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Cesarean delivery (CD) is the most common surgical procedure in the world.1 Inadequate pain control can interfere with care for the neonate, negatively affects bonding and breastfeeding between mother and newborn, and is an unsatisfactory anesthetic outcome.2,3 Multimodal analgesia is an ideal approach.
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Early ambulation
Unhindered care for newborn
Minimal side effects: nausea, sedation, pruritus
Safe with breastfeeding
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Multimodal analgesia can include (Table 55-1):
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Opioid: neuraxial versus systemic
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Acetaminophen
Ketamine
Dexmedetomidine
Peripheral nerve block: quadratus lumborum (QL) or transverse abdominis plane (TAP) block
Oral gabapentin
Low thoracic epidural
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METHOD OF ADMINISTRATION
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Opioid
Neuraxial opioids: the most effective form of postoperative analgesia for CD.3 It is superior to systemic opioids after CD.
Systemic opioids: hydromorphone patient control analgesia (PCA) preferred for patients unable to receive neuraxial morphine (e.g., general anesthesia, patients with opioid use disorders).
NSAIDs
Acetaminophen
Ketamine
20 to 40 mg IV as a supplement for general anesthesia.
For chronic opioid use patient, may require ketamine infusion, dose 0.2 to 0.3 mg/kg/h postoperatively (consult acute pain service).
Dexmedetomidine
For chronic opioid use patients, consider avoiding intrathecal morphine and replacing with 10 µg intrathecal dexmedetomidine.
For intrapartum CD, may consider administer 10 to 20 µg dexmedetomidine via epidural in the patients who experienced multiple breakthrough pain during labor.
QL/TAP block
Ultrasound guided peripheral nerve blocks: 0.25% bupivacaine 15 to 20 mL on each side (limit 0.25 mg/kg bupivacaine). It covers T6-L1 nerve roots involved in lower abdominal surgeries, possibly 12 to 16 hours coverage.
Cautious use after cesarean under epidural anesthesia (local anesthetic toxicity).
Gabapentin PO
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REFERENCES
1. +
Visser
GHA, Ayres-de-Campos
D, Barnea
ER,
et al. FIGO position paper: how to stop the caesarean section epidemic.
Lancet. 2018;392(10155):1286–1287.
[PubMed: 30322563]