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Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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

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

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 3

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

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Funnel plot of comparison: 1 Automated mandatory bolus vs basal infusion, outcome: 1.2 Breakthrough pain (epidural vs CSE).
Figuras y tablas -
Figure 4

Funnel plot of comparison: 1 Automated mandatory bolus vs basal infusion, outcome: 1.2 Breakthrough pain (epidural vs CSE).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 1 Breakthrough pain.
Figuras y tablas -
Analysis 1.1

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 1 Breakthrough pain.

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 2 Breakthrough pain (epidural vs CSE).
Figuras y tablas -
Analysis 1.2

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 2 Breakthrough pain (epidural vs CSE).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 3 Breakthrough pain (PCEA vs no PCEA).
Figuras y tablas -
Analysis 1.3

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 3 Breakthrough pain (PCEA vs no PCEA).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 4 Breakthrough pain (nulliparous vs multiparous).
Figuras y tablas -
Analysis 1.4

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 4 Breakthrough pain (nulliparous vs multiparous).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 5 Caesarean delivery.
Figuras y tablas -
Analysis 1.5

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 5 Caesarean delivery.

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 6 Caesarean delivery (LA + opioids vs LA alone).
Figuras y tablas -
Analysis 1.6

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 6 Caesarean delivery (LA + opioids vs LA alone).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 7 Caesarean delivery (epidural vs CSE).
Figuras y tablas -
Analysis 1.7

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 7 Caesarean delivery (epidural vs CSE).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 8 Caesarean delivery (PCEA vs no PCEA).
Figuras y tablas -
Analysis 1.8

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 8 Caesarean delivery (PCEA vs no PCEA).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 9 Caesarean delivery (nulliparous vs multiparous).
Figuras y tablas -
Analysis 1.9

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 9 Caesarean delivery (nulliparous vs multiparous).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 10 Instrumental delivery.
Figuras y tablas -
Analysis 1.10

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 10 Instrumental delivery.

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 11 Instrumental delivery (LA + opioids vs LA alone).
Figuras y tablas -
Analysis 1.11

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 11 Instrumental delivery (LA + opioids vs LA alone).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 12 Instrumental delivery (epidural vs CSE).
Figuras y tablas -
Analysis 1.12

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 12 Instrumental delivery (epidural vs CSE).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 13 Instrumental delivery (PCEA vs No PCEA).
Figuras y tablas -
Analysis 1.13

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 13 Instrumental delivery (PCEA vs No PCEA).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 14 Instrumental delivery (nulliparous vs multiparous).
Figuras y tablas -
Analysis 1.14

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 14 Instrumental delivery (nulliparous vs multiparous).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 15 Duration of labour in minutes.
Figuras y tablas -
Analysis 1.15

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 15 Duration of labour in minutes.

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 16 Duration of labour in minutes (LA + opioids vs LA alone).
Figuras y tablas -
Analysis 1.16

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 16 Duration of labour in minutes (LA + opioids vs LA alone).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 17 Duration of labour in minutes (epidural vs CSE).
Figuras y tablas -
Analysis 1.17

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 17 Duration of labour in minutes (epidural vs CSE).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 18 Duration of labour in minutes (PCEA vs no PCEA).
Figuras y tablas -
Analysis 1.18

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 18 Duration of labour in minutes (PCEA vs no PCEA).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 19 Duration of labour in minutes (nulliparous vs multiparous).
Figuras y tablas -
Analysis 1.19

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 19 Duration of labour in minutes (nulliparous vs multiparous).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 20 LA consumption per hour.
Figuras y tablas -
Analysis 1.20

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 20 LA consumption per hour.

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 21 LA consumption per hour (LA + opioids vs LA alone).
Figuras y tablas -
Analysis 1.21

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 21 LA consumption per hour (LA + opioids vs LA alone).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 22 LA consumption per hour (epidural vs CSE).
Figuras y tablas -
Analysis 1.22

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 22 LA consumption per hour (epidural vs CSE).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 23 LA consumption per hour (PCEA vs no PCEA).
Figuras y tablas -
Analysis 1.23

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 23 LA consumption per hour (PCEA vs no PCEA).

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Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 24 LA consumption per hour (nulliparous vs multiparous).
Figuras y tablas -
Analysis 1.24

Comparison 1 Automated mandatory bolus vs basal infusion, Outcome 24 LA consumption per hour (nulliparous vs multiparous).

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Summary of findings for the main comparison. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour

Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour

Patient or population: maintenance of epidural analgesia in labour
Setting: patients admitted into the labour ward
Intervention: automated mandatory bolus
Comparison: basal infusion

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Certainty of the evidence
(GRADE)

Risk with basal infusion

Risk with automated mandatory bolus

Breakthrough pain
assessed with: verbal patient reporting or need for rescue analgesia
Follow‐up: range 242 min to 490 min

Study population

RR 0.60
(0.39 to 0.92)

797
(10 RCTs)

⊕⊕⊕⊝
Moderatea

333 per 1000

200 per 1000
(130 to 307)

Caesarean delivery
Follow‐up: range 242 min to 490 min

Study population

RR 0.92
(0.70 to 1.21)

1079
(11 RCTs)

⊕⊕⊝⊝
Lowb

160 per 1000

147 per 1000
(112 to 194)

Instrumental delivery
Follow‐up: range 242 min to 490 min

Study population

RR 0.75
(0.54 to 1.06)

1079
(11 RCTs)

⊕⊕⊝⊝
Lowb

123 per 1000

92 per 1000
(66 to 130)

Duration of labour in min
Follow‐up: range 242 min to 490 min

The mean duration of labour in min ranged from 186.3 to 690.0 min

MD 10.38 min lower
(26.73 lower to 5.96 higher)

—

1079
(11 RCTs)

⊕⊕⊕⊝
Moderatec

LA consumption per hour
Follow‐up: range 242 min to 490 min

The mean LA consumption per hour ranged from 3 mg to 21.4 mg

MD 1.08 mg/h lower
(1.78 lower to 0.38 lower)

—

1121
(12 RCTs)

⊕⊕⊕⊝
Moderated

*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; MD: mean difference; 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.

aDowngraded one level due to considerable statistical heterogeneity for this outcome, i.e. I2 = 69%.
bDowngraded two levels because the upper and lower confidence limit cross the effect size of 5% in either direction and there is inadequate information given the small numbers.
cDowngraded one level because the upper and lower confidence limit cross the effect size of 0.5 in either direction.
dDowngraded one level due to considerable statistical inconsistency for this outcome, i.e. I2 = 89%.

Figuras y tablas -
Summary of findings for the main comparison. Automated mandatory bolus versus basal infusion for maintenance of epidural analgesia in labour
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Comparison 1. Automated mandatory bolus vs basal infusion

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Breakthrough pain Show forest plot

10

797

Risk Ratio (M‐H, Random, 95% CI)

0.60 [0.39, 0.92]

2 Breakthrough pain (epidural vs CSE) Show forest plot

10

797

Risk Ratio (M‐H, Random, 95% CI)

0.60 [0.39, 0.92]

2.1 Epidural

3

313

Risk Ratio (M‐H, Random, 95% CI)

0.40 [0.25, 0.64]

2.2 CSE

7

484

Risk Ratio (M‐H, Random, 95% CI)

0.71 [0.44, 1.13]

3 Breakthrough pain (PCEA vs no PCEA) Show forest plot

10

797

Risk Ratio (M‐H, Random, 95% CI)

0.60 [0.39, 0.92]

3.1 PCEA

5

477

Risk Ratio (M‐H, Random, 95% CI)

0.61 [0.35, 1.07]

3.2 No PCEA

5

320

Risk Ratio (M‐H, Random, 95% CI)

0.58 [0.30, 1.12]

4 Breakthrough pain (nulliparous vs multiparous) Show forest plot

9

669

Risk Ratio (M‐H, Random, 95% CI)

0.62 [0.39, 1.00]

4.1 Nulliparous

8

543

Risk Ratio (M‐H, Random, 95% CI)

0.62 [0.33, 1.15]

4.2 Multiparous

1

126

Risk Ratio (M‐H, Random, 95% CI)

0.59 [0.38, 0.90]

5 Caesarean delivery Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.70, 1.21]

6 Caesarean delivery (LA + opioids vs LA alone) Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.70, 1.21]

6.1 LA + opioids

10

952

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.70, 1.24]

6.2 LA alone

1

127

Risk Ratio (M‐H, Random, 95% CI)

0.74 [0.27, 2.01]

7 Caesarean delivery (epidural vs CSE) Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.70, 1.21]

7.1 Epidural

5

637

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.53, 1.15]

7.2 CSE

6

442

Risk Ratio (M‐H, Random, 95% CI)

1.08 [0.73, 1.59]

8 Caesarean delivery (PCEA vs no PCEA) Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.70, 1.21]

8.1 PCEA

7

801

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.70, 1.37]

8.2 No PCEA

4

278

Risk Ratio (M‐H, Random, 95% CI)

0.81 [0.50, 1.30]

9 Caesarean delivery (nulliparous vs multiparous) Show forest plot

10

951

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.70, 1.25]

9.1 Nulliparous

9

825

Risk Ratio (M‐H, Random, 95% CI)

0.92 [0.69, 1.23]

9.2 Multiparous

1

126

Risk Ratio (M‐H, Random, 95% CI)

3.0 [0.12, 72.27]

10 Instrumental delivery Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.54, 1.06]

11 Instrumental delivery (LA + opioids vs LA alone) Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.57, 1.12]

11.1 LA + opioids

10

952

Risk Ratio (M‐H, Random, 95% CI)

0.77 [0.54, 1.08]

11.2 LA alone

1

127

Risk Ratio (M‐H, Random, 95% CI)

1.97 [0.37, 10.37]

12 Instrumental delivery (epidural vs CSE) Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.57, 1.12]

12.1 Epidural

5

637

Risk Ratio (M‐H, Random, 95% CI)

0.96 [0.53, 1.74]

12.2 CSE

6

442

Risk Ratio (M‐H, Random, 95% CI)

0.59 [0.33, 1.05]

13 Instrumental delivery (PCEA vs No PCEA) Show forest plot

11

1079

Risk Ratio (M‐H, Random, 95% CI)

0.80 [0.57, 1.12]

13.1 No PCEA

4

278

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.60, 1.61]

13.2 PCEA

7

801

Risk Ratio (M‐H, Random, 95% CI)

0.67 [0.42, 1.05]

14 Instrumental delivery (nulliparous vs multiparous) Show forest plot

10

951

Risk Ratio (M‐H, Random, 95% CI)

0.76 [0.54, 1.07]

14.1 Nulliparous

9

825

Risk Ratio (M‐H, Random, 95% CI)

0.76 [0.53, 1.08]

14.2 Multiparous

1

126

Risk Ratio (M‐H, Random, 95% CI)

0.75 [0.17, 3.22]

15 Duration of labour in minutes Show forest plot

11

1079

Mean Difference (IV, Random, 95% CI)

‐10.38 [‐26.73, 5.96]

16 Duration of labour in minutes (LA + opioids vs LA alone) Show forest plot

11

1079

Mean Difference (IV, Random, 95% CI)

‐10.38 [‐26.73, 5.96]

16.1 LA + opioids

10

952

Mean Difference (IV, Random, 95% CI)

‐12.52 [‐31.87, 6.82]

16.2 Duration of labor in minutes (LA alone)

1

127

Mean Difference (IV, Random, 95% CI)

0.0 [‐36.63, 36.63]

17 Duration of labour in minutes (epidural vs CSE) Show forest plot

11

1079

Mean Difference (IV, Random, 95% CI)

‐10.38 [‐26.73, 5.96]

17.1 Epidural

5

637

Mean Difference (IV, Random, 95% CI)

‐3.04 [‐26.42, 20.34]

17.2 CSE

6

442

Mean Difference (IV, Random, 95% CI)

‐32.70 [‐65.20, ‐0.20]

18 Duration of labour in minutes (PCEA vs no PCEA) Show forest plot

11

1079

Mean Difference (IV, Random, 95% CI)

‐10.38 [‐26.73, 5.96]

18.1 PCEA

7

801

Mean Difference (IV, Random, 95% CI)

‐13.24 [‐20.71, ‐5.76]

18.2 No PCEA

4

278

Mean Difference (IV, Random, 95% CI)

‐48.65 [‐129.92, 32.62]

19 Duration of labour in minutes (nulliparous vs multiparous) Show forest plot

10

951

Mean Difference (IV, Random, 95% CI)

‐14.38 [‐21.80, ‐6.96]

19.1 Nulliparous

9

825

Mean Difference (IV, Random, 95% CI)

‐13.92 [‐23.75, ‐4.10]

19.2 Multiparous

1

126

Mean Difference (IV, Random, 95% CI)

‐28.0 [‐76.95, 20.95]

20 LA consumption per hour Show forest plot

12

1121

Mean Difference (IV, Random, 95% CI)

‐1.08 [‐1.78, ‐0.38]

21 LA consumption per hour (LA + opioids vs LA alone) Show forest plot

12

1121

Mean Difference (IV, Random, 95% CI)

‐1.08 [‐1.78, ‐0.38]

21.1 LA + opioids

11

994

Mean Difference (IV, Random, 95% CI)

‐0.75 [‐1.35, ‐0.15]

21.2 LA alone

1

127

Mean Difference (IV, Random, 95% CI)

‐9.50 [‐12.55, ‐6.45]

22 LA consumption per hour (epidural vs CSE) Show forest plot

12

1121

Mean Difference (IV, Random, 95% CI)

‐1.08 [‐1.78, ‐0.38]

22.1 Epidural

5

637

Mean Difference (IV, Random, 95% CI)

‐2.59 [‐4.13, ‐1.05]

22.2 CSE

7

484

Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.80, 0.11]

23 LA consumption per hour (PCEA vs no PCEA) Show forest plot

12

1121

Mean Difference (IV, Random, 95% CI)

‐1.08 [‐1.78, ‐0.38]

23.1 PCEA

7

801

Mean Difference (IV, Random, 95% CI)

‐1.59 [‐2.58, ‐0.60]

23.2 No PCEA

5

320

Mean Difference (IV, Random, 95% CI)

‐0.53 [‐1.58, 0.52]

24 LA consumption per hour (nulliparous vs multiparous) Show forest plot

11

993

Mean Difference (IV, Random, 95% CI)

‐0.89 [‐1.55, ‐0.23]

24.1 Nulliparous

10

867

Mean Difference (IV, Random, 95% CI)

‐0.83 [‐1.51, ‐0.15]

24.2 Multiparous

1

126

Mean Difference (IV, Random, 95% CI)

‐1.80 [‐3.93, 0.33]
Figuras y tablas -
Comparison 1. Automated mandatory bolus vs basal infusion
Ir a la tabla de la revisión