Peri-operative multimodal pain therapy for Caesarean section: Analgesia and fitness for discharge

Abstract

Purpose: To compare, the efficacy of a multi-modal analgesic regimen and single drug therapy with iv PCA morphine after Caesarean delivery with spinal anaesthesia. Methods: Forty ASA 1-2 parturients presenting for elective Caesarean section were randomized to receive multimodal pain treatment with intrathecal morphine, incisional bupivacaine and ibuprofen + acetaminophen po until hospital discharge (Group I) or conventional therapy with iv PCA morphine weaned to acetaminophen + codeine po. (Group 2). Both groups received spinal anaesthesia with 1.7 ml hyperbaric bupivacaine 0.75%. Visual analog pain scores at rest (RVAPS) and with movement (DVAPS) were recorded q 2 hr during the first 24 hr, then q 4 hr until discharge. Time to first walking, eating solid food, flatus, bowel movement, voiding and hospital discharge were recorded. Results: Pain scores were lower in Group I patients during the first 24 hr after spinal injection RVAPS 0.6 ± 0.1 in Group I vs 2.1 ± 0.1 in Group 2 (mean ± SEM), DVAPS 1.9 ± 0.1 in Group I vs 4.1 ± 0.1 in Group 2 (P < 0.0001). Times to first flatus, 36.1 hr ± 2.9 vs 20.5 ± 1.8 (P < 0.05) and to first bowel movement, 74.8 hr ± 5.6 vs 57.4 ± 4.7 (P < 0.0001) were longer in Group 2 patients. There was no difference between groups in time to eating solid food, walking or hospital discharge. Conclusion: Multi-modal pain therapy resulted in improved early post-operative analgesia during the first 24 hr after Caesarean delivery. Patients receiving iv PCA morphine followed by acetaminophen + codeine po were more likely to develop decreased bowel mobility. All patients, with one exception, achieved discharge criteria (eating solid food, absence of nausea, normal lochia, dry incision and DVAPS < 4) at 48 hr after spinal injection.