“It Will Not Hurt a Bit,” “What You Do Not Know Cannot Hurt You,” and Other Myths About Fetal Surgical Pain

Abstract

Advances in health care have made it possible to carry out a number of intrauterine procedures before birth in the hopes of minimizing morbidity and mortality outcomes postnatally. Surgery, ultrasound-guided and endoscopic therapies and terminations exemplify some of the potentially painful antenatal therapies that can occur, with procedures ranging from blood sampling to thoracotomy, abdominal incision, and resection. Fetal surgery is routinely carried out between the 26th and 32nd weeks of gestation, with procedures occurring as early as 20 weeks and as late as 35 weeks. Pain is a serious concern in fetal surgery, both during the surgery itself as well as the long-term ramifications that may ensue. “The plasticity of the developing nervous system may allow for the greatest impact of pain to occur in the least maturely born infants.” Although the use of fetal analgesia for fetal surgery has been considered, few infants receive direct analgesia during these potentially painful procedures. Why? Three main arguments (myths) may be postulated to explain why fetal analgesia has not evolved in line with fetal surgery: first, the fetus does not feel pain or remember pain, and therefore, analgesia is unnecessary; second, the use of fetal analgesia is not possible or safe, nor are there data to support it; and third, the fetus' pain management needs are covered by maternal analgesia delivered transplacentally during the procedure. Herein, we discuss each of these myths and give reasons why we believe them to be problematic. It is our belief that our moral responsibility as caregivers demands that we value the fetus in itself, not simply as a means, and as such, direct pain control consideration ought to be given to the fetus undergoing procedures suspected to cause pain.