The American Society of Anesthesiologists (ASA; Schaumburg, Illinois) House of Delegates recently approved the “Statement on Pain during Cesarean Delivery” from the Committee on Obstetric Anesthesia advising all practitioners on the pervasive problem of failure to achieve pain-free cesarean delivery. Parturients experience pain during cesarean delivery at an alarming 15% rate with some prospective studies reporting rates as high as 23%. With 1.3 million cesarean deliveries annually and a 15% pain rate, about 195,000 parturients experience pain during cesarean delivery in the United States each year. We can and must do better!

Pain during cesarean delivery has significant consequences including adverse experiences during a memorable lifetime event, psychologic distress, an increase in postpartum post-traumatic stress disorder, and an associated increased risk of litigation.  Assessing the quality of neuraxial labor analgesia, considering early replacement for inadequate analgesia, and adequate dosing for conversion to cesarean surgical anesthesia can help avoid inadequate neuraxial anesthesia and the need for conversion to general anesthesia. 

Neuraxial anesthesia is used for more than 95% of elective and 80% of emergent cesarean deliveries in the United States.  Failure to achieve pain-free cesarean deliveries varied by type of anesthesia, occurring in 6% of spinals, 18% of combined spinal epidurals, and 24% of labor epidurals, with an overall 4.9% rate of neuraxial anesthesia conversion to general anesthesia in emergencies.  A recent prospective study showed 11.5% of patients reported pain during cesarean delivery, yet only 34.8% received intravenous analgesia, and 6.5% converted to general anesthesia.  Also, 12.6% of patients without pain still received intravenous analgesics. Although neuraxial anesthesia is very reliable, achieving surgical anesthesia may be inadequate or fail entirely, and general anesthesia may also carry risks including recall.

Fortunately, your professional societies (ASA, Obstetric Anaesthetists’ Association [London, United Kingdom], and College d’Anesthesie-Reanimation en Obstetrique [Paris, France]) are alerting practitioners to this pervasive problem and offer actions you can take to help prevent and treat pain during cesarean delivery.  The ASA statement identifies risk factors for intraoperative pain and promotes optimal care through best practices in the domains of preoperative assessment, minimizing risks of inadequate neuraxial analgesia by evaluation of intrapartum labor epidural analgesia and checking for surgical anesthesia, supplementation of inadequate neuraxial anesthesia, conduct and conversion of general anesthesia, follow-up and referral, and even quality improvement opportunities.  Currently the ASA Committee on Obstetric Anesthesia is developing further materials advising on the treatment of intracesarean pain with systemic and neuraxial adjuvants.

Recognition and acknowledgment of intraoperative pain, the risk factors, how past traumatic experiences affect psychologic distress and pain, opportunities for avoiding and recommendations for treating intraoperative pain, patient education, and shared decision-making may help improve the anesthetic and birth experiences and reduce disparities. Postoperative follow-up and a needs assessment for psychologic support referral are also critical management components.

As a specialty, anesthesiology can and must do better to recognize and acknowledge pain during cesarean delivery as a first step toward not only treating intraoperative pain but also learning how to prevent it and minimizing long-term consequences.