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Practice Bulletin No. 177 Summary: Obstetric Analgesia and Anesthesia

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doi: 10.1097/AOG.0000000000002009
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Clinical Management Questions

  • Which obstetric patients are not candidates for regional analgesia?
  • What is the role of systemic or parenteral agents during labor?
  • What is the association between epidural analgesia and maternal fever?
  • Does epidural analgesia affect the progress of labor or the rates of operative or cesarean delivery?
  • Does preeclampsia affect the choice of analgesia or anesthesia?
  • Do analgesia and anesthesia affect breastfeeding?
  • What anesthesia options are available for an emergent cesarean delivery?
  • What are alternative options when regional analgesia is ineffective for a cesarean delivery?
  • What are the optimal agents for analgesia after a cesarean delivery?
  • When is it appropriate to obtain an anesthesia consultation?
  • How soon after heparin or low-molecular-weight heparin use can regional analgesia be placed and how soon after regional analgesia can a dose be given?

Recommendations and Conclusions

The following recommendations are based on good and consistent scientific evidence (Level A):

  • Neuraxial analgesia does not appear to increase the cesarean delivery rate and, therefore, should not be withheld for that concern.
  • Opioids are associated with adverse effects for the woman and the fetus or newborn, most significantly respiratory depression, so attention should be paid to respiratory status.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

  • Spinal anesthesia, combined spinal–epidural, or general anesthesia are suitable for emergent cesarean delivery when no epidural is in place.
  • Thrombocytopenia is a relative contraindication to neuraxial blockade, but a safe lower limit for platelet count has not been established.

The following recommendations are based primarily on consensus and expert opinion (Level C):

  • In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor.
  • Epidural and spinal analgesia or anesthesia generally are considered acceptable in a patient with a platelet counts greater than or equal to 80,000/microliter provided that the platelet level is stable, there is no other acquired or congenital coagulopathy, the platelet function is normal, and the patient is not receiving any antiplatelet or anticoagulant therapy. In some circumstances, epidural or spinal analgesia and anesthesia may be acceptable for patients with platelet counts below 80,000/microliter.
  • It is recommended to withhold neuraxial blockade for 10–12 hours after the last prophylactic dose of LMW heparin or 24 hours after the last therapeutic dose of LMW heparin.

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A—Recommendations are based on good and consistent scientific evidence.

Level B—Recommendations are based on limited or inconsistent scientific evidence.

Level C—Recommendations are based primarily on consensus and expert opinion.


1. Levels of maternal care. Obstetric Care Consensus No. 2. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:502–15. (Level III)
© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.