Analgesia for Post-Cesarean Delivery Pain

Abstract

Summary A recent survey by Gibbs et al27 indicates that of the cesarean sections performed in this country 41 per cent are conducted using general anesthesia, 34 per cent are conducted using spinal anesthesia, and 21 per cent are conducted using epidural anesthesia. This survey identifies three separate populations of patients and three different routes by which we may tailor the patient’s postoperative analgesia. These routes that involve epidural, intrathecal, and patient-controlled IV analgesic administration are gaining in popularity and are replacing traditional IM analgesics. It has become clear over the past few years that intraspinal narcotics and PCAs can provide the post-cesarean patient with superior analgesia compared with IM narcotics.24, 32 It has also become clear that these techniques can be delivered safely with very little risk to the patient, perhaps no greater than conventional analgesic techniques. The benefits of these new techniques is not limited to better analgesia. Patients given epidural morphine following cesarean section become ambulatory earlier than those given IV morphine for relief of pain.17 Epidural opiate analgesia has been shown to reduce morbidity in high-risk surgical patients and thereby improve outcome.48, 69 There is also evidence that even the low-risk cesarean section patients given intraspinal morphine for postoperative pain relief may have a shorter hospital stay than those given IV and IM narcotics.56 Finally, recent studies by Harrison et al32 and Eisenach et al24 have compared IM, PCA, and epidural narcotics for providing post-cesarean analgesia. They demonstrated that, in terms of providing analgesia, PCA was superior to IM narcotics, and that epidural narcotics were superior to PCA. A surprising finding, and one that deserves further study, was that even though those patients given epidural narcotics reported better analgesia than those given IM or PCA, those patients given PCA reported higher levels of satisfaction compared with prior cesarean deliveries than those patients given epidural narcotics.24 Again, it is not a direct comparison but an implied or inferred comparison. Thus, in those instances when epidural or intrathecal narcotic administration is impossible or undesirable, PCA can provide an attractive alternative, offering excellent analgesia and a high degree of patient satisfaction. In this article we reviewed the analgesic options available for the post-cesarean patient and attempted to outline the risks, benefits, and implementation of three new techniques for providing analgesia. With each new year these techniques have been finding, and will undoubtedly continue to find, wider clinical application, thereby improving the care for women having cesarean deliveries.