Pain management after elective caesarean section under neuraxial anaesthesia: an updated systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations.

Introduction Elective caesarean section is a common and painful procedure. Uncontrolled pain following caesarean section can profoundly and negatively on a wide range of patient and healthcare-centred outcomes. The aim of this systematic review was to update existing recommendations for postoperative pain management after elective caesarean section performed under neuraxial anaesthesia.Methods A systematic review using the PROcedure SPEcific Postoperative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised trials evaluating the efficacy of analgesic, anaesthetic and surgical interventions were retrieved. Systematic reviews and meta-analyses of randomised controlled trials were also reviewed. Trials evaluating pain management for emergency surgical deliveries or caesarean section performed under general anaesthesia were not included.Results Sixty-one randomised controlled trials were included. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, we recommend that clinicians administer intrathecal morphine 50-100 μg or diamorphine 300 μg pre-operatively, and paracetamol, non-steroidal anti-inflammatory drugs and dexamethasone after delivery. If a neuraxial opioid is not administered, clinicians should use one of a range of recommended fascial plane blocks; alternatively, the wound should be infiltrated with local anaesthetic. 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. The peritoneum should not be closed.Discussion An analgesic regimen to manage pain safely and effectively after elective caesarean section based on up-to-date evidence is presented. Consideration has been given to balancing analgesic efficacy and potential adverse effects. Future research should determine the optimal dose of dexamethasone and epidural long-acting opioid, establish the most effective regional analgesic technique and develop standardised outcome sets to better compare techniques.What We Did We looked at many good‐quality research studies to find the best ways to manage pain after a planned caesarean section. We only included studies where the caesarean was planned and done using spinal or epidural anaesthesia. In total, we reviewed 61 studies.Why We Did It A caesarean birth can be very painful, and poor pain control can make recovery harder for parents and babies. We wanted to update advice for doctors so they can give the safest and most effective pain relief after a planned caesarean section.What We Found Giving a small amount of strong pain medicine into the spine during the operation helps reduce pain afterwards. After the baby is born, regular pain relief with paracetamol and anti‐inflammatory medicines works well. If spinal pain medicine is not used, doctors can use numbing injections or nerve blocks to help control pain. Strong pain medicines (opioids) should be used only if needed. Using certain surgical methods can also help reduce pain and improve recovery. These findings give clear, up‐to‐date advice to help people recover more comfortably and safely after a planned caesarean section.