Tailoring postoperative pain management with a procedure‐specific approach: how to best apply this concept to caesarean deliveries

• Published in: Anaesthesia Vol. 76; no. 5; pp. 587 - 589
• Main Authors: Landau, R., Richebé, P.
• Format: Journal Article
• Language: English
• Published: England Blackwell Publishing Ltd 01.05.2021
• Subjects: anaesthesia; Analgesia, Epidural; Analgesics; Anesthesia, Obstetrical; caesarean delivery; Cesarean Section; Clinical decision making; Decision making; Double-Blind Method; Drug addiction; Evidence-based medicine; Female; Humans; obstetric; Pain; Pain management; Pain, Postoperative - prevention & control; postoperative; Postoperative period; Postpartum depression; Pregnancy; postoperative; caesarean delivery; pain; obstetric; anaesthesia
• ISSN: 0003-2409; 1365-2044
• DOI: 10.1111/anae.15251

Undoubtedly, no patient should experience acute severe pain after surgery, and multimodal analgesia ensuring opioid‐sparing approaches should strongly be promoted for optimal postoperative recovery. With that premise in mind, the procedure‐specific pain management (PROSPECT) working group of anaesthetists and surgeons has been formulating practical and evidence‐based recommendations “that facilitate clinical decision‐making across all stages of the peri‐operative period on a procedure‐specific basis” [1, 2]. The updated PROSPECT methodology follows a rigorous approach that begins with a literature search and review process according to reporting items for systematic review and meta‐analysis protocols (PRISMA) recommendations [2]. The primary outcome measure is designated as “postoperative pain intensity scores at rest and/or pain intensity during activity (when available) with a change of more than 10 mm in pain scores considered clinically relevant” [3]. The most recent PROSPECT guidelines have brought light on optimal pain management after straightforward surgical procedures such as hallux valgus repair, rotator cuff repair and oncological breast surgery [4-6].In this issue of Anaesthesia, the PROSPECT methodology was applied to elective caesarean deliveries [7]. A previous review and PROSPECT recommendations was published in 2014 [8]; however, an update was deemed necessary in light of new studies and novel analgesic interventions, such as quadratus lumborum (QL) blocks. The authors should be congratulated for their work since improving the pain trajectory after caesarean delivery will ensure: a better maternal experience; the ability to care for the baby including breastfeeding; a shorter length of stay; and reduced risk for persistent opioid use (and opioid use disorder), postpartum depression and chronic pain [9]. The peri‐partum period should be viewed as a unique opportunity to make a real difference for mothers and newborns, beyond pain scores during the first 24 hours, by reducing opioid exposure and consumption and improving functional recovery and mental health.Bearing in mind that clinical recommendations for post‐caesarean pain management should take into account: the specific obstetric scenario resulting in the indication for a caesarean delivery (‘procedure‐specific’); the patient’s unique characteristics and pain history (‘patient‐specific’); and the outcomes deemed important for postpartum recovery (‘outcome‐specific’), we question the value of the PROSPECT methodology in this specific clinical setting.