The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review

Anesthetic Practices for Lower Segment Cesarean Section in the Sultanate of Oman: A National Survey

Background Over the years, obstetric anesthesia has evolved into a comprehensive sub-specialty. Several countries have their guidelines and recommendations for obstetric anesthesia. This survey aimed to describe the current obstetric anesthesia practices in the Sultanate of Oman by performing a questionnaire-based survey. Methods The Ministry of Health-Centre approved the survey for Studies and Research, Sultanate of Oman (MOH-CSR/25057). A Google Form with 25 questions (seven general questions and 18 specific questions) was initially shared in a WhatsApp group of members of the Oman Society of Anaesthesia and Critical Care (OSACC). Anesthesiologists who were not members were contacted directly and responses were recorded. Results Responses were accepted until midnight on December 31, 2023. The number of responses received was 66. Variations in practices like less compliance to Enhanced Recovery After Surgery (ERAS) pathways, use of oxytocin, and choice of intrathecal opioids were observed. Labor analgesia was not practiced by 30.3% of respondents. The majority of respondents did not follow international recommendations regarding the use of the uterotonic drug oxytocin. Conclusion A lot of heterogeneity in the practice of obstetric anesthesia in the Sultanate of Oman was observed. The limitations included the relatively low number of responses and many aspects that were missed in the survey. The findings of this survey will help in establishing a national task force for obstetric anesthesia, which will guide the members of the task force to develop practice guidelines based on international recommendations and the latest evidence.

Transversus Abdominis Plane Block versus Epidural Anesthesia for Pain Management Post-Caesarean Delivery: A Pilot Study

Background

Effective post-operative analgesia profoundly influences patient recovery and outcomes after caesarean delivery. The Transversus Abdominis Plane (TAP) block represents a potential alternative, potentially offering greater effectiveness than epidural analgesia while causing fewer adverse effects.

Objective

To assess if the abdominal transverse block provides superior postoperative pain relief in patients undergoing caesarean delivery compared to epidural analgesia.

Methods

Participants were divided into parallel groups: an experimental group receiving TAP block (n=25) and a control group receiving epidural analgesia (n=24). All patients received a 10 mg dose of hyoscine at the end of the surgery. Experimental Group received a total of 20 mL of 0.2% ropivacaine. In Epidural group received 0.2% ropivacaine at 4 mL/h for 24 hours. All participants were administered combined with neuroaxial block anesthesia. The patients selected for epidural analgesia received the mentioned dose, while the other group block had the epidural catheter removed after the cesarean section. The primary outcome was post-caesarean pain, evaluated using the Visual Analog Scale (VAS) at four intervals (0, 6, 12, and 24 hours). Also, surgical bleeding and residual motor were evaluated. VAS pain scores between the groups were compared using the Friedman test and Generalized Linear Model (GLM) for non-normally distributed data. The effect size was estimated with Eta Square ([Formula: see text]), considering values ≥0.38 as indicative of large effects. A two-tailed p-value < 0.05 was deemed statistically significant.

Results

Statistically significant differences in pain scores were noted at 0 and 6 hours post-surgery (p<0.01). The TAP block group reported lower pain scores at 0 hours (mean=0.04) and 6 hours (mean=1.16) compared to the epidural group, reflecting a substantial effect size.

Conclusion

The TAP block proves advantageous in mitigating postoperative pain for women post-caesarean delivery, particularly in the initial 6 postpartum hours. This relief promotes early mother-infant bonding and facilitates breastfeeding.

Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review

The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.

Impact of Postoperative Pain on Early Initiation of Breastfeeding and Ambulation After Cesarean Section: A Randomized Trial

Aim: To compare the effect of different analgesic regimens on the time to initiate breastfeeding (BF) and ambulation after cesarean section (CS). Methods: This prospective, double-blinded, placebo-controlled randomized study included 300 women (20-40 years of age) of the American Society of Anesthesiologists status 1 or 2 with singleton term pregnancies scheduled for CS under spinal anesthesia. Women were allocated to three groups of 100 each by computer-generated randomization. As an adjunct to 1,000 mg intravenous acetaminophen, Group 1 received 100 mg rectal diclofenac, Group 2 received 100 mg rectal tramadol, and Group 3 received rectal glycerin suppository. The time to initiate BF and ambulation was compared between different analgesic regimens and corelated with pain score. Results: BF (both with and without support) was initiated significantly earlier in Groups 1 and 2 as compared with control Group 3 (p < 0.001). A significantly shorter time was taken to initiate BF without support in Group 1 as compared with Group 2 (p = 0.028). The time to start ambulation (both with and without assistance) was significantly lower in Groups 1 and 2 as compared with Group 3 and in Group 1 versus Group 2 (p < 0.001). A significant positive correlation was found between the time to initiate BF with support and ambulation without assistance and postoperative pain score at 0, 1, and 6 hours. Conclusion: Effective post-CS analgesia affects early initiation of BF and ambulation in the immediate postnatal period. The inclusion of rectal diclofenac suppository in post-CS analgesic regimens is a promising approach to postoperative delivery care.

Comparison of the analgesic efficacy of ultrasound-guided transmuscular quadratus lumborum block versus thoracic erector spinae block for postoperative analgesia in caesarean section parturients under spinal anaesthesia-A randomised study

Background and Aims

Truncal blocks play an important role in multimodal analgesia regimens to manage the postoperative pain after lower segment caesarean section (LSCS). This study was aimed to compare the analgesic efficacy of ultrasound (US)-guided transmuscular quadratus lumborum block (TQLB) and thoracic erector spinae plane block (TESPB) in parturients of LSCS done under subarachnoid block (SAB).

Methods

In a randomised and double blind study, 60 parturients scheduled for LSCS under spinal anaesthesia were randomly divided into two equal groups: group E (n = 30) and group Q (n = 30). After surgery, each parturient received either US guided bilateral TQLB (group Q) or TESPB (group E) with 20 ml 0.375% ropivacaine and 4 mg dexamethasone on each side. Assessments were done at 2, 4, 6, 8, 10, 12 and 24 h. The primary objective was to compare the duration of analgesia (first request to rescue analgesia) and the secondary objectives were to compare pain scores [numerical rating score (NRS)], total amount of tramadol consumption, incidence of nausea-vomiting, parturient satisfaction and other adverse effects in 24 hours postoperatively.

Results

The duration of analgesia (mean ± standard deviation) was comparable in group E (11.90 ± 2.49 h) and group Q (12.56 ± 3.38 h), P = 0.19. Pain scores (NRS) at rest and on movement were comparable at all time points of 2, 4, 6, 8, 10, 12, and 24 h (P > 0.05). The amount of tramadol used was comparable in group E and group Q (P = 0.48).

Conclusion

TESPB and TQLB are equally efficacious to provide postoperative analgesia after LSCS done under SAB when used as a part of multimodal analgesia.