FRCA Notes

Analgesia following caesarian section

The core curriculum asks for "safe and effective management of post-delivery pain relief".

This subject has yet to appear as a CRQ, though is undeniably fair exam game and of high real-world utility.

Resources

  • Post-LSCS analgesia should adhere to the normal tenets of perioperative analgesia, namely:
    • Multi-modal
    • Opioid-sparing
    • Facilitating prompt return of normal function

  • The strategy employed will depend somewhat on whether neuraxial or general anaesthesia is used during LSCS, though both are covered below
  • Vital signs i.e. RR, SpO2, HR, NIBP and sedation score
  • Recorded every 30mins for 2hrs, then every 2hrs for 24hrs thereafter
  • Recorded on a modified early obstetric warning scoring (MEOWS) chart
  • Formal pain assessment tools can be used
  • Only the short-form brief pain inventory demonstrated sufficient validity and evidence base to be recommended in one study (BJA, 2021)
  • The Obstetric Quality of Recovery-10 questionnaire is another option

Perioperative analgesic strategy for LSCS


  • Long-acting neuraxial opioids should be used, e.g.:
    • Intrathecal: morphine 75-200μg or diamorphine 300-400μg (if you can find any)
    • Epidural: 2-3mg of either morphine or diamorphine down the epidural catheter post-delivery

  • Typically a short-acting opioid is used alongside the long-acting opioid e.g. fentanyl via intrathecal (15μg) or epidural (100μg) routes
  • One could in theory leave an epidural catheter in situ and continue using it as a PCEA for post-operative analgesia
  • Interestingly, use of intrathecal morphine does not reduce the incidence of chronic post-surgical pain following LSCS (BJA, 2022)

  • Clonidine is another option, either intrathecal (75-150mcg (∽1-2μg/kg)) or epidural (150-600μg), but is not recommended by the PROSPECT guidelines
  • Other neuraxial adjuncts e.g. ketamine, midazolam also aren't recommended

  • IV paracetamol
  • IV or PR NSAID
  • IV dexamethasone (prolongs the duration of analgesia from regional anaesthesia)
  • In the absence of neuraxial opioid, IV morphine to provide long-duration opioid analgesia

Local and regional anaesthetic techniques

  • These should be employed if neuraxial opioids aren't used e.g. GA LSCS
  • Options include:
    • Wound infiltration, as either a single shot or continuous infusion
    • Transversus abdominus plane blocks
    • Quadratus lumborum blocks
  • These latter two are both more efficacious than placebo and are equally effective at providing analgesia
  • Their beneficial effect disappears if intrathecal opioids have been administered
  • They can also be used as rescue techniques in women with refractory post-operative pain

Regular, simple analgesics

  • Paracetamol 1g QDS
  • Ibuprofen 600mg QDS for 48hrs, then step down to a normal dosing regimen (i.e. 400mg TDS)
    • Consider concurrent gastric protection

Opioid analgesics

  • Dihydrocodeine 30-60mg QDS
    • Unlike codeine, it is safe to take while breastfeeding although appropriate neonatal monitoring should take place
    • This is often prescribed PRN for breathrough pain
    • It can be prescribed regularly in patients with contraindications to NSAIDs (asthma, kidney injury) to provide a second, regular analgesic alongside paracetamol

  • Morphine
    • Immediate release oral preparations PRN for breakthrough pain e.g. 10-30mg 2-4hrly PRN
    • As a PCA for patients without neuraxial opioids on board
  • Oxycodone is suitable for those with contraindications to morphine, though it is present in breastmilk so should be avoided where possible

  • Tramadol is another option as an oral analgesic whilst breastfeeding, although in practice the above to opioids are usually used instead

Opioid side-effects and their management

Side-effect Management
Sedation Close post-operative monitoring
Respiratory depression Naloxone 400mcg IV
Nausea and vomiting IV cyclizine or ondansetron
Pruritus Incremental doses of naloxone, antihistamine, ondansetron, droperidol or even propofol
Constipation Laxatives e.g. movicol, lactulose, senna
Urinary retention Bladder care, early catheterisation
Delayed gastric emptying Prokinetic e.g. metoclopramide