Pain relief after cesarean section

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Management of acute pain after cesarean section has evolved considerably over the past decade. In many institutions, intravenous patient-controlled analgesia and neuraxial opioids have replaced traditional intramuscular opioid injections. The general approach to pain after cesarean section is changing, shifting away from traditional opioid-based therapy toward a “multimodal” or “balanced” approach. Multimodal pain therapy involves the use of a potent opioid regimen, such as patient-controlled analgesia or neuraxial opioids, in combination with other classes of analgesic drugs. Theoretically, the use of analgesic drugs in combination allows for additive or even synergistic effects in reducing pain while decreasing the side effects produced by each class of drug because smaller drug doses are required. Typical analgesic regimens include opioids; nonopioid analgesics, such as acetaminophen; and nonsteroidal anti-inflammatory drugs, with the variable addition of local anesthetic techniques. Despite current advances in postoperative pain therapy, pain relief may still be inadequate for a substantial number of women. This may be particularly true as they make the transition from relative dependency on potent opioid regimens to full dependency on oral analgesics on the second postoperative day. A recent randomized controlled trial (P. Angle, S. Halpern, B. Leighton, et al, manuscript in preparation) examining pain relief after cesarean section revealed inadequate pain relief in 33% of women who received intrathecal morphine 0.2 mg followed by acetaminophen with codeine on a patient-request basis on the first postoperative day. This was compared with a 9% incidence in women who received regular doses of naproxen in addition to existing pain therapy. The use of naproxen, however, did not affect the incidence of inadequate analgesia on the second postoperative day, with both control and treatment groups experiencing similar incidences of inadequate pain relief respectively (27% v 28%). Further optimization of existing regimens as well as more effective monitoring of pain over the course of hospitalization should lead to improved pain relief. General recommendations are made in the following report. Copyright © 2001 by W.B. Saunders Company