What is the most effective method for managing postoperative pain in a postpartum woman who has undergone a cesarean section (C-section)?

Post-Cesarean Delivery Pain Management

Neuraxial morphine (intrathecal 50-100 μg or epidural 2.5-4 mg) is the most effective method for managing post-cesarean pain, providing superior analgesia for 24-48 hours with minimal opioid requirements. 1, 2

Primary Analgesic Strategy

Neuraxial Opioid Administration

• Add intrathecal morphine 50-100 μg (or diamorphine 300 μg) to spinal anesthesia at the time of cesarean delivery for optimal postoperative pain control. 1
• If epidural anesthesia is used instead, administer epidural morphine 2.5-4 mg through the catheter at the end of surgery—all three doses (2.5,3, and 4 mg) provide equivalent analgesia for approximately 24 hours, with about 27% of patients remaining pain-free for up to 48 hours without additional analgesics. 3
• Neuraxial morphine is the most effective form of postcesarean analgesia and should be used whenever possible, as it dramatically reduces systemic opioid requirements (by more than 50% over 48 hours). 2, 4

Monitoring Considerations

• Identify women at increased risk for respiratory depression (obesity, sleep apnea, concurrent opioid use) who may require more intensive postoperative monitoring, though clinically relevant respiratory depression with appropriate dosing is extremely rare. 2

Multimodal Analgesia Foundation

All patients should receive scheduled (not as-needed) paracetamol and NSAIDs as foundational therapy, regardless of whether neuraxial opioids were used. 5, 1

• Prescribe paracetamol and NSAIDs to be administered after delivery and continued regularly postoperatively. 1
• Add a single dose of intravenous dexamethasone after delivery unless contraindicated, as this reduces postcesarean opioid requirements. 5, 1
• Minimize systemic opioid use through individualized prescribing practices, particularly for breastfeeding mothers. 5

Alternative Regional Techniques (When Neuraxial Morphine Not Used)

If intrathecal morphine or epidural morphine cannot be administered, implement one of the following alternatives:

• Consider local anesthetic infiltration or fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) as very valuable alternatives to neuraxial morphine. 5, 1, 2
• Continuous wound local anesthetic infusion is another option. 1
• Important caveat: The benefits of local and regional analgesic techniques are minimal when intrathecal morphine was used, so reserve these for cases where neuraxial opioids were contraindicated or not administered. 5, 1

Adjunctive Non-Pharmacological Measures

• Apply transcutaneous electrical nerve stimulation (TENS) as an adjunctive measure for additional pain control. 5, 1
• Use abdominal binders for improved pain management. 5, 1

Epidural Analgesia Continuation Considerations

• Postoperative lumbar epidural analgesia impairs mobilization and is generally not recommended for routine postcesarean pain management. 2
• If continuous epidural analgesia is considered necessary, double epidural catheters with lower thoracic epidural analgesia are a possible alternative that may preserve lower extremity function. 2
• A single dose of epidural morphine at the end of surgery is superior to continuous epidural infusions, as morphine alone provides 24-48 hours of analgesia without the motor block and mobilization impairment associated with local anesthetic infusions. 6, 3

Critical Pitfalls to Avoid

• Never dismiss persistent or severe pain as "normal" post-cesarean discomfort—burning, lancinating pain exacerbated by standing or movement may represent ilioinguinal-iliohypogastric nerve injury requiring targeted intervention with nerve blocks. 5, 7
• Adequate analgesia following cesarean delivery is still underused in clinical practice; standardize multimodal analgesia regimens according to institutional protocols. 2
• The addition of local anesthetics (ropivacaine) to epidural morphine offers no benefit in pain control and increases the incidence of adverse effects including hypotension, urinary retention, and paresthesias. 6