A Cross‐Sectional Analysis of the Effect of Patient‐Controlled Epidural Analgesia versus Patient Controlled Analgesia on Postcesarean Pain and Breastfeeding

Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 3)-2025 update

Enhanced Recovery After Cesarean Delivery (ERAC) protocols include evidence-based interventions designed to improve maternal and neonatal outcomes and patient experiences while reducing healthcare-related costs. This is the first update to the Enhanced Recovery After Surgery Society guidelines for postoperative care in cesarean delivery published in 2019. Interventions were selected based on expert consensus. An updated literature search was performed in September 2024 using Embase, PubMed, MEDLINE, EBSCO CINAHL, Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2019 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each postoperative Enhanced Recovery After Cesarean Delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. After a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation system. The 13 recommended Enhanced Recovery After Cesarean Delivery interventions were (1) early drinking and feeding (low evidence, strong recommendation), (2) early discontinuation of intravenous fluid (very low evidence, strong recommendation), (3) early mobilization and ambulation (low evidence, strong recommendation), (4) early removal of urinary catheter (low evidence, strong recommendation), (5) scheduled acetaminophen (moderate evidence, strong recommendation), (6) scheduled nonsteroidal anti-inflammatory drugs (high evidence, strong recommendation), (7) oral rescue opioids (low evidence, strong recommendation), (8) standardized rescue medication protocol for side effects (low to moderate evidence, strong recommendation), (9) venous thromboembolism prophylaxis (low evidence, strong recommendation), (10) anemia remediation (moderate evidence, strong recommendation), (11) breastfeeding support and education (low evidence, strong recommendation), (12) promotion of rest periods (low evidence, strong recommendation), and (13) facilitate patient-centered transition to discharge (low evidence, strong recommendation). The 13 recommended postoperative interventions should be considered in the absence of contraindications in patients undergoing cesarean delivery to optimize maternal recovery and outcomes.

Percutaneous auricular neuromodulation for postoperative analgesia

INTRODUCTION

Postoperative pain is often severe, with many patients still experiencing significant pain upon discharge. While opioids are effective for pain relief, they have numerous side effects and carry a high risk for misuse and dependence. Auricular electric stimulation, a form of neuromodulation, offers a promising alternative by electrically stimulating nerves of the auricle to modulate central pain pathways, potentially reducing postoperative pain and opioid requirements.

AREAS COVERED

This review, based on a search of the MEDLINE/PubMed, Scopus, and Cochrane review online sources from 1980 to 2024, discusses the use of auricular electric stimulation as a form of neuromodulation for management of postoperative pain focusing on the available evidence and future avenues for research.

EXPERT OPINION

Percutaneous auricular nerve stimulation offers a promising neuromodulation technique for managing postoperative pain. By modulating central pain processing through peripheral stimulation, this approach may reduce pain during recovery. Small pilot studies have suggested that auricular stimulation may lower pain intensity and reduce opioid consumption after surgery; however, further research is needed regarding both potential benefits and risks. As a minimally invasive technique, percutaneous auricular stimulation may provide a valuable adjunct to multimodal analgesia, especially in patients at risk of opioid-related complications.

Influence of transcutaneous electrical nerve stimulation on pain intensity and functional activities following lower segment cesarean section

BACKGROUND

Postoperative incisional pain following lower segment cesarean section (LSCS) is one of the commonly reported complaints which may affect mother-infant bonding, and restrict mobility and functional activities.

PURPOSE

To study the influence of transcutaneous electrical nerve stimulation (TENS) on pain intensity and functional activities using the Numerical Pain Rating Scale (NPRS) and the Patient Specific Functional Scale (PSFS) following LSCS from the postoperative day (POD) 1 to POD 4.

METHODS

This quasi-experimental study consisted of 50 postpartum women who underwent LSCS and were assigned to an intervention group (IG) that received TENS and a control group (CG) that received routine hospital care.

RESULTS

NPRS scores between CG and IG (pre-TENS application) showed a statistically significant difference (ηp2 = 0.542, p < .001) from POD 1 to POD 4. Study participants showed an improvement in PSFS scores (ηp2 = 0.412, 0.488, 0.661, 0.304, 0.262, and 0.395, p < .001) in IG compared to CG for bed transitions, bed transfers, sitting, sit to stand, walking, and toileting activities respectively from POD 1 to POD 4 which was statistically significant.

CONCLUSIONS

Our study results suggest that administration of TENS following LSCS shows an improvement in pain intensity and functional activities as reported on NPRS and PSFS respectively.

[Neuraxial Morphine for Postoperative Analgesia after Caesarean Deliveries]

The use of neuraxial morphine, in combination with nonopioid analgesic regimens for postoperative analgesia after Caesarean deliveries is common practice, especially in the Anglo-American world. Neuraxial morphine offers a longer-lasting superior analgesia than intravenous opioids or patient-controlled analgesia. If neuraxial anaesthesia is being used for a caesarean delivery, it may be recommended to concomitantly administer neuraxial morphine for the postoperative analgesia.A low dose of neuraxial morphine in a healthy parturient bears a low morbidity and mortality risk. The optimal frequency, duration and modality of respiratory monitoring for patients at low risk for respiratory depression is dependent on the dose of morphine administered and the patient-specific and obstetric risk profile.

Effect of pumping pressure on onset of lactation after caesarean section: A randomized controlled study

Caesarean section is associated with weaker newborn suction pressure. This nonblinded, randomized trial explored the effect of suction pressures generating by a breast pump on mothers' onset of lactation and milk supply after caesarean section. A high pressure group (-150 mmHg), a low pressure group (-100 mmHg), and a control group (none) were generated under computer random assignment with concealed allocation in 2 tertiary hospitals. The breast pumping began within 2 hr after caesarean operation (6 times a day and 30 min per time) until onset of lactation. The primary outcomes were the timing of onset of lactation, milk supply, and mother's satisfaction in lactation, using both intention-to-treat and per-protocol analyses. The secondary endpoints were the pumping-related pain, nipple injury, and maternal fatigue. All 164 women randomized were included in analysis. The breast pumping at -150 mmHg optimally advanced the timing of the onset of lactation and increased daytime milk supply. The pumping also appeared to boost mothers' confidence in lactation. The results in the per-protocol population (n = 148) were consistent with those of intention-to-treat population (n = 164). However, the pumping aggravated maternal nipple pain and fatigue, though there was no statistical significance. The findings suggest that a higher pumping pressure within the range of normal vaginally born infant suction could promote onset of lactation and milk supply among mothers giving birth by caesarean section. The pumping could also enhance mothers' confidence in breastfeeding.

Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care

OBJECTIVE

To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation.

DESIGN

Retrospective chart review.

METHODS

Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge.

SETTING

A single clinical site that employs seven expert nurses.

PARTICIPANTS

A total of 194 medical records were available for this analysis.

RESULTS

All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038).

CONCLUSION

Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.

Closed-Incision Negative-Pressure Therapy in Obese Patients Undergoing Cesarean Delivery: A Randomized Controlled Trial

Background  Postcesarean wound morbidity is a costly complication of cesarean delivery for which preventative strategies remain understudied. Objective  We compared surgical site occurrences (SSOs) in cesarean patients receiving closed-incision negative-pressure therapy (ciNPT) or standard-of-care (SOC) dressing. Study Design  A single-center randomized controlled trial compared ciNPT (5-7 days) to SOC dressing (1-2 days) in obese women (body mass index [BMI] ≥ 35), undergoing cesarean delivery between 2012 and 2014. Participants were randomized 1:1 and monitored 42 ± 10 days postoperatively. The primary outcome SSOs included unanticipated local inflammation, wound infection, seroma, hematoma, dehiscence, and need for surgical or antibiotic intervention. Results  Of the 92 randomized patients, 82 completed the study. ciNPT and SOC groups had similar baseline characteristics. Mean BMI was 46.5 ± 6.5 and no treatment-related serious adverse events. Compared with SOC, the ciNPT group had fewer SSOs (7/43 [16.3%] vs. 2/39 [5.1%], respectively; p  = 0.16); significantly fewer participants with less incisional pain both at rest (39/46 [84.8%] vs. 20/46 [43.5%]; p  < 0.001) and with incisional pressure (42/46 [91.3%] vs. 25/46 [54.3%]; p  < 0.001); and a 30% decrease in total opioid use (79.1 vs. 55.9 mg morphine equivalents, p  = 0.036). Conclusion  A trend in SSO reduction and a statistically significant reduction in postoperative pain and narcotic use was observed in women using ciNPT.

Comparison of Breastfeeding Outcomes Between Using the Laid-Back and Side-Lying Breastfeeding Positions in Mothers Delivering by Cesarean Section: A Randomized Controlled Trial

BACKGROUND

The breastfeeding position routinely used following a cesarean section is the side-lying position. However, there have been few studies about the effect of breastfeeding positions, including laid-back position on breastfeeding outcomes.

OBJECTIVE

To compare the breastfeeding outcomes between using laid-back and side-lying breastfeeding positions in mothers delivering by cesarean section.

MATERIALS AND METHODS

A randomized controlled trial was conducted. The postpartum mothers delivering by cesarean section who delivered term newborns were randomly assigned to learn the use of a laid-back or side-lying breastfeeding position. The breastfeeding outcomes were assessed by LATCH scores at the second day postpartum and exclusive breastfeeding rates during the 6-week postpartum period. The mother's satisfaction of each breastfeeding position was collected before discharge from the hospital.

RESULTS

The data from 152 postpartum mothers delivering by cesarean section were available for analysis, 76 from the laid-back position group and 76 from side-lying position group. The baseline characteristics of both groups were similar. There were no statistically significant differences of the breastfeeding outcomes, LATCH scores at the second day postpartum and the exclusive breastfeeding rates during the 6-week postpartum period. But the mothers had expressed more satisfaction from the side-lying than the laid-back position.

CONCLUSIONS

Among the mothers who delivered by cesarean section, the use of the laid-back breastfeeding position had not shown different breastfeeding outcomes from the side-lying breastfeeding position. It might be an alternative breastfeeding position, which can be taught for mothers delivering by cesarean section along with the side-lying position.

Nationwide incidence of serious complications of epidural analgesia in the United States

BACKGROUND

This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States.

METHODS

The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately.

RESULTS

A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10(-5) ). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10(-5) ) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10(-5) ) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home.

CONCLUSIONS

This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.

Efficacy and safety of post-cesarean section incisional infiltration with lidocaine and epinephrine versus lidocaine alone in reducing postoperative pain: A randomized controlled double-blinded clinical trial

OBJECTIVE

Aim was to assess the efficacy and safety of incisional infiltration of lidocaine and epinephrine vs. lidocaine only to reduce postcesarean section (C/S) pain.

MATERIAL AND METHODS

It was a prospective, randomized, controlled, double-blinded clinical trial that was conducted in two tertiary hospitals in Egypt and included 153 women undergoing C/S under general anesthesia. They were randomly divided into the following two groups: Group I (control group, number=78), in which the wound was infiltrated before skin closure with 20 mL of 2% lidocaine, and Group II (study group, number=75), in which the wound was infiltrated before skin closure with 20 mL of 2% lidocaine and epinephrine. The primary outcomes were the time to first analgesic (TFA) request (minutes) and the postoperative pain scores that were measured using a visual analogue scale (VAS). The secondary outcomes included the duration of C/S, onset of mobilization, onset of breastfeeding, duration of hospital stay, local or systemic side effects of lidocaine and epinephrine, postoperative pyrexia, and postoperative wound infection.

RESULTS

The pain score determined using VAS after 1 and 2 h was significantly decreased in Group II than in Group I. However, at 4.8 and 16 h, these results were significantly reversed in Group II than in Group I. The cumulative postoperative opioid consumption was significantly less in Group II than in Group I (50 vs. 90 mg). The onset of mobilization, onset of breastfeeding, and duration of hospital stay was significantly shorter in Group II than in Group I, whereas the TFA request was significantly longer in Group II.

CONCLUSION

Administering epinephrine with 2% lidocaine prolongs the anesthetic effect and reduces the opioid analgesic dose postoperatively required, thereby enhancing patient recovery.