per 1000 (34 to 427)	240 per 1000
SEE ADDITIONAL Table 1FOR FURTHER GRADE COMPARISONS
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: 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 certainty: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Risk of bias: serious (effect estimate from single study with design limitations) ² Imprecision: very serious (wide confidence interval crossing the line of no effect, few events, and small sample size) ³ Imprecision: serious (small sample size) ⁴ Imprecision: serious (small sample size and few events)

Summary of findings for the main comparison. IM pethidine compared to placebo for pain management in labour

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Summary of findings 2. Placebo and pethidine comparisons for pain management in labour

OUTCOME	N STUDIES (n women)	EFFECT		CERTAINTY OF EVIDENCE
OUTCOME	N STUDIES (n women)	Relative (95% CI)	Absolute (95% CI)	CERTAINTY OF EVIDENCE
IM pethidine 50 mg/100 mg versus placebo
Maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes)	1 (50)	RR 7.00 (0.38 to 128.87)	0 fewer per 1000 (from 0 fewer to 0 fewer)	⊕⊝⊝⊝ VERY LOW ^a,b
Maternal pain score or pain measured in labour (described as good or fair after 1 hour)	1 (118)	RR 1.75 (1.24 to 2.47)	310 more per 1000 (from 99 more to 608 more)	⊕⊕⊝⊝ LOW ^a,c
Maternal pain score or pain measured in labour (reduction in VAS of at least 40 mm after 30 minutes)	1 (50)	RR 25.00 (1.56 to 400.54)	0 fewer per 1000 (from 0 fewer to 0 fewer)	⊕⊕⊝⊝ LOW ^a,d
Additional analgesia required	1 (50)	RR 0.71 (0.54 to 0.94)	278 fewer per 1000 (from 58 fewer to 442 fewer)	⊕⊕⊝⊝ LOW ^a,c
Epidural	1 (50)	RR 0.50 (0.14 to 1.78)	120 fewer per 1000 (from 187 more to 206 fewer)	⊕⊝⊝⊝ VERY LOW ^a,b
IM pentazocine versus placebo
Maternal pain score measured during labour	1 (89)	‐	MD 3.60 lower (9.91 lower to 2.71 higher)	⊕⊕⊝⊝ LOW ^e
IM tramadol versus no treatment
Maternal satisfaction with analgesia (Analgesic effect described as satisfactory (not clear when measured))	1 (60)	RR 11.00 (0.64 to 190.53)	0 fewer per 1000 (from 0 fewer to 0 fewer)	⊕⊝⊝⊝ VERY LOW ^b,f
IM meptazinol versus pethidine
Maternal pain score or pain measured in labour (Maternal pain relief poor or none (3‐5 PN))	1 (801)	RR 1.01 (0.91 to 1.12)	6 more per 1000 (from 57 fewer to 77 more)	⊕⊕⊝⊝ LOW ^a,g
Maternal pain score or pain measured in labour (Pain intensity 4 or 5 on 5‐point scale (1 hour))	2 (239)	RR 1.11 (0.69 to 1.80)	79 more per 1000 (from 223 fewer to 576 more)	⊕⊝⊝⊝ VERY LOW ^e,h
Additional analgesia required	2 (233)	RR 1.03 (0.88 to 1.20)	20 more per 1000 (from 81 fewer to 134 more)	⊕⊝⊝⊝ VERY LOW ^e,h
Epidural	4 (788)	RR 0.96 (0.71 to 1.29)	7 fewer per 1000 (from 52 fewer to 52 more)	⊕⊝⊝⊝ VERY LOW ^g,i
IM diamorphine + prochlorperazine versus pethidine + prochlorperazine
Maternal satisfaction with analgesia in labour measured during the postnatal period (Global assessment of pain relief at 24 hours)	1 (133)	RR 0.88 (0.67 to 1.16)	78 fewer per 1000 (from 104 more to 214 fewer)	⊕⊝⊝⊝ VERY LOW ^a,e
Maternal pain score or pain measured in labour (Pain intensity at 1 hour (moderate or severe))	1 (133)	RR 0.85 (0.72 to 1.01)	130 fewer per 1000 (from 9 more to 243 fewer)	⊕⊝⊝⊝ VERY LOW ^a,e
Additional analgesia required	1 (133)	RR 1.35 (0.53 to 3.40)	36 more per 1000 (from 48 fewer to 247 more)	⊕⊝⊝⊝ VERY LOW ^a,b
Epidural	1 (133)	RR 1.22 (0.72 to 2.07)	58 more per 1000 (from 74 fewer to 283 more)	⊕⊝⊝⊝ VERY LOW ^a,b
IM tramadol versus pethidine
Maternal pain score or pain measured in labour (Pain intensity: women with poor pain relief)	4 (243)	RR 1.56 (1.10 to 2.21)	142 more per 1000 (from 25 more to 307 more)	⊕⊕⊝⊝ LOW ^c,j
Additional analgesia required	3 (295)	RR 1.07 (0.60 to 1.91)	11 more per 1000 (from 65 fewer to 149 more)	⊕⊝⊝⊝ VERY LOW ^e,j
IM dihydrocodeine 50 mg versus pethidine 100 mg
Maternal pain score or pain measured in labour (Maternal pain relief poor at 1 hour)	1 (138)	RR 1.09 (0.64 to 1.86)	25 more per 1000 (from 99 fewer to 237 more)	⊕⊝⊝⊝ VERY LOW ^a,e
IM pentazocine versus pethidine
Maternal satisfaction with analgesia measured during labour (Pain relief (good or very good) at delivery)	2 (253)	RR 1.08 (0.92 to 1.27)	51 more per 1000 (from 51 fewer to 171 more)	⊕⊝⊝⊝ VERY LOW ^e,h
Maternal pain score or pain measured in labour (Pain relief poor (partial, none or worse)) ‐ No add‐on drugs	3 (365)	Average RR 1.23 (0.74 to 2.05)	135 more per 1000 (from 153 fewer to 616 more)	⊕⊝⊝⊝ VERY LOW ^g,i,k
Maternal pain score or pain measured in labour (Pain relief poor (partial, none or worse)) ‐ With promazine	1 (85)	RR 1.53 (0.66 to 3.58)	88 more per 1000 (from 57 fewer to 430 more)	⊕⊝⊝⊝ VERY LOW ^b,f
Additional analgesia required ‐ pentazocine	1 (94)	RR 0.91 (0.50 to 1.65)	30 fewer per 1000 (from 167 fewer to 217 more)	⊕⊝⊝⊝ VERY LOW ^b,f
Additional analgesia required ‐ pentazocine + promazine	1 (85)	RR 1.67 (0.73 to 3.84)	112 more per 1000 (from 45 fewer to 473 more)	⊕⊝⊝⊝ VERY LOW ^b,f
IM nalbuphine versus pethidine
Maternal satisfaction with analgesia measured during the postnatal period (numbers dissatisfied)	1 (72)	RR 0.73 (0.55 to 0.96)	231 fewer per 1000 (from 34 fewer to 386 fewer)	⊕⊕⊝⊝ LOW ^a,c
Maternal satisfaction with analgesia measured during labour (Pain free)	1 (40)	RR 6.00 (0.79 to 45.42)	250 more per 1000 (from 10 fewer to 1000 more)	⊕⊝⊝⊝ VERY LOW ^b,f
Maternal pain score or pain measured in labour (Pain intensity at 30 minutes: women with severe pain)	1 (295)	RR 0.86 (0.59 to 1.26)	40 fewer per 1000 (from 75 more to 118 fewer)	⊕⊝⊝⊝ VERY LOW ^a,e
Maternal pain score or pain measured in labour (VAS at 60 minutes (at peak of contraction))	1 (72)	‐	MD 8.00 lower (18.55 lower to 2.55 higher)	⊕⊝⊝⊝ VERY LOW ^a,e
Additional analgesia required	1 (72)	RR 1.26 (0.49 to 3.27)	45 more per 1000 (from 87 fewer to 389 more)	⊕⊝⊝⊝ VERY LOW ^a,b
Epidural	1 (307)	RR 1.65 (0.55 to 4.94)	21 more per 1000 (from 14 fewer to 126 more)	⊕⊕⊝⊝ LOW ^l
IM phenazocine versus pethidine
Epidural	1 (212)	RR 1.31 (0.58 to 2.97)	27 more per 1000 (from 36 fewer to 169 more)	⊕⊝⊝⊝ VERY LOW ^a,b
IM diamorphine/morphine versus pethidine
Maternal satisfaction with analgesia (number of women satisfied or very satisfied)	1 (484)	RR 1.13 (1.02 to 1.26)	92 more per 1000 (from 14 more to 184 more)	⊕⊕⊕⊕ HIGH
Maternal satisfaction with analgesia measured during labour or during the postnatal period (Pain relief described as poor)	1 (90)	RR 1.22 (0.56 to 2.66)	44 more per 1000 (from 88 fewer to 332 more)	⊕⊝⊝⊝ VERY LOW ^a,b
Additional analgesia required	2 (574)	RR 1.00 (0.92 to 1.10)	0 fewer per 1000 (from 57 fewer to 71 more)	⊕⊕⊕⊝ MODERATE ^g
Maternal pain relief at 30 mins	1 (484)	‐	MD 0.80 lower (1.24 lower to 0.36 lower)	⊕⊕⊕⊕ HIGH
Maternal pain relief at 60 mins	1 (484)	‐	MD 0.80 lower (1.26 lower to 0.34 lower)	⊕⊕⊕⊕ HIGH
IM butorphanol versus pethidine
Additional analgesia required	1 (80)	RR 0.89 (0.55 to 1.45)	52 fewer per 1000 (from 214 fewer to 214 more)	⊕⊝⊝⊝ VERY LOW ^a,b
IM pethidine versus Entonox
Maternal pain score or pain measured in labour (after 30 mins)	1 (100)	‐	MD 1.66 higher (1.17 higher to 2.15 higher)	⊕⊝⊝⊝ VERY LOW ^c,f
Maternal pain score or pain measured in labour (after 60 mins)	1 (100)	‐	MD 0.36 lower (0.85 lower to 0.13 higher)	⊕⊝⊝⊝ VERY LOW ^e,f
IV pethidine versus placebo
Maternal pain score or pain measured in labour (Pain score 30 mins post analgesia)	1 (240)	‐	MD 4.10 lower (4.56 lower to 3.64 lower)	⊕⊕⊕⊝ MODERATE ^c
IV fentanyl versus no treatment
Maternal pain score or pain measured in labour (Pain score 1 hour post‐analgesia)	1 (70)	‐	MD 5.00 lower (5.47 lower to 4.53 lower)	⊕⊝⊝⊝ VERY LOW ^d,f
Maternal pain score or pain measured in labour (Pain intensity (Severe) after 1 hour)	1 (70)	RR 0.02 (0.00 to 0.25)	868 fewer per 1000 (from 664 fewer to 886 fewer)	⊕⊝⊝⊝ VERY LOW ^d,f
IV fentanyl versus IV pethidine
Maternal pain score or pain measured in labour (Pain score 1 hour after drug administration)	1 (105)	‐	MD 0.20 lower (1.18 lower to 0.78 higher)	⊕⊕⊝⊝ LOW ^a,c
Mean doses of analgesia (non pre‐specified)	1 (105)	‐	MD 0.40 higher (0.14 higher to 0.66 higher)	⊕⊕⊝⊝ LOW ^a,c
IV phenazocine versus IV pethidine
Maternal satisfaction with analgesia measured during labour (women with fair or poor relief)	1 (194)	RR 0.72 (0.48 to 1.10)	104 fewer per 1000 (from 37 more to 193 fewer)	⊕⊝⊝⊝ VERY LOW ^a,b
IV butorphanol versus IV pethidine
Maternal pain score or pain measured in labour (Pain relief score)	1 (80)	‐	MD 0.67 higher (0.25 higher to 1.09 higher)	⊕⊕⊝⊝ LOW ^a,c
Maternal pain score or pain measured in labour (Pain score (1 hour after drug administration))	1 (80)	‐	MD 0.60 lower (1.02 lower to 0.18 lower)	⊕⊕⊝⊝ LOW ^a,c
Additional analgesia required	1 (100)	RR 0.96 (0.63 to 1.45)	19 fewer per 1000 (from 178 fewer to 216 more)	⊕⊝⊝⊝ VERY LOW ^a,e
Epidural	1 (200)	RR 1.00 (0.30 to 3.35)	0 fewer per 1000 (from 35 fewer to 118 more)	⊕⊝⊝⊝ VERY LOW ^a,b
IV morphine versus pethidine
Maternal satisfaction with analgesia (assessed 3 days postpartum)	1 (141)	RR 0.87 (0.78 to 0.98)	124 fewer per 1000 (from 19 fewer to 210 fewer)	⊕⊕⊝⊝ LOW ^a,c
Additional analgesia required	1 (143)	RR 3.41 (1.90 to 6.12)	373 more per 1000 (from 139 more to 793 more)	⊕⊕⊝⊝ LOW ^a,d
IV Nisentil versus IV pethidine
Maternal satisfaction with analgesia, maternal pain score or pain measured in labour, additional analgesia, epidural	1 (395)	‐	‐	No trial reported these outcomes.
PCA pentazocine versus PCA pethidine
Maternal pan score or pain measured in labour	1 (23)	‐	SMD 0.76 lower (1.62 lower to 0.09 higher)	⊕⊝⊝⊝ VERY LOW ^a,e
Maternal pan score or pain measured in labour (rated as good one day after birth)	1 (28)	RR 0.82 (0.51 to 1.32)	141 fewer per 1000 (from 251 more to 385 fewer)	⊕⊝⊝⊝ VERY LOW ^a,e
Epidural	1 (28)	RR 1.50 (0.29 to 7.65)	71 more per 1000 (from 101 fewer to 950 more)	⊕⊝⊝⊝ VERY LOW ^a,e
PCA remifentanil versus PCA pethidine
Maternal pain score in labour	2 (122)	‐	MD 8.59 lower (27.61 lower to 10.44 higher)	⊕⊕⊝⊝ LOW ^e
Additional analgesia required	2 (56)	RR 0.86 (0.69 to 1.08)	124 fewer per 1000 (from 71 more to 276 fewer)	⊕⊝⊝⊝ VERY LOW ^e,h
Epidural	2 (122)	RR 0.42 (0.20 to 0.89)	181 fewer per 1000 (from 34 fewer to 249 fewer)	⊕⊕⊕⊝ MODERATE ^d
PCA nalbuphine versus PCA pethidine
Maternal satisfaction with analgesia in labour measured during the postnatal period (rated good or excellent)	1 (60)	RR 1.29 (0.88 to 1.89)	164 more per 1000 (from 68 fewer to 504 more)	⊕⊝⊝⊝ VERY LOW ^a,e
Maternal satisfaction with analgesia in labour measured during the postnatal period (Would use the same pain relief again)	1 (59)	RR 1.06 (0.79 to 1.43)	43 more per 1000 (from 152 fewer to 311 more)	⊕⊝⊝⊝ VERY LOW ^a,e
Maternal pain score or pain measured in labour	1 (60)	‐	MD 0.40 lower (0.79 lower to 0.01 lower)	⊕⊕⊝⊝ LOW ^a,c
Additional analgesia required	1 (59)	RR 0.83 (0.46 to 1.48)	82 fewer per 1000 (from 232 more to 261 fewer)	⊕⊝⊝⊝ VERY LOW ^a,b
PCA fentanyl versus PCA pethidine
Maternla pain score measured in labour	1 (107)	‐	MD 0.65 lower (1.56 lower to 0.26 higher)	⊕⊕⊝⊝ LOW ^e
Epidural	1 (107)	RR 0.44 (0.21 to 0.92)	190 fewer per 1000 (from 27 fewer to 268 fewer)	⊕⊕⊕⊝ MODERATE ^d
PCA (IM) meptazinol versus PCA (IM) pethidine
Maternal pain score or pain measured in labour (measured 1 day after delivery)	1 (10)	‐	MD 17.60 lower (49.93 lower to 14.73 higher)	⊕⊝⊝⊝ VERY LOW ^a,b
Satisfied with mode of administration (PCA IM)	1 (10)	RR 1.00 (0.71 to 1.41)	0 fewer per 1000 (from 290 fewer to 410 more)	⊕⊝⊝⊝ VERY LOW ^a,b
Epidural	1 (10)	RR 3.00 (0.15 to 59.89)	0 fewer per 1000 (from 0 fewer to 0 fewer)	⊕⊝⊝⊝ VERY LOW ^a,b
Opioids versus TENS
Maternal satisfaction with analgesia measured post delivery (rated as good)	2 (104)	RR 1.23 (0.79 to 1.92)	89 more per 1000 (from 81 fewer to 355 more)	⊕⊝⊝⊝ VERY LOW ^b,h
Maternal pain score measured during labour	2 (290)	Average RR 1.15 (0.81 to 1.61)	97 more per 1000 (from 122 fewer to 393 more)	⊕⊝⊝⊝ VERY LOW ^a,e,k
Maternal pain score measured during labour (after 30 minutes)	1 (60)	‐	MD 20 lower (26.09 lower to 13.91 lower)	⊕⊕⊝⊝ LOW ^a,c
Maternal pain score measured during labour (after 60 minutes)	1 (60)	‐	MD 20.00 lower (25.16 lower to 14.84 lower)	⊕⊕⊝⊝ LOW ^a,c
CI: confidence interval; RR: risk ratio; MD: mean difference ^aRisk of bias: serious (Effect estimate from single study with design limitations) ^bImprecision: very serious (Wide confidence interval crossing the line of no effect, few events, and small sample size) ^cImprecision: serious (Small sample size) ^dImprecision: serious (Small sample size and few events) ^eImprecision: very serious (Wide confidence interval crossing the line of no effect, and small sample size) ^fRisk of bias: very serious (Effect estimate from single study with serious design limitations) ^gImprecision: serious (Wide confidence interval crossing the line of no effect) ^hRisk of bias: serious (Pooled effect provided by studies with design limitations) ⁱRisk of bias: very serious (Pooled effect provided by studies with serious design limitations) ^jRisk of bias: serious (Pooled effect estimate mainly from studies with design limitations) ^kInconsistency: serious (unexplained substantial heterogeneity) ^lImprecision: very serious (Wide confidence interval crossing the line of no effect, and few events)

Summary of findings 2. Placebo and pethidine comparisons for pain management in labour

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Comparison 1. IM pethidine 50 mg/100 mg versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia measured during labour (number of women satisfied or very satisfied after 30 minutes) Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	7.0 [0.38, 128.87]

2 Maternal pain score or pain measured in labour (described as good or fair after 1 hour) Show forest plot	1	116	Risk Ratio (M‐H, Fixed, 95% CI)	1.75 [1.24, 2.47]

3 Maternal pain score or pain measured in labour (reduction in VAS of at least 40 mm after 30 minutes) Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	25.0 [1.56, 400.54]

4 Additional analgesia required Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.54, 0.94]

5 Epidural Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.5 [0.14, 1.78]

6 Nausea and vomiting Show forest plot	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	1.47 [0.65, 3.31]

7 Maternal sleepiness Show forest plot	2	166	Risk Ratio (M‐H, Fixed, 95% CI)	4.67 [2.43, 8.95]

8 Assisted vaginal delivery Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.34, 2.19]

9 Caesarean section Show forest plot	2	140	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.36, 1.37]

10 Neonatal resuscitation Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	1.67 [0.45, 6.24]

11 Low Apgar score (≤ 7) at 1 and 5 minutes Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

11.1 Low scores at 1 minute	2	166	Risk Ratio (M‐H, Random, 95% CI)	1.64 [0.52, 5.18]
11.2 Low scores at 5 minutes	2	200	Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
12 Admission to NICU Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.07, 15.12]

Comparison 1. IM pethidine 50 mg/100 mg versus placebo

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Comparison 2. IM pentazocine versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score measured during labour Show forest plot	1	89	Mean Difference (IV, Fixed, 95% CI)	‐3.60 [‐9.91, 2.71]

2 Nausea and vomiting Show forest plot	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

3 Caesarean section Show forest plot	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.24, 3.35]

4 Assisted vaginal birth Show forest plot	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.60 [0.10, 3.39]

Comparison 2. IM pentazocine versus placebo

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Comparison 3. IM tramadol versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia (Analgesic effect described as satisfactory (not clear when measured)) Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	11.0 [0.64, 190.53]

Comparison 3. IM tramadol versus no treatment

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Comparison 4. IM meptazinol versus pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (Maternal pain relief poor or none (3‐5 PN)) Show forest plot	1	801	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.91, 1.12]

2 Maternal pain score or pain measured in labour (Pain intensity 4 or 5 on 5‐point scale (1 hour)) Show forest plot	2	239	Risk Ratio (M‐H, Random, 95% CI)	1.11 [0.69, 1.80]

3 Additional analgesia required Show forest plot	2	233	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.88, 1.20]

4 Epidural Show forest plot	4	788	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.71, 1.29]

5 Maternal sleepiness Show forest plot	3	1590	Risk Ratio (M‐H, Random, 95% CI)	0.55 [0.28, 1.07]

6 Nausea and vomiting Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 Nausea	3	1590	Risk Ratio (M‐H, Fixed, 95% CI)	1.11 [0.95, 1.28]
6.2 Vomiting	3	1589	Risk Ratio (M‐H, Fixed, 95% CI)	1.25 [1.06, 1.47]
7 Caesarean section Show forest plot	3	1266	Risk Ratio (M‐H, Random, 95% CI)	0.56 [0.16, 2.00]

8 Assisted vaginal birth Show forest plot	3	1266	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.81, 1.22]

9 Breastfeeding at discharge (problems) Show forest plot	1	197	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.17, 3.30]

10 Fetal heart rate changes (decelerations) Show forest plot	1	34	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.92, 1.64]

11 Naloxone administration Show forest plot	1	998	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.77, 1.02]

11.1 < 36 weeks' gestation	1	23	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.49, 1.89]
11.2 ≥ 36 weeks' gestation	1	975	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.77, 1.02]
12 Neonatal resuscitation (by gestation) Show forest plot	2	1356	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.95, 1.05]

12.1 < 36 weeks' gestation	1	23	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.69, 1.16]
12.2 ≥ 36 weeks' gestation	2	1333	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.95, 1.05]
13 Neonatal resuscitation Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.26, 8.60]

14 Apgar score ≤ 7 at 1 minute Show forest plot	6	791	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.56, 1.11]

15 Apgar score ≤ 7 at 5 minutes Show forest plot	3	616	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.05, 5.37]

16 Admission to NICU Show forest plot	1	199	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.48, 1.63]

Comparison 4. IM meptazinol versus pethidine

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Comparison 5. IM diamorphine + prochlorperazine versus pethidine + prochlorperazine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia in labour measured during the postnatal period (Global assessment of pain relief at 24 hours) Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.67, 1.16]

2 Maternal pain score or pain measured in labour (Pain intensity at 1 hour (moderate or severe)) Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.72, 1.01]

3 Additonal analgesia required Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.35 [0.53, 3.40]

4 Epidural Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.72, 2.07]

5 Maternal sleepiness during labour Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.52, 1.66]

6 Vomiting in labour Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.17, 0.86]

7 Caesarean section Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.10, 2.76]

8 Assisted vaginal birth Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.46, 2.02]

9 Neonatal resuscitation Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	1.21 [0.73, 2.02]

10 Apgar < 7 at 1 minute Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.18, 0.91]

11 Apgar < 7 at 5 minutes Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.04, 3.27]

12 Admission to NICU Show forest plot	1	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.21, 1.64]

Comparison 5. IM diamorphine + prochlorperazine versus pethidine + prochlorperazine

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Comparison 6. IM tramadol versus pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (Pain intensity: women with poor pain relief) Show forest plot	4	243	Risk Ratio (M‐H, Fixed, 95% CI)	1.56 [1.10, 2.21]

2 Additional analgesia required Show forest plot	3	295	Risk Ratio (M‐H, Random, 95% CI)	1.07 [0.60, 1.91]

3 Maternal sleepiness in labour Show forest plot	5	409	Risk Ratio (M‐H, Random, 95% CI)	0.57 [0.33, 0.97]

4 Nausea and vomiting in labour Show forest plot	6	454	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.34, 2.76]

5 Caesarean section Show forest plot	3	260	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.23, 2.18]

6 Assisted vaginal birth Show forest plot	3	260	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.12, 2.56]

7 Neonatal resuscitation Show forest plot	1	90	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

8 Apgar scores ≤ 7 at 1 and 5 minutes Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Less than 7 at 1 minute	2	250	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 Less than 7 at 5 minutes	1	160	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Neonatal respiratory distress Show forest plot	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	2.26 [0.64, 7.89]

10 Admission to NICU Show forest plot	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	2.26 [0.64, 7.89]

Comparison 6. IM tramadol versus pethidine

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Comparison 7. IM tramadol + triflupromazine versus pethidine + triflupromazine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal sleepiness in labour Show forest plot	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	2.86 [0.68, 12.12]

2 Nausea and vomiting in labour Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

2.1 Nausea	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.13, 5.25]
2.2 Vomiting	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	0.40 [0.02, 9.35]

Comparison 7. IM tramadol + triflupromazine versus pethidine + triflupromazine

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Comparison 8. IM dihydrocodeine 50 mg versus pethidine 100 mg

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (Maternal pain relief poor at 1 hour) Show forest plot	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.64, 1.86]

2 Maternal sleepiness in labour Show forest plot	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.43, 1.04]

3 Nausea and vomiting in labour Show forest plot	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.40, 1.88]

4 Apgar ≤ 7 at 1 minute Show forest plot	1	138	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.39, 0.84]

Comparison 8. IM dihydrocodeine 50 mg versus pethidine 100 mg

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Comparison 9. IM pentazocine versus pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia measured during labour (Pain relief (good or very good) at delivery) Show forest plot	2	253	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.92, 1.27]

2 Maternal pain score or pain measured in labour (Pain relief poor (partial, none or worse)) Show forest plot	4		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 No add‐on drugs	3	365	Risk Ratio (M‐H, Random, 95% CI)	1.23 [0.74, 2.05]
2.2 With promazine	1	85	Risk Ratio (M‐H, Random, 95% CI)	1.53 [0.66, 3.58]
3 Additional analgesia required Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Pentazocine	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.50, 1.65]
3.2 Pentazocine + promazine	1	85	Risk Ratio (M‐H, Fixed, 95% CI)	1.67 [0.73, 3.84]
4 Maternal sleepiness in labour Show forest plot	3	391	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.89, 1.12]

5 Nausea and vomiting in labour Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

5.1 Nausea	3	391	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.24, 0.90]
5.2 Vomiting	1	73	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.27, 3.14]
6 Assisted vaginal birth Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

6.1 No add‐on drugs	1	94	Risk Ratio (M‐H, Fixed, 95% CI)	5.22 [0.63, 42.97]
6.2 With promazine	1	85	Risk Ratio (M‐H, Fixed, 95% CI)	0.78 [0.23, 2.71]
7 Naloxone administration Show forest plot	1	85	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.09, 2.53]

7.1 With promazine	1	85	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.09, 2.53]
8 Apgar score ≤ 7 at 1 minute Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

8.1 No add‐on drugs	2	242	Risk Ratio (M‐H, Random, 95% CI)	1.39 [0.06, 32.97]
8.2 With promazine	1	66	Risk Ratio (M‐H, Random, 95% CI)	1.13 [0.07, 17.30]
9 Apgar score ≤ 7 at 5 minutes Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 No add‐on drugs	1	62	Risk Ratio (M‐H, Fixed, 95% CI)	0.23 [0.01, 4.54]
9.2 With promazine	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.02, 8.88]

Comparison 9. IM pentazocine versus pethidine

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Comparison 10. IM nalbuphine versus pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia measured during the postnatal period (numbers dissatisfied) Show forest plot	1	72	Risk Ratio (M‐H, Fixed, 95% CI)	0.73 [0.55, 0.96]

2 Maternal satisfaction with analgesia measured during labour (Pain free) Show forest plot	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	6.0 [0.79, 45.42]

3 Maternal pain score or pain measured in labour (Pain intensity at 30 minutes: women with severe pain) Show forest plot	1	295	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.59, 1.26]

4 Maternal pain score or pain measured in labour (VAS at 60 minutes (at peak of contraction)) Show forest plot	1	72	Mean Difference (IV, Fixed, 95% CI)	‐8.0 [‐18.55, 2.55]

5 Additional analgesia required Show forest plot	1	72	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [0.49, 3.27]

6 Epidural Show forest plot	1	307	Risk Ratio (M‐H, Fixed, 95% CI)	1.65 [0.55, 4.94]

7 Maternal sleepiness in labour Show forest plot	1	72	Risk Ratio (M‐H, Fixed, 95% CI)	3.78 [0.86, 16.60]

8 Nausea and vomiting in labour Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

8.1 Nausea	1	301	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.42, 0.91]
8.2 Vomiting	1	301	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.22, 0.76]
8.3 Nausea and vomiting	1	72	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.18, 0.94]
9 Caesarean section Show forest plot	1	310	Risk Ratio (M‐H, Fixed, 95% CI)	0.45 [0.12, 1.69]

10 Assisted vaginal birth Show forest plot	2	382	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.25, 3.85]

11 Naloxone administration Show forest plot	1	72	Risk Ratio (M‐H, Fixed, 95% CI)	6.63 [0.35, 123.93]

12 Apgar score ≤ 7 at 1 and 5 minutes Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

12.1 Low score at 1 minute	2	382	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.72, 1.95]
12.2 Low score at 5 minutes	1	72	Risk Ratio (M‐H, Random, 95% CI)	0.47 [0.04, 4.99]
13 Admission to NICU Show forest plot	1	299	Risk Ratio (M‐H, Fixed, 95% CI)	1.07 [0.61, 1.89]

14 Neonatal neurobehavioural (Scanlon) 2‐4 hours PN Show forest plot	1	72	Mean Difference (IV, Fixed, 95% CI)	‐3.70 [‐6.14, ‐1.26]

Comparison 10. IM nalbuphine versus pethidine

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Comparison 11. IM phenazocine versus pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Epidural Show forest plot	1	212	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.58, 2.97]

2 Vomiting Show forest plot	1	212	Risk Ratio (M‐H, Fixed, 95% CI)	0.39 [0.20, 0.78]

Comparison 11. IM phenazocine versus pethidine

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Comparison 12. IM diamorphine/morphine versus pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia (number of women satisfied or very satisfied) Show forest plot	1	484	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [1.02, 1.26]

2 Maternal satisfaction with analgesia measured during labour or during the postnatal period (Pain relief described as poor) Show forest plot	1	90	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.56, 2.66]

3 Maternal pain score or pain measured in labour (pain relief at 30 mins) Show forest plot	1	484	Mean Difference (IV, Fixed, 95% CI)	‐0.80 [‐1.24, ‐0.36]

4 Maternal pain score or pain measured in labour (pain relief at 60 mins) Show forest plot	1	484	Mean Difference (IV, Fixed, 95% CI)	‐0.80 [‐1.26, ‐0.34]

5 Additional analgesia required Show forest plot	2	574	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.92, 1.10]

6 Maternal sleepiness Show forest plot	1	90	Risk Ratio (M‐H, Fixed, 95% CI)	0.6 [0.29, 1.23]

7 Nausea and vomiting Show forest plot	1	90	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.21, 4.69]

8 Caesarean section Show forest plot	1	484	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.66, 1.35]

9 Assisted vaginal birth Show forest plot	1	484	Risk Ratio (M‐H, Fixed, 95% CI)	1.28 [0.91, 1.80]

10 Naloxone administration Show forest plot	1	484	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.20, 4.83]

11 Neonatal resuscitation Show forest plot	2	574	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.66, 1.41]

12 Apgar < 7 at 1 minute Show forest plot	2	574	Risk Ratio (M‐H, Fixed, 95% CI)	1.15 [0.76, 1.73]

13 Admission to NICU Show forest plot	1	484	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.34, 2.23]

Comparison 12. IM diamorphine/morphine versus pethidine

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Comparison 13. IM butorphanol versus pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Additional analgesia required Show forest plot	1	80	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.55, 1.45]

2 Nausea Show forest plot	1	80	Risk Ratio (M‐H, Fixed, 95% CI)	0.2 [0.01, 4.04]

3 Vomiting Show forest plot	1	80	Risk Ratio (M‐H, Fixed, 95% CI)	0.5 [0.05, 5.30]

4 Neonatal resuscitation Show forest plot	1	80	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.95]

5 Naloxone administration (neonatal) Show forest plot	1	80	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.95]

Comparison 13. IM butorphanol versus pethidine

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Comparison 14. IM Avacan® versus IM pentazocine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Additional analgesia required ‐ Entonox Show forest plot	1	160	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.53, 1.63]

2 Additional analgesia required ‐ pudendal‐paracervical block Show forest plot	1	160	Risk Ratio (M‐H, Fixed, 95% CI)	2.02 [1.16, 3.53]

3 Caesarean section Show forest plot	1	184	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.21, 1.84]

4 Low Apgar score (< 7) "at birth" Show forest plot	1	160	Risk Ratio (M‐H, Fixed, 95% CI)	0.59 [0.27, 1.26]

Comparison 14. IM Avacan® versus IM pentazocine

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Comparison 15. IM pentazocine versus IM Pethilorfan®

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score measured during labour (Pain relief (women NOT obtaining pain relief) at 1 hour) Show forest plot	1	69	Risk Ratio (M‐H, Fixed, 95% CI)	1.22 [0.77, 1.95]

2 Additional analgesia required Show forest plot	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	0.52 [0.10, 2.71]

3 Assisted vaginal birth Show forest plot	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.07, 16.19]

4 Apgar < 8 at 1 minute (non pre‐specified) Show forest plot	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	5.71 [0.72, 45.39]

5 Apgar < 8 at 5 minutes (non pre‐specified) Show forest plot	1	82	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 15. IM pentazocine versus IM Pethilorfan®

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Comparison 16. IM pentazocine versus complementary and alternate medicine (CAM)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score measured during labour Show forest plot	1	89	Mean Difference (IV, Fixed, 95% CI)	‐0.40 [‐7.61, 6.81]

2 Nausea and vomiting Show forest plot	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.30 [0.01, 7.14]

3 Caesarean section Show forest plot	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.24, 3.35]

4 Assisted vaginal delivery Show forest plot	1	89	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.13, 6.07]

Comparison 16. IM pentazocine versus complementary and alternate medicine (CAM)

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Comparison 17. IM pentazocine versus IM tramadol

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia measured during labour (pain relief after 30 mins) Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	2.4 [1.28, 4.48]

2 Maternal satisfaction with analgesia measured during labour (pain after 60 mins) Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.62 [0.91, 2.86]

3 Maternal pain score or pain measured in labour (moderate or severe at 30 mins) Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.55, 1.02]

4 Maternal pain score or pain measured in labour (moderate or severe at 60 mins) Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.81 [0.60, 1.08]

5 Maternal sleepiness during labour Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.67 [0.66, 4.24]

6 Nausea and vomiting Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.06, 15.55]

7 Caesarean section Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.45, 4.99]

8 Assisted vaginal delivery Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [0.19, 21.36]

9 Apgar score < 7 at 1 minute Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.67 [0.42, 6.60]

10 Apgar score < 7 at 5 minutes Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 71.92]

11 Admission to NICU Show forest plot	1	86	Risk Ratio (M‐H, Fixed, 95% CI)	2.87 [0.12, 68.47]

Comparison 17. IM pentazocine versus IM tramadol

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Comparison 18. IM pethidine versus Entonox

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (after 30 mins) Show forest plot	1	100	Mean Difference (IV, Fixed, 95% CI)	1.66 [1.17, 2.15]

2 Maternal pain score or pain measured in labour (after 60 mins) Show forest plot	1	100	Mean Difference (IV, Fixed, 95% CI)	‐0.36 [‐0.85, 0.13]

Comparison 18. IM pethidine versus Entonox

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Comparison 19. IV pethidine versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (Pain score 30 mins post analgesia) Show forest plot	1	240	Mean Difference (IV, Fixed, 95% CI)	‐4.1 [‐4.56, ‐3.64]

2 Nausea and vomiting Show forest plot	1	240	Risk Ratio (M‐H, Fixed, 95% CI)	2.43 [1.05, 5.64]

3 Caesarean section Show forest plot	1	240	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.46, 1.68]

4 Assisted vaginal birth Show forest plot	1	240	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.33, 1.71]

5 Admission to NICU Show forest plot	1	240	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.11, 3.92]

Comparison 19. IV pethidine versus placebo

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Comparison 20. IV fentanyl versus no treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (Pain score 1 hour post‐analgesia) Show forest plot	1	70	Mean Difference (IV, Fixed, 95% CI)	‐5.0 [‐5.47, ‐4.53]

2 Maternal pain score or pain measured in labour (Pain intensity (Severe) after 1 hour) Show forest plot	1	70	Risk Ratio (M‐H, Fixed, 95% CI)	0.02 [0.00, 0.25]

3 Caesarean section Show forest plot	1	70	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.27, 8.43]

Comparison 20. IV fentanyl versus no treatment

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Comparison 21. IV fentanyl versus IV pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (Pain score 1 hour after drug administration) Show forest plot	1	105	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐1.18, 0.78]

2 Mean doses of analgesia (non pre‐specified) Show forest plot	1	105	Mean Difference (IV, Fixed, 95% CI)	0.40 [0.14, 0.66]

3 Maternal sleepiness in labour (sedation) Show forest plot	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	0.05 [0.00, 0.82]

4 Nausea and/or vomiting Show forest plot	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.17, 1.55]

5 Anti‐emetic required (non pre‐specified) Show forest plot	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	0.09 [0.01, 1.52]

6 Caesarean section Show forest plot	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.24, 5.40]

7 Naloxone administered Show forest plot	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	0.16 [0.02, 1.28]

8 Babies requiring resuscitation/ventilatory support Show forest plot	1	105	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.46, 2.32]

9 Apgar score < 7 at 1 minute Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

10 Apgar score < 7 at 5 minutes Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

11 Neurobehavioural score (1 ‐ 2 hours after delivery) Show forest plot	1	105	Mean Difference (IV, Fixed, 95% CI)	1.30 [0.15, 2.45]

12 Neurobehavioural score (2 hours ‐ 24 hours) Show forest plot	1	105	Mean Difference (IV, Fixed, 95% CI)	0.90 [‐0.42, 2.22]

Comparison 21. IV fentanyl versus IV pethidine

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Comparison 22. IV nalbuphine versus IV pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section Show forest plot	1	28	Risk Ratio (M‐H, Fixed, 95% CI)	5.0 [0.26, 95.61]

2 Apgar score < 7 at 1 minute Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3 Apgar score < 7 at 5 minutes Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

Comparison 22. IV nalbuphine versus IV pethidine

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Comparison 23. IV phenazocine versus IV pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia measured during labour (women with fair or poor relief) Show forest plot	1	194	Risk Ratio (M‐H, Fixed, 95% CI)	0.72 [0.48, 1.10]

2 Nausea with vomiting Show forest plot	1	194	Risk Ratio (M‐H, Fixed, 95% CI)	0.4 [0.08, 2.01]

3 Perinatal death Show forest plot	1	194	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

4 Apgar score < 7 at 1 minute Show forest plot	1	194	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 23. IV phenazocine versus IV pethidine

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Comparison 24. IV butorphanol versus IV pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (Pain relief score) Show forest plot	1	80	Mean Difference (IV, Fixed, 95% CI)	0.67 [0.25, 1.09]

2 Maternal pain score or pain measured in labour (Pain score (1 hour after drug administration)) Show forest plot	1	80	Mean Difference (IV, Fixed, 95% CI)	‐0.60 [‐1.02, ‐0.18]

3 Additional analgesia required Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.63, 1.45]

4 Epidural Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.30, 3.35]

5 Nausea and/or vomiting Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.04 [0.00, 0.67]

6 Caesarean section Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	0.8 [0.22, 2.89]

7 Assisted vaginal birth Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	1.3 [0.60, 2.83]

8 Apgar score < 7 at 1 minute Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9 Apgar score < 7 at 5 minutes Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

Comparison 24. IV butorphanol versus IV pethidine

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Comparison 25. IV morphine versus IV pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia (assessed 3 days postpartum) Show forest plot	1	141	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.78, 0.98]

2 Additional analgesia required Show forest plot	1	143	Risk Ratio (M‐H, Fixed, 95% CI)	3.41 [1.90, 6.12]

3 Nausea and vomiting Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

3.1 Nausea	1	20	Risk Ratio (M‐H, Fixed, 95% CI)	0.17 [0.02, 1.14]
3.2 Vomiting	1	20	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.03, 1.86]
4 Caesarean section Show forest plot	1	20	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 25. IV morphine versus IV pethidine

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Comparison 26. IV Nisentil versus IV pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Nausea and vomiting Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Nausea	1	395	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.33, 1.52]
1.2 Vomiting	1	395	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.22, 0.66]
2 Neonatal resuscitation/ventilatory support Show forest plot	1	395	Risk Ratio (M‐H, Fixed, 95% CI)	1.99 [0.85, 4.63]

Comparison 26. IV Nisentil versus IV pethidine

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Comparison 27. IV fentanyl versus IV butorphanol

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Additional analgesia required Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [1.05, 1.85]

2 Epidural Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [1.00, 4.02]

3 Matenal sleepiness (required tactile rousing) Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.64, 14.16]

4 Caesarean section Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.8 [0.23, 2.81]

5 Naloxone required Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.75 [0.81, 3.80]

6 Neonatal resuscitation (Babies requiring ventilatory support) Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	11.0 [0.62, 193.80]

7 Apgar score < 7 at 5 minutes Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	1.2 [0.39, 3.68]

8 Newborn neurobehavioural score at 2‐4 hours Show forest plot	1	100	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐1.61, 1.61]

9 Newborn neurobehavioural score at 24‐36 hours Show forest plot	1	100	Mean Difference (IV, Fixed, 95% CI)	‐0.50 [‐1.62, 0.62]

Comparison 27. IV fentanyl versus IV butorphanol

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Comparison 28. PCA pentazocine versus PCA pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pan score or pain measured in labour Show forest plot	1	23	Mean Difference (IV, Fixed, 95% CI)	‐1.45 [‐2.96, 0.06]

2 Maternal pan score or pain measured in labour (rated as good one day after birth) Show forest plot	1	28	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.51, 1.32]

3 Epidural Show forest plot	1	28	Risk Ratio (M‐H, Fixed, 95% CI)	1.5 [0.29, 7.65]

4 Nausea and vomiting Show forest plot	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.01, 1.61]

5 Maternal sleepiness during labour (Sedation) Show forest plot	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.21 [0.01, 4.09]

6 Caesarean section Show forest plot	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.36 [0.02, 8.07]

7 Breastfeeding at discharge Show forest plot	1	23	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.85, 1.17]

8 Apgar score < 7 at 5 minutes Show forest plot	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 28. PCA pentazocine versus PCA pethidine

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Comparison 29. PCA remifentanil versus PCA pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score in labour Show forest plot	2	122	Mean Difference (IV, Random, 95% CI)	‐8.59 [‐27.61, 10.44]

2 Additional analgesia required Show forest plot	2	56	Risk Ratio (M‐H, Fixed, 95% CI)	0.86 [0.69, 1.08]

3 Epidural Show forest plot	2	122	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.20, 0.89]

4 Maternal sleepiness during labour Show forest plot	1	105	Mean Difference (IV, Fixed, 95% CI)	0.40 [0.14, 0.66]

5 Nausea and vomiting Show forest plot	2	119	Risk Ratio (M‐H, Fixed, 95% CI)	0.95 [0.61, 1.49]

6 Caesarean section Show forest plot	2	97	Risk Ratio (M‐H, Fixed, 95% CI)	1.81 [0.60, 5.46]

7 Assisted vaginal birth Show forest plot	2	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.46, 2.00]

8 Satisfaction with childbirth experience Show forest plot	1	68	Mean Difference (IV, Fixed, 95% CI)	1.10 [0.46, 1.74]

9 Naloxone administered Show forest plot	2	56	Risk Ratio (M‐H, Fixed, 95% CI)	0.3 [0.01, 6.47]

10 Apgar score < 7 at 5 minutes Show forest plot	1	17	Risk Ratio (M‐H, Fixed, 95% CI)	0.13 [0.01, 2.16]

11 Admission to NICU Show forest plot	1	17	Risk Ratio (M‐H, Fixed, 95% CI)	0.3 [0.01, 6.47]

12 Newborn neurobehavioural score (15 minutes post delivery) Show forest plot	1	56	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.93, 1.33]

13 Newborn neurobehavioural score (2 hours post delivery) Show forest plot	1	56	Mean Difference (IV, Fixed, 95% CI)	0.60 [‐0.66, 1.86]

Comparison 29. PCA remifentanil versus PCA pethidine

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Comparison 30. PCA nalbuphine versus PCA pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia in labour measured during the postnatal period (rated good or excellent) Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.88, 1.89]

2 Maternal satisfaction with analgesia in labour measured during the postnatal period (Would use the same pain relief again) Show forest plot	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.79, 1.43]

3 Maternal pain score or pain measured in labour Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	‐0.40 [‐0.79, ‐0.01]

4 Additional analgesia required Show forest plot	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.46, 1.48]

5 Nausea and vomiting Show forest plot	1	59	Risk Ratio (M‐H, Fixed, 95% CI)	0.68 [0.30, 1.54]

6 Apgar score < 7 at 5 minutes Show forest plot	1	41	Risk Ratio (M‐H, Fixed, 95% CI)	0.42 [0.02, 9.76]

Comparison 30. PCA nalbuphine versus PCA pethidine

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Comparison 31. PCA fentanyl versus PCA alfentanil

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia in labour measured during the postnatal period (described as adequate) Show forest plot	1	23	Risk Ratio (M‐H, Fixed, 95% CI)	1.56 [0.93, 2.60]

2 Maternal pain score or pain measured in labour (Pain score at 4‐6 cm cervical dilatation) Show forest plot	1	21	Mean Difference (IV, Fixed, 95% CI)	‐12.80 [‐32.12, 6.52]

3 Nausea Show forest plot	1	23	Risk Ratio (M‐H, Fixed, 95% CI)	2.73 [0.66, 11.30]

4 Caesarean section Show forest plot	1	23	Risk Ratio (M‐H, Fixed, 95% CI)	1.64 [0.33, 8.03]

5 Naloxone required Show forest plot	1	24	Risk Ratio (M‐H, Fixed, 95% CI)	2.36 [0.53, 10.55]

Comparison 31. PCA fentanyl versus PCA alfentanil

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Comparison 32. PCA fentanyl versus PCA pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternla pain score measured in labour Show forest plot	1	107	Mean Difference (IV, Fixed, 95% CI)	‐0.65 [‐1.56, 0.26]

2 Epidural Show forest plot	1	107	Risk Ratio (M‐H, Fixed, 95% CI)	0.44 [0.21, 0.92]

3 Maternal sleepiness during labour Show forest plot	1	107	Mean Difference (IV, Fixed, 95% CI)	‐0.06 [‐0.25, 0.13]

4 Nausea and vomiting Show forest plot	1	102	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.55, 1.37]

5 Caesarean section Show forest plot	1	81	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.03, 2.34]

6 Assisted vaginal birth Show forest plot	1	81	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.22, 1.49]

7 Newborn neurobehavioural score (15 minutes post delivery) Show forest plot	1	63	Mean Difference (IV, Fixed, 95% CI)	‐0.90 [‐2.31, 0.51]

8 Newborn neurobehavioural score (2 hours post delivery) Show forest plot	1	64	Mean Difference (IV, Fixed, 95% CI)	‐0.5 [‐1.95, 0.95]

Comparison 32. PCA fentanyl versus PCA pethidine

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Comparison 33. PCA (IM) meptazinol versus PCA (IM) pethidine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal pain score or pain measured in labour (measured 1 day after delivery) Show forest plot	1	10	Mean Difference (IV, Fixed, 95% CI)	‐17.60 [‐49.93, 14.73]

2 Satisfied with mode of administration (PCA IM) (non pre‐specified) Show forest plot	1	10	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.71, 1.41]

3 Epidural Show forest plot	1	10	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.15, 59.89]

4 Maternal sleepiness in labour (Drowsiness score in labour rated 1 day after delivery) Show forest plot	1	10	Mean Difference (IV, Fixed, 95% CI)	5.60 [‐28.19, 39.39]

5 Nausea (score in labour rated 1 day after delivery) Show forest plot	1	10	Mean Difference (IV, Fixed, 95% CI)	‐8.0 [‐48.70, 32.70]

6 Naloxone administered Show forest plot	1	10	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.08, 11.93]

Comparison 33. PCA (IM) meptazinol versus PCA (IM) pethidine

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Comparison 34. Opioids versus TENS

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Maternal satisfaction with analgesia measured post delivery (rated as good) Show forest plot	2	104	Risk Ratio (M‐H, Fixed, 95% CI)	1.23 [0.79, 1.92]

2 Maternal pain score measured during labour Show forest plot	2	290	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.81, 1.61]

3 Maternal pain score in labour Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

3.1 Pain score (after 30 minutes)	1	60	Mean Difference (IV, Fixed, 95% CI)	‐20.0 [‐26.09, ‐13.91]
3.2 Pain score (after 60 minutes)	1	60	Mean Difference (IV, Fixed, 95% CI)	‐20.0 [‐25.16, ‐14.84]
4 Maternal sleepiness during labour (Drowsiness) Show forest plot	2	290	Risk Ratio (M‐H, Fixed, 95% CI)	8.96 [1.13, 71.07]

5 Nausea and vomiting Show forest plot	3	350	Risk Ratio (M‐H, Fixed, 95% CI)	13.73 [2.72, 69.24]

6 Caesarean section Show forest plot	2	260	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [0.19, 20.90]

7 Assisted vaginal birth Show forest plot	2	260	Risk Ratio (M‐H, Fixed, 95% CI)	1.8 [0.40, 8.18]

8 Fetal heart rate changes in labour (Fetal distress) Show forest plot	1	200	Risk Ratio (M‐H, Fixed, 95% CI)	5.0 [0.24, 102.85]

Comparison 34. Opioids versus TENS

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