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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

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Prolonging the duration of single-shot intrathecal labour analgesia with morphine: A systematic review

Hadeel Al-Kazwini / Irene Sandven / Vegard Dahl
  • Department of Anaesthesia and Intensive Care Medicine, Akershus University Hospital, Loerenskog, Norway
  • Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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/ Leiv Arne Rosseland
  • Corresponding author
  • Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
  • Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Published Online: 2017-12-29 | DOI: https://doi.org/10.1016/j.sjpain.2016.06.010


Background and aims

Single-shot spinal with bupivacaine plus fentanyl or sufentanil is commonly used as analgesia during labour, but the short duration limits the clinical feasibility. Different drugs have been added to prolong the analgesic duration. The additional effect of intra-thecal morphine has been studied during labour pain as well as after surgery. We assessed whether adding morphine to intra-thecal bupivacaine + fentanyl or sufentanil prolongs pain relief during labour.


Meta-analysis of placebo-controlled randomized clinical trials of analgesia prolongation after single-shot intrathecal morphine ≤250µg during labour when given in combination with bupivacaine + fentanyl or sufentanil. After identifying 461 references, 24 eligible studies were evaluated after excluding duplicate publications, case reports, studies of analgesia after caesarean delivery, and epidural labour analgesia. Mean duration in minutes was the primary outcome measure and was included in the calculation of the standardized mean difference. Duration was defined as the time between a single shot spinal until patient request of rescue analgesia. All reported side effects were registered. Results of individual trials were combined using a random effect model. Cochrane tool was used to assess risk of bias.


Five randomized placebo-controlled clinical trials (286 patients) were included in the metaanalysis. A dose of 50–250µg intrathecal morphine prolonged labour analgesia by a mean of 60.6 min (range 3–155 min). Adding morphine demonstrated a medium beneficial effect as we found a pooled effect of standardized mean difference = 0.57 (95% CI: –0.10 to 1.24) with high heterogeneity (I2 =88.1%). However, the beneficial effect was statistically non-significant (z =1.66, p = 0.096). The lower-bias trials showed a small statistically non-significant beneficial effect with lower heterogeneity. In influential analysis, that excluded one study at a time from the meta-analysis, the effect size appears unstable and the results indicate no robustness of effect. Omitting the study with highest effects size reduces the pooled effect markedly and that study suffers from inadequate concealment of treatment allocation and blinding. Trial quality was generally low, and there were too few trials to explore sources of heterogeneity in meta-regression and stratified analyses. In general, performing meta-analyses on a small number of trials are possible and may be helpful if one is aware of the limitations. As few as one more placebo-controlled trial would increase the reliability greatly.


Evidence from this systematic review suggests a possible beneficial prolonging effect of adding morphine to spinal analgesia with bupivacaine + fentanyl or +sufentanil during labour. The study quality was low and heterogeneity high. No severe side effects were reported. More adequately-powered randomized trials with low bias are needed to determine the benefits and harms of adding morphine to spinal local anaesthetic analgesia during labour.


Epidural analgesia is documented as the most effective method for providing pain relief during labour, but from a global perspective most women in labour have no access to epidural analgesia. Adding morphine to single shot spinal injection of low dose bupivacaine, fentanyl or sufentanil may be efficacious but needs to be investigated.

Keywords: Morphine; Spinal; Birth; Pain; Complications


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About the article

Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Box 4950 Nydalen, 0424 Oslo, Norway. Tel.:+47 92204274.

Received: 2016-04-22

Revised: 2016-06-22

Accepted: 2016-06-27

Published Online: 2017-12-29

Ethical issues: Approval of ethical board not required: SeeSection 2.

Conflicts of interest: The authors declare no conflicts of interest. The project received no funding.

Citation Information: Scandinavian Journal of Pain, Volume 13, Issue 1, Pages 36–42, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2016.06.010.

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