Parenteral opioids for maternal pain relief in labour.
BACKGROUND
Parenteral opioids are used for pain relief in labour in many countries throughout the world.


OBJECTIVE
To assess the acceptability, effectiveness and safety of different types, doses and modes of administration of parenteral opioids given to women in labour.


METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010) and reference lists of retrieved studies.


METHODS
We included randomised controlled trials examining the use of intramuscular or intravenous opioids (including patient controlled analgesia) for women in labour. We looked at studies comparing an opioid with placebo or another opioid.


METHODS
At least two review authors independently assessed study eligibility, collected data and assessed risk of bias.


RESULTS
We included 54 studies involving more than 7000 women that compared an opioid with placebo or another opioid administered intramuscularly or intravenously. The 54 studies reported on 27 different comparisons, and for many outcomes only one study contributed data. Overall the evidence was of poor quality regarding the analgesic effect of opioids, satisfaction with analgesia, adverse effects and harm to women and babies. There were few statistically significant results. Many of the studies had small sample sizes, and low statistical power. Overall, findings indicated that parenteral opioids provided some pain relief and moderate satisfaction with analgesia in labour, although up to two-thirds of women who received opioids reported moderate or severe pain and/or poor or moderate pain relief one or two hours after administration. Opioid drugs were associated with maternal nausea, vomiting and drowsiness, although different opioid drugs were associated with different adverse effects. There was no clear evidence of adverse effects of opioids on the newborn. We did not have sufficient evidence to assess which opioid drug provided the best pain relief with the least adverse effects.


CONCLUSIONS
Parenteral opioids provide some relief from pain in labour but are associated with adverse effects. Maternal satisfaction with opioid analgesia was largely unreported but appeared moderate at best. We did not examine the effectiveness and safety of parenteral opioids compared with other methods of pain relief in labour and this review needs to be examined alongside related Cochrane reviews. More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse events for mothers and their newborns.
Ullman
Roz
R
National Collaborating Centre for Women's and Children's Health, 4th Floor, Kings Court, 2-16 Goodge Street, London, UK, W1T 2QA.
Smith
Lesley A
LA
Burns
Ethel
E
Mori
Rintaro
R
Dowswell
Therese
T
D016362:Analgesia, Obstetrical / Q000379:methods*; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D007275:Injections, Intravenous; D048949:Labor Pain / Q000188:drug therapy*; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic
D000701:Analgesics, Opioid
J Obstet Gynecol Neonatal Nurs. 1995 May;24(4):327-31
7643264
J Anesth. 2008;22(2):105-11
18500605
Obstet Gynecol. 1965 Jan;25:68-71
14242552
Br J Obstet Gynaecol. 1999 Nov;106(11):1181-7
10549964
Lancet. 1961 Jan 14;1(7168):75-7
13718807
Br J Anaesth. 2002 Mar;88(3):374-8
11990269
Cochrane Database Syst Rev. 2012 Mar 14;(3):CD009234
22419342
Anaesthesia. 1986 Dec;41(12):1207-13
3812947
Anaesthesia. 1987 Jul;42(7):697-703
3631470
Int J Obstet Anesth. 2001 Apr;10(2):86-90
15321621
Cochrane Database Syst Rev. 2011 Jun 15;(6):CD006168
21678353
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD001063
17943750
Anesth Analg. 2005 Jan;100(1):233-238
15616083
J Gynecol Obstet Biol Reprod (Paris). 1981;10(1):91-8
7252094
Obstet Gynecol. 1989 Oct;74(4):604-6
2797637
J Clin Anesth. 2007 May;19(3):168-74
17531723
Br J Obstet Gynaecol. 1982 Apr;89(4):318-22
7041955
Br J Obstet Gynaecol. 1976 Jan;83(1):56-61
3197
Eur J Clin Pharmacol. 1988;34(5):509-11
3264528
Aust N Z J Obstet Gynaecol. 2009 Feb;49(1):59-63
19281581
Br J Anaesth. 1980 Mar;52(3):265-71
6768376
J Obstet Gynaecol Br Commonw. 1969 Apr;76(4):359-61
4888310
Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003934
19370591
Am J Obstet Gynecol. 1966 Jul 1;95(5):636-9
5940065
Br J Anaesth. 1955 Jul;27(7):346-53
13239939
Cochrane Database Syst Rev. 2008 Oct 08;(4):CD004667
18843666
Z Geburtshilfe Perinatol. 1987 Nov-Dec;191(6):234-7
3331863
S Afr Med J. 1970 Mar 14;44(11):317-9
4907758
J Int Med Res. 1979;7(3):224-30
378732
BJOG. 2004 Oct;111(10):1081-9
15383110
J Obstet Gynecol Neonatal Nurs. 1993 Jul-Aug;22(4):349-56
8410434
Int J Obstet Anesth. 2007 Jul;16(3):221-5
17459691
Acta Anaesthesiol Scand. 2008 Feb;52(2):249-55
18005381
Middle East J Anaesthesiol. 2010 Feb;20(4):539-45
20394251
Lancet. 1957 Jan 19;272(6960):128-32
13399148
J Obstet Gynaecol Br Commonw. 1970 Sep;77(9):824-9
5458774
Prakt Anaesth. 1978 Feb;13(1):13-20
634895
J Gynecol Obstet Biol Reprod (Paris). 1980;9(2):261-6
7005306
Anaesthesia. 1987 Jan;42(1):7-14
3826577
J Obstet Gynaecol Br Commonw. 1970 Sep;77(9):830-6
5458775
Postgrad Med J. 1983;59 Suppl 1:47-51
6835891
Am J Obstet Gynecol. 1962 Oct 1;84:956-61
13910705
J Med Assoc Thai. 1986 Nov;69(11):575-80
3819616
Anaesthesia. 1980 Aug;35(8):763-70
7004257
JAMA. 1962 Jul 28;181:290-4
14488364
Am J Obstet Gynecol. 1969 Sep 15;105(2):197-202
5810448
Am J Obstet Gynecol. 1966 Oct 1;96(3):430-6
5919496
Eur J Obstet Gynecol Reprod Biol. 1984 Sep;18(1-2):25-8
6500147
Can J Anaesth. 2003 Dec;50(10):1039-46
14656784
Birth. 2001 Mar;28(1):5-12
11264622
Gynecol Obstet Invest. 1991;32(1):39-43
1765317
Br Med J. 1970 Jun 27;2(5712):757-9
4913784
Expert Opin Pharmacother. 2007 Dec;8(18):3089-96
18035955
S Afr Med J. 1985 May 11;67(19):764-7
3992403
Am J Obstet Gynecol. 1994 Oct;171(4):993-8
7943116
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001237
17636658
BJOG. 2004 Jul;111(7):648-55
15198753
Epidemiology. 2000 Nov;11(6):715-6
11055636
J Pediatr. 1963 Jun;62:934-5
13982835
Br J Obstet Gynaecol. 1996 Oct;103(10):968-72
8863693
Int J Gynaecol Obstet. 1980;18(5):363-7
6110584
Isr Med Assoc J. 2002 Mar;4(3):178-80
11908257
Obstet Gynecol. 2009 May;113(5):1066-1074
19384122
Br J Obstet Gynaecol. 1975 Feb;82(2):126-31
1125141
Am J Obstet Gynecol. 1958 May;75(5):1105-10
13520837
Birth. 2003 Dec;30(4):235-47
14992154
Anaesthesia. 1979 Nov-Dec;34(10):996-1004
395854
Anesthesiology. 1998 Dec;89(6):1336-44
9856707
N Engl J Med. 1964 Feb 20;270:391-4
14087041
Cochrane Database Syst Rev. 2005 Oct 19;(4):CD000331
16235275
Int J Gynaecol Obstet. 1988 Feb;26(1):75-80
2892742
BMJ. 1999 Apr 3;318(7188):927-30
10102864
Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007214
19370680
Acta Biomed Ateneo Parmense. 2000;71 Suppl 1:397-400
11424777
Acta Anaesthesiol Scand. 2005 Apr;49(4):453-8
15777291
Can J Anaesth. 2007 Aug;54(8):626-33
17666715
Anaesthesia. 1966 Oct;21(4):464-71
5331992
N Z Med J. 2004 Nov 26;117(1206):U1177
15570346
Eur J Obstet Gynecol Reprod Biol. 2006 Dec;129(2):135-9
16406273
Lancet. 1990 Nov 3;336(8723):1105-7
1977988
Cochrane Database Syst Rev. 2018 May 16;5:CD000111
29768662
Br J Anaesth. 1974 May;46(5):365-72
4620356
Am J Obstet Gynecol. 1967 Dec 1;99(7):989-93
6058747
Br Med J. 1964 Mar 14;1(5384):677
14096465
BMC Anesthesiol. 2006 Dec 18;6:15
17176461
Dtsch Med Wochenschr. 1963 Jul 19;88:1426-30
13997902
Cochrane Database Syst Rev. 2012 Jan 18;1:CD009107
22258999
J Ir Med Assoc. 1971 Mar 18;64(408):173-6
5554332
Am J Obstet Gynecol. 1964 Mar 1;88:601-5
14130015
Z Geburtshilfe Perinatol. 1992 Mar-Apr;196(2):78-82
1609533
Lakartidningen. 1971 Oct 18;68:Suppl 3:41-4
5153810
Can J Anaesth. 1994 Aug;41(8):667-72
7923512
Am J Obstet Gynecol. 1966 Sep 15;96(2):213-20
5331843
BMJ. 1990 Nov 10;301(6760):1067-70
2249068
Anesthesiology. 2000 Jul;93(1):122-8
10861155
Geburtshilfe Frauenheilkd. 1991 May;51(5):362-5
1869004
Am J Obstet Gynecol. 2002 May;186(5 Suppl Nature):S94-109
12011876
Zhonghua Fu Chan Ke Za Zhi. 1995 Jun;30(6):345-8
7555368
S Afr Med J. 1981 Jun 13;59(25):908-10
7015539
Am J Obstet Gynecol. 2004 Oct;191(4):1212-8
15507943
Br J Anaesth. 1977 Sep;49(9):891-9
20914
Eur J Obstet Gynecol Reprod Biol. 1992 Sep 23;46(2-3):87-94
1451900
Obstet Gynecol. 1961 Jun;17:714-8
13690207
Ugeskr Laeger. 1972 Oct 23;134(43):2261-5
4564230
Can J Anaesth. 2000 Feb;47(2):113-9
10674503
J Clin Monit Comput. 2000;16(8):597-608
12580236
J Med Assoc Thai. 2002 Nov;85(11):1169-75
12546313
Br J Anaesth. 1965 Jan;37:23-8
14254041
J Midwifery Womens Health. 2004 Nov-Dec;49(6):482-8
15544977
Anaesthesia. 2005 Jan;60(1):22-7
15601268
Anesthesiol Rev. 1991 Jan-Feb;18(1):31-6
10148879
Isr J Med Sci. 1976 Oct;12(10):1141-7
990131
Pediatrics. 1978 Sep;62(3):294-8
704198
Br J Obstet Gynaecol. 1987 Mar;94(3):256-61
3567124
Eur J Obstet Gynecol Reprod Biol. 1993 May;49(3):131-5
8405626
Arch Fr Pediatr. 1979 Nov;36(9 Suppl):LXXV-LXXXI
44182
Res Nurs Health. 1993 Apr;16(2):141-9
8502766
J Perinat Med. 1982;10(1):48-53
7062233
Obstet Gynecol. 1966 Mar;27(3):350-4
5325606
Cochrane Database Syst Rev. 2012 Apr 18;(4):CD009200
22513972
Br Med J. 1964 Aug 8;2(5405):353-5
14160227
Anesthesiology. 2005 May;102(5):1008-13
15851889
Acta Paediatr. 1995 Feb;84(2):140-5
7756797
Br J Obstet Gynaecol. 1986 Mar;93(3):264-9
3516202
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003766
17636733
Cochrane Database Syst Rev. 2011 Jul 06;(7):CD009215
21735438
Int J Biomed Sci. 2009 Mar;5(1):59-62
23675116
Br Med J. 1960 Feb 27;1(5173):595-8
14419650
Obstet Gynecol. 1966 Feb;27(2):290-3
5325604
Ann Saudi Med. 2003 Sep-Oct;23(5):318-20
16868406
J Pediatr. 1964 Dec;65:925-8
14244099
N Engl J Med. 2005 Feb 17;352(7):655-65
15716559
Anestezjol Intens Ter. 2009 Apr-Jun;41(2):84-8
19697825
Int J Gynaecol Obstet. 2003 Jul;82(1):11-6
12834936
Am J Obstet Gynecol. 2002 May;186(5 Suppl Nature):S160-72
12011880
Anesth Analg. 2003 Nov;97(5):1439-1445
14570662
J Obstet Gynecol Neonatal Nurs. 1996 Jan;25(1):82-92
8627407
Cochrane Database Syst Rev. 2011 Jul 06;(7):CD009232
21735441
Obstet Gynecol. 1971 Dec;38(6):907-11
5125442
Br J Anaesth. 2010 Feb;104(2):209-15
20008859
Obstet Gynecol. 1995 Sep;86(3):441-5
7651658
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003401
17636721
Eur J Obstet Gynecol Reprod Biol. 1988 Dec;29(4):257-60
3265921
Ceska Gynekol. 2005 May;70(3):180-3
16047919
Eur J Obstet Gynecol Reprod Biol. 1988 Feb;27(2):99-104
3277876
Anesthesiology. 1992 Nov;77(5):884-7
1443741
J Obstet Gynaecol Br Commonw. 1967 Dec;74(6):925-8
4383689
Obstet Gynecol. 1989 Nov;74(5):702-6
2682412
Eur J Obstet Gynecol Reprod Biol. 1987 Sep;26(1):15-8
3666261
Zentralbl Gynakol. 1992;114(11):551-4
1481587
Obstet Gynecol. 1967 Oct;30(4):568-75
5342863
Fortschr Med. 1980 Apr 24;98(16):632-4
7390376
Med J Aust. 1962 Sep 29;49(2):499-503
14000851
Can Med Assoc J. 1960 Nov 19;83:1088-93
13742151
J Obstet Gynaecol Br Commonw. 1961 Feb;68:88-93
13689779
Cochrane Database Syst Rev. 2012 Jul 11;(7):CD009223
22786524
Can Anaesth Soc J. 1978 Sep;25(5):398-404
359109