Importance of preoperative planning for cesarean delivery, with Beth Ann Clayton DNP, CRNA

Building on her previous discussion regarding the technical and physiological barriers that contribute to a 17% anesthesia failure rate during cesarean deliveries, Beth Ann Clayton, DNP, CRNA, FAANA, FAAN, Practicing CRNA, Nurse Anesthesia program director, University of Cincinnati; Practices clinically at the University of Cincinnati Medical Center, level 4 High-Risk Maternity Care Unit; Member, American Association of Nurse Anesthesiology (AANA), focused on the necessity of a proactive, multimodal plan. For high-risk patients—particularly those with substance use disorder (SUD) or chronic pain—success depends on a continuous strategy that begins before the first incision and extends 72 hours into the postpartum period.

Preoperative optimization and the multimodal approach

Effective pain management for complex patients requires stabilizing their existing medication regimens while layering new analgesics. Clayton emphasized that patients with SUD should remain on their maintenance medications, such as methadone or Subutex, throughout the perioperative period. To optimize the surgical block, Clayton advocates for a "multimodal" approach starting before the procedure begins.

“There are things that we can give preoperatively, such as gabapentin or ketamine and Tylenol,” Clayton stated. This strategy is complemented by adding optimized medications to the spinal or epidural itself. “In our spinal and epidural, we do provide the long-acting opioid, which is called Duramorph, which is a morphine derivative, and if the patient is allergic to Duramorph, we can actually use hydromorphone or Dilaudid as well,” she explained, noting that a short-acting opioid like fentanyl is also frequently added to optimize the block.

Postoperative blocks and "TAP" techniques

So in these patients, we like to provide transabdominal plane (TAP) blocks,” she said. “Those blocks are important because they actually numb the abdominal area where the cesarean delivery is. If the ob-gyn doesn't have an anesthesia provider that can provide a TAP block, the ob-gyn provider themselves could just inject local into the subcutaneous tissue.”

“The TAP blocks last about 12 hours. Those can be repeated the next day,” Clayton said, noting she has provided repeat blocks the morning after surgery to maintain comfort.

Sustaining relief through scheduled analgesia

The cornerstone of the 72-hour postoperative plan is a strict, scheduled rotation of non-opioid medications. Clayton recommends beginning multimodal analgesia immediately following surgery, combining 975 mg to 1000 mg of Tylenol every 8 hours.

“And nonsteroidals, if the patient doesn't have a contraindication to nonsteroidals, the anesthesia provider can give ketorolac at the end of the procedure, and then again, 8 hours later, they should start with oral ibuprofen at a dose of 400 mg and give that every 8 hours,” Clayton detailed. While some patients may still require oxycodone for rescue or patient-controlled analgesia (PCA), a proactive plan ensures that these needs are minimized. Even in emergency scenarios, Clayton concluded that many of these postoperative avenues can still be successfully incorporated to ensure the best possible patient outcomes.