Post-cesarean delivery analgesia

INTRODUCTION — Postoperative pain control after cesarean delivery (CD) is an important issue for patients and health care providers. CD is the most commonly performed inpatient procedure in the United States [1], and women who undergo CD rank postoperative pain a high priority concern among anesthesia-related outcomes [2]. Unlike postoperative analgesia for other surgeries, the plan for analgesia after CD must facilitate bonding between the mother and her neonate and allow safe breastfeeding. These goals are achieved through multimodal analgesia, which for most patients is based on the use of long-acting neuraxial opioids, while minimizing the use of systemic opioids.

This topic will discuss options for effective analgesia after CD with a focus on routine CD and will present our approach. Other aspects of anesthesia for CD are discussed separately. (See "Anesthesia for cesarean delivery".)

Post-CD analgesia for patients who chronically use opioids or who have opioid use disorder is discussed in detail separately. (See "Obstetric anesthesia for patients with opioid use disorder or opioid tolerance", section on 'Post-cesarean delivery analgesia'.)

CREATING A PLAN FOR POSTOPERATIVE ANALGESIA — For most patients, the strategy for post-CD pain control should consist of neuraxial opioid and scheduled nonopioid analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs [NSAIDs]), with systemic opioids reserved for breakthrough pain. Alternative plans are required for patients who receive general anesthesia for CD and may be required for patients with risk factors for severe postoperative pain (eg, patients with chronic pain and/or who chronically use opioids).

Ideally, patients would be stratified preoperatively to receive different analgesic regimens matched to their specific needs. A number of strategies have been studied, including use of preoperative pain prediction tools [3], patient-driven shared decision-making approaches [4,5], and for postdischarge opioids, individualized opioid prescribing practices [6]. One study evaluated the use of a shared decision-making tool to engage patients in a discussion about the tradeoff between increased analgesia and the risk of side effects related to the dose of intrathecal morphine used during spinal anesthesia for CD. Patients who were randomly assigned to have a choice in their analgesia regimen correctly predicted an increased need for opioids, demonstrating the potential benefits of engaging patients when choosing an analgesic regimen [4]. However, further study is required before recommending routine use of this tool.

Setting appropriate maternal expectations for pain and providing education regarding opioid use are important elements of the preoperative discussion with the patient, and may reduce postoperative opioid use. As an example, in a single center trial including 48 patients who underwent CD, patients who were randomly assigned to watch an educational video on postoperative pain management used less opioids in the 14 days after discharge (oxycodone 5 mg pills, median 1.5 [range 0 to 20] versus median 10 [range 0 to 24]) with similar pain scores and satisfaction with pain control [7]. The video included expected pain trajectory after CD, optimal use of nonopioid analgesics, tapering and disposal of opioids, and other aspects of postpartum care. (See 'Opioid use after discharge' below.)

●Goals for post-CD analgesia – The goals for effective post-CD analgesia include the following, which are interrelated:

•Allow maternal bonding with her neonate

•Facilitate postoperative mobilization to reduce the risk of thromboembolism

•Preserve the ability for the mother to care for her infant

•Minimize opioid use

•Allow safe breastfeeding, with minimal transfer of analgesics to the neonate (see 'Breastfeeding considerations' below)

These goals are consistent with the components of enhanced recovery protocols for CD that are increasingly used at many institutions and with the Enhanced Recovery after Cesarean consensus statement from the Society for Obstetric Anesthesia and Perinatology [8].

Consistent with the multidimensional goals for post-CD analgesia, an Obstetric Quality of Recovery Score was developed in 2019 and validated for patients who undergo elective and nonelective CDs [9,10]. The score consists of 11 items in domains of function, pain, and other aspects of patient comfort. This score can be used to assess changes in analgesic protocols.

OUR APPROACH — Our approach to analgesia after CD is presented here. The individual components we use are discussed below. (See 'Options for post-cesarean delivery pain control' below.)

Multimodal analgesia for all patients — We use multimodal, opioid-sparing analgesia for all patients. Multimodal analgesia involves the use of two or more drug classes or techniques that employ different mechanisms of action. This strategy improves analgesia through the additive or synergistic effects of the various components, allows the use of lower analgesic doses, and reduces the incidence and severity of side effects.

Patients who receive neuraxial anesthesia — Our protocol for patients who receive neuraxial anesthesia for CD is as follows. Doses are shown in a table (table 1) and discussed below. (See 'Options for post-cesarean delivery pain control' below.)

●Neuraxial morphine or hydromorphone

●Regularly scheduled oral or intravenous (IV) acetaminophen

●Regularly scheduled oral or IV nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen or ketorolac)

●As-needed oxycodone

Patients who receive general anesthesia — For patients who receive general anesthesia (eg, urgency or contraindication to neuraxial anesthesia) or neuraxial anesthesia without long-acting neuraxial opioids (eg, drug or monitoring unavailable), our approach is as follows. Doses are shown in a table (table 1) and discussed below. (See 'Options for post-cesarean delivery pain control' below.)

●Regularly scheduled oral or IV acetaminophen

●Regularly scheduled oral or IV NSAIDs (eg, ibuprofen or ketorolac)

●Bilateral peripheral nerve block (eg, transversus abdominis plane [TAP] or quadratus lumborum [QL])

●IV patient-controlled analgesia (PCA) with morphine or hydromorphone, continued for up to 24 hours, then transitioned to oral opioids by postoperative day 1

A reasonable alternative to PCA is to start oral opioids immediately postoperatively, with IV opioids available for breakthrough pain.

Severe or ongoing pain — We assess all patients who undergo general anesthesia the day after surgery (or before then if necessary), for adequacy of analgesia and side effects of the pain control regimen. We assess patients who receive long-acting neuraxial opioids on postoperative day 2 (or before then if necessary). For severe or ongoing pain, options include IV opioids (by intermittent bolus or PCA), bilateral TAP or QL blocks, and/or oral gabapentin for select patients. For patients who receive gabapentin, enhanced monitoring for sedation and respiration may be required for the mother and for breastfed neonates. (See 'Adjuvant analgesics' below.)

OPTIONS FOR POST-CESAREAN DELIVERY PAIN CONTROL

Acetaminophen — Acetaminophen is a key component of multimodal, opioid-sparing post-CD analgesia, due to its favorable side effect profile and apparent effectiveness when administered along with nonsteroidal anti-inflammatory drugs (NSAIDs) and neuraxial opioids [11]. For maximal efficacy, acetaminophen should be administered on a regularly scheduled basis around the clock [12].

We avoid administration of combined opioid/acetaminophen preparations (eg, oxycodone/acetaminophen), to allow scheduled administration of acetaminophen, and as-needed administration of opioid. Separate dosing reduces the likelihood of exceeding the maximum recommended daily dose of acetaminophen and may reduce the total daily dose of opioid.

Evidence of efficacy of acetaminophen for post-CD analgesia is conflicting depending on the study design and outcomes evaluated. In one trial of 133 patients who underwent elective CD and received intrathecal morphine, patients were randomly assigned to receive acetaminophen 1 g intravenous (IV) every eight hours postoperatively, in addition to as-needed NSAIDs and opioids [13]. Postoperative opioid consumption was reduced in patients who received acetaminophen (mean oxycodone dose 47 versus 65 mg), whereas pain scores and opioid-related side effects were similar in the two groups. In another trial 140 patients who underwent elective CD with neuraxial opioids were randomly assigned to receive scheduled IV, oral, or no acetaminophen during the first 24 hours postoperatively, in addition to regularly scheduled ketorolac [14]. There was a statistically significant but likely clinically irrelevant decrease in opioid consumption in the first 24 hours in patients who received acetaminophen. Opioid consumption and pain scores were similar in patients who received IV or oral acetaminophen. The primary outcome in this study was opioid consumption at 24 hours, when intrathecal morphine was likely to have been still in effect.

●Dose: Dose and preparation of acetaminophen varies depending on formulary and workflow issues. We use the following dosing regimen:

•1 g IV during surgical closure.

•Starting six hours after the intraoperative dose, 650 mg orally (or IV for patients who are not able to take oral medication) every six hours, or starting eight hours after the intraoperative dose 1000 mg orally every eight hours for 48 to 72 hours postoperatively, maximum 3 g/day. The authors prefer every eight hour dosing to minimize patient interruptions, particularly during sleep.

Nonsteroidal anti-inflammatory drugs — We administer NSAIDs on a scheduled round-the-clock basis after CD for all patients without contraindications; absolute contraindications to NSAIDs (eg, allergies) are rare. We routinely administer NSAIDs for 48 hours after CD, including in patients with preeclampsia and/or hypertension, and avoid NSAIDs for patients with thrombocytopenia or other risk factors for severe bleeding.

●Efficacy – When administered as part of multimodal postoperative pain control strategy, NSAIDs have been shown to reduce pain and opioid consumption. A 2016 meta-analysis of 22 randomized trials including 1300 patients who underwent CD found that the use of NSAIDs reduced pain scores at 12 and 24 hours, reduced opioid consumption, and produced less sedation, without a difference in nausea and vomiting [15]. No data were provided for the type of anesthesia or use of neuraxial opioids in this study.

For maximal efficacy, NSAIDs should be administered on a scheduled rather than as-needed basis [16].

●Adverse effects

•Hypertension – In doses adequate to reduce postoperative pain, NSAIDs can increase blood pressure to a variable degree in both normotensive and hypertensive nonpregnant patients (see "NSAIDs and acetaminophen: Effects on blood pressure and hypertension"). Nonetheless, a 2020 Practice Bulletin from the American Congress of Obstetricians and Gynecologists recommends the use of NSAIDs preferentially over opioids for postpartum pain in patients with hypertensive disorders, including preeclampsia [17]. Several studies of the use of NSAIDs in patients with preeclampsia have found no association between NSAIDs and postpartum blood pressure elevation or other adverse effects [18-21]. (See "Anesthesia for the patient with preeclampsia", section on 'Postoperative pain control'.)

•Effects on platelet function – Nonselective NSAIDs inhibit platelet function and should be avoided in patients with preexisting qualitative or quantitative platelet defects. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Antiplatelet effects'.)

Prospective studies in other surgical specialties have shown that intraoperative ketorolac does not increase estimated blood loss [22]. While evidence is lacking in the obstetric population, nonselective NSAIDs are widely used as standard practice for post-CD analgesia. Cyclooxygenase 2 (COX-2)-specific inhibitors have little or no effect on platelet function in adults and may theoretically be preferable to nonselective NSAIDs for patients at increased risk of bleeding at or after CD [23,24] (see "Overview of COX-2 selective NSAIDs", section on 'Lack of platelet inhibition and use during anticoagulation'). However, efficacy of COX-2 inhibitors for post-CD analgesia has been questioned. In one small trial, 48 patients who underwent spinal anesthesia with intrathecal morphine were randomly assigned to receive scheduled valdecoxib (no longer available in the United States) 20 mg orally every 12 hours for 72 hours after surgery, versus placebo [23]. Postoperative analgesic consumption and pain at rest and with activity were similar in the two groups.

•Effects on the neonate – The transfer of NSAIDs to breast milk is low and administration of NSAIDs to women who breastfeed is generally safe, particularly in the first 24 to 72 hours postpartum when low volumes of breast milk are produced [25,26]. However, NSAIDs (including COX-2 inhibitors) should be considered carefully for breastfeeding mothers of infants with ductal-dependent cardiac lesions [27]. COX-2 inhibitors may theoretically be preferred for mothers of infants with thrombocytopenia or platelet dysfunction, but data are limited.

●Selection of NSAID – The selection of the specific NSAID should be based on hospital formulary availability, breastfeeding safety data, and the patient’s oral intake status. There is no literature comparing the relative efficacy of various nonselective NSAIDs, or comparing the efficacy of nonselective NSAIDs with selective COX-2 inhibitors [28]. IV ketorolac and oral ibuprofen are probably the most commonly used preparations in the United States, though other NSAIDs (eg, naproxen and diclofenac) are reasonable choices and have been studied to some extent in obstetric patients.

COX-2 inhibitors have not been widely used, due to questionable efficacy for post-CD analgesia [23,24] and concerns about potential increased risk of cardiovascular and thrombotic events with some COX-2 inhibitors, given the increased risk of venous thromboembolism in the postpartum period.

A variety of NSAID dosing regimens are used for post-CD analgesia.

●Doses

•Ketorolac – 15 to 30 mg IV during surgery after hemostasis is confirmed; for patients who are unable to take oral medication, 15 mg IV every six to eight hours postoperatively starting six hours after the intraoperative dose.

There may be no benefit to using higher dose ketorolac. In a single institution retrospective study including approximately 1300 patients who underwent CD with multimodal analgesia consisting of neuraxial morphine, rectal acetaminophen and IV ketorolac, opioid use at six hours after surgery was similar in patients who received 15 mg ketorolac IV versus 30 mg IV [29].

•Ibuprofen – 600 mg orally every six hours or 800 mg every eight hours for 48 to 72 hours postoperatively, starting six to eight hours after an intraoperative dose of ketorolac.

•Naproxen – 500 mg orally every 12 hours.

•Celecoxib – 200 to 400 mg orally every 12 hours.

Neuraxial opioids — For patients who receive neuraxial anesthesia for CD, we suggest using long-acting (hydrophilic) neuraxial opioids, rather than systemic opioids, as the basis for a multimodal, postoperative analgesic strategy; this has become standard practice in many institutions. A preservative-free hydrophilic opioid (morphine or hydromorphone) is administered as a single injection as part of the drug solution used for spinal anesthesia or as a single epidural dose during epidural anesthesia. Epidural morphine or hydromorphone is usually administered after delivery of the neonate to eliminate the chance of transfer of drug to the fetus. Neuraxial lipophilic opioid (fentanyl or sufentanil) is usually administered intraoperatively to enhance surgical anesthesia and provide postoperative analgesia prior to the peak effect of morphine or hydromorphone.

Benefits and efficacy — When used along with acetaminophen and NSAIDs, neuraxial opioids provide analgesia for approximately 24 hours after surgery, while minimizing the need for systemic opioids. The single injection technique eliminates the need for the catheter and pump that would be required for continuous epidural analgesia or IV patient-controlled analgesia (PCA), thereby facilitating patient mobilization. Compared with systemic opioids after CD, neuraxial opioids are associated with improved patient satisfaction, lower pain scores, and increased time to first request of a rescue analgesic, though they increase the incidence of pruritus and nausea [30]. Neuraxial opioids have the added benefit of a lower total maternal dose to achieve similar analgesia, compared with systemic opioid, which decreases opioid exposure to a breastfeeding neonate.

The literature comparing the efficacy of neuraxial opioids with systemic opioids is limited. Most published studies were performed before the use of multimodal analgesia and many used doses of neuraxial opioid in excess of those used in current practice.

●A 2010 meta-analysis of 10 small randomized trials (total 442 patients) that compared various doses of epidural morphine with systemic morphine or placebo found that epidural morphine increased the time to first request of rescue analgesia in a dose dependent manner [30]. Epidural morphine increased postoperative nausea (24 versus 16 percent), and increased the risk of pruritus (35 versus 25 percent), compared with systemic opioids; neither outcome was correlated with dose, though the number of patients may have been too low to show a difference. In this meta-analysis, most patients who received epidural morphine received between 4 and 8 mg, which is higher than the recommended dose (1.5 to 3 mg).

●In a trial that evaluated intrathecal morphine doses for post-CD analgesia, 108 parturients were randomly assigned to receive either placebo or one of eight doses of intrathecal morphine ranging from 0.025 mg to 0.5 mg [31]. PCA morphine use in the first 24 hours was lower in patients who received ≥0.075 mg intrathecal morphine, compared with placebo, and was similar in patients who received any dose ≥0.075 mg. There was a dose-related increase in pruritus with intrathecal morphine, but the risk of nausea and vomiting was similar in patients who received intrathecal morphine and those who did not.

Lipophilic opioids (fentanyl and sufentanil) — Lipophilic neuraxial opioids (eg, fentanyl or sufentanil) have rapid onset, and are commonly added to neuraxial local anesthetics (LA) primarily to improve intraoperative analgesia. They may provide analgesia for several hours after administration, before the peak effect of neuraxial morphine occurs, though the range of duration of analgesia is wide. (See "Anesthesia for cesarean delivery", section on 'Epidural drugs for CD' and "Anesthesia for cesarean delivery", section on 'Spinal drugs for CD'.)

Hydrophilic opioids (morphine and hydromorphone) — Morphine is the hydrophilic opioid that is best studied for neuraxial administration and is most commonly used in the United States. If morphine is unavailable, hydromorphone is a reasonable alternative. The side effect profile of the two drugs at equivalent doses is similar [32].

Preservative-free preparations must be used for neuraxial administration.

Morphine — The optimal doses of intrathecal and epidural morphine represent a balance between analgesia and side effects. Both intrathecal and epidural morphine have ceiling effects for analgesic doses, whereas side effects are primarily dose-related. (See 'Side effects and complications' below.)

Delayed, clinically significant respiratory depression is extremely rare in the parturient receiving a low dose of neuraxial morphine. However, a protocol for monitoring for respiratory depression should be in place for all patients who receive neuraxial opioids. In settings in which postoperative monitoring for respiratory depression is not possible, ultra-low doses of 50 mcg intrathecal or 1 mg epidural morphine may be safer alternatives [33]. Respiratory depression and monitoring after neuraxial opioids are discussed below. (See 'Side effects and complications' below.)

●Intrathecal versus epidural morphine – The quality of analgesia and incidence of side effects of intrathecal morphine are similar to epidural administration at clinically relevant doses [34,35]. Onset of analgesia is faster with intrathecal administration, and intrathecal morphine results in lower systemic opioid levels than epidural administration.

The choice of neuraxial route of administration is usually dictated by the neuraxial anesthetic performed (ie, spinal or epidural). For patients who receive combined spinal epidural anesthesia, the spinal route of opioid administration is preferred for because a lower opioid dose is required.

●Intrathecal morphine

•Dose – 75 to 150 mcg.

Doses above 150 mcg do not improve pain scores in the first 24 hours after CD [36]. Higher doses of intrathecal morphine increase the duration of analgesia, but also increase side effects. In a 2016 meta-analysis of 11 randomized trials (480 patients) that compared low dose (50 to 100 mcg) to high dose (>100 to 250 mcg) intrathecal morphine, time to first request for analgesia was longer after high dose morphine (mean difference 4.5 hours, 95% CI 1.85-7.13 hours) [37]. Pain scores at 12 and 24 hours were similar between groups; pruritus and nausea and vomiting were increased in the high dose groups. In a subsequent randomized trial including 144 patients who received neuraxial morphine and IV ketorolac during CD, pain scores, morphine consumption, and nausea were similar in patients who received 50, 100, or 150 mcg intrathecal morphine [38]. Pruritus was increased in patients who received higher doses, but there was no difference in the need for pruritus treatment.

•Duration of action (time to first request for rescue analgesia) – 10 to 27 hours for doses ≤100 mcg, 14 to 40 hours for doses >100 mcg [37].

●Epidural morphine

•Dose – 1.5 to 3 mg.

An analgesic ceiling is reached at 3.75 mg of epidural morphine [39] and doses greater than 2 to 3 mg may increase side effects without further augmentation of analgesia. Even lower doses may be effective when epidural morphine is administered along with multimodal analgesics. In one study of 90 parturients who received epidural morphine during anesthesia for CD along with postoperative scheduled ketorolac and acetaminophen, 1.5 mg epidural morphine provided noninferior analgesia compared with 3 mg, with lower incidence of moderate or severe pruritus at 6 and 12 hours, less nausea and vomiting, with similar 24 hour opioid consumption, pain scores, and patient satisfaction [40].

•Duration of action (time to first request for rescue analgesia) – Mean 19 hours, range 5 to 30 hours.

In a 2010 systematic review including 10 randomized trials of epidural morphine (1 to 8 mg) versus systemic opioids for post-CD analgesia the mean time to first request for supplementary analgesia after epidural morphine was 19 hours, with a range of 5.4 to 29.2 hours [30].

Hydromorphone — Because hydromorphone is less hydrophilic than morphine, onset of action is faster and the duration of action should theoretically be shorter if neuraxial hydromorphone is used. However, studies that have compared the duration of action of neuraxial morphine versus hydromorphone have been conflicting; differences may relate to the heterogeneous doses that were used [41,42]. In a randomized trial that compared what were thought to be equipotent doses of intrathecal morphine versus intrathecal hydromorphone (ie, 150 mcg morphine, 75 mcg hydromorphone), median pain scores at 24 hours, opioid consumption, and the incidence of side effects were similar between groups [32]. The median time to first request for supplemental opioid was 5.4 hours for hydromorphone, compared with 12.1 hours for morphine. This difference was statistically insignificant but may be clinically relevant.

●Intrathecal

•Dose – 75 mcg [43]

•Duration of action (time to first request for rescue analgesia) – 5 to 15 hours [32,41]

●Epidural [42,44,45]

•Dose – 0.4 to 1 mg

•Duration of action (time to first request for rescue analgesia) – 10 to 20 hours

Diamorphine — Diamorphine is a prodrug with no intrinsic opioid activity; it is converted to active metabolites (primarily morphine) by esterases in neural tissue [46]. With its intermediate lipid solubility, neuraxial diamorphine provides a more rapid onset of analgesia, but shorter duration of action compared with morphine. Duration of analgesia is reported at 4 to 16 hours with contemporary doses of neuraxial diamorphine [47-49]. The National Institute for Health Care excellence (NICE) in the United Kingdom recommends doses of 300 to 400 mcg intrathecal or 2.5 to 5 mg epidural diamorphine. [50]. It is the most commonly used neuraxial opioid for post-cesarean analgesia in the United Kingdom; it is not available in the United States.

Side effects and complications — Side effects of neuraxial opioids can be minimized by using the lowest effective doses. Pruritus and nausea are the most common side effects of neuraxial opioids. These and other side effects are discussed separately. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics".)

●Pruritus – Pruritus is a common side effect of neuraxial opioid administration. For unclear reasons, pruritus is more likely to occur in pregnant and postpartum women than in other patient populations [51]. The incidence of pruritus after neuraxial opioid administration is dose-related; at doses used for post-CD analgesia, pruritus occurs in 50 to 80 percent of patients [37].

The etiology of neuraxial opioid-induced pruritus is unclear, but it is not caused by histamine release. Thus, any beneficial effect of an antihistamine is likely due to sedation.

The most effective treatment for opioid-induced pruritus is administration of a small dose of an opioid antagonist such as naloxone (40 to 80 mcg IV, or infusion at 0.25 to 1 mcg/kg/h IV, naltrexone (6 mg orally), or the mixed opioid agonist-antagonist nalbuphine (2.5 to 5 mg IV). Higher doses or infusion of any opioid antagonist may reverse analgesia. Practice for treatment of neuraxial opioid induced pruritus varies among the contributors to this topic. The authors administer nalbuphine 2.5 mg IV for treatment of pruritus, and do not administer prophylactic medication.

Alternative causes for pruritus after neuraxial administration of morphine may exist. Though the mechanism is unclear, the use of neuraxial morphine may be associated with reactivation of latent herpes simplex virus (HSV)-1. Reported reactivation rates vary widely, ranging from 3.5 to 38 percent [52-56]. The treatment of symptomatic pruritus is unchanged in these patients, and antiviral medications may be used topically or systemically to reduce the duration or severity of infection. In patients at risk for HSV-1 reactivation, consideration may be given to using an alternative opioid with less rostral spread [57].

●Nausea and vomiting – We use combination therapy (eg, ondansetron plus dexamethasone) rather than monotherapy for prophylaxis for intraoperative and postoperative nausea and vomiting (PONV) for patients who undergo CD with neuraxial or general anesthesia. We treat PONV with a medication that has immediate rather than delayed onset, and with a drug from a different class (eg, glucocorticoid, 5-HT₃ receptor antagonist, antidopaminergic) than was used for prophylaxis if treating within six hours of the initial dose [58].

Nausea and vomiting are common after CD and etiology is likely multifactorial. Postoperative nausea and/or vomiting occurs in approximately one-third of patients who receive neuraxial opioids [30,37,59,60]. Most studies have reported that the incidence of PONV after neuraxial opioids is dose-related [31,39].

In a meta-analysis of 42 randomized trials of interventions for prevention of nausea and vomiting in women who underwent CD with neuraxial anesthesia, three classes of interventions were found to be effective for postoperative nausea and vomiting: 5HT3 receptor antagonists (eg, ondansetron 4 to 8 mg IV or granisetron 1 to 3 mg IV), dopamine antagonists (eg, metoclopramide 10 mg IV), and antihistamines (eg, dimenhydrinate 50 mg IV) [61]. In this review, dexamethasone, nalbuphine, and P6 acupressure were not found to be effective, though the available data may have been insufficient for some interventions. There were insufficient data to assess combination therapy.

There are little data on the efficacy of PONV prophylaxis with more than one agent during CD, specifically for patients who receive neuraxial opioids. However, use of multimodal prophylaxis (ie, use of more than one drug or intervention with different mechanisms of action) has become the standard of care for PONV prophylaxis for other types of surgery and is recommended as part of some enhanced recovery protocols for CD as well [62,63]. (See "Postoperative nausea and vomiting".)

●Respiratory depression – A protocol should be in place for postpartum respiratory monitoring for all patients who receive neuraxial opioids for post-CD pain control. Respiratory depression is a risk when opioids are administered by any route, including neuraxial injection. Neuraxial opioids do not increase the risk of respiratory depression compared with systemic opioids [33,64].

After a neuraxial bolus of a lipophilic opioid (eg, fentanyl or sufentanil), respiratory depression, if it occurs, would be expected within approximately two hours. Respiratory depression after neuraxial administration of hydrophilic opioid (eg, morphine or hydromorphone) is delayed, and may occur up to 12 hours after injection [65], when a patient is usually on a postpartum floor without intensive monitoring.

•Incidence of respiratory depression – Delayed, clinically significant respiratory depression is extremely rare in the parturient receiving a low dose of neuraxial morphine. The following two studies support the safety of using clinically appropriate doses of neuraxial morphine.

-In a 2018 systematic review of the reported cases of respiratory depression with contemporary doses of neuraxial morphine or diamorphine (commonly used in the United Kingdom, not available in the United States), the incidence of clinically relevant respiratory depression was between 1.08 and 1.63 per 10,000 cases [65]. Clinically significant respiratory depression was defined as the need for an airway intervention; oxygen therapy; pharmacologic therapy with respiratory stimulant or opioid antagonist; or an intervention beyond verbal stimulus to rouse the patient from sedation.

-A 2022 retrospective single-center study evaluated nearly 5000 patients who received either 100 to 450 mcg intrathecal morphine or 3 to 5 mg epidural morphine. In the 24 hours after administration, there were no Rapid Response Team events for respiratory failure. Further, no desaturation events were recorded and no patients required oxygen initiation or naloxone administration.

•Monitoring for respiratory depression – Guidelines for postoperative respiratory monitoring after neuraxial opioids from the American Society of Anesthesiologists and American Society of Regional Anesthesia may not be applicable for obstetric patients who are generally healthy and receive a single dose of intrathecal or epidural morphine. Therefore, the Society of Obstetric Anesthesia and Perinatology (SOAP) published a consensus statement on monitoring following administration of neuraxial morphine for CD analgesia [33]. Our approach to postoperative monitoring is similar to the recommendations that appear in the SOAP consensus statement, which stratify respiratory monitoring based on the dose of opioid administered and patient risk factors for respiratory depression (eg, severe obesity [body mass index >40 kg/m²], obstructive sleep apnea, cardiopulmonary or neurologic disease, chronic opioid use, hypertension, magnesium administration) (algorithm 1) [33].

-For patients without risk factors for respiratory depression who receive low dose neuraxial morphine (ie, >50 mcg and ≤0.15 mg intrathecal or >1 mg and ≤3 mg epidural), respiratory rate and sedation should be assessed every two hours for the first 12 hours after administration.

-Patients at high risk for respiratory depression or who receive higher doses of neuraxial opioids (eg, morphine >150 mcg intrathecal or >3 mg epidural) should have respiratory rate and sedation assessed every hour for the first 12 hours, and every two hours for the subsequent 12 hours, and may require more intensive monitoring (eg, pulse oximetry and capnography).

Neuraxial adjuvants — Neuraxial adjuvants such as clonidine and dexmedetomidine have been used to prolong or enhance postoperative analgesia, but there are not enough data to support routine use of these medications.

Regional anesthesia techniques — Long-acting (hydrophilic) neuraxial opioids are the cornerstone of our strategy for post-CD analgesia. We consider other regional analgesia techniques as follows:

●Proactively for patients who do not receive long-acting neuraxial opioids, or who have risk factors for difficult pain control (ie, chronic pain or opioid use, or past experience of inadequate pain control in whom an epidural catheter cannot be left in place).

●As a rescue technique for severe postoperative pain or escalating postoperative opioid requirements.

Continuous epidural analgesia — We reserve postoperative epidural infusion for patients who are at high risk for severe postoperative pain (eg, chronic opioid use, opioid use disorder). Postoperative epidural infusion is associated with decreased maternal mobility, increased nursing workload, increased cost, and interruptions in thromboprophylaxis. However, in select patients it may be beneficial.

Protocols for epidural infusion depend on the drugs chosen and are institution-specific. The regimen we use is as follows:

Epidural patient-controlled epidural analgesia (PCEA) using bupivacaine 0.1% with fentanyl 2 mcg/mL

●Continuous infusion: 10 to 15 mL/hour

●PCEA demand dose: 5 mL

●Lockout interval: 15 minutes

●One hour maximum limit: 30 to 35 mL

Peripheral nerve blocks — We use peripheral nerve blocks (eg, transversus abdominus plane block, quadratus lumborum [QL] block) for patients who do not receive neuraxial opioids, or as rescue therapy for breakthrough postoperative pain. The transversus abdominis plane (TAP) block is the most commonly used peripheral nerve block for post-CD analgesia. Literature describing the successful use of other blocks (eg, QL and erector spinae plane [ESP] blocks) is rapidly increasing.

Local anesthetic systemic toxicity (LAST) is always a concern when performing these fascial plane blocks, which require relatively large volumes of LA. Pregnant women are at increased risk of LAST. (See "Local anesthetic systemic toxicity", section on 'Patient risk factors'.)

●TAP versus QL blocks – We perform either TAP or lateral QL block based on the best ultrasound image we find when performing the block. A purported advantage of QL blocks is the possibility of providing better visceral analgesia, compared with TAP blocks. However, the literature on the relative benefits of QL versus TAP blocks for post-CD analgesia is conflicting. In one randomized trial in patients who underwent spinal anesthesia for CD without intrathecal morphine, a posterior QL block resulted in better analgesia and lower opioid consumption at 12, 24, and 48 hours, but not at four or six hours, compared with TAP block [66]. In contrast, in a network meta-analysis of 31 randomized trials of TAP and QL blocks for post-CD analgesia, both TAP and QL blocks provided superior analgesia compared with controls in patients who did not receive intrathecal morphine, and similar and minimal additional benefit in patients who did receive intrathecal morphine [67]. Of note, lower extremity weakness can occur after QL, particularly with the more central approaches that involve LA administration near the lumbar plexus, such as in an anterior QL or QL3 approach [68].

●TAP block – We perform TAP blocks for patients who have not received neuraxial hydrophilic opioid or for rescue analgesia [69] for patients who have breakthrough pain postoperatively. We limit the dose of LA for TAP block to 20 mL of 0.25% bupivacaine or 0.2% ropivacaine per side to minimize the risk of LAST. There is no analgesic benefit to higher doses for post-CD analgesia [70]. When used for rescue analgesia, we perform TAP blocks in the patient room, with pulse oximetry and blood pressure monitoring.

Several studies have compared TAP blocks with intrathecal morphine for postcesarean pain management. TAP blocks are associated with fewer side effects such as nausea, vomiting, and pruritus, but the analgesia provided is inferior, with higher pain scores and higher opioid consumption for 24 hours postoperatively [71-74]. Multiple meta-analyses have failed to demonstrate any additional analgesic benefit from TAP block for patients who have received neuraxial hydrophilic opioid (eg, intrathecal morphine) [75-77].

Where liposomal bupivacaine is available, its use may increase the efficacy of TAP block. A 2020 multicenter randomized trial reported lower total opioid consumption through the first 72 hours postoperatively in patients who received TAP blocks with bupivacaine 50 mg plus liposomal bupivacaine 266 mg, compared with bupivacaine 50 mg alone (30 mL each side, 60 mL total), in addition to intrathecal morphine and postoperative acetaminophen and ibuprofen [78].

Adjuncts such as opioids, clonidine, dexmedetomidine, and dexamethasone have all been described for TAP blocks after CD, but evidence is insufficient to recommend their routine use at this time [79-81]. (See "Overview of peripheral nerve blocks", section on 'Adjuvants'.)

TAP block technique is discussed separately. (See "Transversus abdominis plane (TAP) blocks procedure guide".)

●QL block – Several variations of the ultrasound-guided QL block have been described for post-CD pain (ie, anterior QL, lateral QL, posterior QL), which are distinguished by their location relative to the quadratus lumborum muscle [66,82,83]. QL block technique is discussed separately. (See "Quadratus lumborum block procedure guide".)

In patients who have not received intrathecal morphine, QL blocks are associated with reduced opioid usage when compared with controls [82-85].

Of note, QL blocks can result in lower extremity weakness, particularly for the variants that involve more central injection of LA (ie, anterior QL) [68].

●Others – The use of other nerve blocks (eg, ESP, ilioinguinal iliohypogastric [IIH], transversalis fascia plane, QL blocks) has been described and may be beneficial for patients who do not receive neuraxial morphine. Available literature is limited.

ESP blocks may reduce analgesic use and prolong analgesia after cesarean delivery [86], and may provide similar analgesia and quality of recovery compared with QL blocks [87]. Dermatomal coverage from ESP blocks depends on the volume and dose of local anesthetic administered. Blocks placed at low thoracic levels (eg, T9 to 10) should provide appropriate coverage for low transverse incision for CD. (See "Erector spinae plane block procedure guide".)

In a randomized trial of 140 patients who underwent elective CD with either ESP block or intrathecal morphine 100 mcg for analgesia, opioid consumption was lower and time to first request for additional analgesia was longer in the ESP group, whereas pain scores and patient satisfaction were similar [88]. Patients received IV ketorolac during surgery, and scheduled paracetamol (acetaminophen) for the first 24 hours, but no further postoperative NSAIDs. The authors proposed that the apparent superiority of ESP to other peripheral nerve blocks could be due to improved visceral coverage, but available literature remains limited.

IIH blocks may reduce postoperative opioid use for patients who do not receive neuraxial morphine [89]. Studies that have evaluated the benefits of adding IIH blocks to neuraxial morphine have been conflicting [90,91].

Wound infiltration — LA wound infiltration or infusion may be of modest benefit for patients who do not receive neuraxial opioids, but not for patients who do receive them. For wound infusion, protocols vary. A typical procedure would involve placement of a multi-orifice catheter below the fascia at the time of wound closure, followed by a bolus of LA (eg, 15 mL 0.2% ropivacaine) after closure, and an infusion of the same LA solution at 10 mL/hour for 30 hours [92]. The authors of this topic use a more concentrated solution at a lower rate (eg, 0.5% ropivacaine or bupivacaine at 4 to 5 mL/hour), primarily to minimize leakage of LA from the wound. Preoperative infiltration of LAs has not been shown to decrease post-CD pain when compared with infiltration at the time of wound closure [93,94].

●A 2016 meta-analysis of 21 randomized trials that evaluated wound infiltration with LA for post-CD analgesia (11 trials of LA infusion, 10 trials of single injection) found decreased opioid consumption at 24 hours with wound infiltration (mean difference -9.7 mg morphine equivalents, 95% CI -14.8 to -4.5) [95]. There was a statistically significant but likely clinically irrelevant decrease in pain scores at rest with wound infiltration and opioid-related side effects were similar between groups. When catheter techniques were used, subfascial placement was more efficacious; indirect comparison did not demonstrate benefit of use of a catheter over single-shot techniques. In patients who received intrathecal morphine, the opioid-sparing benefits of LA wound infiltration were lost.

●A 2020 systematic review and meta-analysis of 42 studies compared TAP block with wound infiltration and wound catheters following CD [96]. The analysis demonstrated that in the absence of neuraxial opioids, any of the three local anesthetic techniques provided some benefit in the first 24 hours after surgery. There was not a significant difference in 24 hour opioid consumption among the three techniques. The quality of evidence for most included studies was moderate. A 2022 meta-analysis of seven trials that compared single injection wound infiltration with TAP block found similar results [97].

Intraperitoneal local anesthetic — Intraperitoneal administration of LA (such as 20 mL 2% lidocaine or up to 30 mL 1 to 3% chloroprocaine) may improve early postoperative pain scores at two hours after surgery [98], with potentially longer benefit in patients who undergo peritoneal closure [98,99], but studies are small and do not warrant routine use.

LAST may be a concern if intraperitoneal LA is used along with other routes of administration. However, a small study evaluating plasma concentrations after administration of up to 1200 mg chloroprocaine showed reassuring levels without clinical signs of LAST [100].

Systemic opioids — The need for opioids after CD varies widely among patients, with some patients requiring opioids even within the first 24 hours after surgery, when neuraxial opioids should still be in effect. One goal for the use of opioids should be to avoid overprescription and prescription for patients who do not need them. In reports of contemporary protocols for post-CD pain management including neuraxial opioids, acetaminophen and NSAIDs, between 45 and 79 percent of patients required opioids at some point during hospitalization [6,101]. In one study, approximately one in eight patients required IV opioids [101].

Oral versus IV opioids — We suggest using oral opioids rather than intravenous (IV) opioids in patients who tolerate oral intake. One study comparing oral opioids versus IV PCA opioids after CD demonstrated improved analgesia with less nausea and drowsiness in the oral opioid group [102].

Choice of opioid

●Oral opioids – Codeine and tramadol should be avoided for post-CD analgesia, due to concerns that the use of these medications in CYP2D6 ultra-metabolizers can result in excessive amounts of morphine in maternal breast milk, with potential for neonatal overdose and respiratory depression. We agree with a consensus statement from the Society for Obstetric Anesthesia and Perinatology that oral oxycodone or hydrocodone are the preferred rescue opioids for breakthrough pain after CD in breastfeeding women.

Single-medication (eg, oxycodone) pills are preferred to combination acetaminophen-opioid (eg, oxycodone-acetaminophen) pills, with acetaminophen scheduled separately around the clock [103]. (See 'Acetaminophen' above.)

●IV opioids – The choice between IV nurse-administered opioids and IV PCA is often based on institutional resources and staffing. For PCA use, morphine and hydromorphone provide effective analgesia with high levels of patient satisfaction. Hydromorphone does not have active metabolites and may be preferable in breastfeeding women [103,104]. Morphine has a long history of safe use and requires fewer supplementary boluses or alterations to PCA settings compared with fentanyl (table 2) [105].

Reducing postoperative opioid use — Efforts to reduce the doses of opioids prescribed after CD both in the hospital and after discharge are increasing (see 'Opioid use after discharge' below). Several studies have reported equivalent analgesia and reduced morphine milligram equivalent consumption in hospital when relatively low doses of oral opioids were used for post-CD analgesia, compared with higher doses that had traditionally been used. Examples of reported strategies for reducing postoperative opioid consumption in patients who received neuraxial opioid based multimodal analgesia include the following:

●In one single institution study, a quality improvement protocol that eliminated routine opioid orders after CD along with implementing reduced dose guidelines for orders when opioids were necessary, resulted in reduction in the number of patients who received any postoperative opioids in the hospital (45 percent versus 68 percent before the intervention), with similar pain scores and patient satisfaction before and after the intervention [6].

●One study evaluated opioid use before and after implementation of a protocol that split the dose of prescribed as-needed opioid in half, with the first half administered on patient request, and the second half administered one hour later as needed [101]. The split dose administration was associated with 56 percent reduction in opioid use in the first 48 hours (median 4.4 versus 10.0 mg morphine equivalents), with a clinically insignificant increase in average pain score (mean difference -0.2 on 1 to 10 visual analog scale, 95% CI -0.3 to -0.04).

Adjuvant analgesics — Given the adverse effects associated with opioids, as well as the potential for persistent opioid use, there is much interest in identifying effective nonopioid adjuncts (gabapentin, dexamethasone, ketamine, alpha 2 agonists). Existing literature on the analgesic benefits of these agents is inconclusive.

●Gabapentinoids – We do not suggest routine use of gabapentin for post-CD analgesia, due to lack of evidence of benefit, and the risk of sedation [106-108] (see "Nonopioid pharmacotherapy for acute pain in adults", section on 'Gabapentinoids'). We offer gabapentin as a rescue analgesic for select patients with severe post-CD pain or escalating opioid requirements. If used, postdelivery administration is preferred due to the high umbilical vein to maternal vein ratio, and potential breast milk transfer may warrant increased monitoring for neonatal sedation [109,110]. Enhanced monitoring may also be required for the mother if gabapentin is administered along with other sedatives or respiratory depressants.

Gabapentin may have a role in personalized analgesic management for patients at risk for severe pain, though further evidence is needed to define appropriate use [3,4].

●Dexamethasone – The beneficial effects of dexamethasone for postoperative pain are unclear and likely apply to specific types of procedures. A retrospective study and a randomized trial found no analgesic benefit to adding dexamethasone to multimodal post-CD analgesia that included neuraxial morphine [111,112]. In contrast, in a 2022 meta-analysis of randomized trials that evaluated dexamethasone for post CD analgesia, dexamethasone resulted in increased time to first rescue analgesia (5 trials, mean difference 2.64 hours, 95% CI 1.8–3.4) and modestly lower pain scores at rest in the first 4 to 6 hours (10 trials, mean difference -1.29, 95% CI -1.8 to -0.7 on a 0 to 10 scale) [113]. Most patients received neuraxial morphine. Adverse events were not well reported and the quality of evidence low.

The efficacy of dexamethasone may be dose dependent. Higher doses are necessary (eg, >0.1 mg/kg) for analgesia than for prevention of postoperative nausea and vomiting. This is discussed separately. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Dosing'.)

The 2023 guideline for elective CD from the Procedure Specific Pain Management (PROSPECT) group recommended intraoperative dexamethasone as part of multimodal perioperative analgesia [114].

●Ketamine – We do not routinely administer ketamine as part of multimodal post-CD analgesia. The literature on the use of ketamine in this setting is inconclusive. If ketamine has beneficial effects, they are modest, and it is not clear which patient populations might benefit for post-CD analgesia. A meta-analysis [115] of 12 randomized trials that evaluated the use of ketamine during CD found a small reduction in opioid use versus placebo when spinal anesthesia (with or without spinal opioid) was used, but no difference in patients who received general anesthesia [115]. Though individual studies [116] have reported increased incidence of restlessness or drowsiness with subanesthetic doses of ketamine during CD, the meta-analysis reported no significant differences in rates of nausea, vomiting, pruritus, or neurologic symptoms including psychomimetic effects between groups [115].

●Alpha-2 agonists – Administration of neuraxial clonidine may enhance analgesia after CD but is associated with increased intraoperative hypotension and sedation. Routine use is not warranted based on current data, though it may be appropriate in some patients who are expected to have difficulty with pain control, after consideration of possible side effects. A 2018 meta-analysis of 18 randomized trials that evaluated neuraxial administration of clonidine found that clonidine modestly reduced 24 hour morphine consumption and prolonged the time to first request for analgesia, but increased the incidence of intraoperative hypotension and sedation [117]. Neonatal outcomes were not adversely affected.

Limited literature does not support the routine use of IV or intrathecal dexmedetomidine for post-CD analgesia [118,119].

Complementary therapies — Complementary therapies are increasingly suggested for improving analgesia without the use of opioids. Available literature regarding the use of complementary therapies for post CD analgesia is of low quality and efficacy is unclear [120].

BREASTFEEDING CONSIDERATIONS — Supporting and facilitating safe and successful breastfeeding are important goals for post-CD analgesia. It is safe to continue breastfeeding a healthy full-term infant while the mother receives analgesics and/or anesthetics, as long as she is awake, alert, able to hold her infant, and provided that high risk drugs are avoided (ie, tramadol, codeine, meperidine) [121,122]. (See 'Choice of opioid' above and "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Safety of common analgesics in breastfeeding individuals'.)

The total amount of transfer of any drug to breast milk is small in the fist few days after delivery, as the volume of colostrum is very low.

The lowest effective dose of any opioid should be used to minimize breast milk transfer and neonatal sedation. Neuraxial opioids are preferred to other routes of administration when possible, to minimize maternal blood and breast milk levels [123]. Clinically relevant doses of neuraxial morphine for CD are safe for patients intending to breastfeed [124].

If opioids are required, breastfeeding should ideally happen just prior to opioid administration, at the trough of the drug concentration, since drug concentration in breast milk rises and falls in parallel with maternal plasma levels [123].

Highly protein-bound medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) and local anesthetics transfer less readily into breast milk than opioids and other lipophilic drugs [125]. Breastfeeding concerns for the use of NSAIDs is discussed above. (See 'Nonsteroidal anti-inflammatory drugs' above.)

The Lactmed database is a useful resource for clinicians seeking information about medication safety for breastfeeding patients.

ANALGESIA AFTER DISCHARGE — Pain after CD typically resolves over the course of approximately three weeks, with significant variability among patients. In a single institution prospective study including 35 patients who underwent CD, all of whom received an opioid prescription at discharge, the median time to opioid cessation was nine days (interquartile range [IQR] 5 to 12 days), median time to stopping all analgesics was 16 days (IQR 11 to 24 days), and median time to resolution of pain was 21 days (IQR 14 to 27 days) [126].

Opioid use after discharge — Not all women need opioids after discharge, and opioid prescription may not improve postpartum pain. In one trial of 170 patients who underwent CD, patients were randomly assigned to receive prescriptions at discharge for hydrocodone/acetaminophen and ibuprofen or acetaminophen and ibuprofen without hydrocodone, with all analgesics consumed on an as-needed basis [127]. Mean pain score at two to four weeks was lower in the nonopioid group (12.3 ± 19.5 versus 15.9 ± 20.4, on a 0 to 100 scale), with similar patient satisfaction.

Among patients who do use opioids after CD, the majority use opioids for less than two weeks [126,128] and consume a median of 15 to 20 opioid tablets after discharge [129,130]. Most women are prescribed opioids in excess of the amount consumed, with 75 to 84 percent of patients reporting unused tablets after opioid cessation; the majority store the unused opioids in an unlocked location and/or do not dispose of them correctly [128,129]. Reported rates of persistent opioid use after CD in opioid naïve patients are from approximately 1:1000 to 1:50 [131]. Thus strategies to reduce postcesarean opioid prescriptions are warranted. In some institutions, protocols for post-discharge opioid prescription have been instituted [6,130,132,133]. Examples of opioid reduction strategies are as follows:

●Similar to the approach that may be used for patients who are postop from other surgery, the amount of opioid used in the hospital after CD can be used to predict postop needs, and reduce unnecessary postoperative opioid prescription [6,132]. In one single institution study, a new protocol that included basing postop prescription on in hospital postoperative opioid use was associated with a reduced percentage of women who were discharged with an opioid prescription (40 versus 91 percent), without a change in pain scores or patient satisfaction [6].

●In another study, use of tablet computer based shared decision making was associated with a 50 percent decrease in the number of opioids prescribed, without negatively impacting pain control or patient satisfaction [130].

●State laws can also impact opioid prescribing practices. Implementation of a Florida law that restricted the duration of opioid prescriptions was associated with a lower total prescribed opioid dose and a shorter prescription duration for patients after CD [134]. These changes were not associated with increased emergency department visits or an increased need for additional opioid prescriptions.

Choice of opioid for postpartum patients who are breastfeeding is discussed separately. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Safety of common analgesics in breastfeeding individuals'.)

PERSISTENT POSTOPERATIVE PAIN — Severe acute postoperative pain may be a risk factor for the development of persistent post-CD pain [135,136] and this is presumably one reason to optimize postoperative analgesia. However, literature on the efficacy of analgesic interventions for prevention of persistent pain is limited, with mixed results [135,137]. Further study is required before recommending particular interventions with the specific goal of reducing the risk of persistent pain.

Persistent scar pain after CD is often described as neuropathic in nature [138]. The reported incidence of persistent pain at 8 to 12 months after CD varies widely, from 0.3 to as high as 18 percent [135-137,139,140]. Persistent post-CD pain is associated with chronic opioid use, postpartum depression, and interference with daily activities and sleep [141].

In one retrospective cohort study of approximately 850 patients who underwent spinal anesthesia with intrathecal morphine for CD, risk factors for persistent pain for at least three months after surgery included recall of higher pain scores immediately after surgery, presence of pain at sites other than the CD wound, and non-private insurance status [136].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Obstetric anesthesia".)

SUMMARY AND RECOMMENDATIONS

●Goals – The goals for effective post-cesarean delivery (CD) analgesia are to allow maternal-neonatal bonding, facilitate postoperative mobilization and the ability for the mother to care for her infant, minimize opioid use, and allow safe breast feeding. (See 'Creating a plan for postoperative analgesia' above.)

●Our strategy – We use multimodal, opioid sparing analgesia for all patients (table 1). (See 'Multimodal analgesia for all patients' above.)

•For patients who receive neuraxial anesthesia for CD, we suggest using long acting (hydrophilic) neuraxial opioids (ie, morphine or hydromorphone), rather than systemic opioids, as the basis for a multimodal postoperative analgesic strategy (Grade 2C). In addition to neuraxial opioids, we administer regularly scheduled acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), and as needed oral oxycodone. (See 'Patients who receive neuraxial anesthesia' above.)

•For patients who receive general anesthesia or neuraxial anesthesia without long acting neuraxial opioids, we administer regularly scheduled acetaminophen and NSAIDs, and perform bilateral peripheral nerve blocks (eg, transversus abdominis plane [TAP] block or quadratus lumborum [QL] block. We also use IV patient-controlled opioid analgesia (PCA) for 24 hours, or as needed oral opioids. (See 'Patients who receive general anesthesia' above.)

•For severe or ongoing pain despite the above, we use bilateral TAP or QL blocks if not performed previously, IV opioids by intermittent bolus or PCA, and/or gabapentin in select patients with consideration for additional monitoring in the patient and the neonate if breastfeeding. (See 'Severe or ongoing pain' above.)

●Options for analgesia

•Acetaminophen is a key component of multimodal, opioid-sparing post-CD analgesia regimens due to its favorable side effect profile and apparent effectiveness. Acetaminophen should be administered on a regularly scheduled basis around the clock. (See 'Acetaminophen' above.)

•NSAIDs reduce postoperative pain and opioid consumption when administered as part of multimodal analgesia. For maximal efficacy NSAIDs should be administered on a regularly scheduled basis around the clock. (See 'Nonsteroidal anti-inflammatory drugs' above.)

•Single dose neuraxial hydrophilic opioids (eg, morphine or hydromorphone) provide analgesia for approximately 24 hours after surgery when used along with acetaminophen and NSAIDs, and minimize the need for systemic opioids. The single injection technique eliminates the need for the catheter and pump that would be required for continuous epidural analgesia or patient-controlled intravenous (IV) analgesia, thereby facilitating patient mobilization. (See 'Neuraxial opioids' above.)

Side effects of neuraxial opioids (primarily nausea and pruritus) can be minimized by using the lowest effective dose. Delayed respiratory depression is extremely rare in patients who receive a low dose of neuraxial opioid for analgesia after CD. However, a monitoring protocol should be in place for patients who receive neuraxial opioids, based on the dose administered and patient risk factors. (algorithm 1). (See 'Side effects and complications' above.)

•Peripheral nerve blocks (eg, TAP, QL, or erector spinae plane [ESP] blocks) are a beneficial primary analgesic option for patients who do not receive neuraxial opioids during CD, and can be used as a rescue technique for breakthrough pain in patients who do receive neuraxial opioids. (See 'Peripheral nerve blocks' above.)

•The need for systemic opioids in hospital after CD varies widely, reported at between 45 and 80 percent of patients who receive multimodal analgesia with neuraxial opioids. Every effort should be made to avoid overprescription of opioids and prescription for patients who do not need them. (See 'Reducing postoperative opioid use' above.)

For patients who need systemic opioids for analgesia after CD, we suggest using oral opioids rather than IV opioids for patients who tolerate oral intake (Grade 2C). Oral opioids may be associated with improved analgesia and less nausea and/or drowsiness compared with IV opioids. For patients who need IV opioids, the choice between IV nurse-administered opioids and IV PCA is institution specific (table 2).

●Breastfeeding considerations – It is safe to breastfeed a healthy full-term infant while the mother receives analgesics and/or anesthetics after CD, as long as the mother is awake, alert, able to hold her infant, and provided that high risk drugs are avoided (ie, tramadol, codeine, meperidine). (See 'Breastfeeding considerations' above.)

●Analgesia after discharge

•Pain after CD typically resolves over the course of approximately three weeks, with significant variability. (See 'Analgesia after discharge' above.)

•Not all women need opioids after discharge; among those who do use opioids after CD, the majority use them for less than two weeks. A number of strategies have been used to reduce opioid prescription and better match the individual patient’s needs, including basing the prescription on in-hospital opioid use, using shared decision making, and instituting reduced dose prescription protocols. (See 'Opioid use after discharge' above.)