Title: Labour analgesia challenge – when epidural is not possible, what can we do?

Background: Epidural analgesia remains the gold standard for labour, but in some situations cannot be used and an alternative method has to be considered [1].

Case report: Pregnant 31 year-old female, 86kg and 1,63m, with severe scoliosis, submitted to posterior arthrodesis from cervical to sacral vertebrae, asked for labour analgesia. Orthopedic evaluation suggested eligibility for eutocic delivery. The patient described abdominal and back irruptive pain (10/10). PCA-analgesia with remifentanil-bolus was started: 20µg/mL, 2min lockout and increasing bolus doses (15-40µg). The patient asked for 120 bolus, with 90 administrations (total dose: 2407µg) in 6h. Pain score decreased to 2/10. Vomiting was observed and resolved with ondansetron. After total cervix dilation, caesarean was performed under general anaesthesia, due to foetus-pelvic incompatibility. For postoperative analgesia a TAP block was performed, with successful pain relief. The baby had Apgar 10/10/10.

Discussion:Spontaneous vaginal delivery is considered one of the most painful experiences in women’s life. Pain intensity depends highly on physical and psychological factors of the mother. Severe pain adversely affects the parturient and foetus[1]. Remifentanil is a potent short-acting opioid rapidly metabolized by the mother and foetus, with suitable pharmacological profile for labour analgesia, providing adequate pain relief and high maternal satisfaction[2,3]. Maternal sedation and respiratory depression may occur, but with careful monitoring, it has a safe profile[3].

References:1)Joanna S,et all. Remifentanil for labour pain relief. Anaesthesiol Intensive Ther 2015,vol.47,no1,82–86
2)Schnabel A,et all. Remifentanil for labour analgesia:a meta-analysis of randomised controlled trials. Eur J Anaesthesiol.2012;29(4):177-85
3)Tveit TO,et all. Efficacy and side effects of intravenous remifentanil patient-controlled analgesia used in a stepwise approach for labour:an observational study. Int J Obstet Anesth.2013;22(1):19-25

Learning points:Remifentanil can be a safe and effective alternative to epidural in labour analgesia, when this technique is not possible. Careful monitoring to prevent complications is essential.

Labour analgesia challenge - when epidural is not possible, what can we do?