Statement on Pain During Cesarean Delivery

04/10/2024

Developed by: Committee on Obstetric Anesthesia
Original Approval: October 18, 2023

Purpose
The purpose of this statement on pain during cesarean delivery is to support clinician awareness, provide pragmatic advice, and suggested best practices while helping to improve maternal outcomes and patient experience. This statement and recommendations assist the practitioner and patient in making decisions about health care. These recommendations while designed to assist, may be adopted, modified, or rejected according to clinical needs and constraints, are not intended to replace local institutional policies, are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome.¹

Introduction
Neuraxial anesthesia for cesarean delivery is generally considered the preferred method of anesthesia, being used for more than 95% of elective and 80% of emergent cesarean deliveries in the US.^2-4 Although very reliable, neuraxial techniques (i.e. spinal, epidural, combined spinal epidural, et al.) can be inadequate or fail to provide full surgical anesthesia. Pain during cesarean delivery may be treated with supplementation of neuraxial anesthesia, intravenous or inhaled analgesia/anesthesia, or conversion to general anesthesia. In a prospective study of over 5,000 cesarean deliveries, failure to achieve pain-free surgery occurred in 6% of patients with spinal anesthesia, 18% with combined spinal-epidural, 24% with labor epidural to cesarean top-up and with an overall rate of conversion to general anesthesia of 4.9%.⁵ Pain or discomfort during cesarean delivery may be due to multiple reasons, some of which may be preventable.⁶ This statement is intended to help raise awareness, inform, and help improve outcomes and patient experience.

Expert Opinion:
While many hospitals track general anesthesia rates in cesarean delivery for quality improvement, the incidence of pain associated with regional anesthesia has not often been part of quality improvement efforts and remain largely untracked. In a systematic review, 14.6% cesarean deliveries with neuraxial technique required supplemental analgesia or anesthesia.⁷ In prospective surveys, the incidence of pain during cesarean delivery occurred in 11.9%⁸ to 22.7%.⁹ Neuraxial failure can be defined as “failure to provide satisfactory surgical conditions and/or maternal comfort and satisfaction during caesarean section with or without conversion to general anesthesia”.⁹

Pain during cesarean delivery has potential downstream consequences. In the United Kingdom, pain during cesarean delivery was the most common cause for litigation related to obstetric anesthesia care.¹⁰ Pain during cesarean has been described by an obstetric anesthesiologist from their perspective as a patient who experienced pain and offered ideas for practice improvement.¹¹ Significant pain during cesarean may affect the patient experience and has been associated as an independent risk factor for postpartum post-traumatic stress disorder (PTSD).¹² Patient perception may be an important predictor for pain consequences, therefore communication and support are encouraged.^12,13 In a systematic review and meta-analysis, perinatal pain significantly increased (OR 1.43) and epidural analgesia significantly decreased (OR 0.42) the incidence of postpartum depression,¹⁴ although data are conflicting.

Disparities in the type of anesthesia used for cesarean delivery and maternal pain management occur.¹⁵ African-American race (aOR 1.7-1.9) and Hispanic ethnicity (aOR 1.5) had significantly increased association for receiving general anesthesia, even after adjustment for obstetric and non-obstetric covariates.^16,17

Thus, this statement serves to inform practitioners and give recommendations that may help decrease pain during cesarean delivery under neuraxial anesthesia and help identify and guide management to meet individual patient desires and needs. Recognition of risk factors, past medical or non-medical traumatic experiences, patient education, and shared decision making may help improve patient experience and reduce disparities.^15,18

The American Society of Anesthesiologists Committee on Obstetric Anesthesia identified seven areas related to pain during cesarean delivery.

Recommendations
The following recommendations regarding pain during cesarean delivery are organized into seven topics with explanations and suggested best practices:

Preoperative Assessment
Minimizing Risk of Inadequate Regional Anesthesia
Supplementation of Inadequate Regional Anesthesia
Conversion to General Anesthesia
Conduct of General Anesthesia
Follow-Up and Referral
QI

Table 1. Preoperative Assessment

Why This	The preoperative anesthesia assessment is a time when a preoperative conversation with the patient can elicit risk factors, inform the clinician of patient expectations, allow the clinician to give the patient a framework of what will happen during the procedure, and facilitate shared decision making for the anesthetic care plan.
Background	The shared decision-making process explores the risks, benefits, and alternatives to treatment options in a collaborative fashion. When multiple options for management are possible, care should be patient and provider driven.¹⁹ Benefits of shared decision making include patients having fewer regrets about treatment, better perceived communication with clinicians, improved treatment adherence, increased confidence and coping skills, greater comfort with making decisions.²⁰ Moreover, shared decision-making leads to better health outcomes.²¹
Best Practices	Awareness Awareness of the frequency and factors that may contribute to pain or discomfort during cesarean The true prevalence of pain during cesarean section and failure of neuraxial anesthesia is unknown and may be up to 20% or more.^5,8,22,23 There may be significant under-estimation of the true prevalence of pain during cesarean delivery as studies focus on an anesthesia intervention as the defining event, not the occurrence of self-reported pain.¹¹ Preoperative History Identify patients with a history of traumatic delivery, pain during previous cesarean delivery, stress in pregnancy, and anxiety.²³ Risk factors for the development of postpartum PTSD include obstetric events and patient experience. Anesthesia providers are uniquely positioned to mitigate some of these risk factors during cesarean delivery care and to mobilize resources when traumatic experiences occur.¹² Ask about any concerns and fears of upcoming anesthesia, surgery, or pain using compassionate and respectful communication.¹⁸ Inform patients of the risks and benefits of neuraxial anesthesia and general anesthesia along with the potential for pain and discomfort during cesarean delivery.²⁴ Pain during and after cesarean delivery was the most important concern for patients.²⁵ Intraoperative cesarean pain may affect patients and their support system.²⁶ Patients with self-reported unexpected explicit recall after regional anesthesia techniques and sedation report distress (78%) and persistent acute and long-term psychological sequelae (40%) including impact on job performance, family relationships, friendships, and self-reported diagnosis of PTSD.²⁷ Awareness of Risk Factors for Intraoperative Pain^5,6,12,28 Patient specific High BMI H/o spine surgery H/o pain during prior cesarean Fear of pain Chronic pain Opioid use disorder Neuraxial procedure specific Neuraxial administration at the level of L5-S1 Labor specific Intrapartum breakthrough pain Increased pain scores within 2 h of cesarean Chorioamnionitis Obstetric factors Urgent/eminent cesarean Duration of cesarean Exteriorization of uterus Seek your Patient's Participation Create an environment that is supportive to patient involvement in their care decisions. Acknowledging the potential for pain during cesarean section in the preoperative consent emphasizes the importance of the patient’s experience to the anesthesia care team with the goal to build trust and open communication.⁶ Three-talk model of shared decision-making may be helpful:²⁹ Team talk: Work together, describe choices, offer support and ask about goals Option talk: Comparing options using risk communication principles Decision talk: Get to informed preferences, make preference-based decisions Assess Patient Values and Preferences Seek understanding of patient preferences. Set expectations about (dis)comfort during cesarean⁶ When given a choice, postpartum patients weighed their experience of pain versus their risk and preferences of side effects such as exposure of pain medication through breastmilk. Patients were willing to tolerate a pain score of 56 +/- 22 out of a 100 visual analog scale before taking pain medication.²⁵ Reach a Decision with Your Patient Identify a plan Seek confirmation of plan with patient

Table 2. Minimizing Risk of Inadequate Regional Anesthesia

Why This	Inadequate regional anesthesia may necessitate conversion to general anesthesia, which carriers greater risk and potential patient dissatisfaction. Rates of general anesthesia for cesarean delivery may potentially be decreased by applying best obstetric anesthesia practices.
Background	In a prospective study of over 5,000 cesarean deliveries, failure to achieve pain-free surgery occurred in 6% of patients with spinal anesthesia, 18% with combined spinal-epidural, 24% with labor epidural to cesarean top-up and with an overall rate of conversion to general anesthesia of 4.9%.⁵ Local anesthetics, often combined with lipophilic opioids have been demonstrated to provide reliable spinal anesthesia for cesarean delivery.³⁰ Epidural anesthesia is used for approximately 29-44% of cesarean sections and most women who undergo urgent or emergent cesarean sections have an existing epidural catheter in situ for labor analgesia.³¹ The block level should be tested and noted prior to initiating skin incision.^5,13 Patient perception may be an important predictor for pain consequences, therefore communication and support are encouraged.¹²
Best Practices	Use a recognized technique for neuraxial block for cesarean.¹³ Use local anesthetic with lipophilic opioid in spinal anesthesia for cesarean delivery. The ED⁹⁵ for successful cesarean delivery completion was approximately 12 mg of intrathecal hyperbaric bupivacaine when intrathecal fentanyl and morphine were co-administered.^30,32 Inclusion of a spinal opioid was associated with lower failure rate of spinal anesthesia.⁵ Assess quality of analgesia and dosing requirement for labor epidurals, consider early replacement for inadequate labor analgesia and adequate dosing for conversion to cesarean surgical anesthesia Failed conversion of a pre-existing labor epidural catheter to a surgical epidural anesthesia for cesarean delivery presents a challenging clinical situation for the anesthesiologist, particularly for emergent obstetric indications. Increased risk for failed conversion of epidural analgesia to surgical anesthesia occurs with: an increasing number of clinician-administered boluses during labor (OR = 3.2, 95% CI 1.8–5.5) and greater urgency for cesarean delivery (OR = 40.4, 95% CI 8.8–186). Management by an obstetric anesthesiologist decreased epidural conversion failure rate from 7.2% to 1.6%.³³ An increasing number of clinician-administered boluses during labor is associated with increased maternal pain during labor. Breakthrough pain (especially an increase in parturient pain in the 2 hours before a cesarean section) may be a marker for a poorly functioning epidural catheter or it may signify dysfunctional labor and the need for obstetric intervention. Greater urgency for cesarean delivery can lead to use of general anesthesia with no attempt made to convert epidural analgesia to surgical anesthesia because of the perception that it takes less time to induce general anesthesia than it does to convert epidural analgesia to anesthesia. Factors that may lead to successful conversion to surgical anesthesia include awareness of the quality of labor epidural analgesia, willingness to replace epidural catheters providing inadequate labor analgesia or performing another neuraxial technique before starting the cesarean. Early replacement of poorly functioning labor epidurals may improve the success rate of dosing for surgical anesthesia.¹³ A standardized algorithm for labor epidural top-up for breakthrough pain resulted in higher rate of catheter replacement.³⁴ Conversion of labor epidural to cesarean surgical anesthesia may begin in the labor room with a small bolus (i.e. 5 ml) prior to transport, with another bolus on arrival in OR.³⁵ This may help identify working/non-working epidural catheters earlier. Check neuraxial surgical level prior to start of surgery and document sensory level. The Obstetric Anaesthetists’ Association recommends that light touch to a T5 dermatomal level be the primary modality to evaluate the block but acknowledge limitations in this method because it relies on excellent communication between the patient and the clinician.¹³ A patient who is able to do a straight leg raise will almost always not have a block suitable for cesarean delivery regardless of the quality of sensory block. The optimal method of testing neuraxial block to predict full surgical anesthesia has not been determined.¹³

Table 3. Supplementation of Inadequate Regional Anesthesia

Why This	Inadequate regional anesthesia for cesarean delivery can usually be treated with neuraxial and systemic adjuvant medication, providing adequate surgical anesthesia and potentially avoiding conversion to general anesthesia.
Background	Two retrospective reviews reported systemic anesthetic adjuvant administration rates of 13%³⁶ and 18%³⁷ for cesarean delivery. Neuraxial anesthetic adjuvant medications include additional epidural local anesthetics (e.g. lidocaine, chloroprocaine) and lipophilic opioids (e.g. fentanyl). Systemic anesthetic adjuvant medications include intravenous fentanyl, ketamine, midazolam, propofol, and inhaled nitrous oxide et al. Obstetricians can also provide supplemental anesthesia with infiltration of local anesthetic in the surgical field and not exteriorize the uterus for repair, which increases pain. Pain and anxiety may require being addressed separately, with pharmacologic or non-pharmacologic approaches. Pain should not be treated with anxiolytics or hypnotics alone.
Best Practices	Evaluation of Inadequate Blockade Detecting and treating inadequate blockade includes good communication with patients and coordination with surgical/obstetrical teams, as well as situational awareness encompassing fetal, maternal, and surgical contexts. Acknowledge pain or discomfort experienced by the patient. Evaluation should include identifying the location and extent of discomfort, level of anesthesia, surgical progress and stage, and addressing any other factors that can be exacerbating the discomfort (e.g., uterine exteriorization, patient’s ability to communicate, surgical complications). Anesthetic evaluation can include sensory level and blockade quality or ‘density’ for assessing potential response to administering adjuvant agents such as neuraxial lipophilic opioids or alpha₂ adrenergic agonists. If feasible, consider pausing surgical stimulation while addressing pain. Shared Decision Making Shared decision making depends upon situational urgency, emergency treatment paradigms, and patient-system engagement in the prenatal, pre-operative and intra-operative periods. In urgent/emergent situations the anesthesiologist may keep the patient and their support person abreast of developments as reasonably practicable. Communication between obstetrical and anesthesia teams.⁶ Neuraxial Anesthesia Replacement Decisions to replace or not replace neuraxial anesthesia immediately before surgery should weigh maternal and fetal needs and risks, and open discussions together with obstetrician and patient can optimize decision making around replacement of neuraxial anesthesia. Spinal anesthesia soon after epidural anesthesia dosing may be associated with high neuraxial blockade or hypotension. Repeat epidural anesthesia and surgical redosing should consider local anesthetic systemic toxicity considerations. Neuraxial Medications for Inadequate Regional Blockade Local anesthetics, lipophilic opioids, and alpha² agonists have been described as neuraxial adjuvants for patients with inadequate regional blockade.²⁶ If an epidural catheter is in place, consider dosing with supplemental local anesthetics e.g. lidocaine 2% with epinephrine 5 mcg/ml or chloroprocaine 3%, not to exceed recommended doses for systemic toxicity. Lipophilic opioids (e.g. fentanyl) are among the most commonly used neuraxial methods to treat pain. Alpha² adrenergic agonists like IV dexmedetomidine or neuraxial clonidine have also been used. Note that many of these commonly used medications do not have specific FDA approved indications for the neuraxial route of administration. The decision to use or not use these modalities is the individual’s decision based on the surgical, maternal, fetal considerations, judgement on patient responsiveness to these modalities, and other considerations around management of alternative anesthetic options including general anesthesia (e.g., airway examination, course of labor, etc.). Systemic and Inhaled Medications for Inadequate Regional Blockade Lipophilic opioids (e.g. fentanyl), benzodiazepines (e.g. midazolam), alpha-2 adrenergic agonists (e.g. clonidine, dexmedetomidine), sedative hypnotics (e.g. propofol) and nitrous oxide have been described in the treatment of inadequate regional blockade during cesarean delivery.^36,37 When using supplemental opioid, sedative, hypnotic or other medications that can affect respiratory or mental status, the level of consciousness should be monitored. The avoidance of General Anesthesia must be balanced against the risk of deep sedation with an unprotected airway in a population known to be at increased risk of aspiration. ASA intraoperative standards should be met.³⁸ Local Anesthetic Surgical Infiltration Infiltration of local anesthesia in the surgical field has been described to supplement neuraxial anesthesia, prior to skin incision.³⁹ It is used predominantly in low-resource areas where neuraxial anesthesia options for cesarean delivery are lacking. Local anesthetic infiltration to supplement poorly functioning neuraxial anesthesia may be used in an emergency.⁴⁰ There is insufficient evidence to inform recommendations on use or non-use of local anesthesia skin and fascia infiltration as a supplemental analgesic intervention for patients with inadequate regional blockade detected during cesarean delivery. This should not be considered a primary method of supplementation. Documentation Documentation is important in the setting of patient discomfort and pain. A patient’s perception of an intraoperative event may not be consistent with the provider’s perception of the same event.¹² An expression of pain or discomfort by the patient is valid and warrants a discussion regarding next steps.

Table 4. Conversion to General Anesthesia

Why This	Regional anesthesia for cesarean delivery will occasionally be inadequate for surgical anesthesia. The clinician should be able to diagnose the need for and manage this clinical event.
Background	Despite the best efforts of the clinician to provide adequate regional anesthesia, failure of regional anesthesia requiring conversion to general anesthesia occurred in 4.9% in one prospective study.⁵ The conversion rate for scheduled cases was 0.06% in a systematic review.⁷
Best Practices	Patient preferences for conversion to general anesthesia ideally discussed previously in preoperative assessment. Recommendation: Have a preoperative conversation with the patient as described in Table 1. Measures to prevent inadequate regional anesthesia should be utilized. Use best practices to avoid inadequate regional anesthesia as described in Table 2. Assess the nature of the pain or discomfort. If the patient becomes increasingly uncomfortable during the surgery, it is important to first acknowledge the patient’s experience and discomfort and assess the nature and quality of the pain and/or discomfort.^13,37 Dismissal or delayed management of pain may increase the risk of psychological sequelae.¹³ Communicate with the patient that their pain or discomfort will be managed. Attempt to treat pain with neuraxial and/or systemic anesthetic adjuvant medication. Administer additional neuraxial anesthetic and/or systemic anesthetic adjuvant medication as described in Table 3. Be willing to convert to general anesthesia if needed. Have equipment and personnel available. Use situational awareness and shared decision making when deciding to convert to general anesthesia. Depending on the stage of the surgery, the obstetric team should be asked to pause the surgery, assuming it is safe to do so. If measures fail to improve patient comfort, conversion to general anesthesia may become necessary. The anesthesiologist should use their knowledge and expertise in deciding when general anesthesia should be offered.¹³ If possible, there should be shared decision making between the anesthesia care team, surgical team and the patient if intraoperative conversion to general anesthesia is being considered.^13,41 If feasible, consider pausing surgical stimulation while intubating.

Table 5. Conduct of General Anesthesia

Why This	Clinicians should know how to administer general anesthesia for cesarean delivery using best practices.
Background	In a multicenter study of over 257,000 obstetric anesthetics, 5.6% of cesarean deliveries were performed under general anesthesia with an incidence of failed airway was 1:533.⁴² Once the decision has been made to proceed with intraoperative conversion to general anesthesia, skilled assistance should be sought to help with the preparation of medications, airway equipment, suction, and to provide cricoid pressure during the induction of anesthesia and assist with airway management.
Best Practices	Optimal Positioning Patient positioning should be optimized to increase the chances of successful intubation. Recommendation: Raising the head of the bed by 20-30 degrees for pre-oxygenation and intubation in term parturients has been shown to increase functional residual capacity;⁴³ it may also improve lung compliance if mask ventilation is warranted,⁴⁴ slightly improve the view of the glottic opening,⁴⁵ facilitate easier airway manipulation in patients with large breasts, and decrease the risk of gastroesophageal reflux.⁴⁶ In morbidly obese patients, the “ramped” position, with supports placed under the shoulders and upper body, better facilitates flexion of the neck and extension of the head and provides a superior laryngeal view to the sniffing position alone.^47,48 Adequate Pre-Oxygenation (De-Nitrogenation) Pre-oxygenation (de-nitrogenation) with a tight mask-to-face seal with a high fresh gas flow rate of to achieve fractional end-tidal oxygen ≥ 0.8 is recommended. This may be achieved with two-three minutes of tidal breathing or 4-8 vital capacity breaths.^2,46,49 Rapid Sequence Induction Due to concerns for the rare but serious risk of pulmonary aspiration of gastric contents, rapid sequence induction is utilized.² Adequate doses of a hypnotic agent such as propofol 2 – 2.8 mg/kg,⁵⁰ or in the setting of hemodynamic instability, ketamine 1 – 1.5 mg/kg⁵¹ or etomidate 0.3 mg/kg⁵² may be used. Fast-onset neuromuscular blocking agent succinylcholine (1 – 1.5 mg/kg) achieves paralysis within 30 – 40 seconds. High-dose rocuronium (1.0 – 1.2 mg/kg) with sugammadex 16mg/kg as a backup for rocuronium binding and reversal may be used as an alternative, when succinylcholine should be avoided.⁵³ Opioids are typically not routinely administered prior to delivery of the fetus, but may be advisable in some situations such as severe maternal hypertension, cardiac disease or neurologic compromise.^52,54,55 Despite controversy regarding proven efficacy, cricoid pressure is recommended to be applied initially with a force of 10 N, with an increase in force to 30 N upon loss of consciousness.^46,56 Mask ventilation is usually avoided to prevent gastric insufflation, however if necessary to prevent or manage hypoxemia, gentle ventilation below 20 cmH2O pressure is recommended.⁴⁶ Laryngoscopy Since video laryngoscopes usually provide a better view than with direct laryngoscopy, they may be used preferentially, for the first attempt.⁵⁷ Styletted and smaller-diameter cuffed endotracheal tubes of 6.5 or 7.0 mm should be used to minimize tissue trauma.46 Sometimes decreasing cricoid pressure may provide a better view. Correct endotracheal tube placement should be confirmed with continuous expired end-tidal capnography. Difficult or failed attempts should prompt the anesthesia provider to follow the difficult airway guidelines.^46,58 Maintenance of Anesthesia Maintenance of anesthesia should target adequate maternal oxygenation and normocapnia. A FiO2 of 0.3-0.5 is usually sufficient. Prior to delivery, end-tidal levels of 1.0 MAC of inhaled anesthetic agents are usually delivered, with a decrease to <0.5 – 0.75 MAC after delivery, which may be supplemented by 50-70% nitrous oxide, to limit the dose-dependent uterine relaxation associated with volatile agents.^2,59Benzodiazepines (e.g. midazolam) may be administered after delivery to reduce the risk of maternal awareness. Total intravenous anesthesia may reduce the risk of hemorrhage due to having little or no effect on myometrial contractility at usual clinical doses.⁶⁰ Note that patients having general anesthesia for cesarean delivery are considered as at increased risk for intraoperative recall. Consider regional anesthesia techniques to help provide post-operative analgesia e.g. TAP block, wound infiltration.

Table 6. Follow-Up and Referral

Why This	The patient’s experience during cesarean delivery is a unique perspective that should be engaged by the clinician.
Background	Both anesthesiologists and obstetricians significantly underestimated when patients experienced pain during cesarean delivery in a prospective study.⁸ Pain during cesarean has been described by an obstetric anesthesiologist from the perspective of a patient who experience pain and offered ideas for practice improvement.¹¹ Moreover, there are potential long-term effects for patients who have recall of unpleasant events during surgical procedures.²⁷ Patients who experience significant pain or discomfort may benefit from appropriate follow-up and referral.
Best Practices	Engage the patient when they communicate having pain or discomfort during cesarean delivery. Good communication is essential to eliciting patient concerns about pain⁶¹ and helps identify intraoperative pain during cesarean delivery.^6,23 Acknowledge, discuss and treat intraoperative pain. This topic is covered in Tables 3 and 4. On the postoperative visits follow-up with patients who experienced pain and help identify patients who experienced pain during cesarean delivery. The postoperative visit is used for feedback and can elicit anesthetic complications⁶² as well as improved patient satisfaction.⁶³ Appropriately document the patient’s stated experience of pain and your actions to address it. In the United Kingdom, untreated pain during cesarean delivery was the most common cause of litigation related to obstetric anesthesia practice.¹⁰ Clinicians should document an accurate description of the patient’s pain or discomfort and any measures taken to address it. For postoperative recall of intraoperative pain, clinicians should also document the occurrence and management. Refer for follow-up or consultation for significant adverse experiences to an appropriate professional. Anesthetic complications are an independent variable for the development of PTSD.¹²

Table 7. Quality Improvement

Why This	Quality improvement processes systematically improve care and suggest opportunities for improvement.
Background	Anesthesiologists are integral to the safe provision of modern obstetric care, delivery of anesthesia, and perioperative services on labor and delivery. As such, broader quality metrics to guide overall performance are needed. Suggested quality metrics for obstetric anesthesia were previously selected to highlight various areas for potential improvement, and to assist in improving the quality of care provided, but this is not a complete list and did not include pain during cesarean.⁶⁴
Best Practices	Audit Appropriate Metrics⁶ Percentage of patients who receive general anesthesia for cesarean delivery⁶⁴ Percentage of patients who receive systemic analgesic/anesthetic adjunct for cesarean delivery performed under neuraxial anesthesia⁶⁴ The route, amount and drug type have not been validated, but may reveal opportunities for quality improvement and potential changes in practices. Studies have focused on anesthesia interventions as the defining event for metrics, not the occurrence of self-reported pain.¹¹ Other appropriate metrics may be considered or developed in the future.

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