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.
Background : Remifentanil has a suitable pharmacological profile for labour analgesia. Fast set up, onset, and limited time efficacy may render it useful in multiparas with a faster labour progression. The objective of this prospective, non-randomized trial was to compare the pain relief for vaginal delivery between remifentanil patient-controlled analgesia (RPCA) with that of combined spinal-epidural analgesia (CSEA) in multiparas. Methods : After making an informed choice of either RPCA or CSEA, 162 multiparous women in the active phase of first-stage labour were enrolled in this study. The primary outcome was pain intensity measured during the whole period of labour using an 11-point numerical rating scale. The secondary outcomes were satisfaction with pain-relief, adverse effects, labour progress and outcomes. Results : CSEA provided lower pain scores and a higher satisfaction rate than RPCA [3.9 (0.36) vs 2.6 (1.1), P <0.001]. Also, more patients opted for the CSEA for their next labour [CSEA; 77 (95%) vs. RPCA; 65 (81%), P =0.003]. However, more than 80% of women in the RPCA group graded their satisfaction as good and very good with a high rate of recommendation and no crossovers observed. Remifentanil was associated with desaturation, bradypnea and apnoea in 27 (34%), 17 (21%) and 20 (25%) respective cases. All recovered spontaneously upon verbal or tactile stimulation. No clinically important differences were noted in sedation level, labour progress and outcomes. Conclusions : CSEA provided superior pain relief compared to RPCA in multiparas. Despite that, remifentanil was highly rated, with a high rate of recommendation and no crossovers to CSEA. That can be attributed to the fact that women with previewed shorter labour were more likely to choose a less invasive analgesic option which provided an element of personal control. Thus, given no difference in labour outcomes, remifentanil could be offered as a routine analgesic option provided rigorous adherence to the necessary protocols are ensured. The presence of a midwife is essential for timely management of respiratory depression or other severe outcomes.
Background The combined spinal-epidural analgesia (CSEA) proved useful in multiparous women on account of faster onset and better analgesia in the first 30 minutes compared to standard epidural analgesia. Remifentanil has a suitable pharmacological profile for labour analgesia. Fast set up, onset, and limited time efficacy may render it useful in multiparous women with a faster labour progression.Methods The prospective observational study was performed in multiparous women in their active phase of the first stage labour after their informed choice of either RPCA (n=80) or CSEA (n=82). The primary outcome was pain-relief assessed on a 11-point numerical rating scale. The secondary outcomes were with pain-relief satisfaction, adverse effects, labour progress and labour outcomes.Results CSEA provided significantly lower pain scores and a higher satisfaction rate compared to RPCA [3.9 (0.36) vs 2.6 (1.1), P<0.001]. Likewise, more patients from the CSEA group would choose the same technique for the next labour CSEA; 77 (95%) vs. RPCA; 65 (81%), P=0.003. No difference between the groups was observed in recommending the respective technique to others CSEA; 77 (95%) vs. RPCA; 72 (90%), P=0.118. No crossovers were observed in either group. RPCA was associated with desaturation, bradypnea and apnoea in 27 (34%), 17 (21%) and 20 (25%) respective cases. All recovered spontaneously upon verbal or tactile stimulation. No clinically important differences were noted in sedation level, labour progress and labour outcomes between the groups.Conclusions This prospective observational study has shown that despite inferior pain relief and satisfaction, the remifentanil acceptance in multiparous women was still high as the vast majority of them graded their satisfaction rate as high/very high. That can be attributed to the facts that women with previewed shorter labour were more likely to choose a less invasive opioid analgesic option which provides an element of personal control. Thus, given no difference in labour outcomes, remifentanil could be routinely offered to parous women as a labour analgesic option, provided rigorous adherence to the protocols and continuous supervision by midwifes are ensured. Trial registration The trial was registered at ClinicalTrials.gov on November 15, 2016 (ID NCT02963337)
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