What are the post-operative orders for a patient who has undergone a cesarean (C-section) section under spinal anesthesia?

Post-Operative Orders for Cesarean Section Under Spinal Anesthesia

For optimal pain control and recovery after cesarean section under spinal anesthesia, implement a multimodal analgesic regimen centered on scheduled acetaminophen and NSAIDs, with intrathecal morphine 50-100 μg added to the spinal anesthetic, and reserve systemic opioids strictly for breakthrough pain. 1

Immediate Post-Operative Analgesia Protocol

Neuraxial Opioid (If Not Already Administered)

• If intrathecal morphine was NOT added during spinal placement: This represents a missed opportunity for optimal analgesia 1
• If epidural catheter is in place: Administer epidural morphine 2-3 mg or diamorphine 2-3 mg as an alternative 1, 2
• If no neuraxial opioid was given: Implement regional anesthesia backup (see below) 1

Scheduled Non-Opioid Analgesics (Foundation of Pain Management)

• Acetaminophen 650-1000 mg PO every 6 hours for 48 hours (scheduled, not as-needed) 1, 3

  • Scheduled acetaminophen reduces opioid consumption by approximately 9 mg morphine equivalents over 48 hours compared to as-needed administration 3
  • Prevents inadvertent overdose from combination opioid-acetaminophen products 3

• NSAID (ibuprofen 600 mg PO every 6 hours OR ketorolac 15-30 mg IV every 6 hours) for 48 hours 1

  • Start after delivery to avoid interference with uterine contraction 1
  • Continue regularly, not as-needed 1

Adjunctive Medications

• Dexamethasone 8 mg IV single dose (if not given intraoperatively) 1, 2
  • Administer after delivery if not contraindicated 1
  • Reduces pain scores and opioid consumption 2

Rescue Analgesia

Breakthrough Pain Management

• Oxycodone 5-10 mg PO every 4 hours PRN for pain not controlled by scheduled medications 3
• Morphine PCA (alternative): 1 mg bolus, 6-minute lockout, no basal rate 4
• Minimize systemic opioid prescribing through individualized assessment, particularly for breastfeeding mothers 1, 5

Regional Anesthesia Backup (If Intrathecal Morphine NOT Used)

Implement ONE of the following if neuraxial opioid was omitted: 1, 2

• Local anesthetic wound infiltration (single injection at closure) 1
• Continuous wound local anesthetic infusion 1
• Transversus abdominis plane (TAP) block 1, 5
• Quadratus lumborum (QL) block 1, 5

Critical caveat: These regional techniques provide minimal additional benefit when intrathecal morphine was used and should be reserved for cases where neuraxial opioids were contraindicated or not administered 5

Hemodynamic Management

Hypotension Monitoring and Treatment

• Monitor blood pressure every 5 minutes for first 30 minutes, then every 15 minutes for 2 hours 2, 6
• Treat hypotension (SBP <90 mmHg or >20% decrease from baseline) promptly: 2, 6, 7
  • Phenylephrine 50-100 μg IV bolus (preferred vasopressor) 6, 7
  • Ephedrine 5-10 mg IV bolus (alternative, but monitor for potential fetal acidosis) 6, 8
  • IV fluid bolus (crystalloid or colloid) 7

Important pitfall: Untreated hypotension increases maternal nausea/vomiting and may cause fetal bradycardia and acidosis 6

Monitoring for Neuraxial Opioid Side Effects

Respiratory Monitoring (If Intrathecal Morphine Given)

• Continuous pulse oximetry for 12-24 hours 1, 9
• Respiratory rate every 1 hour for 12 hours, then every 2 hours for 12 hours 1
• Naloxone 0.4 mg IV available at bedside for respiratory depression (rate <8/min or SpO2 <90%) 1

Pruritus Management

• Diphenhydramine 25-50 mg PO/IV every 6 hours PRN 9
• Ondansetron 4 mg IV (alternative, may be more effective) 9

Nausea/Vomiting Prophylaxis

• Ondansetron 4 mg IV every 8 hours PRN 1
• Metoclopramide 10 mg IV every 8 hours PRN (alternative) 1

Adjunctive Non-Pharmacologic Measures

• Abdominal binder application immediately post-operatively 1, 5
• Transcutaneous electrical nerve stimulation (TENS) as adjunct 1, 5

Early Mobilization and Recovery

• Ambulation within 6-8 hours once motor block resolved and hemodynamically stable 1
• Foley catheter removal at 12 hours if intrathecal morphine used, or 6 hours if not 1
• Diet advancement as tolerated, typically clear liquids immediately post-op 1

Monitoring for Complications

Newborn Monitoring

• Assess newborn for metabolic acidosis (umbilical artery pH, clinical signs) if maternal ephedrine was used 6
• Monitor acid-base status to ensure acidosis is acute and reversible 6

Maternal Neurologic Assessment

• Document return of motor function (modified Bromage scale) 8
• Assess for postdural puncture headache at 24 and 48 hours 7
• Monitor for persistent groin pain (may indicate ilioinguinal/iliohypogastric nerve injury requiring targeted intervention) 5

Discharge Planning

• Limit opioid prescription to 15-20 tablets of oxycodone 5 mg (or equivalent) 1
• Continue acetaminophen 650-1000 mg every 6 hours and ibuprofen 600 mg every 6 hours for 5-7 days 1
• Educate on safe opioid storage and disposal 1