What is the routine medical management after a Lower Segment Caesarean Section (LSCS)?

Routine Medical Management After Lower Segment Caesarean Section (LSCS)

The optimal post-LSCS management includes a multimodal pain control regimen with paracetamol and NSAIDs as baseline medications, supplemented with intrathecal morphine or alternative regional analgesia techniques, while minimizing systemic opioid use to reduce adverse effects and improve maternal recovery. 1

Pain Management Protocol

First-line Analgesic Strategy

• Add intrathecal morphine 50-100 μg or diamorphine 300 μg to spinal anaesthesia during the procedure 1
• If epidural was used instead, administer epidural morphine 2-3 mg or diamorphine 2-3 mg 1
• Administer a single dose of intravenous dexamethasone after delivery (in absence of contraindications) 1

Baseline Analgesia (Start immediately after delivery)

• Paracetamol: Regular dosing schedule
• NSAIDs: Regular dosing schedule (if no contraindications like asthma triggered by aspirin) 1
• Continue both medications on a scheduled basis, not just as needed

Alternative Regional Techniques (if intrathecal morphine was not used)

• Single injection of local anaesthetic wound infiltration
• Continuous wound local anaesthetic infusion
• Fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) 1
• In patients with multiple allergies, consider lidocaine patches 5% as part of multimodal analgesia 2

Rescue Analgesia

• Use systemic opioids only for breakthrough pain
• Implement strategies to minimize systemic opioid utilization 1
• Consider transcutaneous electrical nerve stimulation (TENS) as an adjunct for pain relief 1

Surgical Site Care

Wound Management

• Keep surgical site clean and dry
• Monitor for signs of surgical site infection (redness, swelling, increased pain, discharge) 3
• Remove dressing as per local protocol (typically 24-48 hours post-surgery)
• Ensure proper patient education on wound care

Infection Prevention

• Continue prophylactic antibiotics if indicated (typically a single dose of cefazolin is administered pre-operatively) 4
• Monitor for signs of infection (fever, tachycardia, increased pain)
• Be aware that SSI rates can be significant (10.3% reported in some studies) 3

Thromboprophylaxis

• Early mobilization should be encouraged
• For patients with risk factors, administer prophylactic low-molecular-weight heparin 5
• Typical dosing: 5,000 units subcutaneously every 8-12 hours for 7 days or until fully ambulatory 5
• Use compression stockings as appropriate
• Ensure adequate hydration

Monitoring and Additional Care

Vital Signs Monitoring

• Regular monitoring of vital signs (temperature, pulse, blood pressure, respiratory rate)
• Monitor for excessive bleeding
• Assess pain levels regularly using standardized pain scales

Bladder and Bowel Function

• Remove urinary catheter within 24 hours if no complications
• Monitor for return of normal bladder function after catheter removal
• Encourage early oral intake and monitor for return of bowel function
• Consider stool softeners to prevent constipation

Breastfeeding Support

• Encourage early breastfeeding
• Position mother comfortably to avoid pressure on the incision site
• Provide lactation support as needed

Discharge Planning

Criteria for Discharge

• Stable vital signs
• Adequate pain control with oral medications
• No signs of infection
• Normal voiding
• Ability to care for self and baby
• Adequate support at home

Discharge Medications

• Continue scheduled paracetamol and NSAIDs
• Provide minimal opioids for breakthrough pain only
• Individualize post-discharge opioid prescribing to reduce unnecessary consumption 1

Follow-up Instructions

• Wound care instructions
• Signs of complications to watch for (infection, bleeding, thromboembolism)
• Activity restrictions (no heavy lifting, gradual return to activities)
• Follow-up appointment timing

Common Pitfalls and Caveats

• Undertreating pain: Inadequate pain management can delay recovery, impair mother-child bonding, impact maternal psychological well-being, and complicate breastfeeding 1
• Overreliance on opioids: Excessive opioid use can lead to sedation, respiratory depression, constipation, and potential for dependence
• Delayed mobilization: Early ambulation reduces the risk of thromboembolism and improves recovery
• Ignoring psychological aspects: Monitor for signs of postpartum depression and provide appropriate support
• Surgical site infections: Risk factors include inappropriate pre-surgical antibiotic prophylaxis, anemia, and comorbid conditions 3

The evidence strongly supports a multimodal approach to post-LSCS pain management, with emphasis on regular non-opioid analgesics supplemented by neuraxial opioids when possible, while minimizing systemic opioid use to improve maternal outcomes and recovery.