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Caesarean Section 2020

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Summary Recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Grades of recommendation and levels of evidence

Grades of recommendation are assigned according to the overall level of evidence on which the recommendations are based, which is determined by the quality and source of evidence: Relationship between quality and source of evidence, levels of evidence and grades of recommendation.

Caesarean section is associated with moderate-to-severe postoperative pain in a significant proportion of women, which may delay recovery and return to activities of daily living; impair mother-child bonding; impact maternal psychological well-being; and complicate breastfeeding (Gamez 2018). Furthermore, inadequate postoperative pain relief may lead to hyperalgesia and persistent postoperative pain (Kainu 2010).

Pain after caesarean section is often under-treated due to unfounded fears that analgesic drugs or interventions might induce maternal and neonatal side-effects and because the severity of post-caesarean section pain is often underestimated (Huang 2019).

The procedure-specific postoperative pain management (PROSPECT) recommendations for pain management after caesarean section were published in 2014 (PROSPECT: C-Section 2014); however, an update was necessary given developments in clinical practice.

The aim of this systematic review was to provide updated recommendations based on recent literature assessing the impact of analgesic and surgical approaches on pain after elective caesarean section performed under neuraxial anaesthesia.  These recommendations should not be applied to other patient populations such as emergency or unplanned caesarean section or surgery performed under general anaesthesia.

Recommended: Pre-operative interventions

  • ‘Pre-operative’ refers to interventions applied before surgical incision
  • Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period
Intrathecal or epidural
opioid
  • Addition of intrathecal long-acting opioid (e.g. morphine 50–100 µg or diamorphine up to 300 µg) to spinal anaesthesia is recommended (Grade A)
  • The safety of intrathecal morphine has been confirmed in patients undergoing caesarean section (Sharawi 2018). Doses lower than 100 µg result in adequate analgesia with a reduced incidence of side-effects compared with higher doses
  • Basic analgesics (i.e. paracetamol and NSAIDs/COX-2-selective inhibitors) and IV dexamethasone should be used with intrathecal morphine
  • Of note, the National Institute of Health and Care Excellence guidelines in the UK recommend intrathecal diamorphine as an alternative to intrathecal morphine (NICE 2019)
  • Epidural morphine 2–3 mg or diamorphine up to 2–3 mg may be used as an alternative, for example, when an epidural catheter is used as part of a combined spinal-epidural technique (Grade A)
Paracetamol
  • Oral paracetamol is recommended (Grade A)

COX, cyclooxygenase; NSAIDs, non-steroidal anti-inflammatory drugs

Recommended: Intra-operative interventions (administered after delivery)
Paracetamol
  • Intravenous paracetamol is recommended, if not administered pre-operatively (Grade A)
NSAIDs/COX-2-selective inhibitors
  • Intravenous NSAID/COX-2-selective inhibitor is recommended, started intra-operatively (after delivery) (Grade A)
Dexamethasone
  • A single dose of intravenous dexamethasone is recommended after delivery (Grade A) for positive effects on pain scores and opioid consumption as well as anti-emetic prophylaxis; caution is required in patients with glucose intolerance
Local/regional techniques
  • If intrathecal morphine is not used, local anaesthetic wound infiltration (single-shot) or continuous wound infusion and/or regional analgesia techniques (fascial plane blocks such as TAP blocks, quadratus lumborum blocks and erector spinae plane blocks) are recommended (Grade A) for their effect in reducing pain scores and opioid requirements

COX, cyclooxygenase; NSAIDs, non-steroidal anti-inflammatory drugs; TAP, transversus abdominis plane block

Recommended: Postoperative interventions

  • ‘Postoperative’ refers to interventions applied at or after wound closure
Paracetamol
  • Oral or intravenous paracetamol is recommended (Grade A), continued regularly postoperatively
  • Regular administration of basic analgesics is important to limit the need for rescue opioid analgesia
NSAIDs/COX-2-selective inhibitors
  • Oral or intravenous NSAID/COX-2-selective inhibitor is recommended (Grade A), continued regularly postoperatively
  • Several studies demonstrated equally good pain control with NSAIDs compared with opioids
Opioids
  • Opioids are recommended for rescue or when other recommended strategies are not possible (e.g. contra-indications to regional anaesthesia) (Grade D)
  • Strategies should be implemented to reduce unnecessary opioid consumption after elective caesarean section
Analgesic adjuncts
  • Analgesic adjuncts including TENS are recommended when available (Grade A)
  • Analgesic adjuncts such as listening to music via headphones and use of TENS may be associated with improved pain relief

COX, cyclooxygenase; NSAIDs, non-steroidal anti-inflammatory drugs; TENS, transcutaneous electrical nerve stimulation

Recommended: Surgical interventions

Incision
  • A Joel-Cohen incision is recommended (Grade A) for benefits in reducing postoperative pain scores
Non-closure of peritoneum
  • Non-closure of the peritoneum is recommended (Grade A) for a reduction in pain scores
Abdominal binders
  • Abdominal binders are recommended (Grade A) based on three studies showing clinically-relevant reduction in pain scores and rescue analgesia consumption

Analgesic interventions that are not recommended for pain management in patients undergoing elective caesarean section.

TAP, transversus abdominis plane block

Overall recommendations for peri-operative pain management in patients undergoing elective caesarean section performed under neuraxial anaesthesia                            

Pre-operative
  • Intrathecal long-acting opioid (e.g. morphine 50–100 µg or diamorphine up to 300 µg) (Grade A).
    Epidural morphine 2–3 mg or diamorphine up to 2–3 mg may be used as an alternative, for example, when an epidural catheter is used as part of a combined spinal-epidural technique (Grade A)
  • Oral paracetamol (Grade A)
Intra-operative after delivery
  • Intravenous paracetamol if not administered pre-operatively (Grade A)
  • Intravenous non-steroidal anti-inflammatory drugs/cyclooxygenase-2-selective inhibitors (Grade A)
  • Intravenous dexamethasone (Grade A)
  • If intrathecal morphine is not used, local anaesthetic wound infiltration (single-shot) or continuous wound infusion and/or regional analgesia techniques (fascial plane blocks such as transversus abdominis plane blocks, quadratus lumborum blocks and erector spinae plane blocks) (Grade A)
Postoperative
  • Oral or intravenous paracetamol (Grade A)
  • Oral or intravenous non-steroidal anti-inflammatory drugs/cyclooxygenase-2-selective inhibitors (Grade A)
  • Opioid for rescue or when other recommended strategies are not possible (e.g. contra-indications to regional anaesthesia) (Grade D)
  • Analgesic adjuncts include transcutaneous electrical nerve stimulation (Grade A)
Surgical technique
  • Joel-Cohen incision (Grade A)
  • Non-closure of peritoneum (Grade A)
  • Abdominal binders (Grade A)