Obstetric anaesthesia: Overview + SIG resources

Abstract
Background: Neuraxial anesthesia is the gold standard technique for cesarean delivery, however pain during cesarean delivery may be underreported. The primary aim of this systematic review and meta-analysis was to determine the incidence of patient reported intraoperative pain during cesarean delivery under neuraxial anesthesia.

Methods: A literature search of databases (PubMed MEDLINE, Embase, Web of Science, Scopus, Cochrane Database of Systematic Reviews, and Central Register of Controlled Trials) was conducted. Search topics included terminology concerning cesarean delivery, neuraxial anesthesia, pain, and incidence. Meta-analyses were performed to calculate pooled incidences of patient reported pain and how mode of anesthesia influenced the incidence of patient reported pain, with included papers assessed for risk of bias.

Results: A total of 2061 abstracts were screened; 34 articles were included (21 randomized studies and 13 non-randomized studies). The crude incidence of intraoperative pain under neuraxial anesthesia was 10.8% (1,229 out of 11,351 patients) and the pooled incidence was 17% (95%CI: 13% - 22%; 1,229 out of 11,351 patients). Patients who received spinal anesthesia had the lowest pooled incidence of pain of 14% (95%CI: 10.0% - 20.0%; 662 out of 8,002 patients) and those who received epidural top-up had the highest pooled incidence of pain of 33% (95%CI: 17.0% - 54.0%; 253 out of 1,395 patients). Risk of bias assessments showed high risk of bias in half of the included studies.

Conclusions: Patient reported pain during cesarean delivery under neuraxial anesthesia is common, with spinal and combined spinal-epidural anesthesia reporting a lower incidence of pain than epidural anesthesia. Intraoperative pain can have significant psychological impact for patients and medicolegal implications for providers. Further prospective studies are required to characterize and understand the impact of patient experiences of pain and develop techniques to reduce this complication.

Abstract
Purpose of review: Pain during cesarean delivery (PDCD) has been overlooked and underreported and is associated with a traumatic birth experience and long-term morbidity. We review the studies reporting on PDCD and summarize available guidance providing roadmaps for anesthesiologists caring for patients during cesarean delivery.

Recent findings: PDCD is a patient-reported outcome and should not be defined by interventions mitigating insufficient neuraxial anesthesia, such as supplemental analgesic medication or general anesthesia. Depending on the cohorts studied and definitions used, current reported rates of PDCD range between 2 and 36%. Preoperative patient counseling, risk stratification, and testing of neuraxial block are mitigating strategies; ultimately, if pain occurs, it should be managed skillfully applying shared decision-making with a supportive follow-up to reduce psychological trauma. Statements from three international organizations offer guidance to prevent and treat PDCD.

Summary: This review provides strategies to mitigate the occurrence of PDCD, with targeted approaches to better prevent and manage PDCD.

Abstract
Background: Spinal anesthesia is considered the method of choice for elective cesarean sections; however, it is not without maternal-fetal risks. Materials and Methods: This study compared the effects on maternal hemodynamics of intrathecal administration of fentanyl or morphine in parturients undergoing spinal anesthesia with 0.5% hyperbaric bupivacaine, with doses varied between 7.5 and 11 mg, depending on the patient's height. Data from a cohort of 170 parturients were analyzed. The administered doses were intrathecal morphine at 0.1 mL (100 µg, solution of 1 mg/mL) or fentanyl at 0.25 mL (25 µg, solution of 50 µg/mL). This study included 80 patients in the fentanyl (F) group and 90 in the morphine (M) group. Results: Group F showed significantly higher post-intervention systolic blood pressure values than group M (95.30 ± 12.99 mmHg vs. 90.58 ± 14.75 mmHg, p = 0.032). The incidence of vomiting was significantly less frequent in group F compared to group M (1, 1.3% vs. 10, 11.1%, p = 0.011). The total dose of ephedrine required for hypotension correction was significantly lower in the F group (12.75 ± 13.26 mg vs. 17.72 ± 16.73 mg, p = 0.035). Conclusions: The addition of fentanyl as an adjuvant alongside the local anesthetic in cesarean section is associated with enhanced hemodynamic stability compared to morphine, requiring lower doses of ephedrine and contributing to increased patient safety during elective cesarean surgery.