Most oral analgesics are safe for women who choose to breastfeed. Acetaminophen and NSAIDs (ibuprofen and diclofenac) are considered safe for most women. The use of NSAIDs in newborns with a ductal-dependent lesion (e.g., hypoplastic left heart) should be avoided.¹³ Given the concern for opioid dependence as well as passage in breast milk, we prefer to use other oral analgesics as first-line options, with oral opioids as second-options. Due to concern for opioid passage into breast milk, we recommend providers avoid the use of codeine, hydrocodone, tramadol, and meperidine in breastfeeding women. The American Academy of Pediatrics prefers the use of morphine, hydromorphone, or butorphanol.¹³

The use of NSAIDs has been shown to decrease overall opioid use and subsequently decrease opioid-related side effects.¹⁴ Given their benefit, NSAIDs should be considered as first-line pain control over opioids. Traditionally, it has been recommended that NSAIDs be avoided in the hypertensive postpartum patient.¹⁵ Newer data have suggested NSAID usage may be safe for this subset of women.¹⁶,¹⁷ The addition of IV acetaminophen with NSAIDs has been shown to improve patient satisfaction.⁷

Transversus abdominis plane (TAP) blocks require a large volume of local anesthetic injected between muscle layers, often under ultrasound guidance. The use of TAP blocks in nonobstetric and gynecologic surgery is mounting which appears to reduce overall opioid usage. These may be considered for large surgeries or in patients where some of the above modalities are contraindicated. Multimodal pain management that decreases opioid consumption and resultant opioid-induced side effects, limited perioperative fluid administration, epidural analgesia, and transverse abdominis plane (TAP) block have all been proven to decrease rates of ileus.¹⁸,¹⁹,²⁰,²¹

In the United States, anesthesia complications account for approximately 2% to 3% of maternal deaths. Aspiration of gastric contents is one of the most common causes of death from general anesthesia.³⁴ Injury from aspiration can occur either by obstruction of the airway or chemical insult to the bronchial epithelium. Pulmonary edema, hypoxia, and rarely cardiovascular collapse and death can occur.³⁵ Animal studies suggest that the mechanism of death in aspiration is the release of proinflammatory cytokines, especially tumor necrosis factor (TNF)-alpha and interleukin (IL)-8.³⁶ The risk of aspiration is greatest during induction with endotracheal intubation and with extubation at emergence, but it can happen at any point in the postoperative period. The incidence of aspiration is three to four times higher in emergent anesthesia situations compared to elective surgeries, and the risk is particularly increased in pregnant women due to decreased lower esophageal sphincter tone.³⁷ Although most experts recommend rapid sequence intubation in all pregnant women, this technique is not supported by the available evidence.³⁸ Aspiration pneumonitis can have a fulminant course and result in respiratory compromise quickly. The primary treatment goal is respiratory support. Animal studies have shown therapeutic benefit from positive-pressure ventilation and intravenous high-molecular-weight colloids.³⁹,⁴⁰

Urinary retention is a common complication of both pelvic surgery and neuraxial anesthesia. Spinal anesthesia blocks both afferent and efferent nerve signals to the bladder, resulting in decreased sensation of fullness and impaired detrusor contractility.⁴¹ During a difficult cesarean or hysterectomy, extensive dissection of the parametrial tissues may disrupt the pelvic splanchnic nerves that supply the bladder, usually resulting in a hypotonic bladder and urinary retention. An indwelling catheter, sometimes for a prolonged interval, is required to decompress the bladder and allow it to regain its normal tone.

Postdural puncture headache (PDPH), or spinal headache, is another common complication of obstetric anesthesia characterized by a positional headache that is worse when upright. The incidence of PDPH after spinal anesthesia is between 3% and 9%, depending on the type and size of needle used. More commonly, PDPH results from inadvertent puncture of the dura during placement of an epidural catheter.⁴² An epidural needle has a larger diameter than a spinal needle, and PDPH is thought to result from decreased cerebrospinal fluid (CSF) pressure due to leakage of CSF through the hole in the dura. Although fewer than 6% of epidural placements are complicated by inadvertent dural puncture, the rate of PDPH in these instances is up to 88%.⁴³ Mild PDPH is usually treated with supportive therapy, including bed rest as needed, oral analgesics, and antiemetics. Aggressive oral and/or intravenous hydration is often encouraged in postpartum patients.⁴⁴ For patients with severe or debilitating symptoms that prevent them from carrying out activities of daily living, an epidural blood
patch should be offered as definitive treatment. A blood patch involves injection of autologous blood through an epidural needle into the epidural space. Epidural blood patch has been shown to reduce the duration and intensity of PDPH compared with both conservative treatment and sham procedure in a recent systematic review based on the results of three randomized controlled trials.⁴⁵,⁴⁶,⁴⁷,⁴⁸ The blood patch procedure usually provides immediate relief within seconds to minutes, with reported success rates between 65% and 98%.⁴⁶,⁴⁹

Spinal epidural hematoma and central nervous system (CNS) infection are rare but potentially life-threatening complications of neuraxial anesthesia. Spinal epidural hematoma results from hemorrhage into the neuraxis. Although the incidence of spinal epidural hematoma appears to be significantly lower in obstetric patients than in other populations, the risk is increased in the setting of coagulopathy or anticoagulation therapy.⁵⁰ Hematoma is less likely with a spinal needle than with an indwelling epidural catheter.⁵¹ The concealed nature of the bleeding necessitates a high index of suspicion in patients with progressive motor and sensory blockade and/or bladder and bowel dysfunction. CNS infection is also exceedingly rare but must be considered in patients with fever, back pain, and neurologic deficits. Epidural abscess is more likely to occur with placement of epidural catheters, whereas meningitis is more common after dural puncture. The incidence of postdural puncture meningitis after spinal anesthesia ranges from 0.2 to 1.3 per 10,000 procedures.⁵² Epidural abscess following placement of epidural catheters is more common, with incidence ranging from 0.5% to 3%.⁵³,⁵⁴,⁵⁵ Diagnosis is confirmed with lumbar puncture or magnetic resonance imaging (MRI).