VOLUME 37, ISSUE 1

In 2022, there were approximately 1.2 million cesarean deliveries performed in the United States.¹ A systematic review reported that approximately 15% of patients experienced pain during cesarean delivery,² and a single-center prospective patient-reported outcome study reported that 22.6% of patients reported pain during cesarean delivery.³ Considering these statistics, it is possible that up to 275,000 patients experience pain during cesarean delivery in the United States each year. To address this issue, the American Society of Anesthesiologists (ASA) Committee on Obstetric Anesthesia drafted the Statement on the Use of Adjuvant Medications and Management of Intraoperative Pain During Cesarean Delivery⁴ that was passed by the ASA House of Delegates during the 2024 ASA Annual Meeting. This statement expands upon the ASA Statement on Pain During Cesarean Delivery.⁵

The ASA statement on adjuvant medications makes recommendations for patients who experience pain during cesarean deliveries performed with neuraxial anesthesia. Adjuvant medications can be administered through intravenous, neuraxial, and inhalational routes. Intravenous medications include fentanyl, ketamine, dexmedetomidine, and propofol. Neuraxial adjuvant medications include fentanyl and local anesthetics while nitrous oxide is the only inhalational adjuvant medication recommended in the statement.

Anxiety is another indication for administration of adjuvant medication during cesarean delivery. Carefully titrated doses of sedatives such as midazolam, dexmedetomidine, and propofol can alleviate anxiety while minimizing the risk of adverse maternal outcomes such as aspiration and adverse outcomes such as respiratory depression.

There may be instances where neuraxial anesthesia with the addition of adjuvant medications proves to be inadequate. When this occurs, anesthesiologists should engage the patient in shared decision making and honor patient requests to convert to general anesthesia when possible.

There are potential psychological sequelae that may result from inadequate anesthesia during cesarean delivery that have been described.⁶ The statement recommends follow up with patients who experienced inadequate anesthesia during cesarean delivery whether they required conversion to general anesthesia or not.

In conclusion, the Statement on the Use of Adjuvant Medications and Management of Intraoperative Pain During Cesarean Delivery provides practical guidance on the treatment of inadequate analgesia during cesarean delivery. Our patients would be well served if the principles outlined in the statement were considered when providing care for obstetric patients.