Example of a protocol for post-cesarean delivery pain management in hospital

Nonopioid analgesics for all patients
Acetaminophen	1 g IV intraoperative plus 650 mg every 6 hours, or 1 g every 8 hours, orally or IV, postoperative
NSAIDs	Ketorolac 15 to 30 mg IV intraoperative; for weight <50 kg, maximum dose 15 mg plus Ibuprofen 600 mg every 6 hours or 800 mg every 8 hours orally, or ketorolac 15 mg IV every 6 hours for 48 to 72 hours postoperative
Patients who have neuraxial anesthesia
Neuraxial opioid	Preservative-free opioid: Morphine 100 to 150 mcg intrathecal (preferred) or 3 mg epidural after delivery* OR Hydromorphone 50 to 75 mcg intrathecal or 0.4 to 1 mg epidural after delivery*
Oral opioid	Oxycodone 2.5 to 5 mg orally every 4 hours as needed for breakthrough pain: VNPS 1 to 4/10: 2.5 mg, repeat in 1 hour if needed^¶ VNPS >4/10: 5 mg, repeat in 1 hour if needed^¶
Patients who have general anesthesia, or neuraxial anesthesia without neuraxial opioid
Nerve block OR Wound infiltration	Bilateral TAP or QL block: 0.25% bupivacaine 20 mL per side OR 0.2% ropivacaine 20 mL per side OR Liposomal bupivacaine 1.3% 10 mL plus 0.25% aqueous bupivacaine 20 mL per side^Δ Wound infiltration: Subfascial (preferred) or subcutaneous wound catheter, 0.5% bupivacaine or ropivacaine 4 to 5 mL/hour
Opioids	IV PCA with morphine or hydromorphone for up to 24 hours, transitioned to oxycodone as above by postoperative day one: Morphine – demand dose 2 mg, lockout interval 10 minutes, without continuous (basal) infusion Hydromorphone – demand dose 0.4 mg, lockout interval 8 minutes, without continuous (basal) infusion OR Oral oxycodone as above, with bolus IV opioids available for breakthrough pain
For severe or ongoing pain, options
Rescue nerve block	Bilateral TAP or QL block as above: 0.25% bupivacaine or 0.2% ropivacaine; consider liposomal bupivacaine
Opioids	Fentanyl 25 to 50 mcg IV every 5 minutes, to maximum of 200 mcg until pain relief or if associated sedation, oxygen saturation <95%, or serious event occurs, such as hypotension (in PACU only) OR Morphine 1 to 3 mg IV every 5 minutes until pain relief or if associated sedation, oxygen saturation <95%, or serious event occurs, such as hypotension (in PACU only); if analgesia is insufficient after total approximately 20 mg, review overall pain control regimen OR Hydromorphone 0.2 to 0.5 mg IV every 5 minutes until pain relief or if associated sedation, oxygen saturation <95%, or serious event occurs, such as hypotension (in PACU only); if analgesia is insufficient after approximately 3 mg, review overall pain control regimen OR IV PCA as above
Nonopioid adjuncts	Gabapentin 200 mg orally every 8 hours for 5 doses; enhanced respiratory monitoring may be necessary

This protocol would be applicable for patients without particular risk factors for severe postoperative pain (eg, chronic pain, opioid tolerant). For further detail, refer to UpToDate content on post-cesarean delivery analgesia.

IV: intravenous; NSAIDs: nonsteroidal anti-inflammatory drugs; VNPS: verbal numerical pain score; TAP: transversus abdominus plane; QL: quadratus lumborum; PCA: patient-controlled analgesia; PACU: post-anesthesia care unit.

* For patients who have combined spinal epidural anesthesia, intrathecal morphine is preferred, rather than epidural morphine, to minimize opioid dose and systemic absorption.

¶ When nursing resources are available, the use of "split-dose" opioid order sets can reduce total opioid consumption.

Δ When liposomal bupivacaine is mixed with aqueous bupivacaine, the dose of bupivacaine must be <50% of the dose of liposomal bupivacaine. Liposomal bupivacaine should not be mixed with other local anesthetics except for aqueous bupivacaine.

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Example of a protocol for post-cesarean delivery pain management in hospital