Remifentanil PCA and midwife training

We read with interest the editorial [1] that accompanied Marr et al.’s case report [2] as well as the previous case reports [3, 4] concerning complications of remifentanil PCA for labour analgesia. Marr et al.’s account suggests to us that central respiratory depression was an unlikely cause. If the arrest was related to remifentanil, we would argue it is more likely to have been opioidinduced muscle rigidity, as evidenced by the patient’s complaint of inability to breathe and initial difficulty in opening her mouth. Either way, we wondered what training was in place for the midwives. When we introduced the same regimen in Aberdeen in 2010, we allowed the PCA to be set up by midwives but limited its use to patients being cared for by those who had passed competency-based training delivered by our acute pain service. Audit has demonstrated a high level of maternal satisfaction but also a number of anticipated opioid-related side effects, including instances of respiratory depression and brief desaturation. However, we now have experience of close to 900 users without critical incident. We introduced remifentanil PCA because of a decrease in the number of tiers of anaesthetic cover in our hospital and consequent delays in the provision of epidural analgesia. Funding was secured because calling in the consultant obstetric anaesthetist to site an epidural out of hours would be likely to result in cancellation of that anaesthetist’s elective work the following day, to allow them adequate rest. Remifentanil PCA allows provision of improved analgesia, either instead of an epidural or at least until the resident anaesthetist is available. In practice, we have found only 4% of women subsequently convert to an epidural.