What are the post-operative orders and guidelines for a cesarean section under spinal anesthesia with bupivacaine plus morphine 0.2mg?

Post-Operative Orders for Cesarean Section Under Spinal Anesthesia with Bupivacaine Plus Intrathecal Morphine 0.2mg

Immediate Post-Operative Monitoring (First 12-24 Hours)

For patients receiving intrathecal morphine 0.2mg, implement hourly respiratory and sedation monitoring for the first 12 hours, followed by every 2 hours for the next 12 hours. 1

Vital Signs Monitoring

• Respiratory rate and sedation level assessed clinically by nursing staff every hour for 12 hours, then every 2 hours for the next 12 hours 1
• Continuous pulse oximetry for first 12-24 hours post-operatively 1
• Blood pressure monitoring every 15 minutes for first hour, then hourly for 12 hours 1
• Standard ASA monitoring including non-invasive blood pressure, ECG, and pulse oximetry 2

Neurological Assessment

• Sensory level assessment at 24,48, and 72 hours post-procedure 1
• Motor block assessment at regular intervals until full recovery 1
• Document complete resolution of motor block before ambulation 1

Multimodal Analgesia Regimen

Administer scheduled paracetamol and NSAIDs postoperatively as the foundation of pain management, with opioids reserved for breakthrough pain only. 1

Scheduled Medications (Start After Delivery)

• Paracetamol 1000mg every 6 hours (oral or IV) - continue regularly for at least 48 hours 1
• NSAIDs (ibuprofen 400-600mg every 6-8 hours OR diclofenac 50-75mg every 8-12 hours) - continue regularly for at least 48 hours, unless contraindicated 1
• Single dose of IV dexamethasone 8mg after delivery (unless contraindicated) for enhanced analgesia and antiemetic effect 1

Rescue Analgesia

• Oral oxycodone 5-10mg every 4-6 hours PRN for breakthrough pain (VAS >4/10) 1
• Avoid routine scheduled opioids given the long-acting intrathecal morphine 0.2mg already administered 1
• Document all rescue opioid use to guide discharge prescribing 1

Expected Analgesia Duration

With intrathecal morphine 0.2mg, expect 15-24 hours of effective analgesia (mean duration 879 ± 725 minutes in recent studies). 3

• Time to first analgesic request typically 15-24 hours 3
• Duration significantly longer than 0.1mg morphine (which provides ~9-10 hours) 4, 3
• Superior postoperative analgesia compared to epidural morphine or patient-controlled epidural analgesia 1

Side Effect Management

Pruritus (Most Common Side Effect)

• Expect mild-to-moderate pruritus in approximately 30-50% of patients 4, 3
• First-line: Diphenhydramine 25-50mg IV/PO every 6 hours PRN 1
• Second-line: Ondansetron 4-8mg IV (dual antipruritic and antiemetic effect) 1
• Most pruritus is mild and does not require treatment 4

Nausea and Vomiting

• Ondansetron 4mg IV every 8 hours PRN for nausea/vomiting 1
• Metoclopramide 10mg IV every 8 hours PRN as alternative 1
• Dexamethasone (given intraoperatively) provides prophylaxis 1

Respiratory Depression (Rare but Serious)

• No respiratory or cardiovascular complications were reported in studies using intrathecal morphine 0.1-0.3mg with appropriate monitoring 1
• Risk is minimal with doses ≤0.2mg when combined with hourly monitoring 4, 3
• Have naloxone 0.4mg IV immediately available for respiratory rate <8/min or SpO2 <92% 1

Hypotension

• Vasopressor support with phenylephrine or ephedrine as needed for systolic BP <90 mmHg or >20% decrease from baseline 2, 5
• Volume loading with crystalloid 500-1000mL if hypotension occurs 5

Ambulation and Activity

• Do not permit ambulation until complete resolution of motor block (typically 4-6 hours post-spinal) 1, 6
• Assess motor function using Bromage scale before first ambulation attempt 6
• Early ambulation (within 6-8 hours) once motor block resolved to reduce thromboembolism risk 1

Discharge Planning and Opioid Prescribing

Implement individualized opioid prescribing based on actual inpatient consumption rather than routine prescriptions. 1

Discharge Medications

• Continue paracetamol 1000mg every 6 hours for 5-7 days 1
• Continue NSAIDs (if tolerated) for 5-7 days 1
• Prescribe minimal opioids: Only 10-15 tablets of oxycodone 5mg (or equivalent) for patients who required rescue opioids during hospitalization 1
• Patients requiring no rescue opioids during admission may not need any opioid prescription at discharge 1

Key Clinical Pitfalls to Avoid

Critical Errors

• Never omit scheduled paracetamol and NSAIDs - these are the foundation of post-cesarean analgesia and must be given regularly, not PRN 2
• Never exceed 100 μg intrathecal morphine in routine cases, as higher doses increase respiratory depression risk without improving analgesia 2
• Never discharge patients with large opioid prescriptions without assessing actual inpatient needs 1

Monitoring Failures

• Do not rely solely on pulse oximetry - clinical assessment of respiratory rate and sedation is essential 1
• Do not discontinue monitoring before 24 hours post-intrathecal morphine administration 1
• Do not permit ambulation without documented motor block resolution 1

Medication Errors

• Do not give additional systemic opioids in the first 12-18 hours unless absolutely necessary, as intrathecal morphine 0.2mg provides excellent analgesia 3
• Do not withhold NSAIDs without clear contraindication (active bleeding, renal dysfunction, peptic ulcer disease) 1

Evidence Quality Note

The 2021 PROSPECT guidelines for cesarean section represent the highest quality evidence (systematic review of 145 studies), strongly recommending intrathecal morphine 50-100 μg as optimal dosing. 1 Your dose of 0.2mg (200 μg) is at the upper end but within the safe range used in multiple studies showing excellent analgesia (mean duration 879 minutes) without respiratory complications when appropriate monitoring is implemented. 3