Hello, I am Beth Ann Clayton, and I welcome you to the postoperative analgesia presentation. The learning objective for this presentation is to discuss anesthetic considerations for cesarean delivery related to postoperative pain control. I have no financial relationships with any commercial interest related to the content of this activity, and I will not discuss off-label use during my presentation. The rate of cesarean deliveries continues to rise globally, with the most recent data showing that they account for 21.1% of births worldwide. Projections indicate that this rate will reach 28.5% by 2030. In the United States, 32.2% of births in 2022 occurred via cesarean delivery, accounting for 1,179,000 births. Therefore, due to the large population undergoing cesarean delivery, the need for efficient pre- and postoperative protocols to improve maternal outcomes, such as pain management, is increasingly relevant. Inadequate pain control in the postpartum maternal patient can have immediate consequences, including impaired breastfeeding and decreased ability to care for the newborn. These circumstances can affect mother-baby bonding negatively. In addition, acute pain can impair maternal mobility. A recent prospective study compared surgical delivery versus vaginal delivery. Despite optimal postoperative analgesia, cesarean delivery was associated with a 44% decreased rate of early ambulation. The hypercoagulable state of the maternal patient and decreased mobility placed the patient at risk for thrombolic events. Inadequate pain can also contribute to the development of postpartum depression and chronic pain. Acute pain, independent of the type of delivery, is predicted for a three-fold increased risk of postpartum depression and a two-and-a-half-fold increased risk of persistent pain at two months post-delivery. Chronic post-surgical pain is pain that persists at least three months after surgery. That pain was not present before surgery and the pain has different characteristics or increased intensity from the preoperative pain. The pain is also localized to the surgical site or referred area with all other possible causes excluded. The definition of chronic post-surgical pain was standardized in 2019 after the inclusion in the new International Classification of Diseases 11th edition. The ICD-11 chronic post-surgical pain definition is pain that develops or increases in intensity after a surgical procedure or tissue injury. The incidence of chronic post-surgical pain in cesarean delivery ranges from 6% to 55%. The rate of severe chronic post-surgical pain due to a cesarean delivery ranges from 5% to 10%. The chronic post-surgical pain can arise from three contributing factors, including central sensitization, neuropathic pain induction, and hyperalgesia. Higher levels of pain in the acute postoperative period have consistently been found to predict pain weeks and months after surgery. This association has been replicated in many surgical cohorts. It has been found that higher pain scores in the immediate 24-hour post-cesarean section period is identified as a risk factor for the development of chronic pain. A meta-analysis in 2016 found that the frequency of cesarean delivery has dramatically increased in recent years. On average, every third child in the United States and every fourth child in Europe is delivered by cesarean delivery. This particular meta-analysis was based on 15 studies, including over 4,000 patients, and it found that clinically relevant incidence of chronic post-surgical pain after cesarean delivery ranged from 15% at 3 months to 11% at 6 to 12 months. The severity of pain at 6 months was most frequently in the mild range, with almost 50% being mild, and then moderate range at 23% and severe at 9.6%. Postpartum women are commonly prescribed opioids at the time of hospital discharge. This particular study demonstrated that approximately 30% of women who have a vaginal delivery are prescribed opioids at the time of discharge, and approximately 87% of women undergoing cesarean delivery receive a post-discharge prescription for opioids. The wide range of morphine dose prescription at discharge, regardless of the type of delivery, suggests that there is a lack of standardization in pain management practices. A 2018 study in the Journal of Obstetric and Gynecology Research found that patients were being discharged with prescriptions for a medium number of 60 opioid tablets, but were only taking 32 of the tablets. A different study analyzed the opioid prescribing patterns after cesarean delivery and demonstrated that the number of prescribed tablets exceeded the number of opioid tablets consumed by a significant margin. This leads to a substantial amount of excess opioid medication available for possible diversion. When were dispensed, a larger number of opioid tablets consumed a number of higher opioid tablets as well, independent of the pain severity at discharge and patient characteristics. Then they found that there was no association between patient satisfaction with pain control and the number of tablets they had used. This prospective study, although it involved a small number of patients, pointed out that important educational problems relative to opioid prescription by caregivers and opioid consumption by postpartum women. Cesarean delivery is considered a source of opioid exposure in a large population of young and often opioid-naive women. A large cohort study demonstrated that approximately 1 in 300 women undergoing cesarean delivery become persistent prescription opioid users. Numerous studies demonstrate that multimodal pain management is superior to unimodal pain management in the treatment of acute post-surgical pain. Consistent extension of these findings to clinical practice in obstetric postoperative care should be made. However, variations continue to exist regarding treatment of post-cesarean pain. The Society for Obstetric Anesthesia and Perinatology recommends that a standardized clinical care pathway, such as an enhanced recovery protocol, be utilized by the institution and all obstetric anesthesia providers. A multimodal analgesia protocol should include low-dose, long-acting, norexial opioids. In addition, scheduled supplemental multimodal oral analgesics, such as nonsteroidals and acetaminophen, and the ability to provide local anesthetic wound infusions or regional nerve fascial plane blocks if needed. The institution should make an effort to minimize opioids by limiting the rescue opioid doses to less than 30 mg of oxycodone in a 24-hour period and utilize non-opioid rescue analgesic options such as tap blocks or gabapentin. In addition, efforts should be made to limit the number of opioid tablets the patient is discharged with to 20 to 30 tablets. The AANA Analgesia and Anesthesia for the Obstetric Patient Evidence-Based Practice Guidelines also recommend multi-analgesia for the most effective means of providing optimum post-cesarean pain control. By administering a combination of medications from different classes with different mechanisms of action, you are able to provide the greatest analgesic efficacy. The synergistic effect of individual analgesics decreases opioid and total drug requirements and decreases the opioid-induced side effects, also decreasing the transfer of individual drugs into the breast milk. The guidelines recommend scheduled nonsteroidals and acetaminophen with a one-time dose of dexamethasone and the minimal amounts of opioids, and as needed, local anesthetic infiltration. Neuraxial opioids provide superior postoperative pain relief compared to IV opioids. One should administer the minimum effective dose of neuraxial opioids. As research has demonstrated, higher doses may increase side effects without analgesic improvement. Neuraxial morphine is the gold standard. The recommended doses are 100 to 150 mics intrathecal or 2 to 3 milligrams via the epidural. The duration of morphine in the neuraxial space is 12 to 24 hours. You may consider the addition of fentanyl for acute pain management at the 3 to 4-hour window. Intrathecal fentanyl recommendation is 10 to 25 mics, recognizing that studies have demonstrated greater than 15 mics intrathecal can cause an increased incidence of puritis and nausea and vomiting. If you administer fentanyl via the epidural space, it is recommended at 50 to 100 mics. If the patient is allergic to morphine, you may consider the addition of preservative-free hydromorphone. The intrathecal dose of hydromorphone is 75 to 100 mics. Again, be sure to use preservative-free. The duration of action of hydromorphone is a little bit shorter at 6 to 24 hours. Non-steroidal anti-inflammatories produce a 30 to 50% decrease in effective opioid dose. It is recommended that they be administered scheduled versus PRN dosing in order to provide greater postoperative pain control and higher patient satisfaction. Antibiotic may be administered 30 milligrams at the end of the case and repeated every 8 hours. You may convert to ibuprofen once the patient is able to take oral meds, and the oral ibuprofen recommendation dosage is 600 to 800 milligrams every 6 to 8 hours. Acetaminophen produces a 10 to 20% decrease in effective opioid dose. It has a synergistic effect with non-steroidal administration. It is recommended that after the first dose, there is not a significant advantage to administering IV aminocytophen over oral. Therefore, the first dose can be 1 gram IV and discontinue once the patient is able to take oral medication. The oral dose of acetaminophen ranges from 650 to 1,000 milligrams every 6 to 8 hours, not to exceed 3,250 milligrams per day. You may consider the administration of dexamethasone. It provides a minor decrease in postoperative pain and decreases postoperative nausea and vomiting. Dexamethasone has a potential to increase blood glucose levels, but there is no demonstrated effect on infection or wound healing. The recommended dose for dexamethasone is 8 milligrams, one time in a 24-hour period. You want to administer it following umbilical cord clamp, since it can increase the maternal blood glucose levels transferring to the fetus. If the patient is diabetic, consider a discussion with the obstetrician as well to determine if dexamethasone is a good option for the patient. Extended use of opioids changes the structure of the nerve cells in the brain. When an individual stops using opioids abruptly, the body will react, leading to symptoms of withdrawal. Patients with opioid use disorder are treated with medication-assisted treatment, including drugs such as methadone, buprenorphine, and naltrexone. Research has demonstrated that opioid-dependent women have a 70% increase in opioid analgesic requirements following cesarean delivery for women on methadone, and a 47% increase for women on buprenorphine maintenance therapy. Therefore, non-opioid adjuncts are essential for analgesic regimes in these patients. Patients with opioid use disorder or pre-existing chronic pain may have more difficulty with pain management. Therefore, you may consider the one-time dose of ketamine or gabapentin to provide additional analgesia. The recommended ketamine dose is 10mg or 0.15mg per kilo given IV preoperatively. The recommended dose for gabapentin is 600mg orally given preoperatively. It is not recommended to administer gabapentin in the postoperative period because of the high sedation rate and the need for the maternal patient to care for the newborn. Improved blocks and wound infiltration of local anesthetic is inferior pain control compared to neuraxial opioids. If you are unable to administer neuraxial morphine or neuraxial hydromorphone, it is recommended to administer a TAP block or QL block. However, the addition of a TAP or QL block to spinal morphine does not definitively improve pain control and therefore is not recommended on a regular basis. The TAP block and the QL block can provide additional analgesia for 12 hours. The local anesthetics typically used for truncal blocks include 0.25% to 0.375% bubivacaine not to exceed 2.5mg per kilo or 0.375% to 0.5% rupivacaine not to exceed 3mg per kilo. It is recommended that health care providers limit IV opioids in the immediate postoperative period. In addition, oral opioids should be limited during the entire hospital stay, not exceeding more than 30mg of oxycodone in a 24-hour period. We have reviewed the evidence-based guidelines surrounding post-caesarean delivery analgesia. In order to put these evidence-based practice guidelines into action in your facility, the best way is to gain team consensus among obstetric providers, nursing, and anesthesia and create a standardized order set that everyone can follow. Over the next few slides, I will provide examples of perioperative order sets including post-caesarean delivery analgesia care. On this first slide, you see with the preoperative orders that there is an order for acetaminophen to be given either orally 975mg or via suppository at 975mg. In the postoperative order set, you can see that you should start acetaminophen 4 hours after the post-order set has been entered. And since you gave Keterolec at the end of the surgery, one should start the oral ibuprofen 8 hours after the post-order set has been entered. Patients that may have a risk for difficult pain management may include a preoperative order set for the administration of gabapentin and postoperative order sets that include the administration of a lidoderm patch or PCA. In addition, anesthesia could provide a TAP or QL block. Once patients are ready to be discharged, it's important that they understand that they need to have a pain management plan to go home with in order to help minimize their pain, facilitate healing, and allow them comfort while moving and performing their daily living activities. The discharge order set should continue to follow the scheduled ibuprofen and scheduled acetaminophen with only using oxycodone for breakthrough pain if needed. The patient should understand that they should stay on this scheduled regime for at least 3 to 7 days after discharge from the hospital. This is an example of a visual discharge plan for post-caesarean delivery patients. It includes scheduled dosing of acetaminophen and ibuprofen, providing the doses and the timing, and recognizing that oxycodone should only be used for intolerable breakthrough pain. In conclusion, severe postpartum pain after caesarean delivery occurs at a higher rate than anticipated. Postoperative pain interferes with maternal early and late functional recovery, newborn feeding, and mother and baby bonding. Therefore, controlling acute postoperative pain is essential to allow early recovery and prevent persistent health problems. Research demonstrates multimodal analgesia provides optimal post-caesarean pain management and is recommended by a professional organization's evidence-based practice guidelines, including the AANA and the Society of Obstetric Anesthesia and Perinatology. Creation of a standardized order set for inpatient and discharge home can help facilitate implementation of these recommendations. Thank you for your attention to this important topic.

postoperative pain management

cesarean deliveries

multimodal analgesia

opioid prescription

standardized care pathways