For most patients, the strategy for post-CD pain control should consist of neuraxial opioid and scheduled nonopioid analgesics.

1. Analgesia
after
Caesarean
Section
Dr Roshana Mallawaarachchi
24th January 2023

2. It is
Important!
2
Moderate -
Severe
Increasing C
Section rate
Morbidity Mother – Child
Development
of chronic pain
(0.3% - 8%)

3. Standard
>90% of women
should score their
worst pain as
<3 on VAS of 0-10
3
VAS score 0 - no pain
1 to 3 - mild pain
4 to 6 - moderate pain
7 to 9 - severe pain
10 - unbearable pain

4. Multimodal
Opioid sparing
Technique
Multimodal analgesia
combines two or more
analgesic agents or
techniques that act by
different mechanisms to
provide analgesia.
4

5. 5

6. Multimodal Approach
Step 1 – Most Post-Operative Pain
Non opioid analgesic: Acetaminophen, NSAIDs, or COX-
2 Selective Inhibitors AND
Local Anesthetic Infiltration
Step 2 – Moderate Post-Operative Pain
Step 1 Strategy AND
Intermittent Doses of Opioid Analgesics
Step 3 – Severe Post-Operative Pain
Step 1 and Step 2 Strategies AND
Local Anesthetic Peripheral Neural Blockade
AND
Use of Sustained Release Opioid Analgesics

7. Central neuraxial block
8
Gold-standard
technique for
CS
Combined use
of LA +
Opioids
Epidural
T10–L1

8. Neuraxial opioids
9
• Superior analgesia over systemic administration
• Diamorphine - Quick onset & Less side effects
• Preservative-free Morphine with Fentanyl
• Intrathecally or epidurally
• Prolonged postoperative analgesia
Intrathecal morphine (100-200 μg) provided optimal analgesia with a
median time to first request for supplemental analgesia of 27 hours

9. 10

10. Optimal dosing strategies
Intrathecal
300-400 μg Diamorphine
Morphine 100μg with Fentanyl 15μg
Only Morphine : Peak effect – 60-90 mins
11

11. Monitoring Long-acting neuraxial
opioids
2 hourly for 12 hours (RR and Sedation score)
High risk: (cardiovascular or neurological comorbidity, OSA or
pre-eclampsia/hypertension, chronic opioid use)
Every hour for 12 h, then every 2 h for 12-24 h (SPO2)
12

12. Complications of neuraxial opiods
13
Naloxone under 2mcg/kg/hr as an infusion have been shown to be effective in treating pruritus in some studies.

13. Sodium Bicarbonate
Neostigmine - No motor or sympathetic blockade, N & V
Clonidine - Reduce opioid consumption and decrease shivering,
but hypotension, dose-dependent sedation, bradycardia, prolonged
motor blockade and perioperative vomiting are common side
Effects. FDA “black box” warning
Dexmedetomidine?
Ketamine – Speedup and prolong. Intrathecal: Neurotoxic
Midazolam
14

14. PCEA or CIEA
15

15. • 1 – very satisfied
• 2 – satisfied
• 3 – not very satisfied
• 4 – not satisfied)
16

16. (24 h) local anaesthetic consumption in the 3 groups 17

17. General anaesthesia
Associated with worse postoperative pain
• TAP Block / Quadratus lumborum blocks (QLB)
• Wound infiltration
• Wound catheter
• IV Opioids via PCA pump
• Fentanyl Patch
18

18. TAP Block
PRENTATION TITLE 19

19. TAP block
Reduces the need for postoperative opioid
Posterior injection is better than lateral
Limited duration of action - rescue technique
20 ml of 0.25% bupivacaine for each side
LA systemic toxicity?
Better post-op mobilisation & return GI functions
Adjuvants: Dexmedetomidine, Clonidine,
Fentanyl
20

20. Efficacy of TAP
block for post
cesarean
delivery
analgesia:
20 ml of 0.25% bupivacaine

21. US guided TAP
block as a
component of
multimodal
analgesic regimen
for lower segment
caesarean section.
20 ml 0.375% ropivacaine
Local anaesthetic systemic toxicity remains unknown

22. Quadratus
lumborum blocks
2
3
US approaches that deposit LA onto
the lateral, posterior and anterior
surfaces of the quadratus lumborum
Muscle.

23. Quadratus lumborum blocks
Significant reduction in 48 hrs opioid consumption
No difference between TAP and QLB
When combined with IT Opioids: No benefit demonstrated with
either QLB or TAP block
24

24. Wound infiltration and wound
catheters
Subfascial catheter
administration of
levobupivacaine is a
viable alternative to
epidural analgesia.
Elastometric balloon pump designRESENTATION TITLE 25

25. Wound infusion
Less post-op morphine consumption
Higher breastfeeding comfort
Similar efficacy to intrathecal morphine
Catheter: preperitoneal or subcutaneous
Adjuvants: Ketorolac, Dexmedetomidine, Mg
26

26. TAP blocks, wound infiltration and
wound catheters are all superior to
placebo in the absence of long-acting
neuraxial opioids,
27

27. Recommendations:
Unless contraindicated, all patients
should receive an around-the-clock
regimen of a non-opioid agent.
• Acetaminophen
• Non-steroidal anti-inflammatory
drugs (NSAIDs)
• Cyclooxyhenase-2 specific drugs
(COXIBs)
Consider supplemental regional
anesthesia techniques
28

28. An analgesic regimen after neuraxial
opioid
(i) 6-8 hourly i.v. or oral paracetamol 1 g commencing 6-8h after the intraoperative
dose
(ii) 6-hourly oral ibuprofen 400-600 mg unless contraindicated,
commencing 6-8 h after the dose of intraoperative diclofenac or ketorolac
(iii) For breakthrough pain, 4-hourly oral opioids, such as
oral morphine 10-20 mg or 6-hourly oral dihydrocodeine 30 mg
Antiemetics, Antipruritics and laxatives
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29. Acetaminophen
30
▶ Treatment of mild to moderate pain
▶ Reduction of adjunctive opioid analgesics for moderate to severe pain
▶ IV infusion should be administered within 15 min
▶ May cause severe hepatotoxicity with overdose
▶ Minimal anti-inflammatory effects
▶ Fewer GI side effects than NSAIDS
▶ Patients not to exceed 4 grams/day

30. NSAIDs
31
Reduce visceral pain from uterus
Potentiate opioid effect and decrease opioid
consumption
Potential problems:
Bleeding, platelet dysfunction and renal insufficiency

31. COX-2 inhibitor (parecoxib)
Opioid sparing is same as ketorolac
Single dose IV / Wound infiltration
Better pain score
Reduce opioid consumption
Act as an Anti-emetic
32
Dexamethasone

32. Gabapentin
Preoperative gabapentin 600mg in the setting of multimodal
analgesia reduces post CS pain and increase maternal satisfaction.
19% of the patient had severe sedation
But there was no difference in the Apgar score
33

33. IV PCA
• The development of chronic pain is variable
• Fluctuating blood level of analgesic
• Superior to conventional IM opioids
• Less efficacious than neuraxial administration
BUT:
Better pain score and less need for rescue analgesia
Patient satisfaction scores are highest
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34. 35

35. Limitation to the use of opioids:
Pruritus
Nausea/vomiting
Sedation
Respiratory depression
Overcome by synergistic or additive analgesia
36

36. Other methods
TENS
Relaxation music
Early skin-to-skin contact
Elastic abdominal binders
Manual cervical dilation
Joel Cohen incision
Blunt fascial opening
More pain in exteriorising uteri
Non closure of peritonium 37

37. PRESENTATION TITLE 38

38.  Diclofenac 100 mg suppository - end of surgery (50 mg
if weight <50 kg). Obtain verbal consent from the patient,
and document this on the anaesthetic chart.
 Regular diclofenac 50mg TDS PO (same dose even if
< 50 kgs). After 12 hours of the PR dose: 6 am, 2 pm
and 10 pm.
 Regular paracetamol 1g PO QDS (1 g TDS if wt< 50
kgs)
 Dihydrocodeine prn 30 mg PO 4-6hourly
 Antiemetic prn such as cyclizine 50mg IV/IM/PO 6-
8hourly.
 Thromboprophylaxis as indicated
 Oral Morphine prn 10-20mg PO 2-4 hourly (not for 4
hours after intrathecal/ epidural diamorphine)
 Chlorpheniramine 4 mg PO prn
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Prescriptions
All cases (unless contraindicated)

39. Prescriptions
Contraindications to
diclofenac
 Hypovolaemia or continuing bleeding
 Pre-existing renal impairment
 Asthma with a history of sensitivity to NSAIDs
 Peptic ulceration.
 Hypersensitivity to NSAIDs
Regular Tramadol 50–100 mg qds PO/IV
40

40. RATSystem
• Recognize
• Assess
• T
reat

41. 42
Limited supply of
opioids
Lack of long acting
intrathecal preservative
free narcotic
Expertise for its use

42. We need to explore the
possibility to establish standard
pain relief methods for post
C-Section.
43