{
  "abstract": "At our institution (Department of Perinatology, Gynaecology clinic, UMC Ljubljana, Slovenia), remifentanil-PCA has been routinely used for labour analgesia since 2013. By 2025, we had performed over 21000 remifentanil applications. Indications included parturient request, cases where epidural analgesia (EA) is contraindicated, unsuccessful epidural administration, accidental dural puncture, technical failure, advanced or rapidly progressing labour, and obstetric indications such as breech presentation, twin deliveries, or trial of labour after caesarean section. Contraindications included parturient refusal, history of opioid allergy, and administration of parenteral opioids within the previous four hours. As remifentanil-PCA is used ‘off-label’, informed consent is mandatory. This includes the explanation of the mode of its use (self-administered small doses of medication), limited analgesic efficacy (to align the experience with expectation to increase the parturient satisfaction), risks and side effects (respiratory depression, sedation, nausea, dizziness, and rare but serious complications like respiratory compromise), obligatory monitoring and safety measures. Remifentanil-PCA has been used by the standard operating protocol (SOP) of the Department of Anaesthesiology and Intensive Therapy at the University Medical Centre Ljubljana, which aligns with the SOP of the Slovene Society of Anaesthesiology and Intensive Care Medicine. Remifentanil-PCA is initiated in the active stage of labour with pain intensity >7 according to VAS scoring. Remifentanil hydrochloride is diluted in normal saline to a concentration of 40 µg/mL and administered in a dose ranging from 20 to 40 µg (starting with a higher dose for multiparas and parturients in an advanced stage of labour). The bolus is delivered at a constant flow rate of 1.67 mL/min, with a lockout interval of 2 min and no background infusion. Each parturient receives supplemental oxygen (2 L/min) via a nasal catheter and is continuously monitored for the level of sedation (should be 2 or less according to Ramsey scoring), oxygen saturation, heart rate, end-tidal CO2, cardiotocography (CTG), and blood pressure every 30 min. To decrease the neonatal side effects, remifentanil-PCA is discontinued during the second stage of labour when the parturient is actively pushing to deliver the baby, or in cases of pathologic CTG. We intend to provide one-to-one midwifery care and have an anaesthetic team always present in the Labour & Delivery ward. Accordingly, over the past 12 years, we have not observed any severe maternal complications, such as cardiorespiratory arrest or respiratory depression requiring mask ventilation or intubation associated with remifentanil-PCA usage. This positive safety record can be attributed to our well-established, continuously reviewed, and rigorously implemented protocols, which have remained largely unchanged, except for the omission of continuous infusion. In a prospective observational trial comparing remifentanil-PCA with combined spinal-epidural analgesia in multiparous women, events such as desaturation below 94%, bradypnea (respiratory rate < 8 breaths/min), and apnoea lasting over 20 seconds were recorded in 34%, 20%, and 25% of parturients, respectively. Each of these events was effectively managed through prompt intervention, ensuring maternal safety. Remifentanil-PCA is not typically chosen for completely pain-free labour but rather for women who prefer to avoid or cannot have neuraxial techniques, or who wish to maintain some level of control over their pain management. Additionally, when a woman’s main issues are fear and anxiety, remifentanil can be beneficial in alleviating these psychological factors. Thus, we strictly emphasise mild to moderate pain relief, the extent of which ranges from severe, unbearable pain (VAS 8–10) to intermediate, tolerable pain (VAS 5–7), helping women better manage their discomfort during labour. In our recent study involving over 1000 parturients (≥37 weeks gestation with singleton, cephalic foetuses, whether spontaneous or induced labour) delivering at our institution between January 1, 2019, and December 31, 2019, the limited analgesic effectiveness of remifentanil-PCA was confirmed, regardless of the phase of the labour at initiation of analgesia or parity. This suggests that remifentanil-PCA could be administered at any stage of labour, which, in addition to immediate availability and rapid pain relief, increases its flexibility in clinical practice. This is especially valuable in rapidly progressing or advanced labour cases, where immediate epidural placement may not be feasible, and effects could be delayed. Despite limited analgesic efficacy, we generally observe good parturient satisfaction with a remifentanil analgesia. This may be attributed to lower expectations regarding pain relief among those who select remifentanil-PCA, as they are already counselled that complete pain relief with remifentanil-PCA is unlikely. In addition, women who choose remifentanil-PCA might value factors such as its immediate availability, rapid onset of self-administered analgesia, continuous midwifery support, and the euphoric and sedative effects of opioids on pain perception reduction. These benefits are especially advantageous for multiparas, given the typically shorter labour duration and the quicker availability and onset of analgesia with remifentanil-PCA compared to epidural analgesia. Remifentanil-PCA has demonstrated advantages over neuraxial analgesia in labour and delivery outcomes. In our cohort study of over 10,000 deliveries comparing epidural analgesia to remifentanil-PCA over 5 years, remifentanil-PCA was associated with lower rates of caesarean delivery (CD) and operative vaginal deliveries (OVD) in nulliparous women with both spontaneous and induced labour, as well as in multiparous women with spontaneous onset of labour. Moreover, remifentanil-PCA was associated with a lower incidence of operative delivery with pathologic CTG in all four studied groups. However, no differences in APGAR < 7 at 5 min, neonatal asphyxia, and NICU admission were recorded between the two analgesic techniques within any of the studied groups. Nevertheless, the associations observed in that study may not necessarily imply a causal relationship. Favourable results of non-operative delivery with remifentanil-PCA may also point to the fact that more complicated labours require EA to assist in their management. Indeed, nulliparous women with EA were older, which represents an independent risk factor for labour dystocia. The reason could be that women with normal labour progress or expectations of faster labour are more likely to choose remifentanil-PCA to avoid the potential adverse/side effects of EA. This is particularly true of multiparous women who can combine a fast delivery with rapid availability and a short use of pain relief. The availability of different options for pain relief, the feeling of control, and constant one-to-one care with remifentanil may furthermore enhance labour progress by increasing satisfaction and reducing stress. Lower operative vaginal delivery rates were also observed in the RESPITE study, which compared remifentanil-PCA with intramuscular pethidine. However, this difference was most likely not directly attributable to remifentanil, but rather to its lower rate of conversion to epidural anaesthesia as epidural anaesthesia itself is associated with a higher operative vaginal delivery rate. In our institution, remifentanil-PCA is also used for certain obstetric conditions, such as a history of previous CD, twin gestation, or a breech presentation, which may pose heightened risks for intrapartum CD with epidural analgesia. A retrospective analysis of 127 planned vaginal breech and 244 twin deliveries for the period 2013–2021 using data from the Slovenian National Perinatal Information System showed no statistically significant nor clinically relevant differences between the EA and remifentanil-PCA groups in the rates of CD in labour, postpartum haemorrhage, obstetric anal sphincter injury (OASI), APGAR score of",
  "authors": [
    {
      "affiliations": [
        "Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Slovenia, Ljubljana, Slovenia"
      ],
      "name": "Tatjana Stopar Pintaric"
    },
    {
      "affiliations": [
        "Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Slovenia, Ljubljana, Slovenia"
      ],
      "name": "Pia Vovk Racman"
    }
  ],
  "title": "FT30 Remifentanil-PCA: practical guidance",
  "uid": "32a5a83d-e730-5bf7-84b4-82d40e6c62ea"
}