Background

The question of whether a fetus has awareness or can feel pain, and the gestational age at which this might begin, has long been debated. The Royal College of Obstetricians and Gynaecologists (RCOG) appraised the evidence and produced reports on fetal awareness in 1997, 2010 and most recently in 2022. The possibility of fetal awareness remains topical and controversial, and a belief that the fetus can feel pain has potential implications on views regarding termination of pregnancy laws and practices. The fetus may be touched or have a procedure performed on it not only in termination of pregnancy but also in an increasing number of fetal medicine interventions and during labour and birth.

Recommendations

1. Practitioners performing therapeutic fetal procedures at 28+0 weeks’ gestation or above should discuss and offer fetal analgesia.
2. Practitioners performing therapeutic fetal procedures below 28+0 weeks’ gestation should discuss the option of fetal analgesia.
3. Practitioners performing feticide at 28+0 weeks’ gestation or above should discuss the option of fetal analgesia.
4. Practitioners performing feticide at gestations below 28+0 weeks’ gestation should not routinely offer or discuss the use of fetal analgesia.
5. Fentanyl 10-20 micrograms per kilogram should be the agent of choice for direct fetal analgesia.
6. Lidocaine is an analgesic and if being used as an alternative to potassium chloride for intra-vascular feticide then additional fentanyl for fetal pain would not be required.
7. If fetal analgesia is planned then this should be administered via direct fetal injection (intravascular or intramuscular). Maternal administration of analgesia with the intention of providing fetal analgesia is of uncertain efficacy as it is not possible to ascertain fetal delivery or dose of a medication when given by this route.

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