Pain management after elective caesarean section under neuraxial anaesthesia: an updated systematic review and procedure‐specific postoperative pain management ( PROSPECT ) recommendations

INTRODUCTION: Elective caesarean section is a common and painful procedure. Uncontrolled pain following caesarean section can profoundly and negatively on a wide range of patient and healthcare-centred outcomes. The aim of this systematic review was to update existing recommendations for postoperative pain management after elective caesarean section performed under neuraxial anaesthesia. METHODS: A systematic review using the PROcedure SPEcific Postoperative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised trials evaluating the efficacy of analgesic, anaesthetic and surgical interventions were retrieved. Systematic reviews and meta-analyses of randomised controlled trials were also reviewed. Trials evaluating pain management for emergency surgical deliveries or caesarean section performed under general anaesthesia were not included. RESULTS: Sixty-one randomised controlled trials were included. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, we recommend that clinicians administer intrathecal morphine 50-100 μg or diamorphine 300 μg pre-operatively, and paracetamol, non-steroidal anti-inflammatory drugs and dexamethasone after delivery. If a neuraxial opioid is not administered, clinicians should use one of a range of recommended fascial plane blocks; alternatively, the wound should be infiltrated with local anaesthetic. 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. The peritoneum should not be closed. DISCUSSION: An analgesic regimen to manage pain safely and effectively after elective caesarean section based on up-to-date evidence is presented. Consideration has been given to balancing analgesic efficacy and potential adverse effects. Future research should determine the optimal dose of dexamethasone and epidural long-acting opioid, establish the most effective regional analgesic technique and develop standardised outcome sets to better compare techniques.