Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia

Abstract

The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

Postoperative Respiratory Compromise following Cesarean Birth: The Impact of Obesity and Systemic Opioids

“…Our findings support the more recent recommendations that neuraxial opioids are not only more effective, but likely safer, than systemic opioids when used in a multimodal strategy for postcesarean analgesia. 25 41 This is also consistent with revised recommendations that allow less surveillance following neuraxial hydrophilic opioids. 41…”

“…12 13 14 15 16 17 18 19 20 21 22 23 Published studies in obstetric literature discuss the impact of neuraxial opioids on respiratory depression and respiratory arrest and generally confirm that the risk of respiratory depression is low. 24 25 39 40 41 Reports on respiratory arrest in postcesarean women are limited. 42 43 44 Here, we found a relationship between respiratory compromise and BMI, but the relationship with opioid dose was less pronounced.…”

“…Many hospitals already have increased respiratory monitoring of postoperative women with obesity, but this is not standardized. 41 This study also has implications regarding the safety and the intensity of postoperative monitoring when using systemic opioids versus neuraxial opioids as a primary strategy for postcesarean analgesia. Our institution opted for systemic opioids because prior recommendations for respiratory monitoring following neuraxial hydrophilic opioids were burdensome to patients and providers.…”

Recomendaciones para la analgesia o anestesia de pacientes obstétricas con COVID-19

“…• El uso de morfina intratecal no está contraindicado en pacientes con COVID-19 y sugerimos ceñirse a la recomendación de Bauchat y cols. [6], respecto a las dosis a utilizarse y la monitorización requerida. • Se debe realizar el posoperatorio en el quirófano y, posteriormente, trasladar a su pieza a la paciente y su acompañante con mascarilla quirúrgica, mientras que el personal con los EPP adecuados.…”

<p>Obesity And Obstetric Anesthesia: Current Insights</p>

“…The study population included 2,283 obese (class I and II) and 886 morbidly obese (class III) parturients 88. Based on these findings and in accordance with guidelines from the ASA, the Society of Obstetric Anesthesia and Perinatology, and the American Society of Regional Anesthesia and Pain Medicine, we continue to use neuraxial morphine in this patient population in conjunction with appropriate monitoring 89,90. When neuraxial morphine is contraindicated due to allergy or intolerance, intravenous patient-controlled analgesia may be used cautiously in a setting where patients can be monitored closely for sedation and respiratory depression.…”