IV Remifentanil PCA for Labor Analgesia 

Indication

For women in labor needing analgesia who are not suitable for regional anesthesia, or when epidural/spinal has failed.

• Low platelets or on anticoagulants
• Previous major spinal surgery (e.g., rods)
• Spina bifida or other anatomical abnormalities
• Failed epidural siting
• Any other patient considered appropriate

Discuss every case with the Consultant Anaesthetist on the labor ward.
Ideally avoid if the patient has already received pethidine.

Safety & Monitoring

• Confirm allergy status before prescribing/administering.
• Continuous pulse oximetry.
• One-to-one midwifery care at all times.
• Dedicated IV line for remifentanil infusion.
• Naloxone prescribed and immediately available in the labor room.
• Resuscitation equipment (ambu bag / C-circuit) in the room.
• Obstetric & Paediatric teams informed of IV opioid use, the labor room number, and that the patient is on Remifentanil PCA.

PCA Protocol

• Preparation: 2 mg remifentanil in 50 ml 0.9% NaCl.
• Concentration: 40 mcg/ml.
• Bolus (start): 20 mcg (0.5 ml).
• Titration: adjust by ±10 mcg steps.
  • Registrar: range 10–30 mcg.
  • 40 mcg only with Consultant approval.
• Lockout: 2 minutes.
• 
  NO BACKGROUND INFUSION
  

Titration must only be performed by an anaesthetist.

Patient Education (explain clearly)

• Press the button when you feel a contraction or pain coming.
• Only the patient should press the button (no one else).
• It is normal that pressing again immediately may not give more—there is a 2-minute lockout.

Additional Guidance

• Entonox may be used concurrently.
• Give supplemental oxygen if SaO₂ < 92%.
• Give naloxone if respiratory rate < 8/min.

Escalation – Call Anaesthetist (bleep 083) if:

• Patient becomes drowsy or has decreased level of consciousness.
• Respiratory rate < 8/min.