Prevention and management of intra-operative pain during caesarean section under neuraxial anaesthesia: a technical and interpersonal approach (24 March 2022)

Summary

A woman who experiences pain during caesarean section under neuraxial anaesthesia is at risk of adverse psychological sequelae. Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. Generic guidelines on caesarean section exist, but they do not provide specific recommendations for this area of anaesthetic practice.

This guidance aims to offer pragmatic advice to support anaesthetists in caring for women during caesarean section. It emphasises the importance of non-technical skills, offers advice on best practice and aims to encourage standardisation. The guidance results from a collaborative effort by anaesthetists, psychologists and patients and has been developed to support clinicians and promote standardisation of practice in this area.

Content

Recommendations

1. Informed consent for anaesthesia for caesarean section requires an explanation of neuraxial techniques and general anaesthesia.
2. For neuraxial techniques, discuss the planned level of block and how it will be tested, the sensations that should be expected with an effective block, the possibility of pain and the potential ways of treating it, including general anaesthesia.
3. For non-elective caesarean section, the discussion should include any potential fetal risks arising from the time taken to deliver the possible modes of anaesthesia.
4. Use a recognised technique for neuraxial block for caesarean delivery with sufficient doses of local anaesthetic and opioids.
5. Use light touch as the primary testing modality, aiming for a block to sensation to T5 or higher. A second, confirmatory sensory modality should be used if the level of block is in doubt.
6. Identify the block level as the point at which sensation is first felt when moving from blocked to unblocked dermatomes between the mid-axillary and mid-clavicular lines bilaterally.
7. Test the lower limit of the block as well as the upper limit, using the back of the leg if necessary to avoid spraying near the genital area.
8. In addition, use straight leg raising as a simple and reproducible test for motor block. An effective block is indicated by the inability to straight leg raise against gravity bilaterally.
9. Acknowledge any complaint of pain or distress and ask the surgeon to stop if safe, then use intravenous fast-acting opioids or ketamine in the first instance.
10. A request for general anaesthesia should be honoured if possible. It is good practice for the anaesthetist to recommend general anaesthesia if effective analgesia is unlikely to be achieved using other methods.
11. Any patient who feels pain during caesarean section should be followed-up before they leave hospital by a senior anaesthetist, who should also contact the patient's general practitioner.