{
  "abstract": "Postoperative Analgesia after Cesarean Section an Update Chalotte De Loecker, MD1, Eva Roofthooft, MD, PhD2, Marc Van de Velde, MD, PhD, ESRA-DRA, FESAIC3 1 Trainee, Department of Anesthesiology, UZ Leuven, Leuven, Belgium 2 Consultant Anesthetist, Department of Anesthesiology, Ziekenhuis aan de Stroom (ZAS) Sint-Augustinus and Sint-Vicentius, Antwerp, Belgium 3 Professor, Department of Cardiovascular Sciences, KULeuven and Consultant, Department of Anesthesiology, UZ Leuven, Leuven, Belgium Adress correspondence: marc.vandevelde@uzleuven.be Introduction Worldwide, the cesarean section rate continues to rise and is estimated to reach a staggering global 30% by 2030. 1 In some areas even rates peaking above 50% are expected, such as in the southern parts of the American continent.1 As a result, cesarean section is worldwide the most performed surgical intervention. Additionally, it is also the most performed intervention out of hours, exposing patients to potentially suboptimal care. Given the increasing frequency of cesarean delivery, the burden on our health care systems is increasing due to increasing cost, increasing demands on staffing and slower functional recovery. Enhanced recovery programs after cesarean section (ERAC) can reduce the impact of surgical delivery allowing more rapid recovery.2 Crucial in ERAC is effective and safe postoperative analgesia. This requires standardized, evidence-based protocols which are easy to implement during normal working hours and also out of hours when less experienced staff is present. The current narrative review describes the current procedure specific (PROSPECT) recommendations for pain relief after cesarean section.3 4Enhanced Recovery After Cesarean (ERAC) Enhanced Recovery After Surgery (ERAS) has revolutionized surgical care for patients. The seminal publication by Kehlet et al. on ERAS in laparoscopic colonic surgery in frail and elderly patients introduced a care bundle which focussed on early mobilisation, early feeding and intensified peri-operative, mulitmodal analgesia.5 Multimodal interventions in the pre-, per- and postoperative period try to control the peri-operative stress response and improve convalescense.6 ERAS guidelines have been introduced for many surgical interventions since this initial publication. The implementation of ERAS care bundles has consistently shown reduced morbidity and mortality, reduced lenght of stay and improved peri-operative outcomes.7 Therefore, implementation of ERAS for cesarean section is crucial to improve outcome after cesarean delivery. In recent years several care bundles were introduced, the so-called ERAC bundles.8 A crucial element of the care bundle is good quality postoperative analgesia minimizing opioid administration. Optimal pain relief comes with a firm protocol that is procedure specific and evidence based.9 PROSPECT has published numerous recommendations in recent years (www.postoppain.org) for a large variety of surgical interventions,10–18 using a well described methodology.19 Postoperative analgesia after Cesarean Section: PROSPECT recommendations explained The PROSPECT group has published two PROSPECT guidelines with recommendations for postoperative analgesia after cesarean. The initial guideline was published on the PROSPECT website in 2014.20 The most recent recommendation was published in 2021 including scientific evidence up to 2020.18 A short update was published in 2023.21 Currently, the group is preparing a third version of the recommendations, which will be released later in 2025. In total 325 studies were included in the two versions of the recommendation and the short update of 2023, spanning the literature up untill 2022. Based on the analysis of these papers and following a Delphi process as described in the PROSPECT methodology, a multimodal analgesia strategy is proposed. Firstly, paracetamol and non steroidal anti-inflammatory agents (NSAIDs) are recommended intraoperatively and postoperatively. Simultanuous and systematic administration is recommended intravenously or orally for at least 48–72 hours. NSAIDs are relatively contraindicated in preeclampsia, thrombocytopenia and following major obstetric hemorrhage. However, these contraindications are relative and in UZ Leuven and ZAS Antwerp, NSAIDs are given liberally also in these situations. The PROSPECT group also recommends the intravenous, intraoperative administration of 5–10 mg dexamethasone (or similar dose of glucocoticosteroid) following delivery of the baby. It has demonstrated analgesic efficacy in cesarean section,22 in many other surgical interventions.23 24 and has other beneficial effects such as prevention of postoperative nausea and vomiting (PONV).25 The use of intrathecal or epidural long-acting opioids such as morphine is recommended. It is suggested that at elective cesarean performed under spinal anesthesia, an intrathecal dose of 50–100 mcg morphine is administered. At unplanned cesarean delivery with a labor epidural catheter in place, it is suggested to administer epidural morphine in a dose of 1.5 to 3.0 mg. Recent evidence seemt to re-affirm the excellent effects of neuraxial long-acting morphine.26 However, neuraxial morphine comes with more pruritus and PONV and potentially (low risk) can cause respiratory depression up to 24 hours after injection. Therefore, careful respiration and sedation monitoring is recommended making implementation of this strategy somewhat more complex. When neuraxial morphine is not used, several regional techniques have shown to produce equivalent analgesic efficacy and opioid sparing effects.27–29 Therefore, PROSPECT recommends, as alternatives to neuraxial morphine, single shot or continuous local anesthetic wound infiltration or fascial plane blocks such as the transversus abdominis plane block (TAP) and quadratus lumborum block (QL). In the 2023 short update, also the erector spinae block (ESP) was recommended. In recent years studies have also been published supporting the transversus fascia plane block and the ilioinguinal-iliohypogastric nerve block.30 31 It must however be made clear that combining neuraxial morphine with a peripheral regional technique has no added value. Finally, PROSPECT recommends the non-closure of the peritoneum, the Joel-Cohen type of incision and the use of postoperative abdominal binders. Transcutaneuous electrical nerve stimulation (TENS) is suggested as an analgesic adjunct. Opioids should be reserved for rescue analgesia and routine use should be avoided. Implementation of the PROSPECT protocol at UZ Leuven was succesful and a 4 month audit revealed excellent levels of analgesia and highly satisfied patients32 Conclusions The strenght of the PROSPECT guidelines is the integration of a systematic review of the literature combined with a clinical evaluation of benefits and side-effects of each intervention performed by specialists from surgery and anesthesia. More importantly, the evidence and recommendations are procedure specific making the PROSPECT guidelines unique. The cesarean section guideline provides the clinician with clear guidance on what is effective and what is not. In 2025 an update will be published most likely adding more blocks to the armamentarium of the clinician.References Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Global Health 2021;6:e005671. doi:10.1136/bmjgh-2021-005671.Sultan P, Sharawi N, Blake L, Habib AS, Brookfield KF, Carvalho B. Impact of enhanced recovery after cesarean delivery on maternal outcomes: a systematic review and meta-analysis. Anaesth Crit Care Pain Med. 2021;100935. doi: 10.1016/j.accpm.2021.100935.Roofthooft E, Joshi GP, Rawal N, Van de Velde M, on behalf of the PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA) and supported by the Obstetric Anaesthetists’ Association (OAA). PROSPECT guideline for elective caesarean section: an updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021;76:665–680. doi:10.1111/anae.15339.Roofthooft E, Joshi GP, Rawal N, Van de Velde M. PROSPECT guideline for elective caesarean section: an update. Anaesthesia 2023;78:1170–1171.Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995 Mar 25;345(8952):763–4. doi: 10.1016/s0140-6736(95)90643-6.Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Brit J Anaesth. 1997;78:606–617.Sauro KM, Smith C, Ibadin S, Thomas A, Ganshorn H, Bakunda L, Bajgain B, Bisch SP, Nelson G. Enhanced recovery after surgery guidelines and hospital length of stay, readmission, complications, and mortality: a meta-analysis of randomized clinical trials. JAMA Netw Open. 2024 Jun 3;7(6):e2417310. doi: 10.1001/jamanetworkopen.2024.17310.Bollag L, Lim G, Sultan P, Habib AS, Landau R, Zakowski M, Tiouririne M, Bhambhani S, Carvalho B. Society for obstetric anesthesia and perinatology: consensus statement and recommendations for enhanced recovery after cesarean. Anesth Analg. 2021 May 1;132(5):1362–1377. doi: 10.1213/ANE.0000000000005257.Joshi GP, Beloeil H, Lobo DN, Pogatzki-Zahn EM, Sauter AR, Van de Velde M, Wu CL, Kehlet H. A critical approach to research on perioperative pain management. PROSPECT working group of the European society of regional anaesthesia and pain therapy. Br J Anaesth. 2025 Mar;134(3):621–626. doi: 10.1016/j.bja.2024.11.004.Lavand’homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific postoperative pain management recommendations. PROSPECT working group of the European society of regional anaesthesia and pain therapy (ESRA). Eur J Anaesthesiol. 2022 Sep 1;39(9):743–757. doi: 10.1097/EJA.0000000000001691. Epub 2022Anger M, Valovska T, Beloeil H, Lirk P, Joshi GP, Van de Velde M, Raeder J. PROSPECT working group* and the European society of regional anaesthesia and pain therapy. Anaesthesia 2021 Aug;76(8):1082–1097. doi: 10.1111/anae.15498. Epub 2021 May 20.Feray S, Lubach J, Joshi GP, Bonnet F, Van de Velde M, PROSPECT Working Group *of the European Society of Regional Anaesthesia and Pain Therapy. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2022 Mar;77(3):311–325. doi: 10.1111/anae.15609. Epub 2021 Nov 5.Aldamluji N, Burgess A, Pogatzki-Zahn E, Raeder J, Beloeil H, PROSPECT Working Group collaborators*. PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021 Jul;76(7):947–961. doi: 10.1111/anae.15299. Epub 2020 Nov 17.Mestdagh FP, Lavand’homme PM, Pirard G, Joshi GP, Sauter AR, Van de Velde M, PROSPECT Working Group∗ of the European Society of Regional Anaesthesia and Pain Therapy (ESRA). Pain management after elective craniotomy: a systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2023 Oct 1;40(10):747–757. doi: 10.1097/EJA.0000000000001877.Maeßen T, Korir N, Van de Velde M, Kennes J, Pogatzki-Zahn E, Joshi GP, PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy. Pain management after cardiac surgery via median sternotomy: a systematic review with procedure-specific postoperative pain management (PROSPECT) recommendations. Eur J Anaesthesiol 2023 Oct 1;40(10):758–768. doi: 10.1097/EJA.0000000000001881.Luxey X, Lemoine A, Dewinter G, Joshi GP, Le Ray C, Raeder J, Van de Velde M, Bonnet MP, PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy. Acute pain management after vaginal delivery with perineal tears or episiotomy. Reg Anesth Pain Med. 2024 Jun 14;rapm-2024–105478. doi: 10.1136/rapm-2024-105478.Suleiman NN, Luedi MM, Joshi G, Dewinter G, Wu CL, Sauter AR, PROSPECT Working Group. Perioperative pain management for cleft palate surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations. Reg Anesth Pain Med. 2024 Sep 2;49(9):635–641.Roofthooft E, Joshi GP, Rawal N, Van de Velde M, PROSPECT Working Group* of the European Society of Regional Anaesthesia and Pain Therapy and supported by the Obstetric Anaesthetists’ Association. PROSPECT guideline for elective caesarean section: updated systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2021 May;76(5):665–680. doi: 10.1111/anae.15339.Joshi GP, Albrecht E, Van de Velde M, Kehlet H, Lobo DN, PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy. PROSPECT methodology for developing procedure-specific pain management recommendations: an update. Anaesthesia 2023 Nov;78(11):1386–1392. doi: 10.1111/anae.16135.www.postoppain.org/cesarean section (ESRA and PROSPECT website)Roofthooft E, Joshi GP, Rawal N, Van de Velde M, PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy. PROSPECT guideline for elective caesarean section: an update and reply. Anaesthesia 2023 Sep;78(9):1176–1177. doi: 10.1111/anae.16075. Epub 2023 Jun 30.Singh NP, Makkar JK, Yadav N, et al. The analgesic efficacy of intravenous dexamethasone for post-caesarean pain: a systematic review with meta-analysis and trial sequential analysis. European Journal of Anaesthesiology Jun 2022;39(6):498–510.Nielsen NI, Kehlet H, Gromov K, et al. High dose dexamethasone in high pain responders undergoing total hip arthroplasty: a randomized controlled trial. European Journal of Anaesthesiology Oct 2023;40(10):737–746.Desai N, Pararajasingham S, Onwochei D, et al. Comparison of intravenous versus perineural dexamethasone as a local anaesthetic adjunct for peripheral nerve blocks in the lower limb: a meta-analysis and systematic review. European Journal of Anaesthesiology Oct 2024;41(10):749–759.Czarnetzki C, Albrecht E, Desmeules J, et al. Dexamethasone for the treatment of established postoperative nausea and vomiting: a randomised dose finding trial. European Journal of Anaesthesiology 2022;39(6):549–557.van den Bosch OFC, Rijsdijz M, Rosier SE, et al. The implementation of intrathecal morphine for caesarean delivery into clinical practice, and assessment of its impact on patient-reported quality of recovery using the ObsQoR-10-Dutch scale: a single-centre cohort study. European Journal of Anaesthesiology Apr 2025;42(4):332–339.Grape S, Kirkham KR, Albrecht E. Transversus abdominis plane block versus local anaesthetic wound infiltration for analgesia after caesarean section: a systematic review and meta-analysis with trial sequential analysis. European Journal of Anaesthesiology Mar 2022;39(3):244–251.Stopar-Pintaric T, Blajic I, Visic U, et al. Posteromedial quadratus lumborum block versus wound infiltration after caesarean section: a randomised, double-blind, controlled study. European Journal of Anaesthesiology Aug 2021;38:S138-S144.Adesope O, Ituk U, Habib AS. Local anaesthetic wound infiltration for postcaesarean section analgesia: a systematic review and meta-analysis. European Journal of Anaesthesiology Oct 2016;33(10):731–742.Pinarbaşi A, Altiparmak B, Korkmaz TM, et al. Ultrasound-guided transversalis fascia plane block or transversus abdominis plane block for recovery after caesarean section: a randomised clinical trial. European Journal of Anaesthesiology Oct 2024;41(10):769–778.Singh NP, Makkar JK, Bhatia N, et al. The analgesic effectiveness of ilioinguinal-iliohypogastric block for caesarean delivery: a meta-analysis and trial sequential analysis. European Journal of Anaesthesiology Aug 2021;38:S87-S96.Gharae N, Roofthooft E, Fileticci N, Devroe S, Vanhove P, Rex S, Van de Velde M. Postoperative pain after cesarean section: an audit of practice after implementation of the PROSPECT recommendations. Acta Anaesthesiologica Belgica 2021;72:109–113.",
  "authors": [
    {
      "affiliations": [
        "Anesthesiology, UZ Leuven and KU Leuven, Leuven, Belgium"
      ],
      "name": "Charlotte De Loecker"
    },
    {
      "affiliations": [
        "Anesthesiology, ZAL Sint Augustinus and ZAS Sint Vicentius, Antwerp, Belgium"
      ],
      "name": "Eva Roofthooft"
    },
    {
      "affiliations": [
        "Anesthesiology, UZ Leuven and KU Leuven, Leuven, Belgium"
      ],
      "name": "Marc Van De Velde"
    }
  ],
  "title": "FT26 Postoperative analgesia after cesarean section: an update",
  "uid": "a2713e41-36e7-54b8-afc2-e85e29ee5c8d"
}