What is the recommended treatment for incisional pain after a Cesarean section (C-section)?

Optimal Treatment for Incisional Pain After C-Section

The recommended treatment for incisional pain after cesarean section is a multimodal approach including scheduled paracetamol and NSAIDs as basic analgesics, with intrathecal morphine 50-100 μg or diamorphine 300 μg administered pre-operatively, and intravenous dexamethasone after delivery. 1, 2

First-Line Pharmacological Management

Pre-operative and Intra-operative Management

• Add intrathecal morphine 50-100 μg or diamorphine 300 μg to spinal anesthesia for post-cesarean pain management 1, 3
• If neuraxial opioids were not administered, implement one of these regional techniques:
  • Single-injection local anesthetic wound infiltration 1, 2
  • Continuous wound local anesthetic infusion 1
  • Fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) 1, 3
• Administer a single dose of intravenous dexamethasone after delivery (unless contraindicated) 1, 3

Post-operative Regimen

• Implement scheduled (not as-needed) administration of:
  • Paracetamol (oral or intravenous) 1, 4
  • NSAIDs (oral or intravenous) 1, 4
• This scheduled regimen has been shown to decrease pain scores at all time intervals and reduce opioid usage by up to 64% compared to as-needed administration 4, 5
• Reserve opioids for rescue analgesia when pain is not adequately controlled with the above measures 1
• When opioids are needed, oral oxycodone may provide better pain control with fewer side effects than IV morphine followed by oral codeine 6

Surgical Techniques That Reduce Post-Cesarean Pain

• Use Joel-Cohen incision technique during the cesarean section 1, 2
• Implement non-closure of the peritoneum 1, 2
• Apply abdominal binders postoperatively 1, 2

Non-Pharmacological Adjuncts

• Consider transcutaneous electrical nerve stimulation (TENS) as an analgesic adjunct 1, 7
  • TENS is particularly effective for cutaneous, movement-associated incisional pain, though less effective for deep pain, afterbirth pain, or gas pain 7
• Hand and foot massage can effectively reduce incision pain scores after cesarean section 8

Important Considerations and Pitfalls

• The benefits of local and regional analgesic techniques (TAP blocks, wound infiltration) are minimal when intrathecal morphine is used, so these should be reserved for cases where neuraxial opioids are contraindicated 1, 2
• Fixed-time interval administration of analgesics (both IV and oral) yields better pain control compared to on-demand protocols, despite fewer total doses being consumed in on-demand groups 5
• Intravenous administration protocols may provide slightly better pain score reduction compared to oral protocols (4.7±1.2 vs 4.0±1.4 on VAS scale) 5
• Develop individualized post-discharge opioid prescribing practices to reduce unnecessary opioid consumption after discharge 1

Algorithm for Pain Management After C-Section

1. Pre-operative: Add intrathecal morphine 50-100 μg or diamorphine 300 μg to spinal anesthesia 1, 3
2. Intra-operative: Administer IV dexamethasone after delivery 1
3. Post-operative:
   • Begin scheduled paracetamol and NSAIDs immediately 1, 4
   • If intrathecal morphine was not used, implement regional analgesia techniques 1
   • Apply abdominal binder 1
   • Consider TENS for additional pain relief 1, 7
   • Use opioids only for breakthrough pain 1

This approach has been shown to provide excellent analgesia while minimizing opioid use and associated side effects 1.