An opioid-free cesarean section, with well-controlled pain, is important for return of function and maternal care for newborns, as well as for prevention of chronic pain [1]. Neuraxial techniques such as epidural, spinal, or combined spinal-epidural anesthesia are generally recommended for most cesarean deliveries, with the choice tailored to patient factors such as anesthetic, fetal and obstetric risk; individual preferences; and progress of labor [2]. The effect of opioids on breastfeeding is important to consider when selecting postcesarean section analgesics [1]. Opioids pass into breast milk and have been known to cause severe central nervous system depression, which can lead to infant mortality [3]. Moreover, cesarean section can be viewed as a gateway to opioid addiction as the primary driver of first exposure to prescription opioids [4]. Patients and especially women, are often overprescribed opioids after surgery, including cesarean section and unused medications pose substantial risk for diversion [5]. Thus, there is a need for opioid-sparing and even opioid-free, approaches for postcesarean pain management.
The ability to provide effective postsurgical analgesia with reduced or eliminated opioid consumption favors use of multimodal pain management approaches [6]. Multimodal pain management options for cesarean delivery include nonsteroidal anti-inflammatory drugs and acetaminophen; neuraxial anesthesia techniques such as epidural with or without opioids and intrathecal opioids with oral or parenteral opioids for rescue; and regional anesthesia techniques such as surgical site infiltration with local anesthetics and Transversus Abdominis Plane (TAP) block [6]. Wound infiltration with a local anesthetic has been demonstrated to provide effective analgesia after cesarean section with a low rate of side effects [7].
Liposomal Bupivacaine (LB; EXPAREL®, bupivacaine liposome injectable suspension; Pacira Pharmaceuticals, Inc., Parsippany, NJ) is a prolonged-release formulation of bupivacaine HCl indicated for single-dose infiltration into the surgical site to produce postsurgical analgesia. LB has been demonstrated to provide postsurgical analgesia for up to 72 hours and reduce opioid consumption, with some patients remaining opioid-free postsurgery [8]. Although a recent retrospective observational study reported significant reduction in postsurgical opioid consumption following wound infiltration with LB for cesarean section, data are limited [9]. Evidence in other surgical settings indicates that meticulous infiltration technique is fundamental to optimizing patient outcomes with LB. This article presents the author’s technique and initial experiences with wound infiltration of LB in cesarean section; three cases are described to exemplify outcomes.
Pre-op
Patients were counseled extensively in the clinic during prenatal checks regarding multi modal opioid free pain management, especially the type of discomfort expected (pain scale) and post operative milestones. Patients counseled that expectation would be no greater than 5/10.
Intra-op personal modifications of routine cesarean section:
• The perineum is entered bluntly and, after checking to make sure there are no adhesions of bowel to the anterior abdominal wall, the peritoneum is stretched
• A large Alexis wound protector retractor (Applied Medical, Rancho Santa Margarita, CA) is placed into the abdomen
• Without externalizing the uterus the endometrial cavity is swept clean of remnant membranes and blood clots using a dry lap tape
• The hysterotomy is then reapproximated with a running locking suture of 0 Monocryl suture (Ethicon, Somerville, NJ), with hemostasis of the incision noted
• The colic gutters are swept clean of amniotic fluid and blood with moist lap tapes
• The rectus muscle is reapproximated using a running suture of 3-0 chromic gut, (Ethicon, Somerville, NJ), without incorporating the peritoneum
• The rectus muscle the rectus fascia is closed with a running suture of 0 Vicryl suture (Ethicon, Somerville, NJ)
• After confirming hemostasis of the subcutaneous space a mixture of 20 mg of Exparel mixed with an additional 20 ml of saline, is injected subfascially. Using a four 10 ml syringes and a 22-gauge needles 2 ml of the LB/saline mixture are injected under the re-approximated fascia, 1 cm apart and taking care to inject the lateral ‘corners’ of the closed fascia incision. The plunger is withdrawn prior to each injection to prevent intravenous injection
• Scarpa’s fascia is reapproximated with a running suture of 3-0 chromic gut
• The skin is closed with 4-0 Monocryl (Ethicon, Somerville, NJ) and the incision is covered with Tegaderm (3M Medical, St. Paul, MN)
• The patient receives 30 mg IV ketorolac either at the end of the case in the OR or in the PACU immediately following surgery
Post-op
• Patient is given ice chips when out of bed to a chair
• Patient is given coffee, tea or coke (caffeine) and the urinary catheter is removed when they walk out of the room and to the nurse’s station
• Once they tolerate the coffee, tea or coke patient is allowed a regular, unrestricted diet
The patient that received general anesthesia was prepped and draped, and the Foley catheter was placed, before intubation. Spinal anesthesia patients were prepped and draped after spinal anesthesia. All patients received preoperative antibiotics.
Patient 1 was a 24-year-old gravida 2, para 1, had a previous cesarean delivery requiring a 4-day hospital stay and 24 hours of bed rest immediately after surgery. She also stated she had significant postpartum depression and was therefore apprehensive about a repeat c section. She was admitted to labor and delivery at 36 weeks, 5 days gestation with regular, painful uterine contractions and cervical change. She was not a candidate for spinal anesthesia secondary to severe scoliosis. She underwent a repeat cesarean section, under general anesthesia, having declined a trial of labor after cesarean section. Postoperatively, she rated her maximum pain as 5/10, complaining mostly of uterine cramping. This pain was relieved after she began walking and after she voided. She tolerated oral pain medication well 1 hour after surgery, ambulated 2 hours after surgery, while voiding and tolerating solids within 4 hours after surgery. At 2- and 6-week follow-ups, she observed that compared with her previous cesarean section she had a more pleasant and less painful postoperative course, including earlier ambulation and no evidence of postpartum depression. Nurses observed that the baby was more awake and feed better than patients with routine opioid postoperative pain management.
Patient 2 was a 20-year-old gravida 1 at 39 weeks estimated gestational age, measured large for dates at term and, after discussion, elected to have a primary cesarean section using the multimodal pain management protocol including local infiltration of LB. She was treated with the multi modal, opioid free pain management protocol, including 1 gram of acetaminophen 12 hours and one hour preoperatively. Postoperatively, she rated her maximum pain as 3/10, which she described as uterine cramping. She tolerated oral pain medication well 3 hours after surgery. The patient was ambulating and tolerated liquids within 3.5 hours after surgery, voided 4.5 hours after surgery and tolerated solid foods within 6 hours after surgery. At her 1-week postoperative visit, she reported no significant pain. At 2, 4 and 6 weeks post operative she reported being pain free, doing well and bonding with her child.
Patient 3 was a 23-year-old gravida 2, para 1 at 37 weeks estimated gestational age, elected to have a primary cesarean section with local infiltration of LB because she had a medio-lateral episiotomy with her previous vaginal delivery, which caused her significant dyspareunia. Her sister had experienced a favorable postpartum course after a primary cesarean section with LB, with no pain after the delivery. The patient presented to labor and delivery with regular, painful uterine contractions and mild cervical change. Her maximum postoperative pain was 4/10, which she described as cramping. She tolerated oral pain medication 3 hours after surgery. Postoperatively she was ambulating, voiding and tolerating oral fluids within 4.5 hours after surgery. She tolerated solids within 6 hours after surgery. At her 3-week postoperative visit, she reported being well and required no pain medication other than ibuprofen and acetaminophen (Table 1).
Dr. Chudacoff’s multi modal cesarean section pain management protocol
Pre-operative
|
Intra-Operative
|
Post-operative
|
Discharge
|
- Patient education - Managing pain expectation and goal of opioid free:
- Goal is pain of less than 5/10 on a scale of 1-10
- Acetaminophen 1gm PO 12 and 1 hour pre-surgery
|
- Spinal or Epidural with anesthetic only
- Local (subfascial) Infiltration intraoperative after fascia closure: LB 266mg/ 20ml in 20ml NS 0.9% Total - 40ml; 22 gauge needle
- Ketorolac 30mg IV at end of case or in PACU
|
- Alternating every 3 hours, scheduled:1) ibuprofen 600mg po q6h; 2) acetaminophen 1gm po q6h
- Ice chips when out of bed and to a chair
- Coffee, Tea, or Coke with first ambulation past nurse’s station
- Catheter removed when walks past nurse’s station
- Regular diet after tolerating po fluids
- Opioids are not written prn. Nurses must call MD to initiate opioid use
|
Same as postoperative for 72h, scheduled, longer as needed
|
The Pain Scale 0 - Pain free.
Mild Pain - Nagging, annoying, but doesn't really interfere with daily living activities.
|
1 - Pain is very mild, barely noticeable. Most of the time you don't think about it. 2 - Minor pain. Annoying and may have occasional stronger twinges. 3 - Pain is noticeable and distracting, however, you can get used to it and adapt.
Moderate Pain – Interferes significantly with daily living activities.
|
|
4 - Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting.
5 - Moderately strong pain. It can't be ignored for more than a few minutes, but with effort you still can manage to work or participate in some social activities.
6 - Moderately strong pain that interferes with normal daily activities. Difficulty concentrating.
Severe Pain - Disabling; unable to perform daily living activities
|
7 - Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep.
8 - Intense pain. Physical activity is severely limited. Conversing requires great effort.
9 -Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably.
10 - Unspeakable pain. Bedridden and possibly delirious. Very few people will ever experience this level of pain.
Characteristic
|
Patient 1
|
Patient 2
|
Patient 3
|
Age, y
|
24
|
20
|
23
|
Gravidity
|
2
|
1
|
2
|
Parity
|
1
|
0
|
1
|
Vaginal
|
0
|
-
|
1
|
Cesarean
|
1
|
-
|
0
|
Gestational age at admission
|
36 wk, 5 d
|
39 wk*
|
37 wk*
|
Scheduled (Y/N)
|
Y
|
Y
|
Y
|
Presentation
|
Cephalic
|
Cephalic
|
Cephalic
|
Dense adhesive tissue (Y/N)
|
N
|
N
|
N
|
Comorbid disorders (Y/N)
|
|
|
|
Opioid use disorder
|
N
|
N
|
N
|
Drug use/abuse disorder
|
N
|
N
|
N
|
Chronic pain disorder
|
N
|
N
|
N
|
Depression
|
Y
|
N
|
N
|
Table 1: Patient Demographics and Clinical Characteristics.
*Estimated gestational age.