Slavic population entered the town in the late 18th century but its number rose just during early 19th century. The city is embellished with many rivers and tile-roofs houses. The mosque in the downtown is beautiful, there are tekke, madrassa , hammam , a number of shops and water mills; and the climate is pleasant and agreeable. There are many vineyards and gardens". In , Karposh, a brigand commander in the region of Dospat present-day Bulgaria , who served as an Ottoman Christian auxiliary force commander, took advantage of the weakening of the Ottomans and discontent that arose concerning higher Ottoman taxation policies, and organized a revolt while Austria staged an attack on the Ottomans. Later changes in the military and political situation in the Balkans had crucial downwards effect on the revolt.

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Publication status and date: New search for studies and content updated no change to conclusions , published in Issue 10, Review content assessed as up-to-date: 6 July Roz Ullman, Lesley Smith, Ethel Burns and Therese Dowswell assessed studies for eligibility, carried out data extraction and analysis, and drafted the text of the review.

Rintaro Mori carried out data extraction and commented on drafts. See other articles in PMC that cite the published article. Abstract Parenteral opioids are used for pain relief in labour in many countries throughout the world. Objectives To assess the acceptability, effectiveness and safety of different types, doses and modes of administration of parenteral opioids given to women in labour.

Selection criteria 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 another opioid, placebo, other non-pharmacological interventions TENS or inhaled analgesia. Data collection and analysis At least two review authors independently assessed study eligibility, collected data and assessed risk of bias. Main results We included 57 studies involving more than women that compared an opioid with placebo, another opioid administered intramuscularly or intravenously or compared with TENS to the back.

The 57 studies reported on 29 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. 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.

Maternal satisfaction with opioid analgesia was largely unreported but appeared moderate at best. This review needs to be examined alongside related Cochrane reviews examining pain management in labour.

More research is needed to determine which analgesic intervention is most effective, and provides greatest satisfaction to women with acceptable adverse effects for mothers and their newborn.

These reviews contribute to an overview of systematic reviews of pain management for women in labour Jones b and share a generic protocol Jones a. Description of the condition Pain during labour is normal, being one of the few examples of pain which does not signal pathology or harm.

This does not make the experience of pain any less, but it may alter the way pain is perceived, both by the woman in labour and those providing care. Characteristics of labour pain Pain during labour is intermittent, accompanying uterine contractions Findley Characteristically the pain intensifies as the contraction increases, reaching a peak when the contraction is at its strongest, then diminishing as the uterus relaxes.

Between contractions the uterus is at rest and there is usually no associated pain. As labour progresses the uterine contractions grow stronger, more frequent and longer lasting; at the same time they become more painful.

Typically the strongest, most frequent, and most painful, uterine contractions occur at the end of the first stage of labour as the cervix reaches full dilatation. While the vast majority of women will describe at least some stages of labour as painful, the severity of reported pain varies considerably Findley Pain relief in labour - physiology and pain perceptions Labour pain as perceived by women is a unique, subjective and complex neuro-hormonal phenomenon, which involves the interaction of physiological and psychological factors Genesi a ; Genesi b ; Trout Several factors have been shown to reduce pain experienced by women in labour.

These include continuous support of a caregiver, attendance of a birth companion and a relaxed birth environment Hodnett Two other key determinants that may influence the pain level that a woman experiences are feeling in control of her behaviour, and the care she receives. The extent to which a woman can actively participate in negotiating the care she receives has also been linked to overall maternal satisfaction with the childbirth experience Green ; Hodnett The degree to which a woman is satisfied with the birth experience is not, therefore, solely associated with the pain felt.

From the clinical point of view, the management of pain during labour involves much more than simply the provision of a pharmacological intervention. A large UK survey that collected maternal and midwifery assessments of pain relief found that midwives rated pethidine more positively than the women who received it Chamberlain Whilst some women prefer to labour without the use of pharmacological analgesia, others opt, for example, to use epidural analgesia throughout labour.

It is important that decisions for coping with the pain of labour are based on informed choice Green ; Hawkins Pain relief in labour - the use of opioids The use of pain-relieving drugs during labour is now standard care in many countries throughout the world Findley ; Reynolds The extent of usage of parenteral opioids during labour is unclear; however, most obstetric units in developed countries offer intramuscular opioids, along with facilities for epidural analgesia.

Opioids are relatively inexpensive, and use of the opioid drugs pethidine, meptazinol or diamorphine during labour is common midwifery and obstetric practice in some countries. In other parts of the world, parenteral opioids commonly used in labour include morphine, nalbuphine, fentanyl and more recently remifentanil Evron Worldwide, pethidine is the most commonly used opioid Bricker In the UK, a midwife can take responsibility for giving a woman an intramuscular injection of either pethidine or diamorphine, without a prescription from a medical practitioner, whether she is working in the hospital or community care setting MHRA A survey of women reported that The use of an opioid varied by parity, with more nulliparae reporting use with or without an epidural compared with multiparous women.

Some maternity practitioners have voiced concerns about the use of parenteral opioid analgesia during labour. These centre on doubt about analgesic effectiveness, and anxiety about the sedative effects on women and babies.

If a woman feels drowsy or sedated, she is less likely to mobilise and adopt an upright position, and as a result this may lengthen her labour, and make it more painful Lawrence Effects on the baby Opioids readily cross the placenta by passive diffusion. It is estimated that it can take a newborn three to six days to eliminate pethidine, and its metabolite, norpethidine, from its system Hogg Pethidine has been shown to significantly affect fetal heart rate variability, accelerations and decelerations during labour Sekhavat ; Solt Changes in normal fetal heart indices have consequences for the woman.

She will be required to have electronic fetal heart rate monitoring EFM if she is in hospital, and transfer to hospital if she is in a community setting. Results from observational studies have reported effects of opioids on the newborn that include inhibited sucking at the breast and decreased alertness, resulting in delayed effective breastfeeding Nissen ; Ransjo-Arvidson ; Righard Why it is important to do this review This review evaluates effects of parenteral opioids for analgesia in labour.

The use of intramuscular injection of opioid analgesia in labour became a traditional part of midwifery practice without evidence from randomised controlled trials for its analgesic effectiveness, impact on labour outcomes or acceptability to women. It is thought its perceived analgesic efficacy may be due, at least in part, to its sedative effects rather than a true reduction in perceived pain NICE There remains uncertainty amongst practitioners as to which opioid provides the most effective pain relief, and whether opioids used during labour are acceptable to women.

The most effective and acceptable mode of administration also remains unknown. In addition, there are concerns about the potential adverse effects associated with the use of opioids in labour, particularly the effects on the newborn in relation to infant feeding. At present, the choice of opioid for analgesia in labour depends on what is available in different hospitals.

However, no matter what facilities and drugs are available, women often have no choice as to which drug is used, and healthcare professionals have little information to guide decision-making. Whilst there have been previous reviews on this topic Bricker ; Elbourne this review provides an up-to-date summary of existing knowledge. We aim to provide best evidence to facilitate discussions between maternity practitioners and women to enable them to make informed decisions about their choice of analgesia during labour.

A second objective is to assess the effects of opioids in labour on the baby in terms of safety, condition at birth and early feeding.

We did not include quasi-randomised trials. We included studies presented only in abstracts provided that there was enough information to allow us to assess eligibility and risk of bias; if there was insufficient information we attempted to contact study authors.

Types of participants Women in labour. Types of interventions Parenteral opioids intramuscular and intravenous drugs, including patient controlled analgesia. Drugs for comparison include pethidine or meperidine, nalbuphine, butorphanol, diamorphine, buprenorphine, meptazinol, pentazocine, tramadol, alfentanil, sufentanil, remifentanil and fentanyl. The following comparisons were eligible for the review.

An opioid versus placebo using the same route of administration. An opioid versus another opioid using the same route of administration. An opioid plus an add-on drug versus another opioid plus the same add-on drug using the same route of administration. One opioid versus the same opioid but a different dose. Where different doses of the same drug were compared with the same comparator e.

This review is one in a series of Cochrane reviews examining pain management in labour. These reviews contribute to an overview of systematic reviews of interventions for pain management in labour Jones b , and share a generic protocol Jones a.

To avoid duplication, the different methods of pain management have been listed in a specific order, from one to Individual reviews focusing on particular interventions include comparisons with only the intervention above it on the list. Methods of pain management identified in the future will be added to the end of the list. The current list is as follows.


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Parenteral opioids for maternal pain management in labour




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