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Objective: To investigate the association between epidural analgesia (EDA) vs patient‐controlled remifentanil analgesia (PCRA) and emergency delivery for presumed fetal compromise, in relation to birth‐weight quintile. Methods: This was a post‐hoc per‐protocol analysis of the RAVEL multicenter equivalence randomized controlled trial. Non‐anomalous singleton pregnancies between 36 + 0 and 42 + 6 weeks' gestation were randomized at the time of requesting pain relief to receive EDA or PCRA. The primary outcome was emergency delivery for presumed fetal compromise. Secondary outcomes included mode of delivery and neonatal outcomes. Analysis was performed according to birth‐weight quintile and was corrected for relevant confounding variables. Results: Of 619 pregnant women, 336 received PCRA and 283 received EDA. Among women receiving EDA, 14.8% had an emergency delivery for presumed fetal compromise, compared with 8.3% of women who received PCRA. After adjusting for parity, women receiving EDA had higher odds of presumed fetal compromise compared to those receiving PCRA (odds ratio, 1.69 (95% CI, 1.01–2.83)). A statistically significant linear‐by‐linear association was observed between presumed fetal compromise and birth‐weight quintile (P = 0.003). The incidence of emergency delivery for presumed fetal compromise was highest in women receiving EDA and delivering a neonate with a birth weight in the lowest quintile. Conclusions: Intrapartum EDA is associated with a higher rate of emergency delivery for presumed fetal compromise compared to treatment with PCRA. Birth‐weight quintile is a strong predictor of this outcome, independent of pain management method. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. Linked articles: There are comments on this article by Cavoretto et al., Rongen et al. and van den Bosch et al. [ABSTRACT FROM AUTHOR]