Postoperative pain relief

  • Jane D. Morrison
  • Elizabeth M. McGrady


In any surgical field the aim of postoperative pain relief is to provide subjective comfort and to prevent the autonomic and somatic reflexes that occur in response to nociceptive stimuli.1 In obstetrics good analgesia is of prime importance as postoperative comfort and mobility play essential roles in the ability of a mother to care for her newborn child. This chapter reviews the advances in postoperative obstetric pain control made over the last 10-15 years.


Caesarean Section Patient Control Analgesia Epidural Morphine Intrathecal Morphine Postoperative Pain Relief 
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  1. I. Kehlet H. Postoperative pain relief-what is the issue? Br J Anaesth 1994; 72: 375–8PubMedCrossRefGoogle Scholar
  2. 2.
    McClure JH. Pain Pathways. In: Wildsmith JAW, Armitage EN (eds). Principles and Practice of Regional Anaesthesia, 1“ edn. Edinburgh: Churchill Livingstone, 15–21, 1987Google Scholar
  3. 3.
    Moore A, Bullingham R, McQuay H, Allen M, Baldwin D, Cole A. Spinal fluid kinetics of morphine and heroin. Clin Pharm Ther 1984; 35: 40–5CrossRefGoogle Scholar
  4. 4.
    Kelly MC, Carabine UA, Mirakhur RK. Intrathecal diamorphine for analgesia after caesarean section. A dose finding study and assessment of side-effects. Anaesthesia 1998; 53: 231–7PubMedCrossRefGoogle Scholar
  5. 5.
    Kotob HIM, Hand CW, Moore RA et al. Intrathecal morphine and heroin in humans: six hour drug levels in spinal fluid and plasma. Anesth Analg 1986; 65: 718–22PubMedCrossRefGoogle Scholar
  6. 6.
    Paterson GMC, McQuay HJ, Bullingham RES, Moore RA. Intradural morphine and diamorphine. Anaesthesia 1984; 39: 113–7PubMedCrossRefGoogle Scholar
  7. 7.
    Patrick JA, Smith M, Cross G, Reynolds F. A comparison of epidural diamorphine with intramuscular papaveretum following caesarean section. International Journal of Obstetric Anesthesia 1992; 1: 25–8CrossRefGoogle Scholar
  8. 8.
    Hallworth SP, Fernando R, Bell R, Parry MG, Lim GH. Comparison of intrathecal and epidural diamorphine for elective caesarean section using a combined spinal-epidural technique. Br J Anaesth 1999; 82: 228–32PubMedCrossRefGoogle Scholar
  9. 9.
    Graham D, Russell I. Double blind study to assess the analgesic sparing effect of 0.3 mg diamorphine given intrathecally at elective caesarean section. International Journal of Obstetric Anesthesia 1995; 4: 178–89CrossRefGoogle Scholar
  10. 10.
    Roulson C, Chan A, Albin M, Carli F. Intrathecal morphine or diamorphine for Cesarean section? Preliminary findings. International Journal of Obstetric Anesthesia 1994; 3: 173CrossRefGoogle Scholar
  11. 11.
    Husiani SW, Russell IF. Intrathecal diamorphine compared with morphine for postoperative analgesia after caesarean section under spinal anaesthesia. Br J Anaesth 1998; 81: 135–9.CrossRefGoogle Scholar
  12. 12.
    Kestin IG, Madden AP, Mulvein JT, Goodman NW. Analgesia for labour and delivery using incremental diamorphine and bupivacaine via a 32-gauge intrathecal catheter. Br J Anaesth 1992; 68: 244–247PubMedCrossRefGoogle Scholar
  13. 13.
    Sneyd JR, Meyer-Whiting M. Intrathecal diamorphine (heroin) for obstetric analgesia. International Journal of Obstetric Anesthesia 1992; 1: 153–5PubMedCrossRefGoogle Scholar
  14. 14.
    Randalls B, Broadway JW, Browne DA, Morgan BM. Comparison of four subarachnoid solutions in a needle-through-needle technique for elective caesarean section. Br J Anaesth 1991; 66: 314–8PubMedCrossRefGoogle Scholar
  15. 15.
    Dahlgren G, Hultstrand C, Jakobsson J, Norman M, Eriksson EW, Martin H. Intrathecal sufentanil, fentanyl, or placebo added to bupivacaine for cesarean section. Anesth Analg 1997; 85: 1288–93PubMedGoogle Scholar
  16. 16.
    Cohen S, Lowenwirt I, Pantuck CB, Amar D, Pantuck EJ. Bupivacaine 0.01% and/or epinephrine 0.5 lg/ml improve epidural fentanyl analgesia after cesarean section. Anesthesiology 1998; 89: 1354–61PubMedCrossRefGoogle Scholar
  17. 17.
    Grass JA, Sakima NT, Schmidt R, Michtisch R, Zuckerman RL, Harris AP. A randomized, double-blind, dose-response comparison of epidural fentanyl versus sufentanil analgesia after cesarean section. Anesth Analg 1997; 85: 365–71.PubMedGoogle Scholar
  18. 18.
    Belzarena SD. Clinical effects of intrathecally administered fentanyl undergoing cesarean section Anesth Analg 1992; 74: 653–7Google Scholar
  19. 19.
    Palmer CM. Early respiratory depression following intrathecal fentanyl-morphine combination. Anesthesiology 1991; 74: 1153–5PubMedCrossRefGoogle Scholar
  20. 20.
    Brockway MS, Noble DW, Sharwood-Smith GH, McClure JH. Profound respiratory depression after extradural fentanyl. Br J Anaesth 1990; 64: 243–5PubMedCrossRefGoogle Scholar
  21. 21.
    Cardoso MMSC, Carvalho JCA, Amaro AR, Prado AA, Cappelli EL. Small doses of intrathecal morphine combined with systemic diclofenac for postoperative pain control after cesarean delivery. Anesth Analg 1998; 86: 538–41.PubMedGoogle Scholar
  22. 22.
    Aboulish E, Rawal N, Rashad MN. The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivicaine for cesarean delivery: a prospective study of 856 cases. Reg Anesth 1991; 16: 137–40Google Scholar
  23. 23.
    Milner AR, Bogod DG, Harwood RJ. Intrathecal administration of morphine for elective caesarean section. Anaesthesia 1996; 51: 871–3PubMedCrossRefGoogle Scholar
  24. 24.
    Sinatra RS. Postoperative analgesia: epidural and spinal techniques. In: Chestnut DH (ed). Obstetric Anesthesia: Principles and Practice. St Louis, MO: Mosby, 533, 1994Google Scholar
  25. 25.
    Dennis AR, Leeson-Payne CG, Hobbs GJ. Analgesia after caesarean section. The use of rectal diclofenac as an adjunct to spinal morphine. Anaesthesia 1995; 50: 297–9PubMedCrossRefGoogle Scholar
  26. 26.
    Gerancher JC, Floyd H, Eisenach J. Determination of an effective dose of intrathecal morphine for pain relief after cesarean delivery. Anesth Analg 1999; 88: 346–51PubMedGoogle Scholar
  27. 27.
    Fuller JG, McMorland GH, Douglas MJ, Palmer L. Epidural morphine for analgesia after caesarean section: a report of 4800 patients. Can J Anaesth 1990; 37: 636–40PubMedCrossRefGoogle Scholar
  28. 28.
    Writer WD, Hurtig JB, Edelist G et al. Epidural morphine prophylaxis of postoperative pain: report of a double-blind multicentre study. Can Anaesth Soc J 1985; 32: 330–38PubMedCrossRefGoogle Scholar
  29. 29.
    Harrison DM, Sinatra R, Morgese L, Chung JH. Epidural narcotic and patient-controlled analgesia for post-cesarean section pain relief. Anesthesiology 1988; 68: 454–7PubMedCrossRefGoogle Scholar
  30. 30.
    Crone L, Conly JM, Clark KM et al. Recurrent herpes simplex virus labialis and the use of epidural morphine in obstetric patients. Anesth Analg 1988; 67: 318–23PubMedCrossRefGoogle Scholar
  31. 31.
    Crone L, Conly J, Storgard C et al. Recurrent herpes simplex labialis in parturients receiving epidural morphine. Anesth Analg 1989; 68: S63Google Scholar
  32. 32.
    Leysen JE, Commereu W, Niemegeers CJE. J3HI Sufentanil, a superior ligand for µ-opiate receptors: binding properties and regional distribution in rat brain and spinal cord. Eur J Pharmacol 1983; 87: 209–25PubMedCrossRefGoogle Scholar
  33. 33.
    McMorland GH, Douglas MJ, Kim JHK, Kamani AA, Swenerton JE, Berkowitz J, Ross PLE, Palmer L. Epidural sufentanil for post-caesarean section analgesia: a lack of benefit of epinephrine. Can J Anaesth 1990; 37: 432–7PubMedCrossRefGoogle Scholar
  34. 34.
    Ostman LP, Owen CL, Bates JN et al. Oxygen saturation in patients the night prior to and the night after Cesarean section during epidural morphine analgesia. Anesthesiology 1988; 69: A691CrossRefGoogle Scholar
  35. 35.
    Milne JA. The respiratory response to pregnancy. Postgrad Med J 1979; 55: 318PubMedCrossRefGoogle Scholar
  36. 36.
    Writer WDR. Epidural morphine for post-caesarean analgesia. Can J Anaesth 1990; 37: 608–612PubMedCrossRefGoogle Scholar
  37. 37.
    Krukowski JA, Hood DD, Eisenach JC, Mallak KA, Parker RL. Intrathecal neostigmine for post-cesarean section analgesia: dose response. Anesth Analg 1997; 84: 1269–75PubMedGoogle Scholar
  38. 38.
    Howell PR, Gambling DR, Pavy T, McMorland G, Douglas MJ. Patient-controlled analgesia following caesarean section under general anaesthesia: a comparison of fentanyl with morphine. Can J Anaesth 1995; 42: 41–5PubMedCrossRefGoogle Scholar
  39. 39.
    Macrae DJ, Munishankrappa S, Burrow LM, Milne MK, Grant IS. Double-blind comparison of the efficacy of extradural diamorphine, extradural phenoperidine and IM diamorphine following caesarean section. Br J Anaesth 1987; 59: 354–9PubMedCrossRefGoogle Scholar
  40. 40.
    Eisenach JC, Grice SC, Dewan DM. Patient-controlled analgesia following cesarean section: a comparison with epidural and intramuscular narcotics. Anesthesiology 1988; 68: 444–8PubMedCrossRefGoogle Scholar
  41. 41.
    Sinatra RS, Lodge K, Sibert K et al. A comparison of morphine, meperidine and oxymorphone as utilized in patient controlled analgesia following cesarean delivery. Anesthesiology 1989; 70: 585–90PubMedCrossRefGoogle Scholar
  42. 42.
    Wittels B, Glosten B, Faure EAM et al. Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes amongst nursing neonates. Anesth Analg 1997; 85: 600–6.PubMedGoogle Scholar
  43. 43.
    James KS, Davidson IT, McGrady E. Patient controlled analgesia following caesarean section: a comparison of morphine and meptazinol. International Journal of Obstetric Anesthesia 1997; 6: 93–6PubMedCrossRefGoogle Scholar
  44. 44.
    Eisenach JC, Detweiler D, Hood D. Hemodynamic and analgesic actions of epidurally administered clonidine. Anesthesiology 1993; 78: 277–87PubMedCrossRefGoogle Scholar
  45. 45.
    Paech MJ, Pavy TJG, Orlikowski CEP, Lim W, Evans SF. Postoperative epidural infusion: a randomized, double-blind, dose-finding trial of clonidine in combination with bupivacaine and fentanyl. Anesth Analg 1997; 84: 1323–8PubMedGoogle Scholar
  46. 46.
    Benhamou D, Thorin D, Brichant J-F, Dailland P, Milon D, Schneider M. Intrathecal clonidine and fentanyl with hyperbaric bupivacaine improves analgesia during cesarean section. Anesth Analg 1998; 87: 609–13Google Scholar
  47. 47.
    De Kock M, Gautier P, Pavlopoulou A, Jonniaux M, Lavand’homme P. Epidural clonidine or bupivacaine as the sole analgesic agent during and after abdominal surgery: a comparative study. Anesthesiology 1999; 90: 1354–62PubMedCrossRefGoogle Scholar
  48. 48.
    Bonnet F, Boico O, Rostaing S, Saada M, Loriferne J-F, Touboul C, Abhay K, Ghignone M. Postoperative analgesia with extradural clonidine. Br J Anaesth 1989; 63: 465–9PubMedCrossRefGoogle Scholar
  49. 49.
    Eisenach JC, Lysak SZ, Viscomi CM. Epidural clonidine analgesia following surgery: phase I. Anesthesiology 1989; 71: 640–6PubMedCrossRefGoogle Scholar
  50. 50.
    Huntoon M, Eisenach JC, Boese P. Epidural clonidine after cesarean section. Appropriate dose and effect of prior local anesthetic. Anesthesiology 1992; 76: 187–93PubMedCrossRefGoogle Scholar
  51. 51.
    Hood DD, D’Angelo RD, Eisenach JC, Curry R, Nelson KE. Postoperative analgesia following intrathecal clonidine or clonidine + neostigmine in elective cesarean section patients. Anesthesiology 1999; 87: A27CrossRefGoogle Scholar
  52. 52.
    Rockemann MG, Seeling W, Duschek S, Reinelt H, Steffen P, Georgieff M. Epidural bolus clonidine/morphine versus epidural patient-controlled bupivacaine/sufentanil: quality of postoperative analgesia and cost-identification analysis. Anesth Analg 1997; 85: 864–9PubMedGoogle Scholar
  53. 53.
    Williams PL, Krafcik JM, Potter BB, Hooper JH, Hearne MJ. Cardiac toxicity of clonidine. Chest 1977; 72: 784–5PubMedCrossRefGoogle Scholar
  54. 54.
    Bernard J-M, Kick O, Bonnet F. Comparison of intravenous and epidural clonidine for postoperative patient-controlled analgesia. Anesth Analg 1995; 81: 706–12PubMedGoogle Scholar
  55. 55.
    Mendez R, Eisenach JC, Kashtan K. Epidural clonidine analgesia after cesarean section. Anesthesiology 1990; 73: 848–52.PubMedCrossRefGoogle Scholar
  56. 56.
    Edwards M, Serrao JM, Gent JP, Goodchild CS. On the mechanism by which midazolam causes spinally mediated analgesia. Anesthesiology 1990; 73: 273–7PubMedCrossRefGoogle Scholar
  57. 57.
    Serrao JM, Gent JP, Goodchild CS. Naloxone reverses the spinal analgesic effects of midazolam. Br J Anaesth 1989; 62: 233–4Google Scholar
  58. 58.
    Valentine JMJ, Lyons G, Bellamy MC. The effect of intrathecal midazolam on post-operative pain. Eur J Anaesthesiol 1996; 13: 589–93PubMedCrossRefGoogle Scholar
  59. 59.
    Hood DD, Eisenach JC, Tuttle RN. Phase I safety assessment of intrathecal neostigmine methyl-sulfate in humans. Anesthesiology 1995; 82: 331–43PubMedCrossRefGoogle Scholar
  60. 60.
    Chung C-J, Kim J-S, Park H-S, Chin Y-J. The efficacy of intrathecal neostigmine, intrathecal morphine, and their combination for post-cesarean section analgesia. Anesth Analg 1998; 87: 341–6PubMedGoogle Scholar
  61. 61.
    Hood DD, Mallak KA, Eisenach JC, Tong C. Interaction between intrathecal neostigmine and epidural clonidine in human volunteers. Anesthesiology 1996; 85: 315–25PubMedCrossRefGoogle Scholar
  62. 62.
    Pan PM, Mok MS. Efficacy of intrathecal neostigmine for the relief of post cesarean pain. Anesthesiology 1995; 83: A786CrossRefGoogle Scholar
  63. 63.
    Bush DJ, Lyons G, MacDonald R. Diclofenac for analgesic after caesarean section. Anaesthesia 1992; 47: 1075–7PubMedCrossRefGoogle Scholar
  64. 64.
    Luthman J, Kay NH, White JB. The morphine sparing effect of diclofenac sodiumfollowing cesarean section under spinal anaesthesia. International Journal of Obstetric Anesthesia 1994; 3: 82–6PubMedCrossRefGoogle Scholar
  65. 65.
    Ganta R, Samra SK, Maddineni VR, Furness G. Comparison of the effectiveness of bilateral ilioinguinal nerve block and wound infiltration for postoperative analgesia after caesarean section. Br J Anaesth 1994; 72: 229–30PubMedCrossRefGoogle Scholar
  66. 66.
    Trotter TN, Hayes-Gregson P, Robinson S, Cole L, Coley S, Fell D. Wound infiltration of local anaesthetic after lower segment caesarean section. Anaesthesia 1991; 46: 404–7PubMedCrossRefGoogle Scholar
  67. 67.
    Bunting R, McConachie I. Ilioinguinal nerve blockade for analgesia after caesarean section. Br J Anaesth 1988; 61: 773–5PubMedCrossRefGoogle Scholar
  68. 68.
    Templeton T. Rectus block for postoperative pain relief. Reg Anesth 1993; 18: 258–60PubMedGoogle Scholar
  69. 69.
    Wittels B, Faure EAM, Chavez R et al. Effective analgesia after bilateral tubal ligation. Anesth Analg 1998; 87: 619–23PubMedGoogle Scholar
  70. 70.
    Woolf CJ, Chong MS. Pre-emptive analgesia: treating postoperative pain by preventing the establishment of central sensitisation. Anesth Analg 1993; 77: 362–79PubMedGoogle Scholar
  71. 71.
    MacDonald R, Bickford Smith PJ. Extradural morphine and pain relief following episiotomy. Br Anaesth 1984; 56: 1201–5.CrossRefGoogle Scholar
  72. 72.
    Niv D, Wolman I, Yasher T et al. Epidural morphine pretreatment for postepisiotomy pain. Clin J Pain 1994; 10: 319–23PubMedCrossRefGoogle Scholar
  73. 73.
    Khan GQ, Lilford RJ. Wound pain may be reduced by prior infiltartion of the episiotomy site after delivery under epidural analgesia. Br J Obstet Gynaecol 1987; 94: 341–4PubMedCrossRefGoogle Scholar
  74. 74.
    Odigie EA. Effectiveness of indomethacin (indocid) suppositories as post-episiotomy analgesia. Int J Gynaecol Obstet 1988; 26: 57–60PubMedCrossRefGoogle Scholar
  75. 75.
    Harrison RF, Brennan M. Evaluation of two local anaesthetic sprays for the relief of postepisiotomy pain. Curr Med Res Opin 1987; 10: 364–9PubMedCrossRefGoogle Scholar
  76. 76.
    Harrison RF, Brennan M. Comparison of two formulations of lignocaine spray with mefenamic acid in the relief of post-episiotomy pain: a placebo-controlled study. Curr Med Res Opin 1987; 10: 375–9PubMedCrossRefGoogle Scholar
  77. 77.
    Grant A, Sleep J. Relief of perineal pain and discomfort after childbirth. In: Chalmers I, Enkin M, Keirse MJNC (eds). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, Vol 2,1347–1356,1991Google Scholar
  78. 78.
    Carapeti EA, Kamm MA, McDonald PJ, Phillips RKS. Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy. Lancet 1998; 351: 169–72PubMedCrossRefGoogle Scholar
  79. 79.
    Choe H, Kim J-S, Ko S-H, Kim D-C, Han Y-J, Song H-S. Epidural verapamil reduces analgesic consumption after lower abdominal surgery. Anesth Analg 1998; 86: 786–90PubMedGoogle Scholar
  80. 80.
    Ready LB. Acute Postoperative Pain. In: Miller RD (ed). Anesthesia. New York: Churchill Livingstone, Vol 2,2327–44,1994Google Scholar
  81. 81.
    Madej T, Strunin L. Comparison of epidural fentanyl with sufentanil. Anaesthesia 1987; 42: 1156–61PubMedCrossRefGoogle Scholar
  82. 82.
    Cohen SE, Labaille T, Benhamou D, Levron JC. Respiratory effects of epidural sufentanil after caesarean section. Anesth Analg 1992; 74: 677–82PubMedGoogle Scholar
  83. 83.
    Beeby D, MacIntosh KC, Bailey M, Welch DB. Postoperative analgesia for caesarean section using epidural methadone. Anaesthesia 1984; 39: 61–3PubMedCrossRefGoogle Scholar

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© Springer-Verlag London 2000

Authors and Affiliations

  • Jane D. Morrison
  • Elizabeth M. McGrady

There are no affiliations available

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