The following are Practice Management Guidelines for analgesia following Caesarean section. Where possible, the aim is to avoid leaving epidural catheters indwelling in order to reduce the low, but significant risk of epidural abscess formation. As a rule, "single shot" techniques such as single dose epidural or spinal morphine provide good analgesia where supplemental NSAID’s can be used. Where NSAID’s are contraindicated (e.g PIH) it is often necessary to use a technique which allows for repeated dosage such as PCA via epidural or intravenous routes.

The alternatives for analgesia are as follows.

1. Epidural anaesthesia with epidural morphine post-op:

• The surgery can be performed under epidural block as per normal practice.
• Three milligrams of preservative free morphine diluted to 10 mls in normal saline is administered via the epidural catheter at the completion of surgery. Document this administration on the anaesthetic chart.
• The epidural catheter is then removed prior to transfer to Recovery and a band-aid placed over the site. Epidural catheter removal should be documented on an Epidural / Spinal Opioid Observation chart (available early 2001).
• 100 mg diclofenac is administered PR in theatre and thereafter 50mg PO tds for three days is charted on the regular medication chart.
• Prescribe the following on the PRN medication chart;

  • Panadeine forte for breakthrough pain
  • Naloxone 40 mcg IV 5 minutely PRN x 5 for severe pruritus
  • Note the patient has had epidural morphine and that systemic opioids must not be given within the first 24 hours postop without contacting the anaesthetic registrar (08596)

• An Epidural / Spinal Opioid Observation chart should be completed. This chart has pre printed standing orders for respiratory and sedation observations, supplemental oxygen and management of complications.
• The APS registrar will need to be called if rescue analgesia is required. IV PCA opioid can then be commenced using a conservative bolus dose.

2. "Single-shot" spinal with intrathecal morphine:

• The surgery can be performed under single shot subarachnoid block.
  A suggested mixture is

  • 2.5 mls 0.5% bupivacaine (plain or heavy)
  • 150 micrograms preservative free morphine
  • +/- 20 micrograms fentanyl

    
    

• 100 mg diclofenac is administered PR in theatre and thereafter 50mg PO tds for three days is charted for the ward.
• Prescribe the following on the PRN medication chart;

  • Panadeine forte for breakthrough pain
  • Naloxone 40 mcg IV 5 minutely PRN x 5 for severe pruritus
  • Note the patient has had intrathecal morphine and that systemic opioids must not be given within the first 24 hours postop without contacting the anaesthetic registrar (08596)

• An Epidural / Spinal Opioid Observation chart should be completed. This chart has pre-printed standing orders for respiratory and sedation observations, supplemental oxygen and management of complications.
• The APS will need to be called if rescue analgesia is required in which case IV PCA opioid can be commenced using a conservative bolus dose.

3. Epidural PCA pethidine:

• Where NSAID’s are contraindicated and an epidural has been used for the surgery, the catheter can be left in situ and PCEA pethidine commenced for postoperative analgesia.
• Prescribe the pethidine on the regular medication chart.
• Complete a Patient Controlled Analgesia chart, noting it is epidural rather than IV PCA. A suggested regime is for 4 ml (20 mg) PCA dose, 10 minute lockout and 1 ml (5 mg) background infusion to prevent the pump occlusion alarm. This chart has pre-printed standing orders for respiratory and sedation observations, supplemental oxygen and management of complications.
• Note on the PRN medication chart that the patient has PCEA and that systemic opioids must not be given without contacting the anaesthetic registrar (08596).

4. Intravenous PCA opioid:

• IV morphine or fentanyl can be used when a Caesarean has been performed under general anaesthesia.
• This is prescribed in the same manner as for any general surgical patient having a PCA commenced.
• If not contraindicated then prescribing supplemental diclofenac will be dose sparing for the morphine and improve analgesia.

5. CONTINUOUS EPIDURAL INFUSION:

• If specifically indicated (eg. severe PIH) a continuous epidural infusion can be continued postoperatively.
• Note that obstetric patients with epidural infusions can only be cared for in the following units.

  • Delivery Suite
  • A3C (Surgical High Dependency)
  • Intensive Care Unit
  • D5B (Neuro/Trauma High Dependency)