Vol 92, No 11 (2021)
Research paper
Published online: 2021-04-15

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Analgesic efficacy of remifentanil patient-controlled analgesia versus combined spinal-epidural technique in multiparous women during labour

Iva Blajic1, Tea Zagar2, Neli Semrl2, Nejc Umek3, Miha Lucovnik24, Tatjana Stopar Pintaric13
Pubmed: 33914329
Ginekol Pol 2021;92(11):797-803.


Objectives: To compare the analgesic profile of remifentanil patient-controlled analgesia (RPCA) and combined spinal-epidural analgesia technique (CSEA) in multiparous women during the entire labour. We hypothesized that CSEA would provide a better and more sustained pain reduction than RPCA.
Material and methods: A prospective observational trial under ID NCT02963337 at a university hospital in Slovenia 2017–2018. Analgesic efficacy, satisfaction with pain-relief, adverse effects, labour progress, and outcomes between RPCA (80) and CSEA (81) were compared.
Results: CSEA provided significantly lower pain scores during the entire labour. Compared to baseline, significant pain reduction was recorded in both groups after 15 min. No difference was recorded compared to baseline with RPCA and CSEA after 45 and 90 mins, respectively. CSEA provided higher satisfaction than RPCA (5 [5–5] vs 5 [4–5], p < 0.0001). More patients with CSEA opted for the same technique for the next labour [CSEA; 77 (95%) vs RPCA; 65 (81%), p = 0.003]. No crossovers were observed. RPCA was associated with desaturation (34%), bradypnea (21%) and apnoea (25%), which were transitional and easily managed. None had severe sedation. No differences were recorded in labour progress and outcomes. Apgar scores were reassuring in all neonates (> 8). None had umbilical artery pH < 7.0.
Conclusions: In multiparas, CSEA provided superior analgesia and satisfaction than RPCA. Nevertheless, RPCA provided a satisfactory experience, suggesting it could be used when neuraxial analgesia is not available, preferred, or contraindicated. In that case, constant presence of midwife is mandatory for management of clinically significant hypoventilation.

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  1. Goodman SR, Smiley RM, Negron MA, et al. A randomized trial of breakthrough pain during combined spinal-epidural versus epidural labor analgesia in parous women. Anesth Analg. 2009; 108(1): 246–251.
  2. Freeman LM, Bloemenkamp KW, Franssen MT, et al. Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial. BMJ. 2015; 350: h846.
  3. Logtenberg S, Oude Rengerink K, Verhoeven CJ, et al. Labour pain with remifentanil patient-controlled analgesia versus epidural analgesia: a randomised equivalence trial. BJOG. 2017; 124(4): 652–660.
  4. Blair JM, Hill DA, Fee JP. Patient-controlled analgesia for labour using remifentanil: a feasibility study. Br J Anaesth. 2001; 87(3): 415–420.
  5. Weiniger CF, Carvalho B, Stocki D, et al. Analysis of Physiological Respiratory Variable Alarm Alerts Among Laboring Women Receiving Remifentanil. Anesth Analg. 2017; 124(4): 1211–1218.
  6. Tveit TO, Seiler S, Halvorsen A, et al. Labour analgesia: a randomised, controlled trial comparing intravenous remifentanil and epidural analgesia with ropivacaine and fentanyl. Eur J Anaesthesiol. 2012; 29(3): 129–136.
  7. Tveit TO, Halvorsen A, Seiler S, et al. Efficacy and side effects of intravenous remifentanil patient-controlled analgesia used in a stepwise approach for labour: an observational study. International Journal of Obstetric Anesthesia. 2013; 22(1): 19–25.
  8. Stocki D, Matot I, Einav S, et al. A randomized controlled trial of the efficacy and respiratory effects of patient-controlled intravenous remifentanil analgesia and patient-controlled epidural analgesia in laboring women. Anesth Analg. 2014; 118(3): 589–597.
  9. Robson MS. Active management of labour. Continual audit is important. BMJ. 1994; 309(6960): 1015.
  10. Todd KH, Funk KG, Funk JP, et al. Clinical significance of reported changes in pain severity. Ann Emerg Med. 1996; 27(4): 485–489.
  11. Wilson MJA, MacArthur C, Hewitt CA, et al. RESPITE Trial Collaborative Group. Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial. Lancet. 2018; 392(10148): 662–672.
  12. Douma MR, Verwey RA, Kam-Endtz CE, et al. Obstetric analgesia: a comparison of patient-controlled meperidine, remifentanil, and fentanyl in labour. Br J Anaesth. 2010; 104(2): 209–215.
  13. Lowe N. Parity Pain During Parturition. Journal of Obstetric, Gynecologic & Neonatal Nursing. 1987; 16(5): 340–346.
  14. Douma MR, Middeldorp JM, Verwey RA, et al. A randomised comparison of intravenous remifentanil patient-controlled analgesia with epidural ropivacaine/sufentanil during labour. Int J Obstet Anesth. 2011; 20(2): 118–123.
  15. Melber AA, Jelting Y, Huber M, et al. Remifentanil patient-controlled analgesia in labour: six-year audit of outcome data of the RemiPCA SAFE Network (2010-2015). Int J Obstet Anesth. 2019; 39: 12–21.
  16. Murray H, Hodgkinson P, Hughes D. Remifentanil patient-controlled intravenous analgesia during labour: a retrospective observational study of 10 years' experience. Int J Obstet Anesth. 2019; 39: 29–34.
  17. Volikas I, Butwick A, Wilkinson C, et al. Maternal and neonatal side-effects of remifentanil patient-controlled analgesia in labour. Br J Anaesth. 2005; 95(4): 504–509.
  18. Messmer AA, Potts JM, Orlikowski CE. A prospective observational study of maternal oxygenation during remifentanil patient-controlled analgesia use in labour. Anaesthesia. 2016; 71(2): 171–176.
  19. Griffin RP, Reynolds F. Maternal hypoxaemia during labour and delivery: the influence of analgesia and effect on neonatal outcome. Anaesthesia. 1995; 50(2): 151–156.
  20. Prelec A, Verdenik I, Poat AA. comparison of frequency of medical interventions and birth outcomes between the midwife led unit and the obstetric unit in low-risk primiparous women. Slov Nurs Rev. 2014; 48(3): 166–176.
  21. Lin R, Tao Y, Yu Y, et al. Intravenous remifentanil versus epidural ropivacaine with sufentanil for labour analgesia: a retrospective study. PLoS One. 2014; 9(11): e112283.
  22. Anim-Somuah M, Smyth R, Cyna A, et al. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database of Systematic Reviews. 2018.
  23. Thorbiörnson A, da Silva Charvalho P, Gupta A, et al. Duration of labor, delivery mode and maternal and neonatal morbidity after remifentanil patient-controlled analgesia compared with epidural analgesia. Eur J Obstet Gynecol Reprod Biol X. 2020; 6: 100106.
  24. Flint AP, Forsling ML, Mitchell MD. Blockade of the Ferguson reflex by lumbar epidural anaesthesia in the parturient sheep: effects on oxytocin secretion and uterine venous prostaglandin F levels. Horm Metab Res. 1978; 10(6): 545–547.
  25. Clyde LA, Lechuga TJ, Ebner CA, et al. Transection of the pelvic or vagus nerve forestalls ripening of the cervix and delays birth in rats. Biol Reprod. 2011; 84(3): 587–594.