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Cesarean delivery (CD) is the most common surgical procedure in the world.1 Inadequate pain control can interfere with care for the neonate, negatively affects bonding and breastfeeding between mother and newborn, and is an unsatisfactory anesthetic outcome.2,3 Multimodal analgesia is an ideal approach.


  • Early ambulation

  • Unhindered care for newborn

  • Minimal side effects: nausea, sedation, pruritus

  • Safe with breastfeeding


Multimodal analgesia can include (Table 55-1):

  • Opioid: neuraxial versus systemic

  • Nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Acetaminophen

  • Ketamine

  • Dexmedetomidine

  • Peripheral nerve block: quadratus lumborum (QL) or transverse abdominis plane (TAP) block

  • Oral gabapentin

  • Low thoracic epidural

TABLE 55-1Analgesia Options for Post-CD


  • Opioid

    • Neuraxial opioids: the most effective form of postoperative analgesia for CD.3 It is superior to systemic opioids after CD.

      • Preservative-free morphine: last up to 24 hours.

      • Dose: Intrathecal: 150 to 250 µg; epidural: 3 mg after cord clamp.

    • Systemic opioids: hydromorphone patient control analgesia (PCA) preferred for patients unable to receive neuraxial morphine (e.g., general anesthesia, patients with opioid use disorders).

  • NSAIDs

    • Medication choice and dose: ketorolac 15 to 30 mg IV Q6H for 24 hours then ibuprofen 600 mg PO (by mouth) Q6H. Round-the-clock order preferred over prn.

  • Acetaminophen

    • Acetaminophen 1 g PO or IV in the recovery room.

    • Then 1 g PO Q8H. Round-the-clock order preferred over prn.

  • Ketamine

    • 20 to 40 mg IV as a supplement for general anesthesia.

    • For chronic opioid use patient, may require ketamine infusion, dose 0.2 to 0.3 mg/kg/h postoperatively (consult acute pain service).

  • Dexmedetomidine

    • For chronic opioid use patients, consider avoiding intrathecal morphine and replacing with 10 µg intrathecal dexmedetomidine.

    • For intrapartum CD, may consider administer 10 to 20 µg dexmedetomidine via epidural in the patients who experienced multiple breakthrough pain during labor.

  • QL/TAP block

    • Ultrasound guided peripheral nerve blocks: 0.25% bupivacaine 15 to 20 mL on each side (limit 0.25 mg/kg bupivacaine). It covers T6-L1 nerve roots involved in lower abdominal surgeries, possibly 12 to 16 hours coverage.

    • Cautious use after cesarean under epidural anesthesia (local anesthetic toxicity).

  • Gabapentin PO

    • Single dose of 300 mg PO preoperatively.4


1. +
Visser  GHA, Ayres-de-Campos  D, Barnea  ER,  et al. FIGO position paper: how to stop the caesarean section epidemic. Lancet. 2018;392(10155):1286–1287.  [PubMed: 30322563]
2. +
Carvalho ...

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