What is the appropriate evaluation and management of new‑onset epigastric pain in a woman immediately after a cesarean delivery?

Epigastric Pain After Cesarean Section

New-onset epigastric pain immediately after cesarean delivery requires urgent evaluation to exclude life-threatening complications—particularly preeclampsia/HELLP syndrome—before initiating any analgesic therapy. 1

Immediate Diagnostic Evaluation

Rule out obstetric emergencies first:

• Measure blood pressure immediately to assess for postpartum preeclampsia (BP ≥140/90 mmHg) 1
• Obtain urgent laboratory tests: complete blood count with platelets, liver enzymes (AST, ALT), bilirubin, and urine protein 1
• Perform focused physical examination for right upper quadrant tenderness, visual changes, severe headache, or altered mental status 1

Critical pitfall: Never dismiss epigastric pain as "normal" post-cesarean discomfort or attribute it solely to surgical pain—this location warrants investigation for specific pathology including HELLP syndrome, hepatic complications, or gastric pathology 2, 1

Management Algorithm After Excluding Emergencies

Step 1: Initiate Scheduled Multimodal Analgesia (Foundation)

Start immediately with scheduled (not PRN) non-opioid analgesics:

• Paracetamol (acetaminophen) 650-975 mg orally every 6-8 hours standing 3, 1
• Ibuprofen 600 mg orally every 6 hours standing (or ketorolac 30 mg IV every 6 hours for first 24 hours if still inpatient) 3, 1

These medications are safe during breastfeeding with minimal transfer to breast milk. 1

Step 2: Add Adjunctive Therapy

Administer single dose of IV dexamethasone if not given during surgery:

• Dexamethasone 4-8 mg IV once (unless contraindicated) to enhance analgesia and reduce opioid requirements 3, 1

Step 3: Reassess at 24-48 Hours

If pain adequately controlled (pain score <4/10):

• Continue scheduled paracetamol and NSAIDs 1
• Encourage early mobilization 3
• Consider abdominal binders for additional support 3, 2

If pain remains severe (≥7/10) despite multimodal therapy:

• Add short-acting opioids (morphine preferred for breastfeeding safety) only as rescue medication 3, 1
• Administer opioids immediately after breastfeeding to minimize infant exposure 1
• Avoid codeine due to risk of neonatal toxicity in ultra-rapid metabolizers 1
• Limit opioid prescription to maximum equivalent of 20 tablets of 5-mg oxycodone using shared decision-making 3

Step 4: Consider Regional Techniques (If Neuraxial Opioids Not Used)

Only if intrathecal/epidural morphine was not administered during cesarean:

• Local anesthetic wound infiltration or continuous wound infusion 3
• Transversus abdominis plane (TAP) or quadratus lumborum blocks 3

Note: These regional techniques provide minimal additional benefit when neuraxial morphine was used 4, 2

Non-Pharmacological Adjuncts

• Apply transcutaneous electrical nerve stimulation (TENS) as analgesic adjunct 3, 2
• Use abdominal binders for pain control and support 3, 2
• Implement early feeding (regular diet within 2 hours post-cesarean) 3

Red Flags Requiring Escalation

Escalate care immediately if:

• Epigastric pain persists or worsens despite optimized multimodal therapy within 24-48 hours 2
• New symptoms develop: visual changes, severe headache, right upper quadrant tenderness, oliguria 1
• Laboratory abnormalities: thrombocytopenia (<100,000), elevated liver enzymes (>2x normal), proteinuria 1
• Pain interferes with mobilization, breastfeeding, or infant care despite scheduled analgesics 3

Common Pitfalls to Avoid

• Never rely on PRN analgesics alone—scheduled administration of paracetamol and NSAIDs is essential for adequate pain control 2, 1
• Do not default to opioids as first-line therapy—implement multimodal non-opioid analgesia first 3
• Avoid excessive opioid prescribing at discharge—most women require far less than routinely prescribed 3
• Do not dismiss location of pain—epigastric pain specifically requires exclusion of serious postpartum complications before attributing to surgical pain 1