VOLUME 36, ISSUE 1

Prospective studies have reported pain during cesarean delivery to occur at an incidence between 11.9% and 22.7% for patients who had apparently adequate regional anesthesia.1,2 Significant pain during cesarean delivery may produce psychologic distress and an increase of postpartum PTSD.3 In response to these findings, the American Society of Anesthesiologists (ASA) Committee on Obstetric Anesthesia, chaired by Mark Zakowski, M.D., F.A.S.A. from Cedars Sinai Medical Center in Los Angeles, California, recently produced the Statement on Pain During Cesarean Delivery4 that was approved by the ASA House of Delegates in October 2023. As a member of the ASA Committee on Obstetric Anesthesia, I was honored to lead the working group that produced this ASA statement.

The statement provides guidance for anesthesiologists to prevent, diagnose, and manage pain during cesarean delivery. The statement makes recommendations regarding 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, and quality improvement.

Essentially, neuraxial blockade should be thoroughly tested prior to initiation of the surgical procedure that includes dermatome testing to cold touch to confirm a T5 level or higher and the inability of the patient being able to raise their legs. Complaints of pain during cesarean delivery by the patient should be acknowledged and immediately assessed. Judicious use of supplemental systemic medications such as intravenous fentanyl or inhaled nitrous oxide as well as neuraxial adjuncts should be considered to treat intraoperative pain. The clinician should use their judgment on when conversion to general anesthesia is indicated and should engage the patient in shared decision making when possible. Patients who experience pain during cesarean delivery should receive postoperative follow up and referral to mental health services if indicated. While there are no established national guidelines on optimal rates of general anesthesia or supplemental medication for cesarean delivery, hospitals should consider tracking these metrics for quality improvement purposes.

The provision of obstetric anesthesia is frequently performed by generalist anesthesiologists. While the ASA’s Statement on Pain During Cesarean Delivery is not meant to usurp local practice patterns or individual hospital guidelines, it can provide a framework for the anesthesiologist who wishes to adopt ASA recognized best practices in obstetric anesthesia. For more information, please visit the American Society of Anesthesiologists website.