Lynn Grigg, BA (Hons), RGN; Ruth Day, MA, BA (Hons), RGN.
Lynn-Lecturer/Practitioner in Pain Management; Ruth-Nurse Consultant in Pain Management, Luton and Dunstable Hospital NHS Trust and University of Luton, BedfordshireThe use of intravenous (IV) remifentanil through patient-controlled analgesia (PCA) for women in labour within a delivery ward is being advocated by some pain teams. This paper will discuss the evidence to support its use and a comparison will be made regarding its efficacy and safety with some of the more commonly used analgesics in the labour ward.
The pain of labour has evoked many responses over the centuries. With the rise of Christianity in the Western world the Bible taught women that child-bearing meant pain: 'I shall give you intense pain in childbearing, you will give birth to your children in pain' (Genesis 3:16). Before Christianity it seems that the pains of labour were seen as the action of evil spirits (Bonica, 1990). This acceptance that pain was inevitable and a normal part of labour, was questioned by Dick-Read in 1933. His text was seminal in re-thinking the role of midwives in labour and in the 'natural childbirth' movement.
McCaffery's statement that 'the 'gold standard' for assessing the existence and intensity of pain is the patient's self-report' holds true for labour pain as much as that of any other type (McCaffery and Pasero, 1999). It is affected by previous experience and expectations, as well as the size of the baby and primiparity (Mander, 1998). Research by Melzack (1984) confirmed that first-time mothers reported higher pain scores than multiparae (Table 1).
Pain relief can be viewed in three main groups, some of which overlap with each other. These groupings are physical, psychological and pharmacological.
Remifentanil is an opioid with mu-specific activity, antagonised by naloxone, and is most commonly used in anaesthesia. It is usually given during the induction of a general anaesthetic, supplementing other analgesic regimens intra-operatively. It has a very rapid onset and short duration of action due to its unique metabolism, giving it a half-life of only three minutes (Volikas and Male, 2001). The pharmacokinetic properties of this opioid have, therefore, led to investigations for use in the field of obstetrics.
There have been mixed reports regarding the use of PCA remifentanil in labour and, according to Thurlow and Waterhouse (2000), there have been no controlled studies regarding its use. Nevertheless, results from some small studies are encouraging, including those of Thurlow and Waterhouse (2000), Volikas and Male (2001) and Owen et al (2002). As remifentanil is such a short-acting drug with a rapid onset - time to peak effect is 60 to 90 seconds according to Saunders and Glass, (2002) - it appears to be an acceptable alternative when an epidural is contraindicated.
In our trust, a large district general hospital with a well-established obstetric unit, we have used remifentanil intravenously by PCA for three patients for whom epidural analgesia was contraindicated. One of these patients was a 32-year-old primigravida, born with spina bifida occulta (a bony defect in the bony arch of the spine), making her unsuitable for epidural insertion. She presented to the labour ward at 38 weeks' gestation with spontaneous rupture of membranes and in active labour. Entonox was given for the first two hours before the decision was made, by the on-call anaesthetist, to offer her a remifentanil PCA.
It may be that remifentanil will become a new way forward in providing labouring women with another option, to provide optimal pain relief for mother and safety for the child.
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