Pain management in childbirth: Neuraxial analgesia and drug alternatives

The Société Française d'Anesthésie et de Réanimation (SFAR) and the Collège d'Anesthésie-Réanimation en Obstétrique (CARO) have collaborated to propose a set of guidelines for the pain management in childbirth: neuraxial analgesia and drug alternatives.

A consensus committee of 32 experts was convened. A formal conflict-of-interest policy (DPI santé) was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. These recommendations have undergone a certification process by the French National Authority for Health (HAS).

Five areas were defined: 1) Placement of neuraxial analgesia; 2) Initiation of neuraxial analgesia; 3) Maintenance of neuraxial analgesia; 4) Management of neuraxial analgesia insufficiency and failure; 5) Drug alternatives to neuraxial analgesia. For each field, the aim of the recommendations was to answer a number of questions formulated by the experts according to the PICO model ('Population, Intervention, Comparison, Outcome'). Based on these questions, an extensive literature search covering the last 24 years was carried out using predefined keywords according to the PRISMA recommendations. Data quality was analyzed using the GRADE method. The recommendations were formulated using the GRADE method, then voted on by all the experts using the GRADE grid method.

The experts' synthesis work and the application of the GRADE® method resulted in 39 recommendations. Among the formalized recommendations, 12 have high levels of evidence (GRADE 1+) and 10 have low levels of evidence (GRADE 2+). For 13 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any evidence in the literature. After 3 rounds of scoring and amendment, strong agreement was reached for all the recommendations.

There was strong agreement among the experts to provide recommendations for improving the management of pain in childbirth using neuraxial analgesia or alternative drug.