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We read with great interest the recent letters documenting incidents of respiratory arrest in women in labour using remifentanil patient-controlled analgesia PCA [1-4]. However, as a unit that routinely uses remifentanil PCA to provide popular and effective labour analgesia, we feel it is important to address some of the issues raised in these letters.

Unlicensed drug use is common in obstetric anaesthetic practice, and patients must be made aware of the unlicensed use. A patient information leaflet about remifentanil PCA, given to women antenatally, is explicit on this point, which is confirmed verbally with each woman before the PCA is started. In addition, we continuously audit outcomes and adverse events (maternal and neonatal) for women receiving remifentanil PCA, and have been reassured of its safety over the last eight years.

We administer remifentanil PCA to approximately 100 women in labour per month using a protocol that includes continuous oxygen saturation monitoring, the constant presence of a midwife, regular documentation of pain scores, respiratory rate and sedation level, and use of a dedicated cannula with an anti-syphon valve. As with all areas where strong parenteral opioids are administered, full resuscitation equipment is immediately available, with supplemental oxygen and ‘bag-valve-mask’ apparatus in the room. In the past two years we have had two significant incidents, both cases of marked respiratory depression, that resolved uneventfully after stopping the PCA and providing basic airway support (stimulation and facemask oxygen). We have not encountered patient dehydration in our practice related to remifentanil PCA [1].

Our continuous audit process has also demonstrated high levels of satisfaction with remifentanil PCA, with many women returning to the unit and choosing the same method of analgesia for subsequent labours. Remifentanil PCA is now the analgesic choice in almost 30% of our deliveries, and since its introduction, the epidural rate in our unit has dropped by one third. There are risks with all methods of analgesia but we consider our experience, attained over several years, demonstrates that with strict protocols in place and one-to-one midwifery care, remifentanil PCA is safe, effective and popular for labour analgesia.

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