Formulary Restriction: Prescribing restricted to anesthesia only. 

For OB PCA use:  Remifentanil is the preferred agent for OB patients who are having a vaginal delivery and are requesting/ requiring analgesia but neuraxial anesthesia is contraindicated.  Situations in which epidurals are contraindicated include: prior spine surgery, concurrent anticoagulation, and congenital spine issues. In the literature, remifentanil is preferred over fentanyl because of its rapid onset, ultrashort duration and its rapid metabolization. Opioids administered to the mother will cross the placenta during labor; however, remifentanil is rapidly metabolized by the fetus and is associated with less risk of respiratory depression and fewer post-delivery complications for baby, compared to fentanyl.

Restrictions: to Anesthesia. Other contraindications criteria should include:

1. 1. Relative contraindication of BMI >40
   2. Baseline O2 saturation < 95% on room air
   3. No fentanyl for one hour prior to remifentanil administration
   4. No hydromorphone or morphine for 4 hours prior to remifentanil administration.
   5. No concurrent nitrous oxide use
   6. No concurrent neuraxial anesthesia

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