Breakthrough pain during cesarean section under neuraxial anesthesia: a two-center prospective audit


Breakthrough pain; Cesarean section; neuraxial anesthesia; intraoperative pain

Published online: Jun 23 2022

Eva Roofthooft, MD 1,2,*, Noémie Lippens 3,*, Steffen Rex, MD, PhD 4,5, Sarah Devroe, MD 2,4, Anneliese Moerman, MD, PhD 3, Nicoletta Filetici, MD 4, Marc Van de Velde, MD, PhD, EDRA, FESAIC 6

* Eva Roofthooft and Noémie Lippens equally share first authorship.

1 Department of Anesthesiology, GZA Hospitals, Antwerp, Belgium;
2 Department of Cardiovascular Sciences, KULeuven, Leuven, Belgium;
3 Department of Anesthesiology, UGent, Gent, Belgium;
4 Department of Anesthesiology, UZLeuven, Leuven, Belgium;
5 Department of Cardiovascular Sciences, KULeuven, Leuven, Belgium;
6 Department of Cardiovascular Sciences, Anesthesiology, KULeuven and UZ Leuven, Leuven, Belgium.


Worldwide, most Cesarean sections (CS) are performed under neuraxial anesthesia. However, neuraxial anesthesia can fail and intraoperative breakthrough pain can occur. The aim of the present investigation was to evaluate the incidence of breakthrough pain in consecutive CS and to describe the potential risk factors for breakthrough pain. In a two center, prospective audit all CS performed under neuraxial anesthesia were included and the occurrence of breakthrough pain as well as all possible risk factors of breakthrough pain were recorded as well as the alternative anesthetic strategy. A total of 393 patients were enrolled in the study over 6 months, 206 in UZ Leuven and 187 in ZNA Middelheim, 295 elective CS and 98 secondary CS. Of all 393 participants, 65 experienced breakthrough pain during the CS (16.5%). Twoo significant risk factors for breakthrough pain during CS were observed: the duration of surgery (p <0.001) and the epidural drug used (p=0.0032). Breakthrough pain during a CS is extremely uncomfortable for the mother. In this observational study, the incidence of breakthrough pain during CS was 16.5%.

Duration of surgery and epidural drug used were both significant risk factors of breakthrough pain during CS in this audit. A pro-active policy is required in order to prevent breakthrough pain or discomfort during CS. Early identification of problematic epidural catheters for labor analgesia, adequate level of anesthetic block before surgery, and administration of a prophylactic epidural top-up if duration of surgery is prolonged as opposed to the choice of local anesthetic used, could be essential in the prevention. Further high-quality studies are needed to evaluate the many potential risk factors associated with breakthrough pain during CS.