piperidines and Labor-Pain

Multiple analgesic strategies for pain relief during labour are available. Recently remifentanil, a short-acting opioid, has recently been used as an alternative analgesic due to its unique pharmacological properties.. To systematically assess the effectiveness of remifentanil intravenous patient-controlled analgesia (PCA) for labour pain, along with any potential harms to the mother and the newborn.. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 December 2015), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), handsearched congress abstracts (November 2015), and reference lists of retrieved studies.. Randomised controlled trials (RCTs) and cluster-randomised trials comparing remifentanil (PCA) with another opioid (intravenous (IV)/intramuscular (IM)), or with another opioid (PCA), or with epidural analgesia, or with remifentanil (continuous IV), or with remifentanil (PCA, different regimen), or with inhalational analgesia, or with placebo/no treatment in all women in labour including high-risk groups with planned vaginal delivery.. Two review authors independently assessed trials for inclusion, extracted data, and appraised study quality.We contacted study authors for additional information other than incomplete outcome data. We performed random-effects meta-analysis.To reduce the risk of random error in meta-analysis we performed trial sequential analysis. We included total zero event trials and used a constant continuity correction of 0.01 (ccc 0.01) for meta-analysis. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to assess the quality of evidence.. Twenty RCTs with 3569 women were included. Of those, 10 trials (2983 participants) compared remifentanil (PCA) to an epidural, four trials (216 participants) to another opioid (IV/IM), three trials (215 participants) to another opioid (PCA), two trials (135 participants) to remifentanil (continuous IV), and one trial (20 participants) to remifentanil (PCA, different regimen). No trials were identified for the remaining comparisons.Methodological quality of studies was moderate to poor. We assessed risk of bias as high for blinding issues and incomplete outcome data in 65% and 45% of the included studies, respectively.There is evidence of effect that women in the remifentanil (PCA) group were more satisfied with pain relief than women in the other opioids (IV/IM) group (standardised mean difference (SMD) 2.11, 95% confidence interval (CI) 0.72 to 3.49, four trials, very low-quality evidence), and that women were less satisfied compared to women in the epidural group (SMD -0.22, 95% CI -0.40 to -0.04, seven trials, very low-quality evidence).There is evidence of effect that remifentanil (PCA) provided stronger pain relief at one hour than other opioids administered IV/IM (SMD -1.58, 95% CI -2.69 to -0.48, three trials, very low-quality evidence) or via PCA (SMD -0.51, 95% CI -1.01 to -0.00, three trials, very low-quality evidence). Pain intensity was higher in the remifentanil (PCA) group compared to the epidural group (SMD 0.57, 95% CI 0.31 to 0.84, six trials, low-quality evidence).Data were limited on safety aspects for both the women and the newborns. Only one study analysed maternal apnoea in a comparison of remifentanil (PCA) versus epidural and reported that half of the women in the remifentanil and none in the epidural group had an apnoea (very low-quality evidence). There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for maternal respiratory depression when compared to epidural analgesia (RR 0.91, 95% CI 0.51 to 1.62, ccc 0.01, three trials, low-quality evidence) and no reliable conclusion might be reached compared to remifentanil (continuous IV) (all study arms included zero events, two trials, low-quality evidence). In one trial of remifentanil (PCA) versus another opioid (IM) three out of 18 women in the remifentanil and none out of 18 in the control group had a respiratory depression (very low-quality evidence).There is no evidence of effect that remifentanil (PCA) was associated with an increased risk f. Based on the current systematic review, there is mostly low-quality evidence to inform practice and future research may significantly alter the current situation. The quality of evidence is mainly limited by poor quality of the studies, inconsistency, and imprecision. More research is needed on maternal and neonatal safety outcomes (maternal apnoea and respiratory depression, Apgar score) and on the optimal mode and regimen of remifentanil administration to provide highest efficacy with reasonable adverse effects for mothers and their newborns.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Apnea; Cesarean Section; Female; Humans; Infant, Newborn; Labor Pain; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Randomized Controlled Trials as Topic; Remifentanil

Although epidural analgesia is considered the gold standard for labor pain management, its use may be restricted in some conditions due to clinical contraindications or availability, and suitable alternatives may be required. The objective of this meta-analysis was to determine whether evidence from randomized trials suggests remifentanil PCA (R-PCA) results in significant differences in maternal satisfaction, analgesic efficacy, and safety compared with conventional epidural analgesia (EA).. We conducted a meta-analysis after systematically searching MEDLINE, EMBASE and Cochrane Library for all randomized controlled trials (RCTs) allocating parturients to R-PCA or EA and reporting at least one outcome of interest.. Eight randomized trials of R-PCA vs EA with 2351 patients were included.. The primary outcome of interest was maternal satisfaction. Secondary outcomes included visual analog pain score (VAS at 1, 2, 3h postoperatively), nausea, vomiting, pruritus, hypoxemia, acute respiratory depression or death (maternal or neonatal), need for Cesarean section, and neonatal Apgar score.. Meta-analysis of the randomized trials showed no significant differences between the R-PCA and EA groups for maternal satisfaction, VAS at 2 or 3h, nausea, vomiting, need for cesarean section, respiratory depression, umbilical pH, and neonatal Apgar score at 1min and 5min. However, incidence of hypoxemia was higher [OR 7.48, 95%CI 3.42-16.36] and VAS at 1h was slightly higher [WMD 1.33, 95%CI 0.30-2.36] with R-PCA versus EA. Pruritus was less frequent in the R-PCA group [OR 0.54, 95%CI 0.32-0.89]. Acute respiratory failure and death were not reported in any of the studies.. While no significant differences were detected for maternal satisfaction or for most clinical outcomes, this meta-analysis remains underpowered to rule out clinically-important differences due to the few existing randomized trials. For obstetric patients who are not candidates for EA, R-PCA may provide an alternative for analgesia in the peri-partum period, but caution is warranted particularly regarding hypoxemia, and suggests the need for increased surveillance and monitoring for R-PCA. Further adequately powered randomized trials with a focus on clinically-relevant maternal and neonatal outcomes are required to more accurately characterize the relative benefits and risks of R-PCA versus EA in this population.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Cesarean Section; Delivery, Obstetric; Female; Humans; Labor Pain; Piperidines; Pregnancy; Randomized Controlled Trials as Topic; Remifentanil

To date the gold standard of treating labour pain is regional analgesia by application of epidural analgesia. When offering epidural analgesia, the programmed intermittent epidural bolus (PIEB) is more effective in terms of pain reduction, less motor blocks and higher satisfaction of the parturient compared to continuous application via perfusor pump. An upcoming alternative to epidural analgesia is remifentanil, a short acting and potent opioid. Remifentanil, however, requires haemodynamic monitoring as cardiac and respiratory impairment has been described. Nitrous oxide has been used for decades in the Anglosphere but it is a greenhouse gas, and interactions with Vitamin B

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Female; Humans; Labor Pain; Nitrous Oxide; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Remifentanil

Delivery and labour pain is normally the most painful event in a woman's lifetime. Physical and psychological factors may influence the severity of labour pain, and labour pain relief is an important issue for the obstetric anaesthetist. We describe the current most effective pharmacological techniques used for labour analgesia: systemically with remifentanil and regionally with epidural analgesia.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Female; Humans; Labor Pain; Piperidines; Pregnancy

Although epidural analgesia is still regarded as the gold standard for labour analgesia due to its efficacy, in cases of contraindication, systemic remifentanil is an alternative. Since the first demonstration of the safety of remifentanil in obstetric analgesia in 1996, this has been repeatedly confirmed for both mother and newborn. The aim of this meta-analysis is to evaluate recently published studies (up to December 2014) on the analgesic efficacy of remifentanil during labour (as a Visual Analogue Scale (VAS) decrease in the first hour by 2 or more).. Search of the US National Library of Medicine, National Institutes of Health (www.pubmed.gov), SCOPUS database (www.scopus.com) and Web of Science database (www.webofknowledge.com) using the key words "labour" and "remifentanil". 44 identified articles were included in the review and 15 published randomised controlled studies were incorporated into the meta-analysis. This was based on the fixed model and described by differences in the VAS between t=0 and t=1 hour after remifentanil administration using the 95% confidence interval (CI). The analysis was computed using the Comprehensive meta-analysis version 2.2.064.. The combined data from the meta-analysis showed a statistically significant decrease in VAS in the remifentanil group. From a comparison of the CIs of summary estimates with a cut-off decrease of VAS 2, for the fixed model, there was a statistically significantly greater decrease in VAS than the cut-off. In the systematic review, we describe possible modes of application, dosage and side-effects for mother, fetus/ newborn.. The meta-analysis presented here confirms that remifentanil for labour analgesia is effective but questions remain which can only be answered by further randomized trials.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Dose-Response Relationship, Drug; Epidemiologic Methods; Female; Humans; Infusion Pumps; Labor Pain; Pain Measurement; Piperidines; Pregnancy; Remifentanil; Risk Assessment; Treatment Outcome

Japan has seen significant developments in obstetric anesthesia in recent years, including the establishment of the Japanese Society of Obstetric Anesthesia and Perinatology. However, labor pain, which is one of the most important issues in obstetric practice, is still not treated aggressively. The rate of epidural administration for labor analgesia is very low in Japan as compared to other developed countries. Remifentanil has been used for labor analgesia, as part of general anesthesia for cesarean delivery, as well as for various fetal procedures around the world. Intravenous patient-controlled analgesia (IVPCA) with remifentanil is considered to be a reasonable option for labor pain relief. Several studies have demonstrated its efficacy with minimal maternal and neonatal adverse effects. On the other hand, reports of cases of maternal cardiac and respiratory arrest with remifentanil IVPCA within the past couple of years have redirected our attention to its safe use. Remifentanil IVPCA warrants one-to-one nursing monitoring, appropriate education of healthcare providers, continuous maternal oxygen saturation monitoring, end-tidal CO

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Cesarean Section; Female; Humans; Japan; Labor Pain; Piperidines; Pregnancy; Remifentanil

Labour is thought to be one of the most intense and painful experiences in a woman's life. Numerous studies using a Visual Analogue Scale invariably demonstrate that 20% of women in labour describe the pain as "unbearable" and 60% describe the pain as "very intense". Since the mid-1980s, continuous epidural analgesia during labour has been considered the gold standard of labour anaesthesia and is currently the most frequently used. There are situations in which this type of analgesia could not be used. An alternative pain management is administration of parenteral opioids, the most frequently used of which is pethidine. Its use is associated with adverse effects and unsatisfactory analgesia. Since the second half of the 20th century, a new generation of opioids, such as fentanyl or remifentanil, has been used. Despite their much better pharmacokinetic and pharmacodynamic parameters, obstetricians, midwives and neonatologists are most aware of pethidine, probably because it has been used for the longest period of time, despite its disadvantages and the risk that its use entails. The drug that is nearest to ideal is remifentanil. The countries in which it is widely used as an alternative type of labour anaesthesia have developed practice standards or guidelines practice. Guidelines and alternatives to pethidine protocols for effective labour analgesia in Poland might be merited.

Topics: Analgesia, Obstetrical; Analgesics, Opioid; Female; Humans; Labor Pain; Meperidine; Pain Measurement; Piperidines; Poland; Practice Guidelines as Topic; Pregnancy; Remifentanil

Since the 1980s epidural analgesia has been considered the gold standard for pain relief in labour. Over the past decade there has been a growing trend in UK maternity units to offer remifentanil PCA as a fast, safe alternative for women where epidural analgesia is contraindicated. Increasingly more obstetric units and anaesthetists are extending the use of remifentanil and in many units it is now preferred over central neuroaxial blocks (Stocki et al 2014). It would appear that remifentanil is being hailed as the panacea for labour pain. Whilst discussion around the use and effects of remifentanil is very well documented in anaesthetic journals, there is very little midwifery research around this subject. Following a review of the current evidence, this article will explore the use of remifentanil in labour, consequences for women and neonates and implications for midwifery practice.

Topics: Analgesia, Obstetrical; Analgesics, Opioid; Female; Humans; Labor Pain; Midwifery; Nurse-Patient Relations; Piperidines; Pregnancy; Professional Autonomy; Remifentanil; United Kingdom

Epidural analgesia is generally accepted as the most effective form of pain relief during labor. Remifentanil patient-controlled IV analgesia (PCIA), which is less invasive than epidural analgesia, may be an attractive alternative. In this meta-analysis, we compared the efficacy and safety of the 2 analgesic techniques for labor pain.. Databases of PubMed, EMBASE, and Cochrane Library were searched independently by 2 reviewers to retrieve eligible randomized controlled clinical trials. The primary end points were pain scores at 1 and 2 hours, and the secondary end points were nausea, vomiting, pruritus, and umbilical artery pH values. Mean difference (MD) or risk ratio with 95% confidence intervals (CIs) were calculated for each end point. GRADE profiler was applied to assess the quality of evidence.. Five eligible trials were retrieved and analyzed. We found that parturients with remifentanil PCIA had higher visual analog scale (10-cm scale) pain scores than those who received epidural analgesia at 1 hour (MD = 1.9 cm; 95% CI, 0.5-3.3; I = 94%) and 2 hours (MD = 3.0 cm; 95% CI, 0.7-5.2; I = 89%) after initiation of analgesia. There was no statistical difference between epidural analgesia and remifentanil PCIA in the incidence of nausea, vomiting, pruritus, or umbilical artery pH values. However, the CIs are quite wide and contain clinically significant differences. According to GRADE profiler, most end points had moderate quality except that pain scores at 1 hour were of low quality.. This meta-analysis suggests that remifentanil PCIA is not superior to epidural analgesia in analgesic efficacy during labor. Given the wide CIs of the pooled results for secondary maternal and neonatal outcomes, definite conclusions cannot be drawn for those outcomes. Further studies are still warranted to validate these conclusions.

Topics: Analgesia, Epidural; Analgesia, Patient-Controlled; Anesthetics, Intravenous; Female; Humans; Labor Pain; Piperidines; Pregnancy; Randomized Controlled Trials as Topic; Remifentanil

Remifentanil is a potent short-acting μ-opioid receptor agonist which is rapidly metabolised in the mother and fetus and may be ideal for labour analgesia.. To assess efficacy and safety of remifentanil compared with other analgesic techniques for labour pain.. We systematically searched the central register of controlled trials of the Cochrane Library (till August 2011) and MEDLINE (till August 2011).. Randomised controlled trials investigating efficacy and safety of remifentanil administered via a patient-controlled analgesia (PCA) device compared with any other analgesic technique for labour pain were included.. We finally included 12 randomised controlled trials (published from 2001 to 2011). Women treated with remifentanil had a lower risk of conversion to epidural analgesia (P < 0.001), a lower mean pain score after 1 h (P < 0.001) and had higher satisfaction scores (P < 0.05) in comparison with women receiving pethidine. Epidural analgesia decreased pain scores compared with remifentanil (P = 0.003). There was only a limited amount of data comparing remifentanil with nitrous oxide or fentanyl. Serious maternal or fetal adverse outcomes were not reported in these trials.. During labour, remifentanil-PCA provided superior analgesia and higher patient satisfaction compared with pethidine with a comparable degree of adverse events. Epidural analgesia provided superior pain relief in comparison with remifentanil. Due to a low number of reported adverse events, the safety issue of remifentanil use in labour remains an open question that needs to be addressed in future trials.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Intravenous; Female; Humans; Labor Pain; Patient Satisfaction; Piperidines; Pregnancy; Randomized Controlled Trials as Topic; Remifentanil

Remifentanil is an ultrashort-acting opioid with favorable pharmacokinetic properties that make it suitable as a labor analgesic. Although it crosses the placenta freely, it is eliminated quickly in the neonate by rapid metabolism and redistribution. We aimed to determine whether remifentanil compared with meperidine is effective in reducing pain scores in laboring parturients. Other effects on the mother, the labor process, and the neonate were also examined.. MEDLINE, CINAHL, Embase, Cochrane CENTRAL, and Maternity and Infant Care databases were searched without language restriction using multiple keywords for labor analgesia, remifentanil, and meperidine. Published abstracts from 5 key research meetings and references from retrieved articles were examined for additional studies. Randomized controlled trials in laboring parturients comparing remifentanil with meperidine were selected. Risk of bias was assessed using criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed for adequacy of sequence generation, allocation concealment, blinding, and completeness of follow-up. Data were extracted from each study using a standardized data collection form. The primary outcome was reduction in pain scores (visual analog scale [VAS], 0-100 mm). We also evaluated maternal side effects (sedation, oxygen desaturation, and bradypnea) and effects on the neonate (Apgar scores, umbilical cord pH, and Neurologic and Adaptive Capacity Scores).. Seven studies (349 patients) were identified for inclusion; only 3 studies were suitable for quantitative synthesis in a meta-analysis (233 patients). We found that remifentanil reduces the mean VAS score at 1 hour by 25 mm more than meperidine (P < 0.001) (95% confidence interval = 19-31 mm). Limited conclusions can be made regarding the side-effect profile of remifentanil because of insufficient data.. Compared with meperidine, remifentanil is superior in reducing mean VAS scores for labor pain after 1 hour.

Topics: Analgesia, Obstetrical; Analgesics, Opioid; Female; Humans; Labor Pain; Meperidine; Odds Ratio; Pain Measurement; Patient Selection; Piperidines; Pregnancy; Remifentanil; Treatment Outcome

There is a need for safe, effective, and easy-to-administer systemic analgesia that ideally has rapid onset and offset, matches the time course of uterine contractions, and does not compromise the fetus. Although neuraxial blockade is the "gold standard" for labor analgesia, systemic analgesia is useful in those cases in which neuraxial analgesia is contraindicated, refused or simply not needed by the parturient, or when skilled anesthesia providers are not available. Because of its unique pharmacologic properties, remifentanil has been investigated, and is used clinically, to provide IV labor analgesia. In this focused review, we summarize the efficacy of remifentanil as a labor analgesic and review the current literature regarding its dose, mode of delivery, safety for the mother and fetus/neonate, as well as the scope for future research.

Topics: Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Female; Fetus; Humans; Infusions, Intravenous; Labor Pain; Pain Measurement; Piperidines; Pregnancy; Remifentanil; Treatment Outcome

About a third of women receiving pethidine for labour pain subsequently require an epidural, which provides effective pain relief but increases the risk of instrumental vaginal delivery. Remifentanil patient-controlled analgesia (PCA) in labour is an alternative to pethidine, but is not widely used. We aimed to evaluate epidural analgesia progression among women using remifentanil PCA compared with pethidine.. We did an open-label, multicentre, randomised controlled trial in 14 UK maternity units. We included women aged 16 years or older, beyond 37 weeks' gestation, in labour with a singleton cephalic presentation, and who requested opioid pain relief. We randomly assigned eligible participants (1:1) to either the intravenous remifentanil PCA group (40 μg bolus on demand with a 2 min lockout) or the intramuscular pethidine group (100 mg every 4 h, up to 400 mg in 24 h), using a web-based or telephone randomisation service with a minimisation algorithm for parity, maternal age, ethnicity, and mode of labour onset. Because of the differences in routes of drug administration, study participants and health-care providers were not masked to the group allocation. The primary outcome was the proportion of women who received epidural analgesia after enrolment for pain relief in labour. Primary analyses were unadjusted and analysed by the intention-to-treat principle. This study is registered with the ISRCTN registry, number ISRCTN29654603.. Between May 13, 2014, and Sept 2, 2016, 201 women were randomly assigned to the remifentanil PCA group and 200 to the pethidine group. One participant in the pethidine group withdrew consent, leaving 199 for analyses. The proportions of epidural conversion were 19% (39 of 201) in the remifentanil PCA group and 41% (81 of 199) in the pethidine group (risk ratio 0·48, 95% CI 0·34-0·66; p<0·0001). There were no serious adverse events or drug reactions directly attributable to either analgesic during the study.. Intravenous remifentanil PCA halved the proportion of epidural conversions compared with intramuscular pethidine. This finding challenges routine pethidine use as standard of care in labour.. National Institute for Health Research Clinician Scientist Award.

Topics: Administration, Intravenous; Adolescent; Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Female; Humans; Injections, Intramuscular; Labor Pain; Meperidine; Outcome Assessment, Health Care; Patient Satisfaction; Piperidines; Pregnancy; Remifentanil; United Kingdom; Young Adult

Our objective was to compare the effect of two pain relief methods (remifentanil vs. nitrous oxide) on the success rate of external cephalic version.. We conducted a randomized open label parallel-group controlled single-center clinical trial with sequential design, at Cruces University Hospital, Spain. Singleton pregnancies in noncephalic presentation at term that were referred for external cephalic version were assigned according to a balanced (1:1) restricted randomization scheme to analgesic treatment with remifentanil or nitrous oxide during the procedure. The primary endpoint was external cephalic version success rate. Secondary endpoints were adverse event rate, degree of pain, cesarean rate and perinatal outcomes.. The trial was stopped early after the second interim analysis due to a very low likelihood of finding substantial differences in efficacy (futility). The external cephalic version success rate was the same in the two arms (31/60, 51.7%) with 120 women recruited, 60 in each arm. The mean pain score was significantly lower in the remifentanil group (3.2 ± 2.4 vs. 6.0 ± 2.3; p < 0.01). No differences were found in external cephalic version-related complications. There was a trend toward a higher frequency of adverse effects in the remifentanil group (18.3% vs. 6.7%, p = 0.10), with a significantly higher incidence rate (21.7 events/100 women vs. 6.7 events/100 women with nitrous oxide, p = 0.03). All reported adverse events were mild and reversible.. Remifentanil for analgesia decreased external cephalic version-related pain but did not increase the success rate of external cephalic version at term and appeared to be associated with an increased frequency of mild adverse effects.

Topics: Adult; Analgesics; Breech Presentation; Cesarean Section; Early Termination of Clinical Trials; Female; Humans; Labor Pain; Labor, Obstetric; Nitrous Oxide; Pain Management; Pain Measurement; Piperidines; Pregnancy; Pregnancy Outcome; Remifentanil; Treatment Outcome

The commonest opioid used for pain relief in labour is pethidine (meperidine); however, its effectiveness has long been challenged and the drug has known side effects including maternal sedation, nausea and potential transfer across the placenta to the foetus. Over a third of women receiving pethidine require an epidural due to inadequate pain relief. Epidural analgesia increases the risk of an instrumental vaginal delivery and its associated effects. Therefore, there is a clear need for a safe, effective, alternative analgesic to pethidine. Evidence suggests that remifentanil patient-controlled analgesia (PCA) reduces epidural conversion rates compared to pethidine; however, no trial has yet investigated this as a primary endpoint. We are, therefore, comparing pethidine intramuscular injection to remifentanil PCA in a randomised controlled trial.. Women in established labour, requesting systemic opioid pain relief, will be randomised to either intravenously administered remifentanil PCA (intervention) or pethidine intramuscular injection (control) in an unblinded, 1:1 individual randomised trial. Following informed consent, 400 women in established labour, who request systemic opioid pain relief, from NHS Trusts across England will undergo a minimised randomisation by a computer or automated telephone system to either pethidine or remifentanil. In order to balance the groups this minimisation is based on four parameters; parity (nulliparous versus multiparous), maternal age (<20, 20 < 30, 30 < 40, 40+ years), ethnicity (South Asian (Pakistani/Indian/Bangladeshi) versus Other) and induced versus spontaneous labour. The effectiveness of pain relief provided by each technique will be recorded every 30 min after time zero, until epidural placement, delivery or transfer to theatre, quantified by Visual Analogue Scale. Incidence of maternal side effects including sedation, delivery mode, foetal distress requiring delivery, neonatal status at delivery and rate of initiation of breastfeeding within the first hour of birth will also be recorded. Maternal satisfaction with her childbirth experience will be determined by a postpartum questionnaire prior to discharge from the delivery ward.. The RESPITE trial's primary outcome is the proportion of women who have an epidural placed for pain relief in labour in each arm.. Current Controlled Trials registration number: ISRCTN29654603 . Registered on 23 July 2013.

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Clinical Protocols; England; Female; Humans; Infusions, Intravenous; Injections, Intramuscular; Labor Pain; Meperidine; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Remifentanil; Research Design; Surveys and Questionnaires; Time Factors; Treatment Outcome; Young Adult

The aim of this study was to compare patient satisfaction between remifentanil patient-controlled analgesia (RPCA) and epidural analgesia (EA) for labor pain.. This prospective cohort study was carried out on primiparous women requesting analgesia for labor at a Teaching Hospital, Amsterdam, the Netherlands. Women self-selected the analgesia of choice (RPCA n = 166 and EA n = 124) and were asked to complete the Woman's Views of Birth Labour Satisfaction Questionnaire (WOMBSLQ), within 24 h (T0), 3 months (T3) and 6 months (T6) after birth. The WOMBSLQ comprises 11 subscales, including pain during labor and general satisfaction. The main outcome measure was general satisfaction.. There was no significant difference in the subscale of general satisfaction with labor and delivery (maximum of 14 points) between both groups at all three time points [median score at T0 for RPCA was 12 vs. 13 for the EA group (p = 0.95); at T3: 12 vs. 12, respectively (p = 0.41); and at T6: 12 vs. 12, respectively (p = 0.69)]. Women in the EA group had significantly better pain relief (maximum of 21 points) at all three time points [median score at T0 for RPCA was 14 vs. 18 for the EA group (p < 0.001); at T3: 13 vs. 17, respectively (p = 0.002); and at T6: 13 vs. 17, respectively (p = 0.003)].. Both self-selected groups did not differ in general satisfaction with labor and delivery at all three time points after birth despite a significantly higher experienced pain in the RPCA group.

Topics: Adult; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Cohort Studies; Female; Humans; Labor Pain; Netherlands; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Remifentanil; Surveys and Questionnaires; Treatment Outcome

Intravenous remifentanil has been described for patient-controlled analgesia in labour. Recently, the application of target-controlled infusion pumps with Minto's pharmacokinetic/pharmacodynamic model has been reported. Hypothetical effect-site remifentanil concentration during patient-controlled analgesia for labour has yet to be examined. The aim of this concept study was to explore characteristics of this parameter.. We performed a historical cohort study based on our previous randomised cross-over clinical trial and analysed hypothetical effect-site remifentanil concentration. Values at spontaneous vaginal delivery and Apgar scores were tested for correlation. The association between pain score and the corresponding effect-site remifentanil concentration before and after bolus administration, and their relative difference, was examined with a linear mixed-effects model, adjusted for other variables.. A series of 23 parturients with uncomplicated singleton pregnancies were included. On average, effect-site remifentanil concentration was highest during the third quarter throughout our recordings (5.5ng/mL; maximum 15.8ng/mL). The mean (median) {IQR} [range] at spontaneous vaginal delivery (n=14) was 2.52 (1.32) {0.95-4.28} [0.65-6.88] ng/mL, all Apgar scores were >7, and no correlation was confirmed. A negative association between effect-site remifentanil concentration before bolus administration and pain score (scale 0-100) was observed (-3.9, 95% CI -5.16 to -2.61, P <0.01).. The residual value of hypothetical effect-site remifentanil concentration before uterine contraction, at the beginning of bolus administration, predicted lower pain scores. Monitoring effect-site remifentanil concentration may be potentially useful when remifentanil is administered for labour analgesia. However, our results need to be confirmed with a pharmacokinetic model optimized for pregnant patients.

Topics: Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Female; Humans; Infant, Newborn; Labor Pain; Male; Piperidines; Pregnancy; Remifentanil

Safe and effective alternatives are required in labor when epidural analgesia is not appropriate. We hypothesized that patient-controlled IV remifentanil labor analgesia would not be inferior to patient-controlled epidural labor analgesia.. This randomized nonblinded controlled noninferiority study in healthy women with a singleton fetus and vertex presentation was performed at 1 site. Women were randomized to receive patient-controlled IV analgesia titrated from 20 mcg up to a maximum bolus dose of 60 mcg with a lockout interval of 1 to 2 minutes, or patient-controlled epidural analgesia 0.1% bupivacaine with 2 mcg/mL fentanyl (initiation bolus 15 mL; maintenance bolus 10 mL, lockout interval 20 minutes, basal infusion 5 mL/h). Crossover was permitted after 30 minutes. The primary study outcome was efficacy (assessed as hourly numerical rating scale [NRS] pain score [11-point NRS] and maternal satisfaction [11-point NRS]); the secondary outcome was safety (maternal apnea). Supplementary oxygen was administered continuously during the respiratory monitoring period. During the first hour of analgesia, the heart rate, respiratory rate, pulse oximetry (SpO2), and end-tidal CO2, as an indication of apnea, were compared. Apnea lasting >40 seconds was managed by light stimulation by the attending anesthesiologist.. Forty women were recruited to the following groups: remifentanil n = 19 (1 exclusion), epidural n = 20. Four crossed over: 3 from the remifentanil to epidural group and 1 from the epidural to remifentanil group. Mean (± SD) baseline NRS pain scores were similar, 8.4 ± 1.5 for remifentanil and 8.7 ± 1.2 for epidural analgesia, P = 0.52. Baseline adjusted mean NRS reduction at 30 minutes for remifentanil was -4.5 (± 0.6) vs -7.1(± 0.6) for epidural analgesia, P < 0.0001 for both. Pain score at 30 minutes was 3.7 ± 2.8 for remifentanil and 1.5 ± 2.2 for epidural analgesia, P = 0.009. Remifentanil was inferior to epidural analgesia with respect to the NRS at all time points, because the observed difference in NRS was greater than the expected -1.5 units. Maternal satisfaction was 8.6 ± 1.4 for the remifentanil group and 9.1 ± 1.5 for epidural group, P = 0.26. Mean respiratory rate was lower in the remifentanil group, 18 ± 4 vs 21 ± 4 breaths/min in the epidural group, P = 0.03. Mean SpO2 was lower in the remifentanil group 96.8% ± 1.4 vs 98.4 ± 1.2 for epidural group, P < 0.0001. There were 9 apnea events; all occurred in 5 women receiving remifentanil (5/19 [26.3%], P = 0.046). Apgar scores and neonatal respiratory outcomes were similar.. IV remifentanil is inferior to epidural analgesia for provision of labor analgesia; however, remifentanil does provide a satisfactory level of labor analgesia. Laboring women receiving remifentanil require suitable monitoring to detect and alert for apnea.

Topics: Adult; Analgesia, Epidural; Analgesia, Patient-Controlled; Anesthetics, Intravenous; Cross-Over Studies; Female; Humans; Labor Pain; Labor, Obstetric; Piperidines; Pregnancy; Remifentanil; Respiratory Mechanics; Treatment Outcome; Young Adult

To improve the analgesic efficiency and to simplify the administration of remifentanil for systemic analgesia in labour, we contrived a modified delivery regimen with a specific infusion profile and variable dosing and conducted a single-blind randomised crossover study to compare it with the previous 'classical' regimen. Parturients received both regimens in interchangeable sets, each with five contractions. We compared pain and satisfaction scores, maternal and fetal vital parameters, side-effects and other events. Twenty-three parturients completed the study. No differences in observed parameters were noticed except for slightly lower blood pressure with the modified regimen. Pain estimates were lower in women starting with the modified regimen (p = 0.005), and there were fewer requests for analgesia within the lockout period (31 vs 69, p = 0.041) and bolus adjustments (0 vs 25, p < 0.001) with the modified regimen.

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Blood Pressure; Cross-Over Studies; Female; Fetal Heart; Heart Rate; Humans; Labor Pain; Labor, Obstetric; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Remifentanil; Single-Blind Method; Treatment Outcome; Young Adult

Remifentanil is a potent short-acting μ-opioid receptor agonist which is rapidly metabolised in the mother and fetus and may be ideal for labour analgesia.. To assess efficacy and safety of remifentanil compared with other analgesic techniques for labour pain.. We systematically searched the central register of controlled trials of the Cochrane Library (till August 2011) and MEDLINE (till August 2011).. Randomised controlled trials investigating efficacy and safety of remifentanil administered via a patient-controlled analgesia (PCA) device compared with any other analgesic technique for labour pain were included.. We finally included 12 randomised controlled trials (published from 2001 to 2011). Women treated with remifentanil had a lower risk of conversion to epidural analgesia (P < 0.001), a lower mean pain score after 1 h (P < 0.001) and had higher satisfaction scores (P < 0.05) in comparison with women receiving pethidine. Epidural analgesia decreased pain scores compared with remifentanil (P = 0.003). There was only a limited amount of data comparing remifentanil with nitrous oxide or fentanyl. Serious maternal or fetal adverse outcomes were not reported in these trials.. During labour, remifentanil-PCA provided superior analgesia and higher patient satisfaction compared with pethidine with a comparable degree of adverse events. Epidural analgesia provided superior pain relief in comparison with remifentanil. Due to a low number of reported adverse events, the safety issue of remifentanil use in labour remains an open question that needs to be addressed in future trials.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Intravenous; Female; Humans; Labor Pain; Patient Satisfaction; Piperidines; Pregnancy; Randomized Controlled Trials as Topic; Remifentanil

We hypothesised that intravenous patient-controlled analgesia (IV PCA) with remifentanil could provide as satisfactory pain relief for labour as epidural analgesia.. Fifty-two parturients with singleton uncomplicated pregnancies were randomised to receive either IV PCA with remifentanil or epidural analgesia with 20 ml levobupivacaine 0.625 mg/ml and fentanyl 2 microg/ml in saline. The PCA dose of remifentanil was given over 1 min with a lockout time of 1 min. The dose was increased starting from the bolus of 0.1 microg/kg and following a dose escalation scheme up until the individual-effective dose was reached. The parturients assessed contraction pain (0-10), pain relief (0-4), sedation and nausea during 60 min.. Forty-five parturients were included in the analysis. The median cervical opening was 4 cm before the study and 7 cm after the study. The median pain scores were 7.3 and 5.2 during remifentanil and epidural analgesia, respectively (P=0.009). The median pain relief scores were 2.5 and 2.8 (P=0.17). There was no difference between the groups in the proportion of parturients who discontinued due to ineffective analgesia, nor in the proportion of parturients who would have liked to continue the given medication at the end of the study. Sedation and low haemoglobin oxygen saturation were observed more often during remifentanil analgesia. Foetal heart rate tracing abnormalities were as common in both groups.. In terms of pain scores, epidural analgesia is superior to that provided by IV remifentanil. However, there was no difference in the pain relief scores between the treatments.

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, Intravenous; Anesthetics, Combined; Anesthetics, Local; Bupivacaine; Double-Blind Method; Female; Fentanyl; Humans; Labor Pain; Levobupivacaine; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Remifentanil; Time Factors; Treatment Outcome

in this study we controlled the efficiency and safety of using remifentanil combined with two different supplementary background infusions for labor analgesia in nulliparous patients.. 60 subjects were allocated to two groups. After programming the patient-controlled analgesia device to deliver a fixed load and demand doses of intravenous remifentanil for all subjects, group r (n = 30) received a background infusion of remifentanil 0.1 microg/kg/min and group R (n = 30) received a supplementary infusion of remifentanil 0.15 microg/kg/min. Visual analogue scale for analgesia, hemodynamic parameters, sedation scales and fetal heart rates were recorded at the 5th, 10th, 20th and 30th min of the study and measurements continued every 15 min during 90 min of labor and delivery. Side effects, Apgar and satisfaction scores were obtained for every subject.. visual analogue scale scores of group R were significantly lower than those of group r throughout labor and delivery (p < 0.05). Hemodynamic parameters and fetal heart rates of the two groups were not different (p > 0.05). Most subjects were awake and only nausea was obtained (p > 0.05). The increase in the Apgar and satisfaction scores was not statistically significant (p > 0.05).. it was determined that remifentanil with a 15-mug demand dose and 0.15 mug/kg/min supplementary continuous infusion is an effective choice for patient-controlled analgesia during labor in nulliparous subjects.

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Drug Therapy, Combination; Female; Humans; Infusions, Intravenous; Labor Pain; Parity; Piperidines; Pregnancy; Remifentanil

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Female; Humans; Labor Pain; Labor, Obstetric; Piperidines; Pregnancy; Remifentanil

Topics: Analgesics, Opioid; Female; Humans; Labor Pain; Piperidines; Pregnancy

Topics: Analgesics, Opioid; Female; Humans; Labor Pain; Piperidines; Pregnancy

The safety of patient-controlled i.v. analgesia (PCA) with remifentanil for obstetrical analgesia remains a matter of concern. The efficacy of remifentanil bolus application, that is, the coincidence between pain and remifentanil effect-site concentration, may be improved by forecasting contractions, but it is not known whether such a technique would also improve safety.. We recorded pain intensity during labour continuously using a handheld dynamometer in 43 parturients. Using these data, we compared different models in their ability to predict future contractions. In addition, we modelled remifentanil effect-site concentration using three simulated modes of bolus administration, with and without prediction of future contractions.. The average duration of pain during contractions recorded by the dynamometer was 45 [14 standard deviation (sd)] s. The time interval between painful contractions was highly variable, with a mean of 151 (31 sd) s during the first and 154 (52 sd) s during the second recording. Using a simple algorithm (three-point moving average), the sd of the difference between predicted and observed inter-contraction intervals can be reduced from 0.95 to 0.79 min. However, the coincidence between remifentanil concentration and pain during contraction is not substantially improved when using these models to guide remifentanil bolus application.. Because of the large variability of inter-contraction intervals, the use of prediction models will not influence the mean remifentanil concentration in-between contractions. Using models predicting future contractions to improve the timing of remifentanil PCA bolus administration will not diminish the need of continuous clinical surveillance and other safety measures.

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Anesthetics, Intravenous; Female; Hand Strength; Humans; Labor Pain; Muscle Strength Dynamometer; Piperidines; Pregnancy; Remifentanil; Uterine Contraction

Topics: Analgesia, Epidural; Analgesia, Patient-Controlled; Anesthetics, Intravenous; Female; Humans; Labor Pain; Piperidines; Pregnancy; Randomized Controlled Trials as Topic; Remifentanil; Respiratory Mechanics

Topics: Adult; Analgesia, Patient-Controlled; Anesthesia, Obstetrical; Anesthetics, Intravenous; Female; Humans; Labor Pain; Labor, Obstetric; Oxygen; Piperidines; Pregnancy; Remifentanil; Vital Signs

Topics: Analgesia, Epidural; Analgesia, Patient-Controlled; Anesthetics, Intravenous; Female; Humans; Labor Pain; Piperidines; Pregnancy; Respiratory Mechanics

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.

Topics: Amides; Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Local; Drug Therapy, Combination; Female; Humans; Labor Pain; Pain Measurement; Piperidines; Pregnancy; Remifentanil; Retrospective Studies; Ropivacaine; Sufentanil; Treatment Outcome

Topics: Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Female; Fetal Heart; Heart Arrest; Humans; Labor Pain; Labor, Induced; Maternal-Fetal Exchange; Piperidines; Pregnancy

Remifentanil has a suitable pharmacological profile for labour analgesia. In this prospective, observational study, intravenous patient-controlled analgesia with remifentanil, using stepwise bolus doses without background infusion, was examined during the first and second stages of labour. Outcomes were pain reduction, maternal satisfaction, maternal and neonatal side effects and remifentanil metabolism in the neonate.. Parturients with normal term singleton pregnancies were recruited. The initial remifentanil bolus dose was 0.15 μg/kg, increasing in steps of 0.15 μg/kg, with a 2-min lock-out. Pain scores using a 100 mm visual analogue scale, systolic and diastolic blood pressures, respiratory rate and maternal sedation were recorded every 15 min. Maternal oxygen saturation and heart rate were monitored continuously. Neonatal data included Apgar scores, clinical examination, naloxone use, resuscitation, umbilical cord blood gases and remifentanil concentrations.. Forty-one parturients were enrolled. Pain scores were significantly reduced in the first 3 h of patient-controlled analgesia use compared to baseline, and at the end of the first and second stages of labour (P<0.05). Maximal pain reduction was 60% (P<0.01). One patient had inadequate pain relief and converted to epidural analgesia. The mean highest dose of remifentanil was 0.7 μg/kg [range 0.3-1.05]. Ninety-three percent of patients were satisfied with their analgesia. The lowest oxygen saturation was 91% and the lowest respiratory rate was 9 breaths/min. Eleven parturients (27%) received supplemental oxygen due to oxygen saturations <92%. Maternal sedation was moderate, and neonatal data reassuring.. Remifentanil intravenous patient-controlled analgesia provides adequate pain relief and high maternal satisfaction during the first and second stages of labour. Maternal sedation and respiratory depression may occur, but no serious neonatal side effects were recorded. Careful monitoring is mandatory.

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Analgesics, Opioid; Apgar Score; Blood Pressure; Female; Heart Rate; Humans; Infant, Newborn; Labor Pain; Labor, Obstetric; Maternal-Fetal Exchange; Pain Management; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Prospective Studies; Remifentanil; Treatment Outcome; Young Adult

Electrohysterography can give the obstetric anesthesiologists a promising parameter to synchronize labor pain relief with remifentanil when patients do not want or cannot have labor epidurals due to their preferences against epidurals or anatomical difficulties in epidural placements.

Topics: Analgesics, Opioid; Electrodiagnosis; Female; Humans; Labor Pain; Piperidines; Pregnancy; Remifentanil

Epidural analgesia is considered as the standard method for labor analgesia by inducing a minimal negative impact on labor while providing effective analgesia. Labor analgesia in the absence of epidural analgesia is difficult to achieve with the commonly used analgesic interventions. If epidural analgesia is not feasible due to coagulation disorders, anticoagulation, inability to insert an epidural catheter or due to the mother''s refusal to accept neuraxial analgesia, there is a need for interventions to cope with labor pain. So far, pethidine, diamorphine, meptazinol and spasmolytics remain the most widely used substances for IM and IV use. Unfortunately, in addition to not being very effective, these interventions may be associated with undesirable side effects for the parturient and the newborn. For a decade, anaesthesiologists have experienced the unique properties of remifentanil in the settings of surgical anaesthesia and conscious sedation since it was introduced for labor analgesia. Unfortunately, remifentanil is not licensed for administration to the pregnant patient, and it is unlikely that the manufacturers would consider the cost justified.. Therefore, relevant concerns, legal issues and precautions are discussed based on the presentation of case series and a protocol is presented on how the use of remifentanil can be safely implemented for labor analgesia in selected situations.. Proper informed consent, appropriate monitoring for the mother and the newborn, one-to-one nursing or midwifery care as well as the availability of an attending physician experienced in neonatal resuscitation and an anaesthesiologist with experience regarding the use of remifentanil are important to ensure that this method retains its good reputation for obstetric analgesia.

Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Anesthetics, Intravenous; Female; Germany; Humans; Informed Consent; Infusions, Intravenous; Labor Pain; Obstetrics; Piperidines; Pregnancy; Remifentanil; Self Administration

In an observational study, we prospectively evaluated the efficacy and safety of remifentanil in 205 parturients. Remifentanil was administered as a continuous infusion. The initial infusion of 0.025 microg x kg(-1) x min(-1) was increased in a stepwise manner to a maximum dose of 0.15 microg x kg(-1) x min(-1). Maternal pain, other maternal and fetal variables, side effects, and satisfaction were recorded. The mean (+/-sd) visual analog score before the start of the infusion was 9.4 +/- 1.2 cm and decreased to 5.1 +/- 0.4 cm after 5 min and 3.6 +/- 1.5 cm after 30 min. The maternal side effects were minimal and no fetal or neonatal side effects were noted.

Topics: Adult; Analgesia, Obstetrical; Analgesics, Opioid; Female; Fetus; Humans; Infusions, Intravenous; Labor Pain; Pain Measurement; Patient Satisfaction; Piperidines; Pregnancy; Prospective Studies; Remifentanil; Treatment Outcome

Topics: Adult; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Delivery, Obstetric; Female; Humans; Infant, Newborn; Infusions, Intravenous; Labor Pain; Male; Multiple Sclerosis; Narcotics; Piperidines; Pregnancy; Pregnancy Complications; Remifentanil

Topics: Adult; Analgesia, Obstetrical; Apnea; Female; Humans; Labor Pain; Labor, Obstetric; Piperidines; Pregnancy; Remifentanil