Pain management during labour can be top of mind for many people who are about to give birth. It is important that you know what all of your options are so that you can make informed decisions on the day.
In April 2023, the National Institute for Health and Care Excellence (NICE) in the United Kingdom published updated guidelines on the use of Remifentanil during labour. Here we outline what it is, and an overview of what the new NICE guidelines recommend.
What is Remifentanil?
Remifentanil is a very strong and powerful opioid medication that works by blocking the transmission of pain signals to the brain.
How is Remifentanil used during labour?
The updated NICE guidelines recommend that Remifentanil should only be administered by an appropriately trained healthcare professional. This includes anaesthetists, obstetricians, and midwives who have completed a training program that covers the use of the drug.
It is given via a drip in a vein in the arm or hand and attached to a pump. Once in place, Remifentanil can continue to be administered through the parent-controlled analgesia (PCA) pump, which allows the parent to control the amount of medication received. The pump is programmed to deliver small doses of the medication whenever the button is pressed, usually during a contraction. As the dose is small, it will normally wear off between each contraction so the parent would need to press it each time they feel a contraction coming on if they wanted to.
It was also recommended by NICE that Remifentanil should only be used in hospitals that have appropriate facilities to monitor the parent and baby’s condition during and after the administration of the drug. This includes facilities for continuous fetal monitoring, the availability of resuscitation equipment, and the ability to provide emergency caesarean section if necessary. This means that it can only be administered on a labour ward (not at a birth centre or home birth).
Benefits of Remifentanil during labour
Remifentanil is fast-acting and can provide pain relief within a few minutes of administration. It will make you feel sleepy and relaxed. Although it will not provide you with complete pain relief, Remifentanil has been shown to enable the parent to feel ‘in control of’ and able to cope better with their contractions and allow them to be more mobile than they would be with an epidural.
You can continue to use ‘gas and air’ (entonox) as an additional form of pain relief, if you would like to.
Remifentanil is quickly removed from your body once you stop administering it, with the effects wearing off within ten minutes.
Remifentanil may be an option for someone who cannot have an epidural due to spinal damage.
Risks and side effects of Remifentanil during labour
Some people may experience dizziness, blurred vision, or sedation while using Remifentanil.
It can also cause respiratory depression, which is a serious concern and requires close monitoring of the parent.
In rare cases, Remifentanil can cause allergic reactions or low blood pressure.
It can also cause drowsiness in baby, causing issues with breathing and feeding in the early hours post-birth.
It is important to note that Remifentanil is not suitable for everyone. It is usually not recommended for those with a history of drug abuse, respiratory problems, or certain medical conditions. It is also not recommended for those who are allergic to opioids or who have a known sensitivity to the medication.
The new NICE guidelines recommend that Remifentanil should only be used as a second-line option for pain relief during labor. The first-line option should still be Entonox (a mixture of nitrous oxide and oxygen) or other non-pharmacological pain relief options such as massage or water immersion (birthing pools).
Like all medications, it is not without risks and side effects. Parents should discuss their pain relief options with their healthcare provider to determine the best course of action for their individual needs.
Finally, not all hospital trusts will have Remifentanil available so do check with your midwife ahead of time to see what options will be available.
If you are birthing in hospital, read this post about birthing on a labour ward, and how you can support your physiology in a clinical environment.
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