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Purpose: We report the use of Patient-Controlled Intravenous Analgesia (PCIA) with remifentanil in two parturients with twin pregnancies in whom epidural analgesia was contraindicated., Clinical Features: Two patients with a twin pregnancy were admitted to the labor ward at 36 weeks of gestation. Epidural analgesia was contraindicated because of anticoagulation therapy or because of severe thrombocytopenia. PCIA remifentanil was offered to these patients. In the first case, pain from contractions was well controlled during labor, and the first twin was easily delivered. On the other hand, the second twin was in the breech position and an internal version was required rapidly because of fetal bradycardia to deliver the baby as soon as possible. Pain increased in intensity during this maneuver and PCIA remifentanil was insufficient. In the second case, the course of labor was uneventful and the patient easily delivered twins., Conclusion: In the case of twin pregnancy, we recommend remifentanil PCIA only if epidural analgesia is contraindicated (and not as a routine) because of the high risk of obstetrical maneuvers or potential cesarean delivery for the second twin, and the lack of efficacy of remifentanil, at the dose used in this report.

Childbirth ranks among the most intense experiences of acute pain. Neuraxial analgesia (i.e. epidural or combined spinal-epidural technique) is the most effective way to relieve that pain but it is contraindicated or impossible to perform for some parturients. We designed a survey of the current use of analgesic alternatives to epidural analgesia (EA) for labor pain, specifically the use of opioid patient-controlled intravenous analgesia (PCIA), in the French part of Belgium (Wallonia and Brussels). A questionnaire was mailed to the departmental chair of the hospitals with an obstetric unit, both in university and non-university centers (total of 53 centers). The questionnaire evaluated the availability of EA, the alternatives used when EA was contraindicated, the use of opioid-based PCIA for labor analgesia as well as opioid preference and doses, and finally the reasons for not using opioid PCIA. The response rate was 67.5% (36 centers). Among the responding hospitals, EA was available for 68% (range 25-85%) of labors and deliveries. When EA was not available or contraindicated, a parenteral opioid (piritramide, tramadol or pethidine) was proposed in 19% (7/36) of the centers, Entonox in 11% (4/36), a pudendal block by obstetricians in 28% (10/36) and non-pharmacologic alternatives (i.e. hypnosis, sophrology, baths and massages) in 19% (7/36). In 28% (10/36) of the centers however, no analgesic alternative was proposed. Opioid PCIA was employed in 36% (13/36) of the centers and for an additional 11% (4/36) only in case of intrauterine death. Remifentanil was the first choice (76.5% of the PCIA), followed by sufentanil (23.5%). Other opioids (piritramide, morphine, fentanyl) and ketamine were also administered by PCIA. Forty-five percents of the centers reported never using opioid PCIA by either lack of knowledge (7%), fear of maternal or fetal side effects (48%) and unability to provide a correct supervision of the parturient during PCIA use (48%), opposition from the pediatricians or obstetricians (17%) or because they considered the technique as ineffective to relieve labor pain (17%). In conclusion, the survey demonstrated that, when EA is contraindicated, systemic opioid administered by PCIA is used in almost half of the centers (47%) and that remifentanil is the first choice, particularly when a live birth is expected.

Background: This study evaluated the efficacy of an epidural single dose of neostigmine combined with sufentanil to provide selective and balanced analgesia at the beginning of labor., Methods: After informed consent, 125 healthy parturients were randomly allocated to receive, after a test dose, a single injection of either epidural sufentanil 20 micrograms (minimal analgesic dose) or 10 micrograms or a combination of sufentanil 10 micrograms with neostigmine 250, 500, or 750 micrograms in a total volume of 12 ml. Pain scores were recorded at regular intervals to determine onset and duration of analgesia. Maternal and fetal vital parameters as well as side effects were closely monitored., Results: Parturients did not differ concerning demographic data. Epidural neostigmine 500 micrograms with sufentanil 10 micrograms produced effective analgesia (visual analog scale <30 mm within 10 min in 72% parturients and within 15 min in 85% parturients; average duration of 119 min, confidence interval 96-142 min) that was as effective as epidural sufentanil 20 micrograms. Epidural combination with neostigmine 250 micrograms was ineffective, whereas 750 micrograms did not produce higher effect than 500 micrograms. No motor block was recorded. Maternal and fetal vital parameters remained stable during labor., Conclusions: Epidural combination of neostigmine 500 micrograms (e.g., 6-7 micrograms/kg) with sufentanil 10 micrograms provides similar duration of analgesia as epidural sufentanil 20 micrograms and allows effective and selective analgesia devoid of side effects in the first stage of labor.

Purpose: To show the use of the short acting opioid remifentanil for labour analgesia when epidural analgesia is considered to be contraindicated., Clinical Features: After Ethics Committee approval and informed consent, six patients (36-40 wk gestation), in whom epidural analgesia was considered contraindicated (women refusing regional analgesia, presenting with coagulation or platelet abnormalities or sepsis) benefited from patient-controlled intravenous analgesia (PCIA) with remifentanil. The Abbott Lifecare patient-controlled analgesia (PCA) pump with remifentanil 50 microg x ml(-1) was set to deliver remifentanil continuous background infusion of 0.05 microg x kg(-1) x min(-1) and 25 microg boluses with a five minutes lockout period. The PCIA was started when the parturients experienced regular painful contractions (cervical dilatation of at least 4 cm) and stopped just before delivery (cervix fully dilated). Maternal monitoring included non-invasive blood pressure measurements, heart rate, percutaneous arterial oxyhemoglobin saturation and respiratory rate. Percutaneous fetal heart rate was continuously monitored. All patients remained alert or sleepy but easily arousable and were satisfied with their analgesia. No particular side effects have been noticed. Apgar scores were between 6 and 10., Conclusion: Remifentanil PCIA combining low continuous background infusion and small bolus doses is an alternative when epidural analgesia in labour is contraindicated. Under careful anesthesia monitoring, the technique seems to be safe for both mother and baby, at least when delivery occurs at or near the normal term of pregnancy.