Grand Rounds

Self-Administered Remifentanil PCA or Pethidine Injection for Labor Pain?

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BACKGROUND AND PURPOSE:

  • Patients may receive narcotics such as pethidine during labor
    • Of those, many women will also receive other analgesics and epidural blocks
  • Patient-controlled anesthesia, such as remifentanil PCA, is an alternative but not commonly used
  • Wilson et al. (The Lancet, 2018) compared remifentanil PCA with pethidine for labor pain and subsequent conversion to epidural analgesia

METHODS:

  • Open-label, multicenter, randomized controlled trial (RCT)
    • Women in labor age ≥16 years requesting opioid
    • >37 weeks | Singleton | Cephalic presentation
  • Patients were randomized to either
    • Intravenous remifentanil PCA group (40 μg bolus on demand with a 2 min lockout)
    • Pethidine IM group (100 mg every 4 h, up to 400 mg in 24 h)
  • Primary outcome: Proportion of women who received epidural analgesia after enrollment for pain relief in labor

RESULTS:

  • 401 women were randomized
    • 201 remifentanil PCA | 199 pethidine IM
  • Proportions of epidural conversion were
    • Remifentanil PCA group: 19%
    • Pethidine group: 41%
    • Risk ratio 0.48; 95% CI, 0.34–0.66 (p<0.0001)
  • Proportions of instrumental vaginal delivery
    • Remifentanil PCA group: 15%
    • Pethidine group: 26%
    • RR 0.59; 95% CI, 0.4-0.88 (p=0.008)
  • There were no serious adverse events in either group

CONCLUSION:

  • Remifentanil PCA decreased need for epidural and instrumental vaginal delivery
  • Data consistent with previous low-quality evidence
  • The authors consider patient-administered PCA to be a superior approach for labor pain

Learn More – Primary Sources:

Intravenous remifentanil patient-controlled analgesia versus intramuscular pethidine for pain relief in labour (RESPITE): an open-label, multicentre, randomised controlled trial

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Related ObG Topics:

Cochrane Review: What are the Risks and Benefits of Epidural Analgesia During Labor?
Does Epidural Anesthesia Impact the Second Stage of Labor?
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