1. Midwife’s Need-to-know
Remifentanil PCA
Midwife’s Need-to-know
This is a short presentation on the remifentanil PCA which as you probably know is growing in popularity amongst staff and patients in many parts of the North West

2. Introduction Very short acting opioid
Alternative to epidural if it’s contraindicated or unable to be sited
Better satisfaction and less neonatal depression than diamorphine or fentanyl
Must be started and prescribed by anaesthetist
Remifentanil makes an excellent drug for use in patient controlled analgesia as it is fast acting and has a very short duration so can be used to cover the pain of contractions but wears off in between.
We’re going to start offering it as an alternative for patients who are not suitable for an epidural, for example if they have a clotting disorder.
It has better patient satisfaction than other opioids like diamorphine and because it is so short acting rarely effects the foetus.
However, it differs from diamorphine in that it must be prescribed, set up and started by the anaesthetist.

3. Contraindications and Precautions
Allergy to opioid drugs
<37 weeks gestation (unless documented intrauterine death)
Other opioids (eg diamorphine) within last 4 hours
Unable to provide one to one midwife care
Caution if BMI>40, patient critically unwell has low body weight or obstructive sleep apnoea
Obviously we should not use remifentanil PCAs in patients who are allergic to opioids (although true allergy is rare). It is also contraindicated in patients of less than 37 weeks gestation, if they have had other opioids within the last four hours and crucially if we are not resourced to provide constant midwife care.
We also need to be aware that the effects of remifentanil can be unpredictable if the patient is morbidly obese, very thin or is unwell, for example sepsis.

4. Patient Preparation
She should have read the Remifentanil information leaflet
Oxygen SPO2 monitoring, continuous CTG
Nasal O2 2L/min
Side effects to warn of
Itch, nausea, dizziness, sedation, respiratory depression
One to one midwife care
Prior to starting the PCA, the patient should be appropriately prepared, having discussed the issues with her midwife and anaesthetist and read the information leaflet.
Continuous sats monitoring and CTG monitoring are required, as well as nasal cannulae delivering 2-4L Oxygen per minute.
The main side effects listed here should also be discussed with the patient, and once again, we need to ensure that one to one midwife care is available at all times.

5. Practicalities Remifentanil needs a separate cannula
Anaesthetist will prepare infusion and set up PCA pump
Timing of pushing the button is key – encourage usage as soon as the contraction starts to achieve peak effect at peak of contraction
A specific prescription/observation chart will be provided with advice and guidance
Entonox may be used at the same time
The anaesthetist will insert a separate cannula for the PCA (usually a 20G pink), and they will prepare the infusion and pump and connect it to the patient.
It is crucial to encourage the patient to get the timing of pushing the button right. They should ideally push it as soon as they feel the start of the contraction so it reaches its peak when the contraction is most painful. This engenders most analgesic satisfaction.
The prescription chart that the anaesthetist provides has some guidance for the midwife.

6. How many mothers will experience side effects?
Desaturation %
Sedation %
Termination due to persistent desaturation despite oxygen therapy %
Nausea + Vomiting %
Pruritus %
Crossover rate ~ 10%
After looking after several patients with the remifentanil PCA you are likely to see some of these side effects. This gives an estimate of their frequency, including the crossover to epidural analgesia.

7. Monitoring
EVERY 30 MINUTES the following observations should be measured and recorded on the Remifentanil PCA Chart:
Respiratory rate
Pulse
Blood pressure
Sedation Score
Pain score
Nausea & Vomiting Score
In addition to continuous saturations monitoring, these parameters should be monitored and recorded every 30 minutes on the prescription chart.

8. Troubleshooting PROBLEM ACTION TO TAKE Oxygen saturations below 95%
Increase nasal Oxygen to 4 l/min
Severe Respiratory Depression
Oxygen saturation below 93% OR
Respiratory rate less than 8 OR
Sedation Score 3
Stop PCA
Shake & verbally stimulate
Oxygen 15 l/min via facemask
Contact Obstetric Anaesthetist
Ensure Naloxone 0.4mg available, give mg if respiratory rate less than 4
APNOEA- BLS and dial 2222
Hypotension
Systolic blood pressure less than 100mmHg OR
Pulse less than 50
Increase intravenous fluid rate
PULSELESS- BLS and dial 2222
Other problems
Inadequate analgesia
Nausea & vomiting score 2 or 3
Contact Obstetric Anaesthetist who may
Check PCA technique
Prescribe an antiemetic
Contacting the Obstetric Anaesthetist
Bleep 7402
If you are concerned about the patient this table gives some protocols to follow, and is also available on the prescription chart.
The key advice is that if the patient becomes unresponsive, stops breathing or drops their blood pressure, stimulate them and call for help, following basic life support guidelines if necessary, and stopping the PCA. Often if a patient’s respiratory rate does drop, they respond readily to verbal stimulation, and since remifentanil is so short acting matters resolve themselves very quickly.

9. Further Practicalities
For replacement syringe please call anaesthetist
When discontinued, remove cannula WITHOUT flushing
Discard and sign for wasted drug when discontinued
If you need more remifentanil, give the anaesthetist plenty of warning as it takes time to prepare the syringe, and when the PCA is discontinued please remove the cannula without flushing it to ensure no drop is inadvertently bolussed into the patient.

10. Summary A safe and effective alternative when epidural not possible
Quick and simple to initiate
One to one monitoring is vital as per the guideline
Please sign that you’ve seen the presentation!
In summary, remifentanil is a safe and effective alternative when and epidural is not viable.
It is quicker and simpler to set up.
It must be remembered that one to one monitoring of the patient by the midwife is vital.
Thank you for your time.