Pain during caesarean section

With around 92% of all sections in the UK now carried out under regional (spinal, epidural or combined spinal-epidural) anaesthesia, the risks associated with obstetric general anaesthesia, previously one of the top causes of maternal mortality, have been largely controlled. But in their place has risen the spectre of pain during caesarean delivery, now almost certainly the commonest successful negligence claim against anaesthetists. Complete comfort cannot be guaranteed for patients being delivered surgically when awake because, although the level of block required for a caesarean section extends to the upper thoracic dermatomes, sometimes this is not enough. We know that a small proportion of patients will feel pain and that in some cases this will warrant intra-operative conversion to general anaesthesia. The Royal College of Anaesthetists sets an audit standard that fewer than 5% of elective patients should feel pain and that fewer than 1% should require conversion to general anaesthesia; these figures rise to 20 and 15% respectively for Category 1 procedures (http://www.rcoa.ac.uk/document-store/audit-recipe-book-section-8-obstetrics-2012). What would lead to an anaesthetist being regarded as delivering an unacceptably low standard of care in such an instance, a conclusion that, in my own medicolegal casebook, applies to a surprisingly high 74% of the 76 claims in which I have given an opinion? Problems seem to arise in four main areas. Record-keeping is often poor in such cases, making it impossible to confirm that these steps were followed. In addition, many patients seem to be motivated, at least in part, by what they perceive as an uncaring or dismissive attitude on the part of the anaesthetist. The general lessons for any doctor seeking to avoid negligence litigation seem to be much the same no matter what the specialty: keep good records, listen to the patient and show her respect, and be nice. All other things being equal, nice doctors don't get sued (as often). Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.