PROSPECT guideline for elective caesarean section: updated systematic review and procedure‐specific postoperative pain management recommendations

Abstract

Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50-100 µg or diamorphine 300 µg administered pre-operatively; paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single-injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel-Cohen incision; non-closure of the peritoneum; and abdominal binders. Transcutaneous electrical nerve stimulation could be used as analgesic adjunct. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations. Some interventions were not recommended due to insufficient, inconsistent or lack of evidence. Of note, these recommendations may not be applicable to unplanned deliveries or caesarean section performed under general anaesthesia.

Paracetamol: A Review of Guideline Recommendations

“…Recently, Abdel Shaheed analyzed data from 36 publications and reported that paracetamol produced modest pain relief in hip and knee osteoarthritis, tension headache, and post-craniotomy pain and that it was ineffective in other conditions [ 145 ]; the authors concluded with the need for large, high-quality trials to reduce uncertainty about the efficacy of paracetamol in common pain conditions. In the last few months, new published studies report the safe use of paracetamol in patients with chronic kidney disease [ 147 ], the significant efficacy of paracetamol for post-arthroplasty pain [ 148 ], the lesser efficacy of paracetamol than ibuprofen for post-laminectomy pain [ 149 ], the opioid-sparing effects of paracetamol in the Emergency Department [ 150 ], the recommendations against paracetamol in lumbar spinal stenosis with neurogenic claudication [ 151 ], and the recommendations in favor of paracetamol for postcesarean pain [ 152 ] and for migraine [ 153 , 154 ].…”

Comparison of the analgesic effects of two quadratus lumborum blocks (QLBs), QLB type II vs QLB type III, in caesarean delivery: A randomised study

“…In the recently published PROSPECT guideline, the use of fascial plane blocks such as QLB is recommended when intrathecal morphine is not used in CD. 37 The low pain scores and opioid consumption in both blocks, as well as the absence of complications, will contribute to its more significant involvement in postoperative pain management in daily practice. Our study was performed in spinal anaesthesia patients and showed that the QLB-III block is superior to QLB-II.…”

The Efficacy and Safety of Local Anesthetic Techniques for Postoperative Analgesia After Cesarean Section: A Bayesian Network Meta-Analysis of Randomized Controlled Trials

“… 1 Although CS has some benefits, such as lowering the risk of birth injuries (eg, asphyxia, shoulder dystocia, fractures 2 ), it can cause moderate to severe postoperative pain. 3 This pain must be taken seriously and treated in a timely manner because it may delay recovery, affect daily activities, and impact maternal psychological well-being. 4 Furthermore, insufficient treatment may cause pain to become persistent 5 and chronic.…”