Labour ward staffing shortages restrict use of beneficial drug

Research by HSJ found suggests that just over half of trusts are already offering remifentanil to women in labour, although some are having to restrict its use due to lack of staffing.

Responses to freedom of information requests from 108 trusts revealed 55 offered remifentanil during labour in 2022-23.

Recent draft National Institute for Health and Care Excellence guidance on intrapartum care, published in April, suggested healthcare professionals “consider intravenous remifentanil patient-controlled analgesia” in obstetric units. This is partly because it reduces the likelihood of forceps or ventouse being required compared to intramuscular pethidine (an opioid commonly used in labour).

However, the drug is not yet mentioned in official NICE guidelines and the opioid’s use in labour is currently off-label (its more common licenced use is alongside anaesthesia in surgery). A Royal College of Anaesthetists spokesperson said the use of drugs off-label “is extremely common in obstetrics given that drug trials do not often include pregnant women”.

Remifentanil has also been in short supply nationally recently, although the RCOA spokesperson said this has since been resolved.

Of the 55 trusts that said they offered remifentanil, 18 mentioned some kind of restriction on its usage in their response. Some mentioned it only being offered to those unable to use an epidural, while others that run multiple delivery suites mentioned offering this pain relief option in some locations but not others.

Another reason cited for being unable to consistently offer remifentanil was a lack of staff.

An Obstetric Anaesthetists’ Association spokesperson explained the “very potent short-acting opioid” could impair or stop breathing, so required continuous supervision. They added: “The OAA is aware of reports that insufficient midwifery staffing levels have limited the use of remifentanil pain relief in labour in maternity units.”

Some of the responses also mentioned that, although remifentanil was offered, not many women currently chose to use it – a point also made by both the RCOA spokesperson and OAA spokesperson.

Details of the responses can be viewed on our map below.

The NICE guidance is expected to be finalised in late September.

The FOI responses also showed that all trusts offered Entonox, which is the trade name for gas and air. However, eight of the 108 – around one in 14 – that answered the question stopped offering it at some point during 2022-23.

Of these eight, four – East Suffolk and North East Essex Foundation Trust, Mid and South Essex FT, The Princess Alexandra Hospital Trust and North West Anglia FT – are in the East of England. A further two – East Kent Hospitals University FT and Ashford and St Peter’s Hospital FT – are in the South East. 

Both current and draft NICE guidance states to “ensure that Entonox (a 50:50 mixture of oxygen and nitrous oxide) is available in all birth settings as it may reduce pain in labour”.

However, its use was suspended at several hospitals last financial year over concerns prolonged exposure was affecting midwives’ health. In March this year, NHS England issued guidance on the matter, stressing “removal of gas and air provision for patients should be a measure of last resort”.

Meanwhile, only eight of 108 trusts that answered the question offered sterile water injections, which are thought to help ease back pain during labour. Notably, six of these trusts are geographical neighbours – the option is offered at Medway FT as well as Maidstone and Tunbridge Wells Trust, at The Rotherham FT and Barnsley Hospital FT (although the latter only until August 2022), and North Tees and Hartlepool FT and South Tees Hospital FT (although the latter said this service is only offered in one location and only by a “small group of midwives”). 

Since 2007, NICE has advised against using injected water papules. However, the draft update revealed this could change, advising healthcare professionals to “consider intracutaneous or subcutaneous sterile water injections as a pain relief option for women in labour with back pain”.

National Childbirth Trust senior policy adviser Elizabeth Duff said: “Having the fullest range of pain relief available in their chosen birth setting is what parents expect, and we know that due to the impact of covid and recent headlines on dangers of nitrous oxide to staff, these options are decreasing.

“To help parents best progress through their maternity care journey, they should be offered the widest possible range of both pain-relief medication and non-pharmaceutical methods, so that every stage of labour can be managed effectively.”