Anaesthesia 2021, 76, 665–680 doi:10.1111/anae.

15339

Guidelines

PROSPECT guideline for elective caesarean section:

updated systematic review and procedure-specific
postoperative pain management recommendations
E. Roofthooft,1,2 G. P. Joshi,3 N. Rawal,4 M. Van de Velde,5 and on behalf of the PROSPECT
Working Group* of the European Society of Regional Anaesthesia and Pain Therapy and
supported by the Obstetric Anaesthetists’ Association

1 Consultant, Department of Anesthesiology, GZA Sint-Augustinus Hospital, Antwerp, Belgium

2 PhD Student, 5 Professor and Chair, Department of Cardiovascular Sciences, KULeuven and UZLeuven, Leuven,
Belgium
3 Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center,
Dallas, Texas, USA
4 Professor, Department of Anesthesiology, Orebro University, Orebro, Sweden

Summary
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.

.................................................................................................................................................................
Correspondence to: M. Van de Velde
Email: [email protected]
Accepted: 5 November 2020

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Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit
commercial exploitation.

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This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use,
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Anaesthesia 2021, 76, 665–680 Roofthooft et al. | Guidelines for pain management after caesarean section

Keywords: analgesia; caesarean section; caesarean delivery; pain

* Members of the PROSPECT Working Group, see Appendix 1.
This article is accompanied by an editorial by Landau and Richebé, Anaesthesia 2021; 76: 587–9.
Twitter: @MarcVandeVelde6

Recommendations recommendations for postpartum pain management which

1 Implement strategies to minimise systemic opioid are available on their website.
utilisation and develop individualised or stratified post-
discharge opioid prescribing practices to reduce How does this guideline differ from
unnecessary opioid analgesic consumption after other guidelines?
elective caesarean section. The updated systematic review further confirms the
2 Add intrathecal morphine 50–100 µg or diamor- previous recommendations. Also, an updated PROSPECT
phine 300 µg to spinal anaesthesia. Epidural morphine approach was used to develop the current
2–3 mg or diamorphine 2–3 mg may be used as an recommendations such that the available evidence is
alternative, for example, when an epidural catheter is critically assessed for current clinical relevance and the use
used as part of a combined spinal-epidural technique. of simple, non-opioid analgesics such as paracetamol and
3 Prescribe paracetamol and a non-steroidal anti- NSAIDs as basic analgesics. This approach reports true
inflammatory drug (NSAID) administered after delivery clinical effectiveness by balancing the invasiveness of the
and continued regularly postoperatively. analgesic interventions and the degree of pain after surgery,
4 Administer a single dose of intravenous (i.v.) as well as balancing efficacy and adverse effects.
dexamethasone after delivery in the absence of contra-
indications. Introduction
5 Consider a single injection of local anaesthetic infiltration, Caesarean section is associated with moderate-to-severe
continuous wound local anaesthetic infusion and/or postoperative pain in a significant proportion of women,
fascial plane blocks, if intrathecal morphine is not used. which may delay recovery and return to activities of daily
6 Use a surgical technique that includes the Joel-Cohen living; impair mother-child bonding; impact maternal
incision, non-closure of the peritoneum and abdominal psychological well-being; and may complicate
binders. breastfeeding [1]. Furthermore, inadequate postoperative
7 Consider the use of transcutaneous electrical nerve pain relief may lead to hyperalgesia and persistent
stimulation as an analgesic adjunct. postoperative pain [2].
Pain after caesarean section is often under-treated due
Why was this guideline developed? to unfounded fears that analgesic drugs or interventions
Caesarean section is associated with moderate-to-severe might induce maternal and neonatal side-effects and
postoperative pain which may influence recovery, because the severity of post-caesarean section pain is often
psychological maternal well-being, breastfeeding and underestimated [3]. Based on a systematic review
mother-child bonding. The aim of this guideline is to performed in 2014 [4], the PROSPECT Working Group [5,6],
provide clinicians with updated evidence for optimal pain which is a collaboration of surgeons and anaesthetists,
management following elective caesarean section under previously provided recommendations for pain
neuraxial anaesthesia. management in women undergoing caesarean section.
Recently, several new techniques have been developed to
What other guidelines are available on manage pain after caesarean, such as the quadratus
this topic? lumborum block; slow-release local anaesthetics; and non-
The procedure-specific postoperative pain management pharmacological approaches. Additionally, in the last
(PROSPECT) recommendations for pain management after decade, attention has shifted to reduce opioid use and to
caesarean section were published in 2014; however, an implement protocols for enhanced recovery after caesarean
update assessing analgesic interventions was necessary section. Therefore, an updated systematic review on
given developments in clinical practice. The American analgesic interventions for pain management after elective
College of Obstetricians and Gynecologists has provided caesarean section performed using neuraxial anaesthesia

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Roofthooft et al. | Guidelines for pain management after caesarean section Anaesthesia 2021, 76, 665–680

was needed. In addition, it was deemed necessary to re- treatment arms. We also evaluated for each study if patients
assess the recommendations to align them with the received ‘basic’ analgesia (i.e. paracetamol and/or NSAIDs)
updated PROSPECT approach that considers current and ‘baseline’ analgesia (i.e. routine administration of an
clinical relevance and clinical effectiveness by balancing the analgesic additional to the study intervention). We decided
invasiveness of the analgesic interventions and the degree not to perform a meta-analysis a priori due to heterogeneity
of pain after surgery, as well as balancing efficacy and in study design and result reporting, restricting pooled
adverse effects [7,8]. analysis.
The aim of this systematic review was to provide Recommendations were made according to
updated recommendations based on recent literature PROSPECT methodology [8]. In brief, this involved a
assessing the impact of analgesic and surgical grading of A–D according to the overall level of evidence, as
approaches on pain after elective caesarean section determined by the quality of studies included, consistency
performed under neuraxial anaesthesia. Postoperative of evidence and study design. The proposed
pain scores were the primary outcome measures. Other recommendations were sent to the PROSPECT Working
recovery outcomes assessed included cumulative opioid Group for review and comments and a modified Delphi
consumption and adverse effects. The limitations of the approach was utilised as previously described. Once a
available evidence were also assessed. The ultimate aim consensus was achieved the lead authors drafted the final
was to develop recommendations for pain management document, which was ultimately approved by the Working
after elective caesarean section performed under Group. The Obstetric Anaesthetists’ Association Executive
neuraxial anaesthesia. Committee were consulted on the final PROSPECT
recommendations and offered their support.
Methods
The methods of this review adhered to the previously Results
reported PROSPECT methodology [8]. Specific to this study, A total of 145 studies were included, of which 126 were
the Embase, MEDLINE, PubMed and Cochrane databases randomised controlled trials and 19 were systematic
(Cochrane Central Register of Controlled Trials; Cochrane reviews and meta-analyses (Fig. 1) [9–153]. The
Database of Abstracts or Reviews of Effects; Cochrane methodological quality assessments of the 126 randomised
Database of Systematic Reviews) were searched for controlled trials included in the final qualitative analysis are
randomised controlled trials, systematic reviews and meta- summarised in online Supporting Information Table S1. The
analyses published between 1 May 2014 and 22 October characteristics of the included studies are shown in online
2020. The search terms used were: (cesarean section OR Supporting Information Tables S2 and S3.
cesarean OR cesarean delivery) AND (pain OR
postoperative pain OR analgesia OR anesthesia Systemic non-opioid and opioid analgesics
OR anaesthesia OR anesthetic) AND (anesthetics neuraxial When paracetamol was administered pre-operatively rather
OR intrathecal OR spinal OR epidural analgesia OR than at the end of surgery, only minor differences were
paravertebral blocks OR peripheral nerve OR peripheral noted [9]. In one study, rectal paracetamol was shown to be
block OR regional nerve OR transversus abdominis plane superior to pre-operative oral paracetamol combined with
block OR infiltration OR instillation OR NSAID OR COX-2 OR i.v. paracetamol at the end of surgery [10]. In one study,
paracetamol OR acetaminophen OR gabapentin opioid consumption was reduced with i.v. paracetamol
OR pregabalin OR clonidine OR opioid OR ketamine OR compared with placebo but there was no difference in pain
corticosteroid OR dexamethasone OR peritoneal closure scores [11]. In another study, no differences in opioid
OR skin incision OR skin closure). Only studies in which consumption and pain scores were noted with i.v.
patients underwent elective caesarean section under paracetamol [12].
neuraxial anaesthesia were included. A meta-analysis concluded that systemic NSAIDs
Quality assessment, data extraction and data analysis reduced pain scores, decreased opioid consumption,
adhered to the PROSPECT methodology [8]. In this study, reduced opioid-related side-effects and increased patient
we defined a change of more than 10/100 mm on the visual satisfaction [13]. A Cochrane review evaluated oral
analogue scale or numerical rating score as clinically- analgesics, comprising primarily but not exclusively
relevant [8]. The effectiveness of each intervention for each NSAIDs, but could not draw any conclusions due to the low
outcome was evaluated qualitatively by assessing the quality of studies, small number of included patients and
number of studies showing a significant difference between substantial heterogeneity in the studied drugs

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Anaesthesia 2021, 76, 665–680 Roofthooft et al. | Guidelines for pain management after caesarean section

Figure 1 Flow diagram of studies included in this systematic review.

(paracetamol; celecoxib; ibuprofen; gabapentin; analgesia regimen [20]. The multimodal regimen consisted of
combination) [14]. Inthigood et al. evaluated a single dose intrathecal morphine, rectal and oral paracetamol and i.v. and
of i.v. parecoxib 40 mg and noted better pain scores than oral NSAID [20]. Administration of pregabalin combined with
with placebo [15]. Three studies compared an NSAID with intramuscular diclofenac, but without intrathecal morphine,
an opioid and demonstrated equally effective or superior was associated with lower pain scores and reduced opioid
analgesia with NSAIDs [16–18]. The addition of rectal requirements [21]. In another study, gabapentin provided
diclofenac to pentazocine was also associated with better superior analgesia compared with intrathecal fentanyl [22]. In
analgesia then pentazocine alone [19]. the two latter studies, basic analgesia consisted of diclofenac
Four randomised controlled trials [20–23] and a meta- [21,22]. In a study conducted on patients who did not receive
analysis [24] evaluated pre-operative gabapentinoids for any basic analgesia, adding vitamin B complex to gabapentin
analgesia after caesarean section. No significant benefits reduced pain scores and opioid consumption compared with
were reported with gabapentin when added to a multimodal the use of gabapentin alone [23]. A systematic review

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Roofthooft et al. | Guidelines for pain management after caesarean section Anaesthesia 2021, 76, 665–680

reported a clinically significant reduction in 24-h pain scores pelvic pain), pain scores with movement were lower in
with pre-operative gabapentin. Side-effects such as sedation patients receiving 300 µg vs. those receiving 150 µg
and dizziness were reported in several of the included studies intrathecal morphine [43]. In a comparative study, intrathecal
[24]. morphine provided better analgesia compared with epidural
Adding i.v. lidocaine to i.v. patient-controlled analgesia morphine and patient-controlled epidural analgesia of
(PCA) with morphine did not improve pain scores or opioid ropivacaine with sufentanil [44]. In two studies, women were
consumption [25]. One randomised controlled trial offered to choose the analgesic strategy and select either no
evaluated the effects of i.v. ketamine on postoperative intrathecal morphine or a low or high dose of intrathecal
analgesia [26]. A bolus of i.v. ketamine after delivery of the morphine [45,46]. Having a choice did not impact on rescue
fetus reduced pain and rescue analgesics in the first 12 h opioid consumption, but women were very good in
after caesarean section [26]. In the latter study, no basic predicting their actual opioid needs. Choosing high-dose
analgesia or additional baseline analgesia was given [26]. A intrathecal morphine was associated with increased rescue
meta-analysis on the i.v. use of ketamine demonstrated analgesia and more vomiting [45,46]. Apart from one study
marginal improvements in pain scores and a mild reduction [44], all studies used basic analgesia with NSAIDs [42,43,46]
in morphine consumption [27]. or a combination of NSAIDs and paracetamol [45]. Intrathecal
Compared with sufentanil PCA alone, the addition of morphine was similar to intrathecal hydromorphone in a
dexmedetomidine to a sufentanil PCA in the postoperative recent trial by Sharpe et al. [47].
period was associated with lower pain scores, reduced Ten trials evaluated the neuraxial administration of ɑ2-
sufentanil consumption, reduced need for rescue analgesia agonists such as clonidine and dexmedetomidine [48–57].
and a higher patient satisfaction. However, the improved pain A meta-analysis showed that neuraxial clonidine increased
scores were not clinically relevant [28]. In the latter study, no the duration and quality of analgesia and reduced
basic or additional baseline analgesia was given [28]. morphine consumption [48]. However, more side-effects
Four randomised controlled trials evaluated the use of such as hypotension and intra-operative sedation were
i.v. dexamethasone [29–32]. Use of i.v. dexamethasone was noted. No improvements in analgesia were reported with
associated with better pain scores; prolongation of intrathecal or i.v. clonidine, whether administered alone [49]
analgesic effect [29]; a reduction in opioid consumption or in combination with intrathecal morphine [50]. One study
[30]; and a reduced need for postoperative anti-emetics demonstrated the superiority of intrathecal clonidine to
[31]. One study reported better analgesia when intrathecal fentanyl [51]. Addition of epidural
dexamethasone was administered as wound infiltration as dexmedetomidine to combined spinal-epidural
opposed to i.v. administration [32]. Intravenous anaesthesia resulted in improved intra-operative and
dexamethasone was not as effective as i.v. tramadol [32]. postoperative analgesia and less requirements for opioid
Several studies compared various systemic opioids rescue [52]. A comparison of intrathecal dexmedetomidine
(oxycodone; sufentanil; tramadol; dezocine; butorphanol; with intrathecal morphine did not demonstrate any
hydromorphone; tapentadol) [33–40]. No individual drug significant differences in duration of analgesia, pain scores
was clearly superior in terms of analgesia or side-effect or need for rescue analgesia. However, both intrathecal
profile compared with any other opioid. morphine and intrathecal dexmedetomidine provided
better analgesia when compared with isobaric bupivacaine
Neuraxial adjuvant drugs (53). Administration of intrathecal dexmedetomidine
One meta-analysis [41] and three randomised controlled resulted in improved postoperative analgesia when
trials [42–44] evaluated the administration of intrathecal compared with isobaric bupivacaine or ropivacaine alone
morphine. The meta-analysis compared low (50–100 µg) [54,55]. Intrathecal dexmedetomidine combined with
and high (> 100 µg) doses of intrathecal morphine and intrathecal magnesium sulphate or intrathecal morphine
concluded that high doses increase the duration of improved analgesia which was of longer duration than
analgesia but were more likely to be associated with side- analgesia produced by magnesium sulphate alone [56,57].
effects. Pain scores were similar in both groups [41]. A dose- Adding intrathecal fentanyl to bupivacaine improved initial
response study of intrathecal morphine showed that 50 µg analgesia [58]. However, when morphine is also added to
doses were as effective as 100 µg and 150 µg, with a similar the intrathecal mixture, fentanyl might induce acute opioid
requirement for rescue opioids. The risk of pruritus was tolerance and result in greater opioid consumption [59].
lowest after 50 µg morphine [42]. In patients with an Intrathecal buprenorphine [60] and epidural
anticipated high pain intensity (such as patients with chronic hydromorphone [61] resulted in improved postoperative

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Anaesthesia 2021, 76, 665–680 Roofthooft et al. | Guidelines for pain management after caesarean section

analgesia and reduced opioid consumption compared with dexmedetomidine as adjuvants to wound infiltration
intrathecal bupivacaine or ropivacaine alone. reduced pain scores [81,82].
A meta-analysis evaluating the effect of neuraxial A rectus sheath block provides no additional analgesic
magnesium on postoperative analgesia demonstrated a benefit when added to multimodal analgesia which also
longer duration of sensory block, lower pain scores and includes intrathecal morphine [83]. Adding a field block
reduced rescue analgesia requirements then neuraxial after caesarean section to intrathecal morphine also did not
mixtures of local anaesthetic without magnesium [62]. improve analgesia after caesarean section [84].
The use of intrathecal midazolam was evaluated in There were five studies that compared transversus
several studies [63,64]. A comparative study demonstrated abdominis plane (TAP) blocks against placebo or no TAP
that intrathecal magnesium and intrathecal sufentanil were block [85–89]. Apart from one study [85], all studies noted
superior to intrathecal midazolam [63]. Intrathecal that TAP blocks improved pain relief, increased patient
midazolam prolonged the duration of spinal anaesthesia satisfaction and resulted in a reduction of rescue analgesia.
when compared with placebo [64]. Intrathecal ketamine A comparison between lateral and posterior approaches
prolonged analgesia when compared with fentanyl [65,66]. concluded that the posterior approach resulted in better
A meta-analysis showed that intrathecal neostigmine pain scores which was only clinically relevant at 12 h
improved analgesia after caesarean section, although it was postoperatively. This approach also resulted in reduced
associated with an increased risk of nausea and vomiting need for rescue analgesia [90]. Comparison between
[67]. A study showed that a faster speed of intrathecal surgeon-administered and anaesthetist-administered TAP
injection of fentanyl and local anaesthetic results in blocks did not show any differences in postoperative
improved postoperative analgesia with a more sustained analgesia [91].
duration [68]. Several studies evaluated the role of local anaesthetic
adjuvants for TAP blocks. Pain scores, opioid consumption
Local and regional analgesia techniques and duration of analgesia were significantly improved when
Intraperitoneal local anaesthetic instillation resulted in dexamethasone was added to local anaesthetic for TAP
lower early pain scores [69], and reduced pain scores at blocks [92]. Fentanyl added to TAP blocks failed to improve
24 h in a sub-group in which the peritoneum was closed the quality of analgesia [93]. The addition of ɑ2-agonists
[69]. The use of topical analgesia (e.g. eutectic mixture of (clonidine or dexmedetomidine) prolonged the duration of
local anaesthetic cream) failed to reduce pain scores at 24 analgesia, reduced the need for rescue drugs and improved
and 48 h [70]. patient satisfaction [94–96]. However, mild sedation was
Three studies demonstrated that local anaesthetic noted in some patients [94–96].
wound infiltration reduced pain scores and the need for Several studies compared TAP blocks with alternative
rescue analgesia during the first 24 h after caesarean regional anaesthesia techniques [97–103]. In a comparison
section [71–73], while one study showed only limited of TAP blocks with epidural analgesia which included high-
benefits [74]. Apart from one study [72], basic analgesia with dose epidural morphine, improved analgesia with the
ibuprofen and paracetamol was provided. Another two epidural analgesia was noted [97]. Three studies compared
studies which used multimodal analgesia showed improved intrathecal morphine with TAP blocks [98–100]. In two of
pain scores, less morphine consumption and higher these, there was better analgesia with intrathecal morphine
breastfeeding comfort with continuous wound infusion and a reduced requirement for rescue analgesia. However,
compared with no infusion [75,76]. Local anaesthetic wound postoperative mobilisation and return of gastro-intestinal
infusion resulted in similar analgesic effects as intrathecal function was better with TAP blocks [98,99]. The third study
morphine [76]. A meta-analysis confirmed that both single- could not discriminate between the two techniques in terms
shot local anaesthetic wound infiltration and continuous of pain relief and other clinical outcomes [100]. Three
wound infusion reduce postoperative opioid consumption randomised controlled trials compared TAP blocks with
and mildly improve pain scores [77]. Pain scores were continuous local anaesthetic wound infusion and noted no
similar whether the catheter was placed preperitoneal or differences in postoperative analgesia [101–103].
subcutaneously [78]. Adding ketorolac improved analgesia Three meta-analyses confirmed the efficacy of TAP
of wound infiltration and reduced opioid consumption [79]. blocks for analgesia after caesarean section but concluded
In a recent study, ketorolac added to wound infiltration did that they do not confer any benefit over intrathecal
not improve analgesia but intrathecal morphine was morphine [104–106]. A combination of ilioinguinal and
administered in both groups [80]. Magnesium and iliohypogastric nerves block with TAP blocks vs. no blocks

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Roofthooft et al. | Guidelines for pain management after caesarean section Anaesthesia 2021, 76, 665–680

resulted in less rescue opioid consumption and lower pain analgesia was noted [132–134]. Two studies evaluated the
scores [107]. Adding dexmedetomidine to a ropivacaine application of manual cervical dilation at the end of
bilateral ultrasound-guided TAP block resulted in lower caesarean section and compared it with no cervical dilation
postoperative pain scores and less rescue opioid [108]. and came to conflicting conclusions [135,136]. One study
Quadratus lumborum blocks were evaluated in 11 trials noted improved pain scores until 7 days postoperatively
[109–119]. Compared with a sham block, quadratus [135] while the other did not report any pain reduction [36].
lumborum blocks produced better analgesia. In two trials Pre-operative vaginal cleansing resulted in minor but
quadratus lumborum blocks were found to be superior to a statistically significant reductions in postoperative pain
TAP blocks [113,114,118,119]. In one study, quadratus scores [137].
lumborum blocks were less effective than a single epidural
bolus of local anaesthetic [115]. Adding quadratus Surgical interventions
lumborum blocks to intrathecal morphine did not improve A systematic review [138] confirmed the superiority of the
analgesia [116]. However, in a direct comparison, a Joel-Cohen (also called modified Misgav-Ladach) incision
quadratus lumborum block was similar to intrathecal compared with Pfannenstiel incision in reducing
morphine [117]. Two recent meta-analyses evaluated TAP postoperative pain [139]. No differences in pain scores were
blocks, wound infusion and quadratus lumborum blocks noted between using a scalpel vs. diathermy for the skin
with or without intrathecal morphine and concluded that all incision [139].
three regional anaesthetic techniques are superior to no A blunt fascial opening resulted in less postoperative
regional technique in the absence of intrathecal morphine pain [140]. The older technique of extraperitoneal section
[120,121]. When intrathecal morphine is administered, was associated with better pain scores up to 48 h
adding these techniques confers no further advantages. postoperatively [141]. In one study, the absence of making a
Two studies recently evaluated the erector spinae bladder flap at opening the uterus resulted in clinically-
plane block (ESP) compared with TAP block and intrathecal relevant improvements in postoperative pain scores [142]. A
morphine and in both studies the ESP block improved comparison between uterine exteriorisation and in situ
analgesia [122,123]. closure of the uterus showed more postoperative pain with
exteriorised uteri [143]. However, one meta-analysis did not
Patient-controlled epidural analgesia show any difference in postoperative pain between the two
Patient-controlled epidural analgesia added to intrathecal modalities of uterine closure [144].
morphine resulted in a further lowering of postoperative A comparison between two techniques of pyramidalis
pain scores and less need for rescue opioid [124]. Adding muscle dissection found no differences in postoperative
fentanyl to patient-controlled epidural analgesia with pain [145]. Reduced pain scores when the peritoneum was
levobupivacaine did not improve analgesia [125]. not closed were reported [146]. One study reported a
significant reduction in postoperative pain scores when the
Postoperative interventions rectus muscle was not re-approximated [147]. A Cochrane
Several investigators reported on the beneficial effects of review noted minimal evidence for reduced pain scores
transcutaneous electrical nerve stimulation on pain scores, when the peritoneum was not closed after caesarean
rescue analgesia use and patient satisfaction [126,127]. A section [148]. When applying laser irradiation to the
study demonstrated that self-administered oral opioid caesarean section wound at the end of surgery, less pain
analgesia was as effective as parenteral nurse-administered during the first 24 h postoperatively was noted [149,150].
drugs [128]. A comparison of a fixed time-interval with on- No differences in pain scores were noted between
demand oral analgesia concluded that the latter was interrupted and continuous wound suturing [151]. Similarly,
associated with better pain scores [129]. One study two meta-analyses did not show any difference in pain
evaluated the use of relaxation sounds intra- or scores whether skin closure was performed with sutures or
postoperatively and showed improved pain scores [130]. staples [152,153].
One study evaluated the use of early skin-to-skin contact
between mother and baby and noted no differences in Discussion
postoperative pain scores [131]. The majority of the studies included in this systematic review
Three studies evaluated the use of elastic abdominal were determined to be of high quality. The updated
binders after caesarean section [132–134]. In all three, a literature strengthens the previous PROSPECT
clinically-relevant reduction in pain scores and rescue recommendations for pain management in patients

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Table 1 Overall recommendations for pain management in patients undergoing elective caesarean section.
Pre-operatively
• Intrathecal long-acting opioid (e.g. morphine 50–100 µg or diamorphine up to 300 µg) (Grade A). Epidural morphine 2–3 mg or
diamorphine up to 2–3 mg may be used as an alternative, for example, when an epidural catheter is used as part of a combined
spinal-epidural technique (Grade A)
• Oral paracetamol (Grade A)

Intra-operative after delivery

• Intravenous paracetamol if not administered pre-operatively (Grade A)
• Intravenous non-steroidal anti-inflammatory drugs (Grade A)
• Intravenous dexamethasone (Grade A)
• If intrathecal morphine not used, local anaesthetic wound infiltration (single-shot) or continuous wound infusion and/or regional
analgesia techniques (fascial plane blocks such as transversus abdominis plane blocks and quadratus lumborum blocks) (Grade A)

Postoperative
• Oral or intravenous paracetamol (Grade A)
• Oral or intravenous non-steroidal anti-inflammatory drugs (Grade A)
• Opioid for rescue or when other recommended strategies are not possible (e.g. contra-indications to regional anaesthesia) (Grade D)
• Analgesic adjuncts include transcutaneous electrical nerve stimulation (Grade A)

Surgical technique
• Joel-Cohen incision (Grade A)
• Non-closure of peritoneum (Grade A)
• Abdominal binders (Grade A)

undergoing elective caesarean section and modifies it in addition, i.v. dexamethasone provides anti-emetic
certain aspects. The updated PROSPECT methodology prophylaxis. Thus, i.v. dexamethasone is recommended.
further strengthens the recommendations, because it goes Caution is required in patients with glucose intolerance.
beyond assessment of the available evidence based solely Intrathecal morphine at doses of 100 µg or lower is
on statistical analysis [8]. recommended. Doses lower than 100 µg result in adequate
Of note, it is essential to highlight that this guideline analgesia with a reduced incidence of side-effects. Recently,
focuses on elective caesarean section under neuraxial Sharawi et al. confirmed the safety of intrathecal morphine
anaesthesia. Importantly, these recommendations should when used in patients undergoing caesarean section [154].
not be applied to other patient populations such as Importantly, basic analgesics (i.e. paracetamol and NSAIDs)
emergency or unplanned caesarean section or surgery and i.v. dexamethasone should be used with intrathecal
performed under general anaesthesia. morphine. Of note, the National Institute of Health and Care
The recommended strategies have sufficient Excellence (NICE) guidelines in the UK recommend
procedure-specific evidence and have a positive balance of intrathecal diamorphine as an alternative to intrathecal
clinical benefits and risk of side-effects (Table 1). Basic morphine [155]. Intrathecal diamorphine 300 µg is
analgesia after caesarean section should always consist of recommended. When spinal anaesthesia is not possible or
paracetamol and NSAIDs started intra-operatively (after when an epidural catheter is in situ, epidural morphine or
delivery) and continued postoperatively, unless there are diamorphine both in doses of 2–3 mg can be used.
contra-indications. Of note, several studies demonstrated Various local anaesthetic techniques such as TAP
equally good pain control with NSAIDs compared with blocks, quadratus lumborum blocks and local
opioids. Regular administration of basic analgesics is anaesthetic wound infiltration are effective in reducing
important to limit the need for rescue opioid analgesia. pain scores and opioid requirements. Given that the
Moreover, studies investigating an analgesic strategy to potential side-effects of these regional analgesic
manage pain relief after caesarean section should not omit techniques are limited, they are recommended.
this basic strategy of analgesia so as to establish the However, the additional value of any of these
additional value of an investigational approach. In addition techniques when combined with intrathecal morphine
to basic analgesics, i.v. dexamethasone demonstrated appears to be minimal. Therefore, these blocks may be
positive effects on pain scores and opioid consumption. In administered if intrathecal morphine is not used.

672 © 2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
Roofthooft et al. | Guidelines for pain management after caesarean section Anaesthesia 2021, 76, 665–680

Table 2 Analgesic interventions that are not recommended for pain management in patients undergoing elective caesarean
section.
Intervention Reason for not recommending
Pre-operative Gabapentinoids Limited procedure-specific evidence and concerns of side-effects
Intra-operative Intravenous ketamine Limited procedure-specific evidence and concerns of side-effects
Intravenous dexmedetomidine Limited procedure-specific evidence and concerns of side-effects
Intravenous tramadol and butorphanol Limited procedure-specific evidence
Neuraxial clonidine Inconsistent procedure-specific evidence and concerns of side-effects
Neuraxial dexmedetomidine Inconsistent procedure-specific evidence and concerns for side-effects
Intrathecal buprenorphine Limited procedure-specific evidence
Epidural hydromorphone Limited procedure-specific evidence
Intrathecal midazolam Limited procedure-specific evidence and concerns of side-effects
Intrathecal neostigmine Concerns of side-effects
Intrathecal ketamine Limited procedure-specific evidence and concerns of side-effects
Intraperitoneal local anaesthetic Lack of procedure-specific evidence
Topical skin analgesia Lack of procedure-specific evidence
Clonidine added to TAP Lack of procedure-specific evidence
Dexmedetomidine added to TAP Limited procedure-specific evidence
Fentanyl added to TAP Lack of procedure-specific evidence
Rectus sheath block Lack of procedure-specific evidence
Field block Lack of procedure-specific evidence
Music Limited procedure-specific evidence
Postoperative Skin-to-skin contact Limited procedure-specific evidence
Intravenous lidocaine Lack of procedure-specific evidence
Patient controlled epidural analgesia Limited procedure-specific evidence and concerns of side-effects
Surgical technique Method of incision: diathermy Inconsistent procedure-specific evidence
Absence of a bladder flap Limited procedure-specific evidence
Blunt fascial opening Limited procedure-specific evidence
Uterine exteriorisation Inconsistent procedure-specific evidence
Skin incision lasering postoperatively Limited procedure-specific evidence
Type of skin closure Lack of procedure-specific evidence
Vaginal cleansing Lack of procedure-specific evidence
Cervical dilation Inconsistent procedure-specific evidence
Type of pyramidalis muscle dissection Lack of procedure-specific evidence
Rectus muscle re-approximation Limited procedure-specific evidence
TAP, transversus abdominis plane block.

Surgical techniques that have been shown to be to concerns about side-effects such as sedation and
beneficial and are therefore recommended include Joel- respiratory depression [156]. Furthermore, it is not clear if
Cohen incision and avoidance of peritoneum closure. Using gabapentinoids add to our current recommendations of
abdominal binders postoperatively is recommended with basic analgesia, i.v. dexamethasone and regional analgesia.
sufficient procedure-specific evidence being identified. Several intra-operative interventions are not
Analgesic adjuncts such as listening to music via recommended due to inconsistent or limited or lack of
headphones and use of transcutaneous electrical nerve procedure-specific evidence and/or concerns of side-
stimulation may be associated with improved pain relief and effects (Table 2). For example, intra-operative
are recommended when available. dexmedetomidine infusion has been shown to provide
Although pre-operative gabapentinoids were improved postoperative pain relief; however, it is not
recommended previously, they are no longer recommended because its benefits on top of basic
recommended despite positive studies of their benefits due analgesia remain unknown, and due to concerns of side-

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Anaesthesia 2021, 76, 665–680 Roofthooft et al. | Guidelines for pain management after caesarean section

effects including hypotension and bradycardia which can influence of analgesic interventions on patient-reported
be prolonged and might impede ambulation [157]. outcomes such as mother-child bonding, breast feeding
Similarly, although, a sub-anaesthetic dose of i.v. ketamine ability, time to ambulation and return to activities of daily
has demonstrated positive effects on postoperative pain living. Validated scoring tools such as the quality of
scores [158], it is not recommended because its benefits recovery-11 are useful metrics that should be considered.
over basic analgesia are unknown, and concerns of side- In summary, this review has identified an analgesic
effects such as hallucinations that might impair the regimen that can be used for optimal pain management
recollection of the birth experience and mother-child after elective caesarean section performed under neuraxial
bonding [158,159]. anaesthesia. A combination of basic analgesics such as
Intrathecal or epidural administration of paracetamol; NSAIDs or cyclo-oxygenase-2–selective
buprenorphine, hydromorphone, midazolam, ɑ2- inhibitors; and i.v. dexamethasone, along with a local/
adrenergic agonists, neostigmine and ketamine has been regional analgesic techniques (e.g. intrathecal morphine
reported to prolong the analgesic duration of morphine. 50–100 µg or diamorphine 300 µg); local anaesthetic
However, they cannot be recommended due to inconsistent infiltration with or without a field blocks such as ilio-inguinal
procedure-specific evidence and due to the potential side- and iliohypogastric nerves blocks or fascial plane blocks
effects such as hypotension or sedation. Additionally, in (e.g. TAP, quadratus lumborum or ESP blocks) are
most studies, hypotension occurs as frequently as sedation. recommended. However, the benefits of local and regional
Peritoneal instillation of local anaesthetics cannot be analgesic techniques are not apparent with the use of
recommended due to a lack of procedure-specific intrathecal morphine or diamorphine. Analgesic adjuncts
evidence. Similarly, topical local anaesthetic cream such as listening to music via headphones and
application is not recommended due to a lack of procedure- transcutaneous electrical nerve stimulation may be used
specific evidence. when available. Several aspects of the surgical technique
The limitations of this review are related to those of the clearly yield positive analgesic effects after caesarean
included studies. There was considerable heterogeneity section including the Joel-Cohen incision, non-closure of
between studies with regard to dosing regimens and route the peritoneum and the use of abdominal binders. The
of administration as well as the timing of pain assessments. PROSPECT recommendation for postoperative analgesia
The small size of most studies makes it impossible to draw after caesarean section has established a multimodal pre-,
conclusions about the safety profile of an individual intra- and postoperative analgesic strategy which combined
intervention. In the majority of included studies, the with certain surgical approaches and adjuvant techniques
analgesic intervention was not evaluated against an may provide excellent analgesia.
optimised multimodal analgesic regimen. Moreover,
measuring just pain scores and/or opioid consumption is Acknowledgements
not sufficient and more comprehensive, patient-centred This PROSPECT recommendation is supported by the
tools to assess pain relief and functionality would better Obstetric Anaesthetists’ Association. PROSPECT is supported
reflect day-to-day clinical practice but are unfortunately by an unrestricted grant from the European Society of
poorly reported in the literature. Also, because most studies Regional Anaesthesia and Pain Therapy. In the past,
include healthy, full-term parturients, our recommendations PROSPECT has received unrestricted grants from Pfizer Inc.
may not be applicable to parturients with co-existing New York, NY, USA and Grunenthal, Aachen, Germany.
medical conditions such as morbid obesity, chronic pain as GJ has received honoraria from Baxter and Pacira
well as preterm delivery. Furthermore, the PROSPECT Pharmaceuticals. MVdV has received honoraria from
methodology uses a minimal clinically important difference Sintetica, Grunenthal, Vifor Pharma, MSD, Nordic Pharma,
in pain scores of 1/10. However, this difference has never Janssen Pharmaceuticals, Heron Therapeutics and Aquettant.
been validated in obstetric patients. EP-Z has received honoraria from Mundipharma, Grunenthal,
Future adequately powered studies should assess the MSD, Janssen-Cilag GmbH, Fresenius Kabi and AcelRx. No
effects of analgesic interventions not only on pain, opioid other external funding or competing interests declared.
consumption, opioid-related adverse events and
complications associated with the intervention, but also
outcome measures such as time to ambulation, hospital stay
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association with postoperative respiratory depression.
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Appendix 1 support the interventions that are not recommended in
patients undergoing caesarean section.
PROSPECT Working Group
G. P. Joshi, E. Pogatzki-Zahn, M. Van de Velde, S. Schug, H.
Kehlet, F. Bonnet, N. Rawal, A. Delbos, P. Lavand’homme, H.

680 © 2020 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.