Remifentanil patient-controlled analgesia for labour analgesia: guidance from the obstetric anaesthetists’ association

BACKGROUND: Remifentanil patient-controlled analgesia (PCA) has emerged as an important option for labour analgesia, particularly for women who are unable to receive neuraxial analgesia. Concerns about maternal safety and staffing requirements suggest that in many maternity units, it is only infrequently used, leading to variation in practice. In 2023, the UK National Institute for Health and Care Excellence recommended that all labouring women be informed about the full range of analgesia options, including remifentanil PCA, highlighting the need for a standardised management approach. METHODS: To address these challenges, the Obstetric Anaesthetists' Association convened an expert working group to develop evidence-based guidance. The group undertook a review of the literature, and used a modified Delphi approach to create consensus statements and recommendations. Recommendations were developed based on the evidence. Where evidence was insufficient to support recommendations, statements were provided with an associated level of certainty. These recommendations aim to support clinicians in providing well tolerated, effective and patient-centred care when using remifentanil PCA for labour analgesia. Statements and recommendations are graded according to the US Preventive Services Task Force grading methodology, ensuring transparency and robustness in the development process. RESULTS: A total of 757 articles were identified in the initial literature search. Further screening identified 83 full text articles of relevance. A structured narrative review was produced which covered patient suitability for remifentanil PCA (maternal and foetal factors), practical use of remifentanil PCA, standards of care for women receiving remifentanil PCA and quality assurance and monitoring. The working party agreed on 19 recommendations and six statements. These were generally assigned a low or moderate level of certainty. The safety of mother and baby were the key priorities in producing these guidelines. CONCLUSIONS: Remifentanil PCA can provide effective labour analgesia, particularly when neuraxial techniques are contraindicated or declined. Despite some inherent risks, when managed within defined parameters, there is now an established record of efficacy and safety. It is essential that labour wards have clear protocols for administration and monitoring, and for staff to be trained in recognising and managing complications. There is a lack of data for remifentanil PCA use in higher-risk maternal and foetal groups; this is an area of research priority. These first evidence-based guidelines aim to standardise care and support the well tolerated and effective use of remifentanil PCA in labour.