Neuraxial anesthesia and pain management for cesarean delivery

Optimal neuraxial anesthesia for cesarean delivery requires a thorough understanding of patient, obstetrical, surgical, and anesthesia-related factors which can impact pain during and after cesarean delivery. While not all cesarean deliveries are the same from an obstetrical standpoint, not all anesthetics provide the same degree of anesthetic blockade and postcesarean analgesia; therefore, context is crucial to provide patients with a safe and pain-free experience. Communication between obstetrical and anesthesia teams is key to ensure that the anesthetic approach is tailored to the clinical scenario, particularly if emergency cesarean delivery is needed, and follows best practices for cesarean delivery anesthesia. We propose several important considerations for the management of anesthesia and analgesia for cesarean delivery, focusing on patient-reported outcomes related to intraoperative and postoperative pain. Considerations include: (1) understanding the innervation of the uterus, peritoneum and abdominal wall, and the pain pathways involved with sensations and pain during and after cesarean delivery (eg, visceral sensations such as occurs with uterine manipulation may be very uncomfortable for some patients); (2) understanding the different neuraxial anesthetic and analgesic approaches (eg, epidural, spinal, combined spinal-epidural) with their specific advantages, limitations, and indications (eg, spinal anesthesia provides the most reliable neuraxial block, with the fastest onset but a limited duration, though it can be extended by the addition of adjuvants); (3) selecting the most appropriate anesthetic technique and neuraxial medications (eg, local anesthetics, opioids, adjuvants including alpha_2-adrenergic agonists) to prevent, mitigate, manage intraoperative discomfort, and optimize postoperative analgesia; (4) recognizing that intraoperative pain during cesarean delivery occurs in approximately 15% of cesarean deliveries and shivering in up to 50% of cesarean delivery (from a complex interplay of heat loss, disrupted thermoregulation, psychological stress, and surgical factors), necessitating multifaceted prevention approaches; (5) preoperatively identifying patient-specific risk factors for intraoperative pain (eg, opioid use disorder, chronic pain, previous traumatic childbirth experience, anxiety) to promote thorough counseling (eg, setting expectations, avoiding traumatizing circumstances, incorporating shared decision-making, offering general anesthesia if neuraxial block is inadequate) and tailored strategies; (6) optimizing interdisciplinary communication to identify inadequate labor epidural analgesia and allow replacement if intrapartum cesarean delivery becomes indicated, as well as adequate testing of neuraxial block by the anesthesia team and the obstetricians before proceeding with skin incision constitutes best practices; (7) recognizing the obstetric, surgical, and anesthesia-related factors associated with increased intraoperative and postoperative pain (eg, uterine exteriorization, intrapartum cesarean delivery, repeat cesarean delivery, use of an epidural anesthetic rather than a spinal or combined spinal-epidural anesthetic) should prompt specific approaches to enhance anesthesia and postoperative analgesia (eg, enhanced doses of neuraxial opioid, prolonged use of epidural analgesia with local anesthetic solutions or repeated doses of epidural morphine, abdominal wall blocks, particularly if neuraxial morphine could not be used); and (8) implementing stepwise opioid-sparing multimodal analgesia (eg, acetaminophen and nonsteroidal antiinflammatory drugs taken together) and personalized protocols for opioid prescriptions after cesarean delivery, since these have been shown to significantly reduce in-hospital opioid consumption and unnecessary opioid prescription without increasing postoperative pain.