Caesarean Section 2020

Caesarean section-specific evidence

Data table:  Paracetamol for pain management after caesarean section

Arguments for…

• In one RCT, IV paracetamol was associated with a reduction in opioid requirements compared with placebo but there was no difference in pain scores (Altenau 2017).
• One study found that rectal paracetamol improved the quality and duration of analgesia compared with pre-operative oral paracetamol combined with IV paracetamol at the end of surgery (Mahajan 2017).

Arguments against…

• One placebo-controlled study demonstrated only minor differences when paracetamol was administered pre-operatively (Towers 2018).
• In another RCT, no differences in opioid consumption and pain scores were noted with IV paracetamol compared with placebo (Bernstein 2020).

PROSPECT Recommendations

• Oral or IV paracetamol is recommended (Grade A), administered pre-operatively (oral) or intra-operatively (IV) if not administered pre-operatively, and continued regularly postoperatively.
• Regular administration of basic analgesics is important to limit the need for rescue opioid analgesia.

Caesarean section-specific evidence

Data table: NSAIDs for pain management after caesarean section

Arguments for…

• In one meta-analysis, NSAIDs reduced pain scores, decreased opioid consumption, reduced opioid-related side effects and increased patient satisfaction (Zeng 2016).
• One study found that a single dose of IV parecoxib 40 mg was associated with better pain scores than placebo (Inthigood 2017).
• Three studies compared an NSAID with an opioid and demonstrated equally effective or superior analgesia with NSAIDs (Mahdavi 2016; Thippeswamy 2016; Khezri 2018).
  • Mahdavi 2016 compared diclofenac suppository to morphine suppository. Diclofenac was associated with significantly decreased subjective pain scores in the first 12 hours postoperatively.
  • IM piroxicam was effective in reducing pain scores for 24 hours compared with tramadol (Thippeswamy 2016).
  • Another study compared ketorolac versus meperidine and placebo (Khezri 2018). Time to request for first analgesic was longer in both treatment groups compared with placebo.
• In one RCT, the addition of rectal diclofenac to pentazocine was also associated with better analgesia then pentazocine alone (Olajetu 2016).

Arguments against…

• A Cochrane review evaluated oral analgesics, comprising primarily but not exclusively NSAIDs, but could not draw any conclusions due to the low quality of studies, small number of included patients and substantial heterogeneity in the studied drugs (paracetamol; celecoxib; ibuprofen; gabapentin; combination) (Mkontwana 2015).

PROSPECT Recommendations

• NSAIDs/COX-2-selective inhibitors are recommended (Grade A), started intra-operatively (IV, after delivery) and continued regularly postoperatively (oral or IV).
• Several studies demonstrated equally good pain control with NSAIDs compared with opioids.

Caesarean section-specific evidence

Data table: IV lidocaine for pain relief after caesarean section

Arguments against…

• One RCT showed that adding IV lidocaine to IV patient-controlled analgesia (PCA) with morphine did not improve pain scores or opioid consumption (Habibi 2019).

PROSPECT Recommendations

• IV lidocaine is not recommended for pain relief after caesarean section due to lack of procedure-specific evidence.

Caesarean section-specific evidence

• Eight studies compared either IV tramadol (in combination with butorphanol in two studies) or oxycodone versus various other systemic opioids (sufentanil; dezocine; hydromorphone; tapentadol; morphine; codeine; oral oxycodone) (Niklasson 2015; Chi 2017; Nie 2017; Zhu 2018; Cai 2020; Duan 2018; Ffrench-O’Carroll 2019; Makela 2019). No individual drug was clearly superior in terms of analgesia or side-effect profile compared with any other opioid.
• One study found that self-administered oral opioid analgesia was as effective as parenteral nurse-administered drugs (Bonnal 2016).
• Administration of oral analgesia (tramadol, paracetamol and diclofenac) in fixed time intervals was superior to drug administration following patient demand in terms of pain scores (Yefet 2017).

PROSPECT Recommendations

• 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.
• IV tramadol and butorphanol is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.

Caesarean section-specific evidence

Data table: Patient-controlled epidural anaesthesia for pain management after caesarean section

 Arguments for…

• Patient-controlled epidural analgesia added to IT morphine resulted in a further lowering of postoperative pain scores and less need for rescue opioid (Sato 2020).

Arguments against…

• Adding fentanyl to patient-controlled epidural analgesia with levobupivacaine did not improve analgesia (Chen 2014).

PROSPECT Recommendations

• Patient-controlled epidural analgesia is not recommended for pain relief after caesarean section due to limited procedure-specific evidence and concerns of side-effects.

Caesarean section-specific evidence

Data table: TENS for pain management after caesarean section

Arguments for…

• Two studies showed that TENS was associated with favourable outcomes compared with sham TENS or no TENS, in terms of pain scores, rescue analgesia use and patient satisfaction (Khooshideh 2017; Chakravarthy 2019).

PROSPECT Recommendations

• Analgesic adjuncts including TENS are recommended when available (Grade A)
• Use of TENS may be associated with improved pain relief.

Caesarean section-specific evidence

Data table: Skin-to-skin contact for pain management after caesarean section

 Arguments against…

• In a small study, the use of early versus late skin-to-skin contact between mother and baby showed no differences in postoperative pain scores (Kollmann 2017).

PROSPECT Recommendations

• Early versus late skin-to-skin contact is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.

Caesarean section-specific evidence

Data table: Music and sounds for pain relief after caesarean section

Arguments for…

• One RCT evaluated the use of relaxation sounds intra- or postoperatively and showed improved pain scores compared with controls (Farzaneh 2019).

PROSPECT Recommendations

• Music and sounds are not recommended for pain relief after caesarean section due to limited procedure specific evidence.

Caesarean section-specific evidence

Data Table: Abdominal binders for pain management after caesarean section

 Arguments for…

• Three studies evaluated the use of elastic abdominal binders after caesarean section (Ghana 2017; Gustafson 2018; Karaca 2019). In all three studies, a clinically relevant reduction in pain scores was noted compared with placebo.

PROSPECT Recommendations

• Abdominal binders are recommended (Grade A) based on three studies showing clinically relevant reduction in pain scores.