Page 437 Acute Pain Management

Pain after Caesarean section
After Caesarean section utilising epidural anaesthesia, epidural opioids were more effective
than intermittent injections of parenteral opioids (ASA, 2007 Level I). Single‐dose epidural
morphine (particularly a slow‐release formulation) (Carvalho et al, 2007 Level II) or intrathecal
morphine (Girgin et al, 2008 Level II) reduced post Caesarean section analgesic requirements.
The addition of clonidine to intrathecal hyperbaric bupivacaine improved early analgesia after
Caesarean section, but did not reduce morphine consumption during the first 24 hours
(van Tuijl et al, 2006 Level II).
Following Caesarean section under general anaesthesia, local anaesthetic wound infiltration
reduced postoperative opioid requirements (Bamigboye & Justus, 2008 Level II), and bolus doses
of local anaesthetic via an incisional catheter were as effective as epidural bolus doses (Ranta
et al, 2006 Level II). Following Caesarean section under spinal anaesthesia, local anaesthetic
transversus abdominus block reduced postoperative opioid requirements (McDonnell et al, 2008
Level II), but addition of a coxib had no advantage over intrathecal morphine alone (Carvalho et
al, 2006 Level II). Local anaesthetic techniques (wound infiltration or catheter, ilio‐inguinal/ilio‐
hypogatsric block, transversus abdominus plane block) reduce opioid consumption following
Caesarean section performed under general or regional anaesthesia, but the impact on opioid‐
related side‐effects was not evaluated (Bamigboye & Hofmeyr, 2009 Level I).
Prior caesarean section is a risk factor for chronic pelvic pain (Latthe et al, 2006 Level I).
Persistent post‐surgical pain has been reported in 6% to 12% of women following Caesarean
section (Nikolajsen et al, 2004 Level IV), is likely to be neuropathic in nature and may be under‐
recognised (Gillett & Jones, 2009).
Key messages
1. Epidural and combined spinal‐epidural analgesia provide superior pain relief for labour and
delivery compared with systemic analgesics (S) (Level I [Cochrane Review]).
2. Combined spinal‐epidural in comparison with epidural analgesia reduces time to effective
analgesia and increases the incidence of pruritus (U), does not increase maternal
satisfaction (R), but increases the risk of urinary retention (N) (Level I [Cochrane Review]).
3. Epidural analgesia does not increase the incidence of Caesarean section or long‐term
backache (S) (Level I [Cochrane Review]).
4. Epidural analgesia is associated with increased duration of labour and increased rate of
instrumental vaginal delivery (S) (Level I [Cochrane Review]).
5. Hypnosis used in labour reduces analgesic requirements (S) and improves satisfaction (N)
(Level I [Cochrane Review]).
6. Acupuncture reduces analgesic requirements in labour (U) (Level I [Cochrane Review]). CHAPTER 11
7. TENS may reduce severe pain in labour but does not reliably reduce pain scores (U) or
analgesic requirements (N) (Level I [Cochrane Review]).
8. Local anaesthetic wound infiltration and abdominal nerve blocks reduce opioid
consumption following Caesarean section (N) (Level I [Cochrane Review]).
9. Continuous or one‐to‐one support by a midwife or trained layperson during labour reduces
analgesic use, operative delivery and dissatisfaction (U) (Level I).
10. There is no significant difference in any outcome between use of bupivacaine and
ropivacaine for epidural labour analgesia (U) (Level I).

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