Incidence of pain during cesarean delivery with neuraxial anesthesia: an international, prospective cohort study

Background: Neuraxial anesthesia techniques are considered the preferred technique for cesarean delivery, however the true incidence of pain during cesarean delivery with neuraxial anesthesia is not currently known. To date studies have been retrospective or conducted in a single center. The primary aim of this international cohort study was to prospectively determine the incidence of patient reported pain during cesarean delivery with neuraxial anesthesia. Methods: We conducted, over 8 weeks, a multicenter cohort study in 15 centers across the United States of America and Canada; all patients who underwent cesarean delivery with neuraxial anesthesia were surveyed on postpartum day 1 regarding the presence of intraoperative pain, grade their pain using a numeric rating score (0-10) and rate their satisfaction (Yes/No) with their pain management.. Results: A total of 3,693 patients were included in the analysis. An overall incidence of patient reported pain during cesarean delivery was 7.6% (95% CI 6.8%, 8.5%) with 282 of 3,693 patients reporting pain. In patients undergoing elective cesarean delivery, intraoperative pain was reported in 3.7% (95% CI 2.7%, 5.0%) with spinal, 9.2% (95% CI 6.7%, 12.2%) with combined spinal-epidural and 12.2% (95% CI 4.1%, 26.2%) with epidural top-up anesthesia. In the non-elective setting, pain was more commonly reported by patients, 5.7% (95% CI 4.0, 7.8) with spinal, 7.1% (95% CI 4.7%, 10.1%) with combined spinal-epidural, 8.0% (95% CI 2.2%, 19.2%) with dural puncture epidural and 13.2% (CI 95% CI 11.1%, 15.5%) with epidural top-up anesthesia. Patients who had intraoperative pain reported a median (IQR) numeric rating score of 6 (4-8) out of 10. In those who reported pain, dissatisfaction with how the pain was managed by the anesthesia team was reported by 29 (10.3%) patients. Conclusions: Overall incidence of patient reported pain during cesarean delivery with neuraxial anesthesia in this multicenter cohort was 7.6%. This varied significantly by anesthesia technique, with spinal having the lowest incidence and epidural top-up the highest. Further work is required to characterize the pain experience, understand its impact, and develop techniques to reduce its incidence.