BJA Education, 22(5): 197e203 (2022)

doi: 10.1016/j.bjae.2021.12.008
Advance Access Publication Date: 8 March 2022

Matrix codes: 1D02,

2E01, 3B00

Analgesia for Caesarean section

G. Neall1, S. Bampoe2 and P. Sultan3,*
1
Northwick Park Hospital, London, UK, 2Centre for Perioperative Medicine, University College London,
London, UK and 3Stanford University School of Medicine, Stanford, CA, USA
*Corresponding author. psultan@stanford.edu

Keywords: analgesia; Caesarean section; obstetrics

Learning objectives Key points

By reading this article, you should be able to:
 Plan an effective, context-appropriate, opioid-
sparing, multimodal analgesic strategy for
women undergoing Caesarean section.
 Explain the importance of optimum analgesia in
promoting enhanced recovery after elective and
emergency Caesarean section performed under
neuraxial or general anaesthesia.
 Describe the importance of tailoring analgesia
regimens according to the individual patient’s
experience and expectations.
Caesarean section (CS) is one of the most common surgical
procedures, with an estimated 29.7 million procedures per-
formed worldwide in 2015.1 A recent report from the National
Obstetric Anaesthetic Database shows that, on average,
Georgina Neall BA BSc MA FRCA is a specialty registrar in anaes-
thesia at Northwick Park Hospital, London, with interests in ob-
stetric anaesthesia, orthopaedics and trauma and medical education.
Sohail Bampoe BSc MSc FRCA is an honorary associate professor at
the Centre for Perioperative Medicine, University College London. He
is the National Institute for Health Research Clinical Research
Network North Thames specialty group lead in anaesthesia, peri-
operative care and pain, and director of the trainees with an interest
in perioperative medicine group.
Pervez Sultan, FRCA, MD (Res) is an associate professor of obstetric
anaesthesiology at Stanford University School of Medicine and an
Arline and Pete Harman endowed faculty scholar of the Stanford
Maternal and Child Health Research Institute. His research interests
include defining, characterising and measuring postpartum
recovery.
 Effective analgesia with minimal adverse effects
promotes maternal functional recovery and op-
timises maternaleneonatal bonding.
 Pain after Caesarean section consists of visceral
and somatic components and should be managed
holistically.
 Analgesia after Caesarean section should include
multimodal opioid-sparing strategies.
 Optimal analgesia should balance the benefits of
analgesia with the risk of adverse effects.
182,601 CS were performed each year in the UK between 2009
and 2014.2
Caesarean section differs significantly from other surgical
procedures in that its performance and the quality of post-
operative recovery have implications for two individuals: the
patient and their infant.
It is a unique procedure given the imperative for a mother
to tend her neonate in the immediate postoperative period.
Caesarean section is a major abdominal surgery, associated
with moderate-to-severe postoperative pain. If poorly
managed, this postoperative pain may not only impair the
mother’s experience and satisfaction, but it may also carry a
significant burden of morbidity.3 The consequences of inad-
equate analgesia include delayed mobility with increased risk
of thromboembolism, longer hospital length of stay and
greater likelihood of hyperalgesia and chronic pain, associ-
ated with the risks of long-term opioid use and dependency.
The experience of pain after CS can compromise maternal
ability to care for and interact with the neonate, impair
maternaleneonatal bonding, reduce the likelihood of suc-
cessful breastfeeding and may also contribute to postnatal
depression.3
This article summarises recent guidance and evidence
regarding the provision of optimal analgesia after elective and
non-elective CS in contemporary practice.

Accepted: 16 December 2021

© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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Analgesia for Caesarean section

Measures of postpartum pain
A fundamental goal in the management of analgesia after CS
is to retain the mother’s ability to care for her infant, unim-
paired by either pain or adverse effects of analgesic medica-
tions. Analgesia therefore constitutes an important aspect of
enhanced recovery after CS.4,5 When assessing analgesic ef-
ficacy, pain should be considered part of a holistic evaluation
of experience after surgery and postpartum recovery.
Commonly used metrics of postpartum pain include static
and dynamic pain severity scores at different time points,
area-under-the-curve analyses of pain severity scores, time
until first request for analgesics and requirements for sup-
plemental opioids. However, there has been a recent move
away from measuring pain in isolation in the perioperative
setting. The Brief Pain Inventory (Short Form) was recently
identified as the best available multidimensional patient-
reported outcome measure of postpartum pain.6 The Obstet-
ric Quality of Recovery-10 questionnaire is another patient-
reported outcome measure, which includes the assessment
of pain within its evaluation of global postpartum recovery
during inpatient hospitalisation after all delivery modes.7,8
Multimodal analgesia for Caesarean section
Multimodal analgesic strategies target multiple central and
peripheral pain pathways to reduce both the somatic and
visceral nociception associated with pain after CS. An ideal
analgesic regimen after CS should provide high-quality
maternal analgesia with minimal adverse effects, facilitating
a prompt return to normal function. Ideal properties of a
multimodal analgesic strategy for CS are summarised in
Table 1.
Prescribing different classes of systemic analgesics with
synergistic actions reduces the required dosage of any single
agent and can, in particular, reduce reliance on systemic
opioids.9 A multimodal regimen may include the following
elements, which will be explored in greater detail:
(i) Central neuraxial block (CNB; local anaesthetic [LA] with
long-acting intrathecal [IT] or epidural opioids) or general
anaesthesia (GA) with LA abdominal wall techniques.
(ii) Postoperative analgesia:
(a) Scheduled non-opioid oral analgesia
(b) Rescue oral opioid analgesia
(c) Medications to manage the adverse effects of opioids
An example of a multimodal analgesia regimen that could
be considered in patients undergoing CS is provided in Fig. 1.
Central neuraxial block
Neuraxial anaesthesia is the gold-standard technique for CS as
recommended by professional societies, including the Obstetric
Anaesthetists’ Association, the Society for Obstetric Anesthesia
and Perinatology, the American Pain Society and the National
Institute for Health and Care Excellence (NICE).5,10
The combined use of neuraxial (either via the IT or epidural
routes) LA and opioids is recommended for intraoperative
anaesthesia, but importantly it also provides postoperative
analgesia.
There remains much debate about the choice of neuraxial
opioid, optimal dosing strategies and the effectiveness of
additional non-opioid adjuncts. Until recently, the preferred
neuraxial opioid in the UK was diamorphine because of its
quicker onset of action and a lower theoretical risk of respi-
ratory depression, pruritus, sedation and nausea compared
with IT preservative-free morphine. However, problems with
supply have obliged many UK hospitals to modify their anal-
gesic protocols towards European and American practice of
using preservative-free morphine with fentanyl. Intrathecal

Table 1 Properties of an ideal multimodal analgesic strategy for Caesarean section. CNB, central neuraxial block; ERAS, Enhanced
Recovery After Surgery; QLB, quadratus lumborum block; TAP, transversus abdominis plane.

Subgroup Features

Maternal Effective acute-phase analgesia promotes prompt return of:

(i) Mobility
(ii) Oral intake
(iii) Normal bowel function
(iv) Micturition: Trial without urinary catheter
(v) Activities of daily living
Few adverse effects: inactive metabolites (no nausea, vomiting, sedation, pruritus, constipation or
respiratory depression)
Readily available after discharge home
Little risk of dependency (especially long-term opioids)
Minimal risk of hyperalgesia or chronic pain
Maternaleneonatal Promotes maternaleneonatal bonding
Promotes breastfeeding
Minimal transfer in breast milk
No neonatal adverse effects
Expertise Mainstream techniques (CNB, TAP, QLB, wound infiltration and wound catheters)
Low risk/easily performed procedures
Multidisciplinary team approach (analgesics given easily during inpatient stay)
Resource Promotes ERAS programme for reduced hospital length of stay
Affordable and cost-effective
Available, easily managed medications
Inexpensive consumables

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 Analgesia for Caesarean section

Anaesthetic Spinal with Epidural with opioids General anaesthesia

intrathecal opioids Diamorphine 2–3 mg
Diamorphine 300 mcg or
or Morphine 1–3
Morphine 50–150 mg+fentanyl 50–100 mcg
mg+fentanyl 15 mcg

After delivery
Paracetamol 1 g i.v. Morphine i.v.
Intraoperative

Diclofenac 75 mg i.v. or 100 mg p.r. as required

or ketorolac 15–30 mg i.v.

Asleep TAP, QLB,

wound infiltration or
wound catheters

Regular simple analgesics

Paracetamol 1 g p.o. or i.v. 6–8 hourly
Postoperative

Ibuprofen 400–600 mg p.o. 6 hourly

Breakthrough pain
Morphine 10 mg p.o. 4 hourly or i.v. as required
PCA opioid
with or without rescue
Dihydrocodeine 30 mg p.o. 6 hourly as required
TAP/QLB block
(Anti-emetics/laxatives/antipruritics to manage adverse effects)

Fig 1 Example of an algorithm summarising strategies for opioid-sparing multimodal analgesia after Caesarean section. For all medications, avoid use if con-
traindicated. QLB, quadratus lumborum block; TAP, transversus abdominis plane; PCA, patient-controlled analgesia.

morphine (ITM) in combination with fentanyl is widely
regarded as an effective and safe alternative to diamorphine
for CS analgesia.11 Evidence suggests minimal differences in
efficacy and adverse effects between IT morphine and
diamorphine.12,13
Pharmacokinetics of intrathecal opioids
Fentanyl is highly lipophilic, causing it to diffuse rapidly out of
the CSF into lipid-rich receptor and non-receptor sites (such as
myelin, epidural fat and white matter), producing its rapid
onset of action. However, because of its high pKa, ion trapping
occurs and only 8% of the dose is available to receptors within
the CNS grey matter.
In comparison, diamorphine is less lipid soluble, so it dif-
fuses more slowly out of the CSF. Its lower pKa allows 34% of a
dose to reach the dorsal horn of the spinal cord. Here, ester-
ases within the grey matter metabolise diamorphine to water-
soluble 6-monoacetyl morphine and morphine molecules.
These factors result in a relatively long analgesic effect.
Morphine is the least lipophilic of the opioids used
commonly via the IT route. It has the slowest rate of diffusion
into lipid-rich sites and therefore the slowest onset of action.
It demonstrates a lower affinity for non-receptor sites and
therefore remains within the CSF, facilitating more cephalad
spread. Therefore, morphine has a theoretically greater po-
tential for delayed respiratory depression, although there is
little evidence for this potential with doses used in contem-
porary practice.14
Dosage of long-acting neuraxial opioids
The optimal IT opioid dose is likely to be patient specific,
balancing optimal pain relief with minimal incidence of
adverse effects, including pruritus, nausea and vomiting and
respiratory depression.
A study by Carvalho and colleagues demonstrated that
patients contribute valuable information to the planning of
their postoperative analgesia. Women were offered a choice
between a higher (200 mcg) or a lower dose (100 mcg) of ITM,
with the rationale explained to the patients before receiving
the drug (the higher dose produces better analgesia but carries
a greater risk of nausea and adverse effects). Parturients were
then randomised to receive either the higher or the lower dose
and were unaware that their preferred dose was not given.
Predictably, women choosing the higher dose (i.e. women who
were more concerned about pain) tended to require greater
amounts of supplementary postoperative opioids, whatever
dose of IT opioid they had actually received. There were no
significant differences in pain scores or supplementary opi-
oids between women receiving high and low doses, possibly
because of an ‘analgesic ceiling’ effect beyond which there
may be no additional benefit. Of the women who chose the
lower dose, most cited fear of nausea as their main reason for
selecting this dose. However, there was also no difference in
the rates of reported nausea, but the low-dose preference
group required more rescue anti-emetics.15
A meta-analysis by Sultan and colleagues comparing low-
dose ITM (50e100 mcg) with high dose (>100e250 mcg)

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Analgesia for Caesarean section
found no differences between the two dose groups in pain
scores at 12 and 24 h or in the requirement for supplementary
systemic opioids.16 However, the lower dose was associated
with reduced incidence of nausea and vomiting with an odds
ratio of 0.44 (95% confidence interval: 0.27e0.73), and the
higher dose was associated with an increased incidence of
pruritus. There were no apparent differences in fetal out-
comes (Apgar scores or umbilical artery pH) and no cases of
maternal respiratory depression in either arm of the 11
studies included. Although the higher-dose group had a
longer mean duration of analgesia (time from ITM to first
supplemental opioid; primary outcome of the study) of 4.5 h
compared with the low-dose group, this was at the expense of
more adverse effects. Lower-dose regimens are therefore
likely to be effective, although further studies are needed to
evaluate the optimum dose for specific patient groups, such as
patients with chronic pain, opioid dependency and previous
experience of severe pain after CS.
Guidance from the UK NICE (2004) recommends 300e400
mcg of IT diamorphine or 2.5e5 mg via the epidural route.10
More recently, the European procedure-specific post-
operative pain management (PROSPECT) collaboration, using
meta-analysis data from RCTs since 2014, published guide-
lines recommending lower neuraxial doses.3 These guidelines
recommend 300 mcg of IT diamorphine or 50e100 mcg of ITM
or 2e3 mg of either epidural morphine or diamorphine. The
Society for Obstetric Anesthesia and Perinatology (SOAP) has
published an enhanced recovery after CS consensus state-
ment recommending ITM doses of 50e150 mcg or epidural
morphine doses between 1 and 3 mg.5
Respiratory depression after long-acting neuraxial
opioids
Respiratory depression is perhaps the greatest concern related
to the use of long-acting neuraxial opioids. However, a recent
review of 78 international studies published between 1990 and
2016 reported that respiratory depression was rare in obstetric
patients with an estimated prevalence of 1.08e1.63 per 10,000
women experiencing clinically significant respiratory depres-
sion after contemporary doses of long-acting neuraxial opioids
T7
T8
Thoracoabdominal
T9
nerves
T10
T11
Subcostal nerve T12
Iliohypogastric nerve
L1
Ilioinguinal nerve
Fig 2 Diagram showing the nerves supplying the incisions used commonly for CS. ASIS, anterior superior iliac crest; ICL, intercristal line; SP, symphysis pubis.
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(ITM 150 mcg or epidural morphine 3 mg; IT diamorphine
400 mcg or epidural diamorphine 5 mg).17
Neuraxial adjuncts
There has been much interest in non-opioid IT adjuncts for
analgesia after CS, but consistent evidence supporting their
use is lacking and concerns remain over undesirable adverse
effects. Adjuncts investigated in the CS setting include
buprenorphine, midazolam, neostigmine, ketamine and a2
agonists (clonidine and dexmedetomidine). None of these
adjuncts are recommended for routine use after CS and none
were included in the recent PROSPECT recommendations.3
General anaesthesia for Caesarean section
Whilst neuraxial techniques are the preferred and most
frequently used mode of anaesthesia for CS, there are situa-
tions that may necessitate GA, such as contraindications to
neuraxial anaesthesia, patient’s preference and urgency of
delivery. Caesarean section under GA is relatively uncommon,
accounting for approximately 8% and 6% of deliveries within
the UK and US healthcare settings, respectively.2 General
anaesthesia for CS is associated with worse postoperative pain,
as it is not usually possible to use long-acting neuraxial opi-
oids.18 Postoperative analgesia after GA frequently involves
giving opioids i.v. via a PCA device. In the absence of neuraxial
opioids, abdominal wall plane blocks, wound infiltration and
wound catheter techniques have all been shown to provide
superior analgesia when compared with placebo, and therefore
should be considered in this setting.3,19,20 The nerves supplying
incision sites used for CS are depicted in Fig. 2.
Common local anaesthesia techniques for
Caesarean section
Transversus abdominis plane blocks
Transversus abdominis plane (TAP) blocks are the most
studied truncal nerve blocks in patients undergoing CS. The
landmark technique has been largely superseded by the
ICL
ASIS
Joel-Cohen
Midline
Pfannenstiel
SP

ultrasound-guided (anterior subcostal, lateral and posterior)
approaches. Meta-analysis data demonstrate that a more
posterior injection site may produce superior and more pro-
longed analgesia compared with lateral TAP blockade.21 When
long-acting IT opioids are not used, TAP blocks have been
shown to confer better analgesia after CS in three meta-
analyses involving data from 20 published RCTs.20 Trans-
versus abdominis plane blocks should therefore be considered
if long-acting neuraxial opioids are not given. Recently, TAP
blocks using liposomal bupivacaine were shown to provide
prolonged analgesia in patients receiving ITM, but this finding
remains a novel technique and requires further study.22
Because of the limited duration of action of TAP block
when long-acting opioids and multimodal analgesia are used,
it may currently be better suited as a rescue technique (for
severe breakthrough postpartum pain or women requiring
escalating doses of opioids to control their pain), rather than
as a routine block offered to all patients.20 Bilateral large-
volume blocks of vascular fascial planes can carry a higher
risk of LA systemic toxicity (LAST). A meta-analysis of 14
studies comparing the safety and efficacy of high-dose (>50
mg of bupivacaine equivalents per side) vs low-dose (50 mg
per side) LA for TAP blocks in the CS setting demonstrated that
lower doses (20 ml of 0.25% bupivacaine for each side) were
associated with similar analgesia compared with higher doses
and should therefore preferentially be utilised to minimise the
risk of LAST.23
Quadratus lumborum blocks
Quadratus lumborum block (QLB) describes a group of three
ultrasound-guided approaches that deposit LA onto the lateral,
posterior and anterior surfaces of the quadratus lumborum
muscle, posterior to the transversalis fascia. Xu and colleagues
performed a meta-analysis of data pooled from 12 studies,
which demonstrated a significant reduction in 48 h opioid
consumption with QLB in the absence of long-acting neuraxial
opioids and lower 12 h resting pain scores compared with
placebo or no block.24 However, subgroup analysis of different
QLB approaches was not possible because of the lack of studies
utilising the lateral and anterior approaches.24
QLB compared with TAP block
A recent network meta-analysis compared the efficacy of QLB
with TAP blocks and found that, in the absence of IT opioids,
these two blocks were consistently better than the control
group at reducing pain scores and systemic opioid consump-
tion after CS.25 There were no significant differences demon-
strated for analgesia-related outcomes between TAP and QLB
techniques. When combined with IT opioids, there was no
benefit demonstrated with either QLB or TAP block, once more
suggesting that the benefit of these techniques remains
largely confined to CS performed under GA, where long-acting
neuraxial opioids are precluded (because of the urgency of
delivery, allergy or in low-resource settings with lack of
preservative-free opioids or adequate monitoring capabilities)
and for rescue analgesia.25
Miscellaneous abdominal wall blocks
Other abdominal wall blocks have been described, including
ilioinguinal and iliohypogastric, erector spinae plane and
rectus sheath blocks. However, evidence supporting their
benefit after CS is lacking, and further studies and future
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Analgesia for Caesarean section
meta-analyses are needed to help determine their efficacy,
with or without neuraxial opioids and with concomitant use
of multimodal analgesic regimens.
Wound infiltration and wound catheters
Regional analgesia offers clear benefits for mothers after CS
when neuraxial opioids are not given. However, its safe de-
livery depends on many factors, including the practitioner’s
expertise. Patient-specific characteristics, such as extremes of
habitus or previous abdominal surgery, can make the perfor-
mance of truncal blocks more challenging. In addition to
generic risks (infection, bleeding, i.v. injection and allergic
reaction), block-specific risks should be anticipated by the
practitioner and explained to the patient. Resource-poor
countries may not have reliable access to high-quality ultra-
sound equipment or consumables necessary to perform the
aforementioned abdominal wall blocks. In these situations,
wound infiltration is a viable alternative that has been
demonstrated to provide superior analgesia compared with
placebo in the absence of long-acting neuraxial opioids. A
network meta-analysis demonstrated that TAP blocks, wound
infiltration and wound catheters were all superior to placebo
in the absence of long-acting neuraxial opioids, but no dif-
ferences were demonstrable between TAP blocks and either
wound infiltration or wound catheter techniques.19
Postoperative analgesia
A postoperative prescribing regimen must consider surgical
pain but also iatrogenic discomfort, such as nausea and
vomiting, itching and constipation. An opioid-sparing
approach should reduce the incidence of these problems
and typically relies on regular paracetamol and NSAIDs,
which should be given unless contraindicated.26
Paracetamol prescribed regularly significantly decreases
the amount of opioids required compared with when
paracetamoleopioid combination analgesics are given, as
requested.27 A meta-analysis by Zeng and colleagues
demonstrated lower pain scores, less opioid use (with fewer
opioid-related adverse effects) and increased patient satis-
faction scores with administration of regular systemic NSAIDs
compared with control.28 When used together, paracetamol
and NSAIDs have a marked synergistic effect with signifi-
cantly better pain scores compared with single-agent use in
the non-obstetric setting.29,30
Although doses and agents may vary in different countries,
a typical analgesic regimen after neuraxial opioid adminis-
tration could include:
(i) 6e8 hourly i.v. or oral paracetamol 1 g commencing 6e8
h after the intraoperative dose
(ii) 6-hourly oral ibuprofen 400e600 mg unless contra-
indicated, commencing 6e8 h after the dose of intra-
operative diclofenac or ketorolac
(iii) For breakthrough pain, 4-hourly oral opioids, such as
oral morphine 10e20 mg or 6-hourly oral dihydrocodeine
30 mg, should be offered to women.
Anti-emetics, antipruritics and laxatives should also be
prescribed to manage opioid-induced adverse effects, such as
nausea, vomiting, pruritus and constipation.31
In the absence of IT or epidural opioids, PCA analgesia may
be required. However, in the presence of robust multimodal
analgesic strategies, regular oral medication may be
BJA Education - Volume 22, Number 5, 2022 201
Analgesia for Caesarean section
sufficient, with the advantage of minimising opioid use. In
addition, PROSPECT guidance suggests considering rescue
abdominal wall blocks if pain is refractory.3
In the presence of long-acting neuraxial opioids (ITM
50e150 mcg), the SOAP recommends that patients should be
monitored (ventilatory frequency and sedation) 2 hourly for 12
h.32 A risk-stratification approach with more frequent and
longer respiratory monitoring is recommended for high-risk
patients (every hour for 12 h, then every 2 h for 12e24 h).32
High-risk situations include those situations with cardiovas-
cular or neurological comorbidity, obstructive sleep apnoea or
pre-eclampsia/hypertension, chronic opioid use, administra-
tion of systemic sedatives or magnesium and GA or a peri-
operative desaturation event.32
Transfer to breast milk
Fetal and neonatal transfer of analgesic agents must be
considered when prescribing analgesic medications in the
peripartum setting. This transfer includes transplacental
transfer before delivery or via breast milk after delivery.
Agents that cause adverse effects for the neonate, such as
sedation and respiratory depression, should be used with
caution.
There are isolated cases where codeine has been impli-
cated in unexpected infant fatalities when given using stan-
dard doses in patients who are ‘ultra-rapid’ metabolisers of
the drug. The Medicines and Healthcare products Regulatory
Agency, the European Medicines Agency and the US Food and
Drug Administration (FDA) all advise against using codeine in
breastfeeding mothers; the FDA also recommends avoiding
tramadol. However, the UK Drugs in Lactation Advisory Ser-
vice states that both dihydrocodeine and tramadol may still be
used, with concomitant monitoring of the neonate for seda-
tion, breathing difficulties, constipation, poor feeding or
reduced weight gain, and recommends additional monitoring
for preterm or other high-risk neonates.33
Summary
Currently, an ideal strategy for analgesia after CS involves a
multimodal approach. Given the variable and highly sub-
jective nature of pain, the provision of analgesia after CS
should be tailored to meet the requirements of individual
patients. The overall strategy should account for the
procedure, desired postoperative maternal and neonatal re-
covery outcomes and, most importantly, the needs and ex-
pectations of the patient. Analgesia regimens need to
balance the benefits of adequate dosing to optimise anal-
gesic duration against the risk of subsequent development of
adverse effects for mother and neonate. A holistic approach
to analgesia for CS can ultimately help to optimise maternal
and neonatal recovery.
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
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