The need to review the 1997 RCOG Working Party Report on Fetal Awareness arose following discussion during the House of Commons Science and Technology Committee Report on Scientific Developments relating to the Abortion Act 1967. In accepting the findings and conclusions of the House of Commons report, the Minister of State for Public Health recommended that ‘the College review their 1997 report into fetal pain’.
Accordingly, this Working Party was established with the remit and membership described. The intention was to review the relevant science and clinical practice relevant to the issue of fetal awareness and, in particular, evidence published since 1997. In so doing, the report was completely rewritten, not only to take account of recent literature but also the evidence presented to the House of Commons Committee.
In reviewing the neuroanatomical and physiological evidence in the fetus, it was apparent that connections from the periphery to the cortex are not intact before 24 weeks of gestation and, as most neuroscientists believe that the cortex is necessary for pain perception, it can be concluded that the fetus cannot experience pain in any sense prior to this gestation. After 24 weeks there is continuing development and elaboration of intracortical networks such that noxious stimuli in newborn preterm infants produce cortical responses. Such connections to the cortex are necessary for pain experience but not sufficient, as experience of external stimuli requires consciousness.
Furthermore, there is increasing evidence that the fetus never experiences a state of true wakefulness in utero and is kept, by the presence of its chemical environment, in a continuous sleep-like unconsciousness or sedation. This state can suppress higher cortical activation in the presence of intrusive external stimuli. This observation highlights the important differences between fetal and neonatal life and the difficulties of extrapolating from observations made in newborn preterm infants to the fetus.
The implications of these scientific observations for clinical practice are such that the need for analgesia prior to intrauterine intervention, for diagnostic or therapeutic reasons, becomes much less compelling. Indeed, in the light of current evidence, the Working Party concluded that the use of analgesia provided no clear benefit to the fetus. Furthermore, because of possible risks and difficulties in administration, fetal analgesia should not be employed where the only consideration is concern about fetal awareness or pain. Similarly, there appeared to be no clear benefit in considering the need for fetal analgesia prior to termination of pregnancy, even after 24 weeks, in cases of fetal abnormality.
However, this did not obviate the need to consider feticide in these circumstances and, in this respect, further recommendations of relevance are included in the parallel report on Termination of Pregnancy for Fetal Abnormality.