Remifentanil – An Alternative to Epidural?
Draft guidelines released by NICE (The National Institute for Health and Care Excellence) this month recommend that women and birthing people in labour should be offered an alternative to an epidural in the form of a painkiller called Remifentanil.
Here’s what you need to know about it, from The Positive Birth Company’s resident midwife Sarah…
WHAT IS REMIFENTANIL AND HOW DOES IT WORK?
Remifentanil is a powerful analgesic with a short effect that quickly leaves the body. It’s administered via an IV drip so you can control it yourself by pressing a button. Small doses of Remifentanil are given from a pump through a tube that’s inserted into a vein in your hand or arm.
“If you opt for Remifentanil as pain relief, then the midwife will take your blood pressure every 15 minutes to start with and regularly after that,” explains Sarah. “The Anaesthetist will be present for the first few doses whilst setting up the pump. The midwife will need to be with you at all times and an oxygen saturation monitor will be on your finger as there is a risk of the drug affecting your breathing and blood pressure.”
WHAT ARE THE ADVANTAGES?
NICE says advantages may include:
Enabling labour to be more mobile than with an epidural (however extra monitoring may restrict you from moving completely freely and using a birth pool).
Evidence suggests fewer epidurals might mean fewer births using instruments like forceps and ventouse.
Can be used as alternative if you wanted but were unable to have an epidural for reasons such as allergies or blood clotting issues
You are able to use gas and air at the same time as Remifentanil, and if you decide you do not like it could still decide to have an epidural instead (if there is no medical reason preventing you).
However, it’s also worth noting that some hospitals in England recently paused the use of gas and air over concerns for maternity ward staff after finding high residual levels of nitrous oxide in delivery suites (read our blog post on that here).
IS IT EFFECTIVE?
Research suggests that those using Remifentanil were more satisfied with the labour pain relief when compared to Pethidine, although it was not considered as effective as an epidural.
Some experienced certain side effects such as feeling temporarily sleepy, sick or dizzy.
NEED TO KNOW
”As with all interventions this will often mean a change in your birth environment (like moving from the Midwife led unit) to the consultant unit, where continuous monitoring will be necessary to monitor you and your baby”, warns Sarah.
“On arrival, an Intravenous (IV) cannula will be inserted in your hand and a midwife will put up IV fluids. Both these things will restrict your ability to move freely, so do ask if a wireless baby monitor is available to use.”
Sarah says it’s also important to be aware of the potential effects of the drug on you and baby. “The effects are often similar to women and birthing people that have had the Pethidine injection and may feel sick or dizzy or ‘out of it’ (anti-sickness medication can be given to help with this).”
“The effects on baby have been found to be similar to Pethidine which can mean the baby is a little more ‘sleepy’ and sometimes slower to make that first cry and cry breath,” says Sarah. The sleepiness can affect their normal instinctive feeding behaviours and the effects of the drug on your natural oxytocin levels may delay lactation too.”
OTHER THINGS TO BE AWARE OF
While Sarah says it’s great to see an alternative to epidurals being recommended by NICE, it’s also important to know that starting off with alternative methods of pain relief is always the best route if possible. “Breathing, relaxation, massage, TENs and water immersion are all worth using first,” says Sarah. “Then moving onto Entonox before considering requesting this opioid pain relief.”
“As with all interventions this will often mean a change in your birth environment, like moving from the Midwife led unit to the consultant unit, where continuous monitoring will be necessary to monitor you and your baby,” says Sarah.
The BRAIN framework
The B.R.A.I.N. framework that we teach in hypnobirthing will help you decide if Remafentanil is right for you. This is a framework that allows you to navigate conversations with your health providers to make an informed decision.
B.R.A.I.N. stands for Benefits, Risk, Alternative, Instinct, Nothing.
In this case, the conversation would mean:
What are the Benefits of using Remafentanil?
What are the Risks of using it?
What is the Alternative?
What does my Instinct tell me?
What happens if I do Nothing (and don’t use it)?
The birthing environment
Your birth environment makes all the difference in birth - and, contrary to popular opinion, creating a calm and relaxing birthing environment is possible if you opt for pain relief interventions and need to be monitored.
Hypnobirthing will teach you how to think about your birth environment, wherever that environment is, giving you practical tips on things you can do to create a birth sanctuary - whether that’s at home, on a labour ward or in theatre.
Breathing
As Sarah notes, it’s always best to try alternative methods before opting for pain relief. This includes breathing. Your breath is an incredibly powerful tool in birth and the science shows it can really transform a labour experience if used correctly - so much so that you may decide you don’t need to use pain relief intervention at all.
In hypnobirthing you’ll learn about Up Breathing (and Down Breathing) which is the technique to help breathe through each surge and remain calm, relaxed and in control.
OUR RESOURCES
You’ll find all of these techniques and so much more in our multi-award winning Ultimate Birth Pack.
Use our best-selling virtual birth partner and hypnobirthing-friendly surge timer, the Freya app, to coach you through your birth.
Read the latest NICE guidelines regarding the use of Remifentanil as covered by the British Medical Journal here.
