Remifentanil with appropriate pharmacological properties seems to be an ideal alternative to epidural analgesia during labour. A retrospective cohort study was undertaken to assess the efficacy and safety of remifentanil intravenous patient-controlled analgesia (IVPCA) compared with epidural analgesia. Medical records of 370 primiparas who received remifentanil IVPCA or epidural analgesia were reviewed. Pain and sedation scores, overall satisfaction, the extent of pain control, maternal side effects and neonatal outcome as primary observational indicators were collected. There was a significant decline of pain scores in both groups. Pain reduction was greater in the epidural group throughout the whole study period (0∼180 min) (P<0.0001), and pain scores in the remifentanil group showed an increasing trend one hour later. The remifentanil group had a lower SpO2 (P<0.0001) and a higher sedation score (P<0.0001) within 30 min after treatment. The epidural group had a higher overall satisfaction score (3.8±0.4 vs. 3.7±0.6, P = 0.007) and pain relief score (2.9±0.3 vs. 2.8±0.4, P<0.0001) compared with the remifentanil group. There was no significant difference on side effects between the two groups, except that a higher rate of dizziness (1% vs. 21.8%, P<0.0001) was observed during remifentanil analgesia. And logistic regression analysis demonstrated that nausea, vomiting were associated with oxytocin usage and instrumental delivery, and dizziness was associated to the type and duration of analgesia. Neonatal outcomes such as Apgar scores and umbilical-cord blood gas analysis were within the normal range, but umbilical pH and base excess of neonatus in the remifentanil group were significantly lower. Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia, with more sedation on parturients and a trend of newborn acidosis. Despite these adverse effects, remifentanil IVPCA can still be an alternative option for labor analgesia under the condition of one-to-one bedside care, continuous monitoring, oxygen supply and preparation for neonatal resuscitation.

Background Combined spinal epidural anesthesia (CSEA) is commonly performed in cesarean deliveries. However, it is difficult to perform in obese parturients because of positioning challenges. The aim of this study was to compare the effect of different approaches to CSEA under the guidance of ultrasound. Methods One hundred obese patients (BMI ≥ 30 kg/m2) who underwent elective cesarean section were randomly enrolled. Patients were assigned to a median approach group and a paramedian approach group randomly. Clinical characteristics were compared between groups. First-attempt success rate, the median positioning time and total operation time, ultrasonic predicted anesthesia puncture depth, actual puncture depth, anesthesia adverse reactions, complications after anesthesia, and patients’ satisfaction with the epidural puncture were recorded. Results The first-attempt success rate was significantly different between the two groups [92% (46/50) vs. 76% (38/50), P  =  0.029]. The median positioning time and total operation time in the paramedian approach group were higher than those in the median approach group (227.7 s vs. 201.6 s, P  =  0.037; 251.3 s vs. 247.4 s, P  =  0.145). The incidence of postanesthesia complications in the paramedian approach group was significantly lower than that in the median approach group (2% vs. 12%, P  =  0.026), and patient satisfaction was higher in the paramedian approach group than in the median approach group (P  =  0.032). Conclusion The ultrasound-guided paramedian approach for CSEA is time-consuming, but it can effectively improve the success rate of the first puncture, reduce the incidence of anesthesia-related adverse reactions, and improve patient satisfaction. Trial registration: This study was registered with the Chinese Clinical Trial Registry (ChiCTR1900024722) on July 24, 2019

As compared to the lateral positions, CSEA with hypobaric ropivacaine in the sitting position is more likely to cause hypotension and excessively high block level.

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