title: Remifentanil patient-controlled analgesia for labour: a complete audit cycle.
abstract: Remifentanil patient-controlled analgesia (PCA) was introduced to a small maternity unit where an extensive epidural service was difficult to provide. This was a new service and the New Zealand College of Midwives had serious doubts about the efficacy and safety of remifentanil, so auditing its use was important. In a two-stage audit, clinical notes of 244 consecutive remifentanil users were studied between January 2008 and November 2009. We developed a questionnaire to assess the parturients' satisfaction with remifentanil PCA and designed a proforma to evaluate it against four standards of best practice. During the two audit periods, timely commencement of PCA was achieved in 65% and 82% of cases, respectively. A 70% compliance rate with monitoring standards fell to 10% after the withdrawal of supervision by an acute pain team, but improved to 91% following implementation of regular midwifery training sessions and a redesigned partogram and prescription flowchart. Ninety-four percent of women rated remifentanil PCA as excellent, very good or good. Maternal side-effects were nausea, pruritus and drowsiness. A comparison of Apgar scores of consecutive neonates born by normal vaginal delivery to women receiving no analgesia, with those born to women using remifentanil PCA, demonstrated no difference. As a result of our audit, remifentanil PCA is now viewed by our midwives as an effective and safe method when accompanied by 1:1 care and appropriate monitoring. With our input other maternity units have introduced it, especially where epidural service provision is limited, and for patients in whom epidural analgesia is contraindicated.
authors.affiliation: Department of Anaesthetics, Rotorua Hospital, Rotorua, New Zealand. ulrike.buehner@lakessdhb.govt.nz
authors.forename: U
authors.initials: U
authors.lastname: Buehner
authors.forename: J R
authors.initials: JR
authors.lastname: Broadbent
authors.forename: B
authors.initials: B
authors.lastname: Chesterfield
mesh_terms: D000328:Adult; D016362:Analgesia, Obstetrical; D016058:Analgesia, Patient-Controlled; D018686:Anesthetics, Intravenous / Q000009:adverse effects / Q000627:therapeutic use*; D001034:Apgar Score; D005260:Female; D005333:Fetus / Q000187:drug effects; D019983:Guideline Adherence; D006801:Humans; D008485:Medical Audit; D008880:Midwifery; D016343:Monitoring, Intraoperative; D008991:Monitoring, Physiologic; D009520:New Zealand; D017060:Patient Satisfaction; D010880:Piperidines / Q000009:adverse effects / Q000627:therapeutic use*; D020250:Postoperative Nausea and Vomiting / Q000453:epidemiology; D011247:Pregnancy; D011537:Pruritus / Q000139:chemically induced / Q000453:epidemiology; D000077208:Remifentanil; D011795:Surveys and Questionnaires
chemical_list: D018686:Anesthetics, Intravenous; D010880:Piperidines; D000077208:Remifentanil