Intra-Operative

Expand all

PROSPECT Recommendations

  • Combined spinal-epidural anaesthesia or spinal anaesthesia are recommended (GoR A) based on procedure-specific evidence (LoE 1)
  • Consensus agreement 100% (9/9)
  • There is no evidence of analgesic benefit to recommend general anaesthesia over neuraxial anaesthesia (i.e., epidural anaesthesia, spinal anaesthesia, and combined spinal epidural anaesthesia), due to lack of direct comparative studies focusing on postoperative analgesia (GoR D). However, neuraxial anaesthesia techniques are recommended for safety reasons (e.g., neuraxial anaesthesia obviates the need for airway manipulation and avoids the postoperative sedative effects of general anaesthetics)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • Three studies comparing CSEA with EA showed a significant reduction in pain scores with CSEA during or after surgery but the results related to the time to first analgesic request were inconsistent Davies et al 1997 Click here for more information
  • A systematic review comparing the efficacy and side effects of SpA and EA showed no differences in unplanned interventions for pain relief postoperatively. However, there was an increased need for treatment for hypotension in women undergoing SpA Ng et al 2004
  • A systematic review comparing the effects of regional anaesthesia with those of GA showed (based upon one RCT) that the time to first request for analgesia was longer with EA compared with GA. There were no significant differences in the Apgar scores at 1, 5 and 10 min Afolabi and Lesi 2012
  • CSEA with epidural volume extension (EVE) was not superior to SpA in reducing intraoperative pain scores and the time to first analgesic request Lew et al 2004
  • One study showed a significant reduction in the time to first analgesic request for the SpA group compared with the CSEA group. However, there was no significant difference in supplemental analgesic use Thorén et al 1994
  • Two studies comparing EA with SpA showed inconsistent results related to pain scores and the need for supplemental analgesic use Paraskeva et al 2012 Click here for more information
  • Combined spinal-epidural anaesthesia (CSEA) vs epidural anaesthesia (EA) or spinal anaesthesia (SpA) study details Click here for more information
  • EA vs SpA study details Click here for more information
  • EA or SpA versus general anaesthesia (GA) study details Click here for more information
  • CSEA vs EA or SpA
  • EA vs SpA
  • EA or SpA vs GA

PROSPECT Recommendations

  • Intrathecal morphine below 200 µg is recommended if the patient has received spinal anaesthesia (GoR A) based on procedure-specific evidence for improved postoperative analgesia (LoE 1)
  • However, due to opioid-related side effects, including delayed respiratory depression, alternative analgesic techniques should be considered
  • Consensus agreement 100% (9/9)
  • Epidural opioids are recommended if the patient has received epidural anaesthesia (GoR A) based on procedure-specific evidence for improved postoperative analgesia (LoE 1)
  • However, due to opioid related side effects, including delayed respiratory depression, alternative analgesic techniques should be considered
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence: Epidural or IT Analgesia With Anaesthesia

  • Fewer patients receiving IT morphine 100 µg during surgery requested supplemental analgesia compared with patients receiving postoperative oral oxycodone, but there was no significant difference in pain scores or consumption of supplemental analgesia and IT morphine was associated with a higher incidence of pruritus McDonnell et al 2010 Click here for more information
  • The combination of IT morphine 0.2 mg with spinal bupivacaine compared with spinal bupivacaine alone prolonged the time to first analgesic request. However, women receiving IT morphine reported nausea and pruritus significantly more often Abouleish et al 1988
  • The time to first PCA demand was longer in each of four groups receiving IT morphine (0.1, 0.2, 0.3, 0.4 mg) in combination with SpA bupivacaine than in the control group (0 mg morphine). The IT morphine groups showed a significantly lower total PCA morphine demand in the first 24 hours than the control group. There were no significant differences between mean VAS scores Girgin et al 2008
  • IT morphine 50 µg or 100 µg reduced pain scores, rescue analgesia requirements and increased the time to first request for rescue analgesics compared with no IT morphine Mikuni et al 2010 Click here for more information
  • Postoperative pain was significantly lower in a group receiving IT morphine added to SpA with bupivacaine than in a group receiving saline plus SpA. Morphine consumption was significantly lower in the IT morphine group Swart et al 1997
  • The addition of IT morphine 0.2 mg to hyperbaric bupivacaine 0.5% for SpA compared with hyperbaric bupivacaine alone reduced postoperative pain scores, the need for additional analgesia and prolonged the time to first analgesic request Terajima et al 2003
  • The administration of IT morphine 0.25 mg or 0.1 mg during SpA was superior to saline for postoperative pain relief. However, the higher dose of IT morphine was associated with significantly increased occurrence of pruritus Abboud et al 1988
  • The coadministration of IT sufentanil 5 µg and IT morphine 100 µg was superior to IT sufentanil 5 µg plus a single injection of s.c. morphine 10 mg for postoperative pain relief and consumption of supplemental analgesia Draisci et al 2009
  • Women undergoing caesarean delivery with CSEA benefited from the additional administration of IT morphine (0.1 and 0.2 mg) to 15 mg of spinal levobupivacaine. It prolonged the time to the first analgesic request compared with saline; however, there were no significant differences in postoperative pain scores Unlugenc et al 2012
  • Time to first analgesic request was significantly shorter following epidural diamorphine 3 mg (2 boluses) administration compared with IT morphine 0.2 mg. However, IT morphine was associated with higher incidence of PONV Caranza et al 1999
  • Similar pain relief was achieved with the administration of PCEA pethidine compared with IT morphine during surgery plus IV pethidine via PCA or IT morphine during surgery plus postoperative oral paracetamol and codeine. Patients receiving epidural pethidine had a trend for higher pain scores but also lower nausea and pruritus scores Paech et al 2000
  • CSEA with hyperbaric bupivacaine plus sufentanil 5 µg and epidural lidocaine combined with either epidural morphine or IT morphine produced similar postoperative pain relief and similar time to first analgesic demand. However, women receiving epidural morphine had a decreased 24 h morphine consumption Dualé et al 2003
  • A randomised controlled study comparing IT morphine 100 µg, IT morphine 200 µg and epidural morphine 3 mg showed no significant differences in postoperative pain scores and the time to first request for rescue analgesia Sarvela et al 2002
  • The combination of neostigmine 12.5 µg and morphine 50 µg administered with SpA with 0.5% hyperbaric bupivacaine 12 mg had a prolonged analgesic effect compared with either neostigmine or morphine alone Chung et al 1998 Click here for more information
  • In combination with SpA with 0.5% hyperbaric bupivacaine 10 mg, morphine 0.2 mg was associated with longer duration of analgesia and less requirement for supplementary analgesia compared with nalbuphine 0.2 mg, 0.8 mg or 1.6 mg Culebras et al 2000 Click here for more information
  • IT morphine 0.1 mg was superior in postoperative pain relief, supplemental need for analgesia and time to first analgesic request compared with IT fentanyl 25 µg, when combined with IT hyperbaric bupivacaine Siti Salmah and Choy 2009
  • For patients receiving IT morphine, the addition of diclofenac IM every 8 h compared to diclofenac IM only on request significantly reduced pain scores at 24 h, independent of the doses of IT morphine (0.1 mg, 0.05 mg, 0.025 mg) Cardoso et al 1998
  • IT ketamine 0.1 mg/kg added to spinal bupivacaine compared with bupivacaine alone prolonged intraoperative anaesthesia, increased the time to the first analgesic request and decreased the total analgesic consumption in the first 24 postoperative hours Khezri et al 2013
  • The addition of IT fentanyl 0, 5, 10 or 25 µg to SpA with IT morphine showed no difference in postoperative morphine consumption via PCA. However, pain scores were higher in women receiving fentanyl 5, 10 and 25 µg compared with 0 µg Carvalho et al 2012
  • The addition of dextromethorphan to different doses of IT morphine was not superior to placebo combined with the same doses of IT morphine for pain relief. Higher doses of morphine were associated with a significantly increased incidence of PONV and pruritus Choi et al 2003
  • Spinal morphine 0.1 mg combined with IV ketorolac was not superior to different doses of spinal morphine (0.1 mg or 0.2 mg) or IV ketorolac alone in terms of pain relief and time to first analgesic request Cohen et al 1996
  • The administration of IT fentanyl 25 µg was superior to IT ketamine 0.05 mg/kg, both added to plain bupivacaine for spinal analgesia, for providing postoperative pain relief and prolonging the time to first analgesic request Unlugenc et al 2006
  • IT or epidural opioids study details
  • IT ketamine study details Click here for more information
  • IT opioid vs placebo/control or systemic opioid
  • IT opioid vs epidural opioid
  • Comparisons of different IT opioid regimens
  • Other regimens
  • IT ketamine with spinal LA
  • The comparison of either IT morphine 0.1 mg or diamorphine 0.25 mg in combination with SpA using hyperbaric bupivacaine and fentanyl 12.5 µg showed no differences in postoperative pain relief, time of first PCA use or cumulative morphine requirement postoperatively Barkshire et al 2001
  • There were no significant differences between groups receiving either morphine 0.1 mg or 0.2 mg combined with IT 0.5% bupivacaine 2.5 mL in VAS pain scores and time to first analgesic request Milner et al 1996

C-Section-Specific Evidence: Epidural Analgesia Continued After Anaesthesia

  • Epidural morphine was superior to placebo for pain relief, duration of pain relief and reduction of additional analgesics. However, patients in the morphine group reported pruritus significantly more frequently Binsted 1983
  • A systematic review of RCTs comparing epidural morphine with parenteral opioids showed that a single bolus of epidural morphine provides better pain relief than parenteral opioids but with an effect limited to the POD 1 and with an increase in morphine side effects Bonnet et al 2010
  • There were no significant differences in pain scores, morphine consumption and time to first analgesic request between butorphanol 2 mg IV (with epidural saline) and epidural butorphanol 2 mg (plus saline IV), but both regimens provided superior analgesia to saline placebo in the first 2 h postoperatively Camann et al 1992
  • Epidural morphine 5 mg compared with IV morphine 5 mg was superior for reducing the need for supplemental analgesics and prolonging the time to first analgesic request. However, significantly more patients receiving epidural morphine experienced pruritus Cohen and Woods 1983
  • Epidural fentanyl was associated with lower postoperative pain scores and a lower incidence of PONV than IV fentanyl Cohen et al 2002
  • Fentanyl (20 µg, 10 min lockout) administered via PCEA compared with the same dose via IV PCA resulted in lower pain scores at rest at 8, 12, 24 h, but not at 0.5 and 4 h and in lower pain scores on coughing at 8 and 12 h, but not at remaining points in time. There was no significant difference in PONV between the two groups, but patients receiving fentanyl via PCEA experienced pruritus significantly more frequently Cooper et al 1995
  • The administration of epidural fentanyl via PCA was superior to IV morphine via PCA in pain scores at rest 4 and 8 h, but not at recovery, 12 and 21 h as well as in lower pain scores on coughing at 4, 8 and 21 h, but not at remaining assessment times. The incidence of PONV and drowsiness was significantly lower in patients receiving epidural fentanyl via PCA Cooper et al 1999
  • Epidural morphine was superior to IM morphine in pain relief and the need for morphine consumption. The two groups were similar in the occurrence of PONV and pruritus Daley et al 1990
  • The administration of sufentanil PCEA was superior to morphine iPCA in reducing pain at rest at 30 min and 2 h, but not between 6 h and POD 2 and in reducing pain on movement at POD 2, but not on POD 1. The incidence of PONV was similar between the two groups, but patients receiving epidural sufentanil experienced pruritus significantly more frequently Grass et al 1994
  • PCEA administration reduced drug consumption within 24 h compared with IV PCA administration for both pethidine and fentanyl. The number of PCA demands was lower with pethidine than fentanyl. Patients preferred PCEA to IV PCA administration for pethidine but not fentanyl Ngan Kee et al 1997
  • The administration of epidural meperidine via PCA was superior to IV meperidine via PCA for pain, sedation and satisfaction scores Paech et al 1994
  • There was no significant difference between the incidence of PONV, sedation and dizziness in the epidural pethidine group and IM pethidine group. However, patients receiving epidural pethidine had lower pain scores during the first 2 h Perriss et al 1990
  • The duration of analgesia was significantly longer in patients receiving epidural diamorphine 3 mg compared with IM morphine 10 mg. However, only the pain score at 5 hours was lower in the diamorphine group Stevens et al 1991
  • The administration of epidural diamorphine was superior to IV diamorphine via PCA for pain scores at 1 and 2 h, but not between 4 and 48 h. The incidence of pruritus and PONV was similar between the two groups Stoddart et al 1993
  • The combination of epidural morphine 2 mg plus diclofenac sodium 75 mg IM was superior to epidural morphine 2 mg plus saline solution IM and to epidural saline plus diclofenac 75 mg IM for pain relief. However, patients receiving epidural morphine experienced PONV and pruritus significantly more often Sun et al 1992
  • PCEA meperidine was significantly superior to IM meperidine for pain relief. The incidence of nausea and pruritus was similar between the two groups Yarnell et al 1992
  • The duration of analgesia was significantly longer in patients receiving epidural buprenorphine plus bupivacaine in comparison to patients receiving epidural bupivacaine plus clonidine and it was the lowest in patients receiving epidural bupivacaine alone Agarwal et al 2010
  • Ropivacaine plus fentanyl administered by PCEA was superior to ropivacaine alone for pain scores and supplemental analgesics. But patients receiving ropivacaine plus fentanyl reported pruritus significantly more frequently Buggy et al 2000
  • Epidural fentanyl plus bupivacaine was associated with reduced fentanyl consumption in 48 h compared with epidural fentanyl alone Cohen et al 2002
  • The administration of fentanyl or bupivacaine plus fentanyl administered via PCEA was superior to bupivacaine alone via PCEA in pain scores at rest at 12 h, but not at 0.5, 4, 8 and 24 h. There were no significant differences between the three groups in pain scores on coughing at any assessment time. However, the incidence of pruritus was significantly lower in patients receiving only bupivacaine compared with the two other groups Cooper et al 1996
  • Epidural morphine 2 mg twice per day for 3 days was not superior to 0.1% ropivacaine administered by PCEA (5 mg bolus, 15 min lockout, with 3 mg/h background infusion, <60 mg/4 h) for 3 days in pain relief and supplemental analgesic request. Moreover, epidural morphine was associated with significantly higher incidence of nausea, vomiting and pruritus Chen et al 2011
  • The duration of analgesia was significantly longer in patients receiving epidural buprenorphine plus bupivacaine in comparison to patients receiving epidural bupivacaine plus clonidine and it was the lowest in patients receiving epidural bupivacaine alone Agarwal et al 2010
  • No significant additive or synergistic interactions were observed between the administration of epidural fentanyl, epidural clonidine and combined epidural fentanyl plus clonidine with regards to morphine given via iPCA Eisenach et al 1994
  • Epidural opioids vs systemic opioids/placebo study details
    Click here for more information
  • Epidural opioid vs IT opioid study details Click here for more information
  • Epidural opioid +/- LA vs epidural opioid or LA study details Click here for more information
  • Comparative studies of different epidural opioids study details Click here for more information
  • Epidural clonidine study details Click here for more information
  • Epidural opioids vs systemic opioids/placebo
  • Epidural opioid vs IT opioid
  • Epidural opioid +/- LA vs epidural opioid or LA
  • Comparative studies of different opioids
  • Epidural clonidine
  • The administration of PCEA pethidine compared with IT morphine during surgery plus IV pethidine via PCA or IT morphine during surgery plus postoperative oral paracetamol and codeine produced similar pain relief at most time points. Patients receiving epidural pethidine had a trend towards higher pain scores but also lower nausea and pruritus scores Paech et al 2000
  • Epidural butorphanol (1 mg, or 2 mg, or 4 mg) provided significantly faster pain relief compared with 5 mg epidural morphine, but the duration of pain relief and the time before remedication was significantly longer in patients receiving morphine instead of butorphanol Abboud et al 1987
  • The duration of analgesia was significantly longer in patients receiving epidural morphine compared with epidural fentanyl, buprenorphine or butorphanol. However, the incidence of pruritus was significantly higher in the morphine and fentanyl groups Ackerman et al 1989
  • Epidural butorphanol produced a longer duration of analgesia with less pruritus than epidural sufentanil, but pain scores of patients receiving sufentanil were significantly lower Bansal et al 2009
  • Epidural morphine was superior to epidural fentanyl for duration of analgesia. However patients that received fentanyl had significantly lower pain scores during the first two hours, but not afterwards Blanco et al 1987
  • The epidural administration of morphine 4 mg and combination of morphine 2 mg plus sufentanil 25 µg was superior compared to sufentanil 50 µg in pain relief between 2 and 12 h, but not before. Patients receiving sufentanil 50 µg required more frequent supplementary analgesia. The incidence of pruritus and PONV did not differ between the three groups; however, dizziness was only observed in patients receiving sufentanil alone or in combination with morphine Dottrens et al 1992
  • PCEA administration reduced drug consumption within 24 h compared with IV PCA administration for both pethidine and fentanyl. The number of PCA demands was lower with pethidine than fentanyl. Patients preferred PCEA to IV PCA administration for pethidine but not fentanyl Ngan Kee et al 1997
  • Epidural meperidine 30 mg (10 mg/mL) followed by epidural meperidine via PCA for 24 h (group 1) produced higher pain scores between 8 and 16 h compared with epidural morphine 3 mg (1 mg/mL) followed by saline via PCA for 24 h (group 2) or epidural morphine 3 mg (1 mg/mL) without saline PCEA (group 3). However, women receiving epidural morphine (groups 2 and 3) experienced nausea and pruritus more frequently Rosaeg et al 1994
  • The epidural administration of morphine bolus (5 mg) and subsequent saline infusion for 24 h compared with morphine bolus (2.6 mg) and subsequent morphine infusion (0.1 mL/h, 5 mg/24 h) produced similar pain scores and occurrence of side effects Sharar et al 1991
  • Epidural sufentanil delivered by PCA with a concomitant infusion of either sufentanil or saline produced similar pain scores overall, with significantly less pain at 6 h in the sufentanil infusion group, but not at 0,12, 18 and 24h. The incidence of PONV did not differ between the groups Vercauteren et al 1995
  • The comparison of patients receiving epidural fentanyl intraoperatively and epidural fentanyl via PCEA after surgery with patients receiving epidural morphine during surgery and saline via PCEA afterwards showed no significant difference for pain relief Yu and Gambling 1993

C-Section-Specific Evidence: IT Analgesia Continued After Anaesthesia

  • IT morphine was superior to wound infiltration with ropivacaine or placebo for reducing the consumption of supplemental analgesics Kainu et al 2012 Click here for more information
  • IT opioid versus LA wound infiltration or placebo study details Click here for more information
  • IT opioid vs epidural opioid study details Click here for more information
  • IT opioid vs LA wound infiltration or placebo
  • IT opioid vs epidural opioid
  • The administration of PCEA pethidine compared with IT morphine during surgery plus IV pethidine via PCA or IT morphine during surgery plus postoperative oral paracetamol and codeine produced similar pain relief at most time points. Patients receiving epidural pethidine had a trend towards higher pain scores but also lower nausea and pruritus scores Paech et al 2000

PROSPECT Recommendations

  • Neuraxial clonidine is not recommended (GoR D), although procedure-specific evidence suggests it provides superior analgesia, because of side effects (e.g. hypotension)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • The comparison of three doses of IT clonidine (150 µg, 300 µg and 450 µg) demonstrated a dose-dependent effect. A higher dose was significantly associated with lower pain scores and a delayed request for supplemental analgesics Filos et al 1994
  • Epidural infusion of clonidine (400 µg bolus plus 10 µg/h) and (800 µg bolus plus 20 µg/h) compared with placebo prolonged the time to first analgesic request. Only the high-dose clonidine group needed less morphine via iPCA compared with the placebo group Mendez et al 1990
  • Analgesia with bupivacaine (0.06 mg/cm body height) plus clonidine (75 µg) or plus clonidine and fentanyl (12.5 µg) was superior to bupivacaine alone. Time to first analgesic request was significantly prolonged following anaesthesia with bupivacaine, clonidine and fentanyl compared with the other groups. Intraoperative nausea-vomiting was more frequent in the group given bupivacaine alone Benhamou et al 1998
  • The administration of IT clonidine 150 µg was superior to placebo in terms of postoperative pain relief and time to first analgesic request. However, the side effects sedation, hypotension and dryness of mouth were more frequent in the clonidine group Filos et al 1992
  • Spinal bupivacaine combined with sufentanil 2 µg and 75 µg clonidine was superior to sufentanil 2 µg alone and 150 µg clonidine alone in the time to first analgesic request. However, there was no significant difference among the three groups in postoperative pain scores and in the need for supplemental analgesia Lavand'homme et al 2008
  • Spinal anaesthesia with a combination of subarachnoid morphine100 µg and clonidine at different doses compared with subarachnoid morphine100 µg alone or clonidine 150 µg alone significantly improves postoperative pain relief, but increases intraoperative sedation Paech et al 2004
  • Spinal bupivacaine plus clonidine 75 µg was superior in terms of duration of postoperative analgesia compared with spinal bupivacaine plus fentanyl 25 µg without any increase in maternal side effects Singh et al 2013
  • Spinal anaesthesia with bupivacaine 0.5% (2.2 mL) plus clonidine 75 µg was superior to bupivacaine 0.5% (2.2 mL) alone in time to first analgesic request and pain score at 1h, but not on 24h, without significant maternal and neonatal side-effects van Tuijl et al 2006
  • Neuraxial clonidine study details Click here for more information

PROSPECT Recommendations

  • Transverse abdominal incision is recommended over vertical incision (GoR A, LoE 1). Amongst transverse incisions the Joel-Cohen incision and similar modifications are superior to the Pfannenstiel incision for outcomes related to postoperative pain (GoR A, LoE 1)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • Joel-Cohen-based compared with Pfannenstiel caesarean section techniques were associated with lower duration of postoperative pain and with less use of analgesia Hofmeyr et al 2008
  • The Joel-Cohen incision was significantly superior to the Pfannenstiel incision for operative time, postoperative pain, postoperative need for supplemental analgesia, time to get out from bed and time to walk straight without support Abuelghar et al 2013
  • A systematic review of RCTs comparing different abdominal incisions showed that the Joel-Cohen incision was superior to the Pfannenstiel approach in reducing postoperative analgesic requirements, total dose of analgesia in the first 24 h and in increasing the time to first analgesic request Mathai et al 2013
  • A systematic review showed that there is little information available to inform the choice of the most appropriate surgical technique for uterine incision and uterine closure to adopt Dodd et al 2008
  • Surgical techniques study details Click here for more information

PROSPECT Recommendations

  • Non-closure of the peritoneum is recommended (GoR A) based on procedure-specific evidence for postoperative analgesia (LoE 1)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • A systematic review evaluating the effects of non-closure as an alternative to closure of the peritoneum showed that the number of postoperative analgesic doses was reduced in the peritoneal non-closure group Bamigboye and Hofmeyr 2003
  • Non-closure of both the visceral and the parietal peritoneum produced a significant reduction in pain scores and need for supplemental analgesia compared with closure Tabasi et al 2013
  • Non-closure and closure of the parietal peritoneum showed no differences in duration of surgery and postoperative pain scores. However, the non-closure group had a significantly reduced requirement for supplemental analgesia as well as shorter time to mobilisation and oral intake Altinbas et al 2013
  • Parietal peritoneal non-closure was associated with significantly lower pain scores and morphine consumption compared with closure Shahin et al 2009
  • Non-closure versus closure study details Click here for more information

PROSPECT Recommendations

  • No recommendation can be made with respect to skin closure techniques, as there is no effect on postoperative analgesia (GoR A, LoE 1)
  • Consensus agreement 100% (9/9)

C-Section-Specific Evidence

  • A systematic review assessing different effects of skin closure techniques and materials showed no conclusive evidence about how the skin should be closed after caesarean section Mackeen et al 2012
  • Techniques and materials for skin closure study details Click here for more information