Intraoperative Pain during Cesarean Delivery under Neuraxial Anesthesia: A Systematic Review and Meta-analysis.

Summary

Across 34 studies (11,351 patients), pooled patient-reported intraoperative pain during cesarean under neuraxial anesthesia was 17% (95% CI, 13–22). Spinal (14%) and combined spinal-epidural had lower pain incidence than epidural top-up (33%). About half of included studies had high risk of bias, underscoring the need for more rigorous prospective research.

Key Findings

• Pooled intraoperative pain incidence under neuraxial anesthesia: 17% (95% CI, 13–22).
• Spinal anesthesia had the lowest pooled pain incidence: 14% (95% CI, 10–20; 662/8,002).
• Epidural top-up had the highest pooled pain incidence: 33% (95% CI, 17–54; 253/1,395).
• Approximately half of included studies were at high risk of bias.

Clinical Implications

Counsel patients about a nontrivial risk of intraoperative pain under neuraxial anesthesia; preferentially consider spinal or combined spinal-epidural over epidural top-up for cesarean when feasible; implement vigilant intraoperative testing and rescue analgesia protocols.

Limitations

• High heterogeneity and high risk of bias in about half of included studies
• Limited patient-level data to adjust for confounders (eg, urgency, dosing, surgical factors)

Future Directions

Prospective, standardized, patient-centered studies to evaluate predictors, preventions, and intraoperative rescue strategies; incorporate patient-reported experience measures and medicolegal outcomes.