Remifentanil versus combined spinal-epidural technique for labour analgesia in multiparous women: a prospective non-randomized trial

Abstract

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.