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 dexamethasone for pain management after caesarean section

Arguments for…

• Three RCTs evaluated the use of IV dexamethasone versus placebo (Shalu 2017; Ituk 2018 ; Maged 2018).
  • Pain scores were lower with dexamethasone compared to placebo and use was associated with a prolonged analgesic effect (Shalu 2017).
  • A reduction in pain scores and opioid use at 12 hours after delivery was observed in another RCT comparing dexamethasone 8 mg with placebo (Ituk 2018).
  • One study reported significantly better pain scores and reduced nausea with IV dexamethasone compared with placebo. Furthermore, pain scores were improved when dexamethasone was administered as wound infiltration as opposed to IV administration (Maged 2018).

Arguments against…

• IV dexamethasone (8 mg) was less effective for analgesia than IV tramadol (100 mg); tramadol was associated with lower pain scores and opioid consumption (Edomwonyi 2017).

PROSPECT Recommendations

• A single dose of IV 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.

Caesarean section-specific evidence

Data Table: Gabapentinoids for pain relief after caesarean section

Arguments for…

• Pregabalin (300 mg) administered 1 hour before surgery was associated with lower pain scores and reduced opioid requirements when compared with placebo or 150 mg of pregabalin (El Kenany 2016). Basic analgesia consisted of diclofenac.
• In another study, gabapentin provided superior analgesia compared with IT fentanyl (Najafi Anaraki 2014). Basic analgesia consisted of diclofenac.
• In a study of patients who did not receive any basic analgesia, adding vitamin B complex to gabapentin (300 mg) reduced pain scores and opioid consumption compared with the use of gabapentin alone (Khezri 2017).
• A systematic review reported a clinically significant reduction in 24-hour pain scores with pre-operative gabapentin versus placebo. Side-effects such as sedation and dizziness were reported in several of the included studies (Felder 2019).

Arguments against…

• No significant benefits were reported with gabapentin (preoperative 600 mg gabapentin followed by 200 mg every 8 hours for 48 hours) when added to a multimodal analgesia regimen (Monks 2015). The multimodal regimen consisted of IT morphine, rectal and oral paracetamol and IV and oral NSAID.

PROSPECT Recommendations

• Gabapentinoids are 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: IV ketamine for pain management after caesarean section

Arguments for…

• One randomised controlled trial evaluated the effects of IV ketamine on postoperative analgesia (Rahmanian 2015). A bolus of IV ketamine after delivery of the fetus reduced pain and rescue analgesics in the first 12 hours after caesarean section. No basic analgesia or additional baseline analgesia was reported.
• A meta-analysis on the IV use of ketamine demonstrated marginal improvements in pain scores and a mild reduction in morphine consumption (Wang 2020).

PROSPECT Recommendations

• IV ketamine 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: IV dexmedetomidine for pain management after caesarean section

Arguments for…

• Administration of IV dexmedetomidine (0.5 μg/kg) after delivery followed by addition of dexmedetomidine (300 μg) to sufentanil (100 μg) IV-PCA in the postoperative period was associated with lower pain scores, reduced sufentanil consumption, reduced need for rescue analgesia and higher patient satisfaction compared with saline IV after delivery and sufentanil IV-PCA. However, the improvement in pain scores was not clinically relevant (Nie 2018). No basic or additional baseline analgesia was given.

PROSPECT Recommendations

• Dexmedetomidine 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: Neuraxial opioids for pain management after caesarean section 

Arguments for…

• A meta-analysis compared low (50–100 μg) and high (>100 μg) doses of IT morphine and concluded that high doses increase the duration of analgesia but were more likely to be associated with side-effects. Pain scores were similar in both groups (Sultan 2016).
• A dose-response study of IT morphine showed that 50 μg doses were as effective as 100 μg and 150 μg, with a similar requirement for rescue opioids. The risk of pruritus was lowest after 50 μg morphine (Berger 2016). Basic analgesia was NSAIDs.
• In patients with an anticipated high pain intensity (such as patients with chronic pelvic pain), pain scores with movement were lower in patients receiving 300 μg than in those receiving 150 μg IT morphine (Booth 2016). Basic analgesia was NSAIDs.
• In a comparative study, IT morphine provided better analgesia compared with epidural morphine and patient-controlled epidural analgesia of ropivacaine with sufentanil (Kaufner 2016).
• Two studies offered women a choice of analgesic strategy: to select either no IT morphine or a low or high dose of IT morphine (Carvalho 2017; Carvalho 2019). Having a choice did not impact on rescue opioid consumption, but women were very good at predicting their actual opioid needs. Choosing high-dose IT morphine was associated with increased rescue analgesia and more vomiting (Carvalho 2017; Carvalho 2019). Basic analgesia was NSAIDs (Carvalho 2017) or a combination of NSAIDs and paracetamol (Carvalho 2019).
• IT morphine and IT hydromorphone provided similarly effective post-caesarean analgesia when combined with a multimodal analgesia regimen (Sharpe 2020).
• IT buprenorphine (Ravindran 2017) and epidural hydromorphone (Yang 2019) resulted in improved postoperative analgesia and reduced opioid consumption compared with IT bupivacaine or ropivacaine alone.
• A study showed that a faster speed of IT injection of fentanyl and local anaesthetic results in improved postoperative analgesia with a more sustained duration (Hussien 2019).

Arguments against…

• Adding IT fentanyl (25 μg) to bupivacaine improved initial analgesia (Weigl 2016). However, when morphine (100 μg) is also added to the IT mixture, fentanyl might induce acute opioid tolerance and result in greater opioid consumption (Weigl 2017).
  

PROSPECT Recommendations

• The addition of IT 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 IT 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 IT morphine.
  • Of note, the National Institute of Health and Care Excellence guidelines in the UK recommend IT diamorphine as an alternative to IT 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).
• IT buprenorphine is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.
• Epidural hydromorphone is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.

Caesarean section-specific evidence

Data table: Neuraxial alpha-2 adrenergic receptor agonists for pain relief after caesarean section

Arguments for…

• In one study, patients had a longer duration of analgesia with IT clonidine (75 μg) compared with IT fentanyl or placebo (Khezri 2014).
• Addition of epidural dexmedetomidine (0.5 μg/kg) to combined spinal-epidural anaesthesia resulted in improved intraoperative and postoperative analgesia and reduced requirement for opioid rescue (Yousef 2015).
• IT dexmedetomidine (3 or 5 µg) resulted in improved postoperative analgesia when compared with isobaric bupivacaine (Bi 2017) or ropivacaine alone (Bi 2020).
• IT dexmedetomidine (5 µg) combined with IT magnesium sulphate or IT morphine improved analgesia which was of longer duration than analgesia produced by magnesium sulphate alone (Mostafa 2020).

Arguments against…

• A meta-analysis showed that neuraxial clonidine increased the duration and quality of analgesia and reduced morphine consumption (Allen 2018). However, more side effects such as hypotension and intra-operative sedation were noted.
• One RCT showed that IT or IV clonidine (75 μg) had no effect on pain scores compared with placebo (Fernandes 2018).
• One study demonstrated no improvement in analgesia when IT clonidine (75 μg) was administered in combination with IT morphine (Carvalho 2016).
• A comparison of IT dexmedetomidine (5 µg) with IT morphine (100 µg) did not demonstrate any significant differences in duration of analgesia, pain scores or need for rescue analgesia (Qi 2016). However, both IT morphine and IT dexmedetomidine provided better analgesia when compared with isobaric bupivacaine (Qi 2016).
• Addition of dexmedetomidine to epidural morphine did not reduce pain scores or opioid use (Yang 2020).
  

PROSPECT Recommendations

• Neuraxial alpha-2 adrenergic agonists are not recommended for pain relief after caesarean section due to inconsistent procedure-specific evidence and concerns of side-effects.

Caesarean section-specific evidence 

Arguments for…

• A meta-analysis evaluating the effect of neuraxial magnesium on postoperative analgesia demonstrated a longer duration of sensory block, lower pain scores and reduced rescue analgesia requirements than neuraxial mixtures of local anaesthetic without magnesium (Wang 2017).

PROSPECT Recommendations

• Neuraxial magnesium is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.

Caesarean section-specific evidence 

Arguments against…

• A meta-analysis showed that IT neostigmine improved analgesia after caesarean section, although it was associated with an increased risk of nausea and vomiting (Cossu 2015).

PROSPECT Recommendations

• IT neostigmine is not recommended for pain relief after caesarean section due to concerns of side effects.

Caesarean section-specific evidence

Data table: IT midazolam for pain management after caesarean section

 Arguments for…

• Midazolam (2 mg) prolonged duration of spinal anaesthesia compared with placebo (Dodawad 2016).

Arguments against…

• A comparative study demonstrated that IT magnesium and IT sufentanil were superior to IT midazolam (Abdollahpour 2015).

PROSPECT Recommendations

• IT midazolam 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: IT ketamine for pain management after caesarean section 

Arguments for…

• In combination with bupivacaine, IT ketamine (0.1 mg/kg) prolonged analgesia compared with placebo, and was as effective as fentanyl (Khezri 2016).
• IT low-dose ketamine (10 mg) combined with midazolam and low-dose bupivacaine prolonged postoperative analgesia compared with fentanyl and low-dose bupivacaine (Basuni 2016).

PROSPECT Recommendations

• IT ketamine 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: Local anaesthetic wound infiltration for pain management after caesarean section 

Arguments for…

• A meta-analysis confirmed that both single-shot local anaesthetic wound infiltration and continuous wound infusion reduce postoperative opioid consumption and mildly improve pain scores (Adesope 2016).
• Pain scores and/or the need for rescue analgesia during the first 24 hours were reduced in three RCTs where local anaesthetic wound infiltration was used (Larsen 2015; Ghenaee 2015; Nasir 2019), while one further study showed only limited benefits (Reinikainen 2014). In all studies except for one (Ghenaee 2015), basic analgesia with ibuprofen and paracetamol was used.
  • Local anaesthetic wound infiltration with high dose/low volume ropivacaine (50 ml, 0.5%) had a limited opioid-sparing effect and was associated with a longer time to maximum pain scores compared with placebo (Larsen 2015), with no significant effect on pain intensity versus low dose/high volume ropivacaine (125 ml, 0.2%) (Larsen 2015).
  • Local would infiltration with lidocaine (4 mg/kg, 2%, 30 ml) reduced post operative pain and analgesic requirements compared with placebo (Ghenaee 2015).
  • Local wound infiltration with ropivacaine (20 ml, 0.5%) significantly reducedpain scores at 4, 6 and 12 hours after surgery, as well as the need for rescue analgesia, compared with placebo (Nasir 2019).
  • One RCT showed that continuous wound infiltration with ropivacaine did not decrease the need for opioids and had no impact on pain scores or patient satisfaction after caesarean section (Reinikainen 2014).
• Another two studies which used multimodal analgesia showed improved pain scores, less morphine consumption and higher breastfeeding comfort with continuous wound infusion compared with no infusion (Jolly 2015; Lalmand 2017).
  • Adding continuous levobupivacaine infiltration to multimodal analgesia after cesarean section without subarachnoid morphine decreased postoperative morphine consumption and pain scores (Jolly 2015).
  • Local anaesthetic wound infusion resulted in similar analgesic effects as IT morphine: prolonged duration of analgesia and reduced opioid consumption compared with placebo (Lalmand 2017).
• Two meta-analyses evaluated TAP blocks, wound infusion, and QL blocks with or without IT morphine and concluded that all three regional anaesthetic techniques are superior to no regional technique in the absence of IT morphine ( Sultan 2020; El-Boghdadly 2020). When IT morphine is administered, adding these techniques confers no further advantages.
• Pain scores were similar whether the catheter (delivering bolus and infusion of bupivacaine 0.25%) was placed in the preperitoneal or subcutaneous layer (Thomas, 2019).
• One study showed that ketorolac improved analgesia of wound infiltration and reduced opioid consumption (Wagner-Kovavcec 2018). Another study found that ketorolac added to wound infiltration did not improve analgesia, but IT morphine was administered in both groups (Barney, 2020).
• Magnesium and dexmedetomidine as adjuvants to wound infiltration improved analgesia (Kundra 2016; Bhardwaj 2017).
  • In one RCT, addition of magnesium sulphate to ropivacaine was associated with a reduction in rescue analgesia requirements (Kundra 2016).
  • Another RCT found that dexmedetomidine (1.5 μg/kg) added to ropivacaine for the surgical wound infiltration significantly reduced postoperative pain and rescue analgesic consumption compared to ropivacaine alone (Bhardwaj 2017).

PROSPECT Recommendations

• If IT morphine is not used, local anaesthetic wound infiltration (single-shot) or continuous wound infusion is recommended (Grade A) for effects in reducing pain scores and opioid requirements.

Caesarean section-specific evidence

Data table: Transversus abdominis plane (TAP) block for pain management after caesarean section 

Arguments for…

• Four out of five studies comparing TAP blocks against placebo or no TAP block found they improved pain relief, increased patient satisfaction and resulted in a reduction of rescue analgesia (Fusco 2016; Jadon 2018; Kupiec 2018; Kakade 2019).
  • One other RCT found that TAP block did not improve early or late pain outcomes after caesarean delivery (McKeen 2014).
• A comparison between lateral and posterior approaches concluded that the posterior approach resulted in better pain scores; the difference was only clinically relevant at 12 hours postoperatively. This approach also reduced the need for rescue analgesia (Faiz 2017).
• No differences in postoperative analgesia were seen between surgeon-administered and anaesthetist-administered TAP blocks (Narasimhulu 2018).
• Several studies evaluated the role of local anaesthetic adjuvants for TAP blocks:
  • Pain scores, opioid consumption and duration of analgesia were significantly improved when dexamethasone was added to local anaesthetic for TAP blocks (Gupta, 2019)
  • Fentanyl added to TAP blocks failed to improve the quality of analgesia (John, 2017).
  • Adding dexmedetomidine to a ropivacaine bilateral ultrasound-guided TAP block resulted in lower postoperative pain scores and rescue opioid use (Qian 2020).
  • Addition of ɑ2-agonists (clonidine or dexmedetomidine) prolonged duration of analgesia, reduced the need for rescue drugs and improved satisfaction. However, mild sedation was noted in some patients (Singh 2016; Acharya 2018; Parameswari 2018).
• Several studies compared TAP blocks with alternative regional anaesthesia techniques:
  • In a comparison of TAP blocks with epidural analgesia which included high-dose epidural morphine, improved analgesia was noted with the epidural (Canakci 2018).
  • Three studies compared IT morphine with TAP blocks (Jarraya 2016; Dereu 2019; Kwikiriza 2019). In two of these, there was better analgesia with IT morphine and a reduced requirement for rescue analgesia. However, postoperative mobilisation and return of gastrointestinal function was better with TAP blocks (Jarraya 2016; Dereu 2019). The third study could not discriminate between the two techniques in terms of pain relief and other clinical outcomes (Kwikiriza 2019).
  • Three RCTs compared TAP blocks with continuous local anaesthetic wound infusion and noted no differences in postoperative analgesia (Telnes 2015; Klasen 2016; Tawfik 2017).
• Three meta analyses confirmed the efficacy of TAP blocks for analgesia after caesarean section but concluded that they do not confer any benefit over IT morphine (Fusco 2015; Champaneria 2016; Ng 2018).
• Two meta-analyses evaluated TAP blocks, wound infusion, and QL blocks with or without IT morphine and concluded that all three regional anaesthetic techniques are superior to no regional technique in the absence of IT morphine (Sultan 2020; El-Boghdadly 2020). When IT morphine is administered, adding these techniques confers no further advantages.
• A combination of ilioinguinal and iliohypogastric nerves block with TAP blocks versus no blocks resulted in less rescue opioid consumption and lower pain scores (Staker 2018).

PROSPECT Recommendations

• If IT morphine is not used, TAP blocks are recommended (Grade A) for their effect in reducing pain scores and opioid requirements.
• Clonidine and fentanyl added to TAP block are not recommended for pain relief after caesarean section due to lack of procedure-specific evidence; dexmedetomidine added to TAP block is not recommended due to limited procedure-specific evidence.

Caesarean section-specific evidence

Data table: Quantus luburum (QL) block for pain management after caesarean section

Arguments for…

• Compared with a sham block or no block, QL block produced better analgesia in six RCTs:
  • QL block after caesarean section was effective for reducing pain scores and opioid use compared with sham block (Blanco 2015).
  • QL block was associated with reduced postoperative ketobemidone consumption and lower pain scores compared with sham block (Krohg 2018).
  • Patients who received bilateral transmuscular QL block had lower pain scores and longer time to first opioid request than those who received a sham block (Hansen 2019).
  • QL block significantly reduced morphine consumption and reduced pain scores up to 48 hours postoperatively compared with no block (Mieszkowski 2018).
  • One small study showed that QL block was associated with lower pain scores compared with sham block (Yoshida 2020).
  • Another RCT showed a reduction in pain scores at 6 hrs only with QL block compared with sham block; there was no difference in morphine consumption (Irwin 2020).
• Two studies found benefits of QL block compared with TAP block:
  • QL block reduced morphine consumption compared with TAP block although pain scores at rest were similar (Blanco 2016).
  • QL block provided more prolonged and effective analgesia in comparison to TAP block up to 72 hours post-caesarean section (Verma 2019).
• In a direct comparison, QL block was associated with lower pain scores and opioid requirements than either IT morphine or saline control. IT morphine also reduced pain scores compared with control (Salama 2020).
• Two meta-analyses evaluated TAP blocks, wound infusion, and QL blocks with or without IT morphine and concluded that all three regional anaesthetic techniques are superior to no regional technique in the absence of IT morphine (Sultan 2020; El-Boghdadly 2020). When IT morphine is administered, adding these techniques confers no further advantages.

Arguments against…

• In one study, QL blocks were less effective in terms of pain scores and rescue analgesia than a single epidural bolus of local anaesthetic (Kang 2019).
• IT morphine improved postoperative analgesia versus placebo but the combination of posterior QL block with IT morphine did not lead to further improvement (Tamura 2019).

PROSPECT Recommendations

• If IT morphine is not used, quadratus lumborum block is recommended (Grade A) for its effect in reducing pain scores and opioid requirements.

Caesarean section-specific evidence

Data table: Erector spinae plane (ESP) block for pain management after caesarean section

• In two studies, ESP block improved analgesia, reducing pain scores and opioid consumption compared with TAP block (Boules 2020) and IT morphine (Hamed 2020). Patients received basic analgesia with paracetamol and NSAIDs.

PROSPECT Recommendations

• If IT morphine is not used, erector spinae plane block is recommended (Grade A) for its effect in reducing pain scores and opioid requirements.

Caesarean section-specific evidence

Data table: Intraperitoneal analgesia for pain relief after caesarean section

 Arguments for…

• Intraperitoneal local anaesthetic instillation resulted in lower early pain scores (only at 2 hours) versus placebo, and reduced pain scores at 24 hours in a subgroup in which the peritoneum was closed (Patel 2017).

PROSPECT Recommendations

• Intraperitoneal local anaesthetic is not recommended for pain relief after caesarean section due to lack of procedure-specific evidence.

Caesarean section-specific evidence

Data table: Rectus sheath block for pain relief after caesarean section

Arguments against…

• A rectus sheath block provided no additional analgesic benefit when added to multimodal analgesia which also included IT morphine (Lui 2017).

PROSPECT Recommendations

• Rectus sheath block is not recommended for pain relief after caesarean section due to lack of procedure-specific evidence.

Caesarean section-specific evidence

Data table: Direct field block for pain relief after caesarean section 

Arguments against…

• Adding a field block after caesarean section to IT morphine did not improve analgesia (Triyasunant 2015).

PROSPECT Recommendations

• Direct field block is not recommended for pain relief after caesarean section due to lack of procedure-specific evidence.

Caesarean section-specific evidence

Data table: Topical skin analgesia for pain relief after caesarean section

Arguments against…

• The use of topical analgesia (e.g. eutectic mixture of local anaesthetic cream) failed to reduce pain scores at 24 and 48 hours (Grosse-Steffen 2017).

PROSPECT Recommendations

• Topical skin analgesia is not recommended for pain relief after caesarean section due to lack of procedure-specific evidence.

Caesarean section-specific evidence

Arguments for…

• A systematic review (Gizzo 2015) confirmed the superiority of the Joel-Cohen (also called modified Misgav-Ladach) incision compared with Pfannenstiel incision in reducing postoperative pain.
• The older technique of extraperitoneal section was associated with better pain scores up to 48 hours postoperatively compared with transperitoneal section (Yapca 2020).

PROSPECT Recommendations

• A Joel-Cohen incision is recommended (Grade A) for benefits in reducing postoperative pain scores.

Caesarean section-specific evidence

Data table: Diathermy versus scalpel for pain management after caesarean section

 Arguments against…

• No differences in pain scores were noted between a scalpel and diathermy for the skin incision (Elbohoty 2015).
  

PROSPECT Recommendations

• Diathermy is not recommended for pain relief after caesarean section due to inconsistent procedure-specific evidence.

Caesarean section specific-evidence

Data table: Absence of bladder flap for pain management after caesarean section

 Arguments for…

• In one study, the absence of a bladder flap at opening the uterus resulted in clinically relevant improvements in postoperative pain scores compared with formation of a bladder flap (Akhlagi 2017).

PROSPECT Recommendations

• Absence of a bladder flap is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.

Caesarean section specific evidence

Data table: Blunt fascial opening for pain management after caesarean section

 Arguments for…

• A blunt fascial opening resulted in less postoperative pain compared with sharp fascial opening (Yilmaz 2018).

PROSPECT Recommendations

• Blunt fascial opening is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.

Caesarean section-specific evidence

Data table: Type of pyramidalis muscle dissection for pain management after caesarean section

• No significant differences in pain scores were observed between two types of pyramidalis muscle dissection. In one group, the pyramidalis muscle was left attached to the rectus muscles and in the other group the connection between the pyramidalis muscle and the rectus sheath was preserved (Skret-Magierlo 2015).

PROSPECT Recommendations

• Neither method of pyramidalis muscle dissection can be recommended over the other for pain relief after caesarean section due to lack of procedure-specific evidence.

Caesarean section-specific evidence

Data table: Non-closure of peritoneum for pain management after caesarean section

 Arguments for…

• A single study showed a reduction in pain scores when the peritoneum was not closed compared with when the peritoneum was closed (Eken 2017).
• A Cochrane review noted minimal evidence for reduced pain scores when the peritoneum was not closed after caesarean section (Bamigboye 2014).

PROSPECT Recommendations

• Non-closure of the peritoneum is recommended (Grade A) due to a reduction in pain scores.

Caesarean section-specific evidence

Data table: Rectus muscle re-approximation for pain management after caesarean section

 Arguments against…

• Rectus muscle re-approximation was associated with higher pain scores compared with no rectus muscle re-approximation (Omran 2019).

PROSPECT Recommendations

• Rectus muscle re-approximation is not recommended for pain relief after caesarean section due to limited procedure- specific evidence.

Caesarean section-specific evidence

Data table: Uterine exteriorisation for pain management after caesarean section

Arguments against…

• A comparison between uterine exteriorisation and in situ closure of the uterus showed more postoperative pain with exteriorised uteri (El-Khayat 2014).
• However, a meta-analysis did not show any difference in postoperative pain between the two modalities of uterine closure (Zaphiratos 2015).

PROSPECT Recommendations

• Uterine exteriorisation is not recommended for pain relief after caesarean section due to inconsistent procedure-specific evidence.

Caesarean section-specific evidence

Data table: Skin incision lasering at end of surgery for pain management after caesarean section

 Arguments for…

• In one study, when applying laser irradiation to the caesarean section wound at the end of surgery, less pain was noted during the first 24 hours postoperatively, compared with sham laser treatment (Poursalehan 2018).
• In a second study, pain scores were lower with skin-incision lasering at two different doses compared with controls (Pires de Holanda 2020).

PROSPECT Recommendations

• Skin incision lasering at the end of surgery is not recommended for pain relief after caesarean section due to limited procedure-specific evidence.

Caesarean section-specific evidence

Data table: Type of skin closure for pain management after caesarean section

 Arguments against…

• No differences in pain scores were observed when interrupted subcuticular suturing was compared with continuous subcuticular suturing. A reduction in surgical wound complications was noted in the interrupted skin closure group (Maged 2019).
• Two meta-analyses did not show any difference in pain scores whether skin closure was performed with sutures or staples (Mackeen 2015; Wang 2016).

PROSPECT Recommendations

• Due to a lack of procedure-specific evidence, no specific type of skin closure can be recommended for pain relief after caesarean section.

Caesarean section-specific evidence

Data table: Vaginal cleansing for pain management after caesarean section

 Arguments for…

• Pre-operative vaginal cleansing with povidone iodine resulted in minor but statistically significant reductions in postoperative pain scores compared with no pre-operative vaginal cleansing (Goymen 2017).

PROSPECT Recommendations

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

Caesarean section-specific evidence

Data table: Cervical dilation for pain management after caesarean section

 Arguments for…

• One study noted improved pain scores at the 8^th, 30^th, 48^th hour and 7^th day post-operatively (but not on day 4) when manual cervical dilation at the end of surgery was compared with no cervical dilation. Patients in this study were classified as clinically obese (Alalfy 2019).

Arguments against…

• No significant differences in pain scores were observed between non-dilated patients and patients undergoing cervical dilatation (Sakinci 2015).

PROSPECT Recommendations

• Cervical dilation is not recommended for pain relief after caesarean section due to inconsistent procedure-specific evidence.