Labour pain relief: remifentanil

What is remifentanil?

Remifentanil is an opioid painkiller that has a strong effect on pain. It acts very quickly and wears off very fast so it can be used to manage each contraction during labour (OAA, 2017; Wilson et al, 2018).

Why is remifentanil used?

Your caregiver might suggest remifentanil as an alternative to an epidural if you can’t have one or don't want one (OAA, 2017). Reasons for not being able to have an epidural could include allergies, blood clotting issues or an irregularity with the spine that would prevent an epidural from being administered (Hernandez and Singh, 2021).

Remifentanil may also be considered as an alternative to other opioids, such as pethidine (Wilson et al, 2018).

How is remifentanil used?

Small doses of remifentanil are given from a pump and through a tube that is inserted into a vein in your hand or arm (OAA, 2017; NHS, 2020).

You can press a button to give yourself a dose when you feel a contraction (OAA, 2016). This is called patient-controlled intravenous analgesia (PCIA). It takes 10 to 15 minutes to set up and then works in a few minutes (OAA, 2016).

How effective is remifentanil?

In research, women report that remifentanil is more effective for pain relief than other opioids, like pethidine or diamorphine, but less effective than an epidural (Freeman et al, 2015; Weibel et al, 2017; Wilson et al, 2018; Moran et al, 2019). Research suggests it reduces the need for epidurals more than pethidine does (Wilson et al, 2018). Effectiveness varies, and some people choose to use gas and air as well (OAA, 2016).

Most research around remifentanil considers it as an alternative to other opioids, which have their own side effects. So it is hard to compare outcomes with labours that do not use these forms of stronger pain relief.

Is it suitable for everyone?

Your healthcare professional will discuss with you any considerations, such as allergies, other medication you may be taking that could interact with remifentanil, or any health issues that could affect suitability (NICE, 2022). For example, remifentanil may not be suitable for women with severe heart or lung disease (NICE, 2022).

What do women say?

Compared with pethidine, women said they were more satisfied with the labour pain relief from remifentanil (Wilson et al, 2018). Compared with an epidural, they said the pain relief from remifentanil was not as effective (Freeman et al, 2015).

Women using pethidine and those using remifentanil both described side effects that they didn’t like (Moran et al, 2019). 

Some women said that remifentanil made them feel ‘out of it’ or confused, similar to being drunk. Others liked the fact that it wore off quickly and felt they were able to focus on their labour (Moran et al, 2019).

What are the side effects of remifentanil for mum and baby?

• Movement may be restricted by the remifentanil drip (Moran et al, 2019).
• Anxiety that the drip may run out (Moran et al, 2019).
• You may feel sleepy or sick, and your breathing might be affected.
• Around one in 100 women may need to stop using it because it slows their breathing too much and some will need additional oxygen (OAA, 2016, 2017). 
• If used for a long time, remifentanil may build up in the body, which increases the risk of side effects (OAA, 2017).
• The baby might be slower to breathe at first (OAA, 2016); remifentanil has a similar impact on the baby to pethidine (Wilson et al, 2018).

How does remifentanil affect labour?

The extra monitoring that comes with using remifentanil may restrict you from moving freely (Moran et al, 2019). 

How does remifentanil affect breastfeeding?

One study suggested that remifentanil showed no difference in the effect on women breastfeeding within an hour of giving birth compared to women receiving pethidine (Wilson et al, 2018). This  suggests the effect on the baby is similar to intramuscular opioids, so we might assume that the effect on breastfeeding is similar. 

Pethidine can have an adverse effect on a newborn’s sucking ability and breastfeeding. It also effects the mother’s level of the hormone oxytocin, which may delay lactation (Hemati et al, 2018). Opioids can also make babies sleepy after birth, which can affect their normal instinctive behaviours (Lowth, 2017).      

Does remifentanil have any long-term effects?

There is no research available on this.

How long does the pain relief from remifentanil last?

Remifentanil wears off with each contraction, so it can be stopped at any time if the woman doesn't like it.

Availability and timing: where and when can I get remifantanil?

Not every maternity unit uses remifentanil, so discuss with your midwife whether it is available where you plan to give birth. Anaesthetists have to administer remifentanil, so it is only available on obstetric units and the woman would be supervised by a midwife (Ronel and Weiniger, 2019).

Remifentanil is a relatively new option that is not licensed for labour and so it is not available in all maternity departments in the UK routinely (Wilson et al, 2018; Ronel and Weiniger, 2019; NICE, 2022).

How can my birth partner help if I’m using remifentanil?

Your birth partner can help you to remain in a good position, comfortable, hydrated and emotionally supported.

Can I use remifentanil with other pain relief?

Remifentanil will not be used within four hours of morphine or pethidine (UHS, 2014) but it can be used with Entonox (OAA, 2016).

As with any opioid, hospitals won't support its use at the same time as a birth pool (Corfe, 2017).

Would I need any extra procedures with remifentanil?

Your baby’s heartbeat may be monitored continuously (OAA, 2016). Your oxygen levels will be monitored via a clip on your finger and you might need extra oxygen (OAA, 2016).

Any considerations around ethnicity or cultural beliefs? 

Remifentanil may provide an option for stronger pain relief for people whose cultural expectations of birth mean they are unlikely to consider an epidural (Moran et al, 2019). 

There is substantial evidence that people from minority ethnic groups are less likely to receive pain medication, and will receive lower doses when they do (Campbell and Edwards, 2012). Research shows that the clinician’s empathy for the patient is affected by whether they are the same ethnicity, speak the same language, or have cultural competence training (Campbell and Edwards, 2012).   

What about disability? 

Remifentanil may be an option for someone who could not have an epidural due to damage or an abnormality in the spine (Hernandez and Singh, 2021). 

This page was last reviewed in March 2022.

Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about pregnancy and life with a new baby.

Research from the Royal College of Obstetricians and Gynaecologists (RCOG) about the use of water as pain relief in labour.