There is a range of options for post operative analgesia following a Caesarean Section. There is a lack of high level evidence supporting one clear method and hence these guidelines constitute a local practice recommendation.
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Process
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Patient selection
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Note: These guidelines are for patients who have had a caesarean section under regional anaesthesia only.
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Patients booked for elective caesarean section should have their postoperative pain management discussed with them. Patients at high risk for postoperative pain management problems (eg. Chronic pain, substance abuse) should have a detailed pain management strategy developed preoperatively. (link to WADS CPG: Analgesia post caesarean section: under development).
At the Women's the main strategy is to use a combination of approaches (multimodal analgesia) with paracetamol, NSAIDs, and opioids. This has been found to improve analgesia and decrease doses of individual agents (Level 1).
This approach is used routinely for elective caesarean sections under regional anaesthesia. Patients having general anaesthetics or who have comorbidities restricting the use of some of these agents will often require other techniques e.g. PCA.
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Analgesics
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Paracetamol
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- 1g orally strictly 6 hourly (max 4gm /24 hrs)
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If not tolerating oral fluids then give IV or rectal. Rectal route less reliable and effective than oral or IV routes (Level 2).
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Non steroidal anti inflammatory drugs
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NSAIDS given regularly with paracetamol improve analgesia (level 1).
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- Diclofenac: 50 mg orally 8 hourly or 100 mg PR 18 hourly.
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Note: Proctitis may occur with diclofenac suppositories. Oral diclofenac should be routinely ordered in preference to suppositories in patients who are able to take oral medications. Other oral NSAIDs may be substituted for Diclofenac.
Parenteral NSAIDs such as ketorolac or parecoxib may be considered by the acute pain service.
Side effects of NSAIDs may limit their use. Caution must be used in patients with renal impairment, peptic ulceration and NSAID sensitive bronchospasm. Care must be exercised in patients with preeclampsia or other pregnancy conditions where renal function may be compromised. In patients with a bleeding risk e.g. ante or post partum haemorrhage, concurrent anticoagulant use, the use of a COX -2 selective inhibitor (parecoxib) can be considered. These agents do not impair platelet function in comparison with non selective NSAIDS (Level 2).
Monitor urine output and renal function in patients on NSAIDS.
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Oxycodone
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Oxycodone is a potent semi synthetic opioid that may be used for post operative analgesia. It can be administered orally or rectally.
Oral oxycodone can offer equivalent or superior analgesia after caesarean section compared with IV morphine PCA (level 2).
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Potential side effects
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- Respiratory depression
- Drowsiness / sedation
- Confusion
- Nausea and vomiting
- Itch
- Constipation
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Dosage
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- 5-15 mg orally 4 hrly PRN
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For patients unable to tolerate oral medications 30mg (Oxycodone pectinate) can be administered PR. A single PR dose may be appropriate at the end of a LUSCS under regional anaesthesia.
Controlled release preparations eg oxycontin should not be used in the early management of acute postoperative pain because of the difficulties in titrating dose to the pain level but may be considered in selected patients by the acute pain service.
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NOTE: NO other oral/rectal/intravenous or intramuscular opioids or sedative agents (e.g. temazepam) should be given concurrently with oxycodone.
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Other analgesics
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Other analgesics such as tramadol or substitution with different opioids should be considered by the acute pain service for patients with particular pain problems. These include patients with poorly controlled pain, pre existing chronic pain, drug dependant patients and patients who are unable to tolerate NSAIDs.
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Monitoring and management of adverse effects.
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Pulse and Blood Pressure every 4 hours
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Respiratory depression and sedation
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Sedation score is a more reliable indicator than respiratory rate of opioid induced respiratory depression
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- Respiratory rate and sedation score every hour for first 12 hours, then every 2 hours for the first 24 hrs.
- After the first 24 hrs regularly reassess sedation score and respiratory rate before and after administering oxycodone analgesia. Document on vital signs chart.
- Notify anaesthetist or unit doctor if sedation score >/= 2 or respiratory rate <8
- Naloxone should be available immediately to treat respiratory depression.
- Pulse oximetry MUST BE used in high-risk patients:
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 | - sedation score >/=2
- significant cardiorespiratory impairment
- sleep apnoea, snoring, or airway obstruction
- concurrent sedative agents.
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Inadequate analgesia
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Regular and routine assessment of pain will result in improved pain management (Level 3).
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- Pain score (at rest and with movement/deep cough) every 2 hours while awake for first 24 hrs postoperatively
- After first 24 hrs regularly reassess pain score and before and after administering analgesia. Document on vital signs chart.
- Notify anaesthetist or unit doctor if consecutive pain scores of 8-10.
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Nausea and vomiting
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All patients on opioid therapy must have antiemetics ordered
Notify anaesthetist or unit doctor if not responding to treatment.
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References
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Evidence table
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Revised and updated: 31 July 2007
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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