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Study flow diagram
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Figure 1

Study flow diagram

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Figure 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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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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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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Funnel plot of comparison: 1 Aspirin versus placebo for perineal pain, outcome: 1.1 Adequate pain relief as reported by the woman
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Figure 4

Funnel plot of comparison: 1 Aspirin versus placebo for perineal pain, outcome: 1.1 Adequate pain relief as reported by the woman

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Funnel plot of comparison: 1 Aspirin versus placebo for perineal pain, outcome: 1.2 Need for additional pain relief
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Figure 5

Funnel plot of comparison: 1 Aspirin versus placebo for perineal pain, outcome: 1.2 Need for additional pain relief

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Funnel plot of comparison: 1 Aspirin versus placebo for perineal pain, outcome: 1.3 Maternal adverse effects
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Figure 6

Funnel plot of comparison: 1 Aspirin versus placebo for perineal pain, outcome: 1.3 Maternal adverse effects

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Comparison 1 Aspirin versus placebo for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.
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Analysis 1.1

Comparison 1 Aspirin versus placebo for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.

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Comparison 1 Aspirin versus placebo for perineal pain, Outcome 2 Need for additional pain relief.
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Analysis 1.2

Comparison 1 Aspirin versus placebo for perineal pain, Outcome 2 Need for additional pain relief.

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Comparison 1 Aspirin versus placebo for perineal pain, Outcome 3 Maternal adverse effects.
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Analysis 1.3

Comparison 1 Aspirin versus placebo for perineal pain, Outcome 3 Maternal adverse effects.

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Comparison 2 300 mg aspirin versus 600 mg aspirin for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.
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Analysis 2.1

Comparison 2 300 mg aspirin versus 600 mg aspirin for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.

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Comparison 2 300 mg aspirin versus 600 mg aspirin for perineal pain, Outcome 2 Need for additional pain relief.
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Analysis 2.2

Comparison 2 300 mg aspirin versus 600 mg aspirin for perineal pain, Outcome 2 Need for additional pain relief.

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Comparison 2 300 mg aspirin versus 600 mg aspirin for perineal pain, Outcome 3 Maternal adverse effects.
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Analysis 2.3

Comparison 2 300 mg aspirin versus 600 mg aspirin for perineal pain, Outcome 3 Maternal adverse effects.

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Comparison 3 600 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.
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Analysis 3.1

Comparison 3 600 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.

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Comparison 3 600 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 2 Need for additional pain relief.
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Analysis 3.2

Comparison 3 600 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 2 Need for additional pain relief.

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Comparison 3 600 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 3 Maternal adverse effects.
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Analysis 3.3

Comparison 3 600 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 3 Maternal adverse effects.

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Comparison 4 300 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.
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Analysis 4.1

Comparison 4 300 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 1 Adequate pain relief as reported by the woman.

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Comparison 4 300 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 2 Need for additional pain relief.
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Analysis 4.2

Comparison 4 300 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 2 Need for additional pain relief.

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Comparison 4 300 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 3 Maternal adverse effects.
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Analysis 4.3

Comparison 4 300 mg aspirin versus 1200 mg aspirin for perineal pain, Outcome 3 Maternal adverse effects.

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Summary of findings for the main comparison. Aspirin compared with placebo for perineal pain in the early postpartum period

Aspirin compared with placebo for perineal pain in the early postpartum period

Patient or population: women with perineal pain in the early postpartum period

Settings: 17 RCTs published from 1967 to 1997 (11 RCTs conducted in USA, 3 in Venezuela, 1 each in Belgium, Canada and India)

Intervention: aspirin (single dose)

Comparison: placebo

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Placebo

Aspirin

Adequate pain relief as reported by the woman

(4 to 8 hours)

Study population

RR 2.03 (1.69, 2.42)

1001 (13 RCTs)

⊕⊕⊝⊝
low1

253 per 1000

513 per 1000 (427 to 612)

Need for additional pain relief

(4 to 8 hours)

Study population

RR 0.25 (0.17, 0.37)

744 (10 RCTs)

⊕⊝⊝⊝
very low1,2

267 per 1000

67 per 1000 (45 to 99)

Maternal adverse effects

(4 to 8 hours)

Study population

RR 1.08 (0.57, 2.06)

1067 (14 RCTs)

⊕⊝⊝⊝
very low1,3

27 per 1000

29 per 1000 (15 to 55)

Neonatal adverse effects

(0 RCTs)

Not reported by any of the included RCTs

Perineal pain at six weeks postpartum

(0 RCTs)

Not reported by any of the included RCTs

*The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1Study limitations: downgraded two levels due to the serious risk of bias

2Publication bias: downgraded by one level based on visual inspection of funnel plot which indicates likely publication bias

3Imprecision: downgraded one level due to few events and wide 95% CI around the pooled estimate which includes no effect

Figuras y tablas -
Summary of findings for the main comparison. Aspirin compared with placebo for perineal pain in the early postpartum period
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Comparison 1. Aspirin versus placebo for perineal pain

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Adequate pain relief as reported by the woman Show forest plot

13

1001

Risk Ratio (M‐H, Fixed, 95% CI)

2.03 [1.69, 2.42]

1.1 300 mg aspirin

1

53

Risk Ratio (M‐H, Fixed, 95% CI)

2.6 [0.36, 18.88]

1.2 500 to 650 mg aspirin

11

800

Risk Ratio (M‐H, Fixed, 95% CI)

1.98 [1.64, 2.39]

1.3 900 mg aspirin

1

40

Risk Ratio (M‐H, Fixed, 95% CI)

1.83 [0.84, 3.99]

1.4 1200 mg aspirin

3

108

Risk Ratio (M‐H, Fixed, 95% CI)

2.75 [1.25, 6.06]

2 Need for additional pain relief Show forest plot

10

744

Risk Ratio (M‐H, Fixed, 95% CI)

0.25 [0.17, 0.37]

2.1 300 mg aspirin

1

53

Risk Ratio (M‐H, Fixed, 95% CI)

0.16 [0.03, 0.79]

2.2 500 to 650 mg aspirin

9

569

Risk Ratio (M‐H, Fixed, 95% CI)

0.27 [0.17, 0.41]

2.3 900 mg aspirin

1

40

Risk Ratio (M‐H, Fixed, 95% CI)

0.14 [0.01, 2.60]

2.4 1200 mg aspirin

2

82

Risk Ratio (M‐H, Fixed, 95% CI)

0.20 [0.06, 0.70]

3 Maternal adverse effects Show forest plot

14

1067

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.57, 2.06]

3.1 300 mg aspirin

1

53

Risk Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

3.2 500 to 650 mg aspirin

13

892

Risk Ratio (M‐H, Fixed, 95% CI)

1.13 [0.51, 2.53]

3.3 900 mg aspirin

1

40

Risk Ratio (M‐H, Fixed, 95% CI)

2.5 [0.55, 11.41]

3.4 1200 mg aspirin

2

82

Risk Ratio (M‐H, Fixed, 95% CI)

0.10 [0.01, 1.80]
Figuras y tablas -
Comparison 1. Aspirin versus placebo for perineal pain
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Comparison 2. 300 mg aspirin versus 600 mg aspirin for perineal pain

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Adequate pain relief as reported by the woman Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2 Need for additional pain relief Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3 Maternal adverse effects Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only
Figuras y tablas -
Comparison 2. 300 mg aspirin versus 600 mg aspirin for perineal pain
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Comparison 3. 600 mg aspirin versus 1200 mg aspirin for perineal pain

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Adequate pain relief as reported by the woman Show forest plot

2

121

Risk Ratio (M‐H, Fixed, 95% CI)

0.85 [0.52, 1.39]

2 Need for additional pain relief Show forest plot

2

121

Risk Ratio (M‐H, Fixed, 95% CI)

1.32 [0.30, 5.68]

3 Maternal adverse effects Show forest plot

2

121

Risk Ratio (M‐H, Fixed, 95% CI)

3.0 [0.13, 69.52]
Figuras y tablas -
Comparison 3. 600 mg aspirin versus 1200 mg aspirin for perineal pain
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Comparison 4. 300 mg aspirin versus 1200 mg aspirin for perineal pain

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Adequate pain relief as reported by the woman Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2 Need for additional pain relief Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3 Maternal adverse effects Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only
Figuras y tablas -
Comparison 4. 300 mg aspirin versus 1200 mg aspirin for perineal pain
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