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

Background: Neuraxial anesthesia is the definitive 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 articles assessed for risk of bias. Results: A total of 2,061 abstracts were screened; 34 articles were included (21 randomized studies and 13 nonrandomized studies). The crude incidence of intraoperative pain under neuraxial anesthesia was 10.8% (1,229 of 11,351 patients), and the pooled incidence was 17% (95% CI, 13 to 22%; 1,229 of 11,351 patients). Patients who received spinal anesthesia had the lowest pooled incidence of pain of 14% (95% CI, 10.0 to 20.0%; 662 of 8,002 patients), and those who received epidural top-up had the highest pooled incidence of pain of 33% (95% CI, 17.0 to 54.0%; 253 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 psychologic 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.