J.

ROACH
VIJAY ET AI 169

References 3. Australian Medical Association Code of Ethics, July, 1992.

1. Australian and New Zealand College of Anaesthetists. College
4.Taylor L. Medical John Wright and
Bristol, United Kingdom. 1980.
Policy Document P6. 1996 Minimum Requirements for the
Anaesthesia Record.
5. Campion F. Good medical records can be strongest malpractice
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Aust. NZ J Obstet Gynaecol

1998; 38: 2: 169

Oral Medication for Post-Caesarean Analgesia

J. Monagle: FANCZA, A. Molnars MBBS (Hons) and W. Shearer; FANCZA
Department of Anaesthesia, Dandenong Hospital, Victoria

Summary: A regimen of morphine, paracetamol and aspirin administered orally was

evaluated in 20 patients following Caesarean section; 18 of 20 reported no or mild
impairment in their ability to care for their babies. There was a high level of
satisfaction with 18 of 20 being very satisfied with their postoperative analgesia.
There was a low incidence of side-effects with this regimen. It was acceptable to both
patients and staff.

Analgesia is required postoperatively for all After fluid loading with 1,000 mL of crystalloid
patients undergoing significant surgery. The aims solution and premedication with metoclopramide
should be good pain relief with minimal side-effects 10 mg and atropine 250 mcg, spinal anaesthesia was
and minimal limitations on the early return to normal performed in a routine manner utilizing 27 gauge
function. Optimal analgesia may not necessarily be Sprotte needles. Patients received 2.25 to 3.0 mL of
best practice in pain relief if mobility is limited or 0.5% hyperbaric bupivicaine solution in the
side-effects are significant. This is particularly true subarachnoid space. Ephedrine was used to maintain
following Caesarean section as new mothers are keen normotension. The incision was transverse lower
to be involved in the care of their babies. We present abdominal (Pfannenstiel) in all patients.
this report of our experience using a combination of At the completion of the operation and upon
oral analgesics to provide an effective analgesic entering the recovery room all patients received 1 g of
regimen with a low rate of side-effects and high oral paracetamol and 2 tablets each containing
incidence of patient and staff acceptance. We are morphine hydrochloride 5 mg and aspirin 250 mg
unaware of any other reports describing the use of oral (Morphalgin, Fawns and McAllan P/L, Clayton,
analgesics for post-Caesarean analgesia. Victoria). Each woman then received 1 g of oral
paracetamol and 2 tablets of Morphalgin every 4
METHODS hours between 6 am and 10 pm for 72 hours as a strict
A prospective audit of 20 consecutive women using order. The intravenous cannula was removed when the
the analgesic regimen utilized in this hospital over the motor blockade of the spinal anaesthetic had resolved.
past 2 years was performed. All of the women were fit Each woman was made aware that a dose of morphine
and healthy. There were no contraindications for (0.1 mg/kg subcutaneously 2-hourly prn) was
regional analgesia or use of oral morphine, aspirin and available on request if the oral regimen did not
paracetamol in these women. provide adequate pain relief. A dose of 10 mg of
1. Deputy Director.
metoclopramide was also available if required for
2. Registrar. nausea or vomiting.
3. Director. Patients were followed regularly for 72 hours
Address for correspondence: postpartum. At this time they were asked to rate
Dr John Monagle, nausea, vomiting or pruritus during this period as
Department of Anaesthesia,
Dandenong Hospital, none, mild, moderate or severe. They were also asked
David Street, if pain had not at all, mildly, moderately or severely
Dandenong, Victoria 3175. impaired their ability to look after their babies.
170 ALJST.
AND N.Z. JOUKNAL OF OBSTETRICS AND GYNAECO1,OGY

Each woman was asked to rate their overall The combination of morphine, aspirin and
satisfaction with postoperative pain relief as either not paracetamol provides a multimodal approach to
satisfied, somewhat satisfied or very satisfied. They analgesia. By combining the 3 agents synergistic and
were also asked if they would be happy to have the additive effects occur to provide a better quality
same regimen of postoperative analgesia for a future analgesia than if 1 agent was to be used alone (5).
Caesarean section or whether they would like an Aspirin is a nonsteroidal antiinflammatory drug
alternative. (NSAID). NSAIDs inhibit prostaglandin synthesis
thus decreasing the production of algesic mediators
RESULTS that are released during surgery and by doing so
There was no report of vomiting or pruritus decrease analgesic requirements (6). NSAIDs have an
amongst any of the patients. One woman reported opioid-sparing effect following Caesarean section (7).
moderate nausea and she received 1 dose of Aspirin, like other NSAIDs, may produce side-
metoclopramide 6 hours postdelivery and experienced effects such as gastric ulceration, renal impairment or
no further nausea. All other women reported no increased bleeding. However the risk and incidence of
nausea and they received no doses of antiemetic. side-effects of aspirin in the perioperative period are
Of the 20 patients 4 stated that pain caused no not well documented. Aspirin should be avoided in
impairment, 14 mild impairment and 2 moderate those patients with a past history of a gastric ulcer and
impairment in their ability to look after their babies. those with aspirin-sensitive asthma. All NSAIDs
There was no report of severe impairment. Six should be avoided in postsurgical patients who are
patients received breakthrough doses of morphine. No hypovolaemic or who have other risk factors
one received more than 1 dose and all doses were predisposing to postoperative renal failure (8).
required within 6 hours of delivery. Of the 20 patients Although aspirin causes an increase in skin bleeding
18 stated they were very satisfied with their times NSAIDs have been used after Caesarean
postoperative analgesia and would be happy with the delivery without any appreciable increase in blood
same regimen if they were to undergo another loss (9).
The safety of using aspirin in breast-feeding
Caesarean section. One patient was somewhat
women is controversial, although Morphalgin has
satisfied but would prefer better analgesia next time.
traditionally been the analgesic of the obstetricians’
One patient was not satisfied and would prefer
choice in our institution. Aspirin is excreted in breast
another method next time.
milk and levels in infants are measurable (10). As
such, several authors have advised against the use of
DISCUSSION aspirin in breast-feeding because of its role in the
Several techniques have shown to be effective in aetiology of Reye syndrome (1 I). The association
providing analgesia post-Caesarean section. However between Reye syndrome and aspirin remains
these techniques do have their limitations. Opioids via controversial (12). There have been no reports of
either intravenous patient-controlled administration or Reye syndrome in infants of breast-feeding women
epidural route provide superior analgesia and patient taking aspirin. Schoenfeld et a1 (13) in a review
satisfaction than traditional intramuscular analgesia concluded that breast feeding need not be avoided in
(1). The disadvantage of patient-controlled delivery of mothers taking up to 2.4 g of aspirin per day.
analgesia is that ongoing intravenous access and the Paracetamol is a widely used analgesic. Given alone
use of bulky equipment is required, which limits it provides considerable analgesia post-Caesarean
mobilization (2). The disadvantage with neuroaxial section (14). Although it is commonly classed as a
placement of opioids either via the epidural or NSAID, its action differs from aspirin in that it only
subarachnoid space is the high incidence of pruritus has weak peripheral antiinflammatory effects and it is
(60-80% with larger doses) and nausea (up to 50%) believed that its central inhibition of prostaglandin
with a risk of respiratory depression and recurrence of synthesis confers its analgesic effect. It is also thought
herpes simplex labialis ( 5 % ) (1-3). to have an analgesic effect via N-methyl-D-aspartate
Continuous infusion of epidural local analgesics is (NMDA) receptors in the spinal cord (15).
an extremely effective analgesic technique. However Theoretically by combining aspirin and paracetamol
it also requires intravenous access and use of bulky there should be additive-synergistic effects with
equipment as well as the unique side-effects of reduction in postoperative pain. Postoperative use of
hypotension secondary to a sympathetic blockade and paracetamol has an opioid-sparing effect with opioid
ongoing motor block. Both of these side-effects limit requirements being reduced 16-26% after elective
mobilization and patient satisfaction. There have also postgynaecological laparotomy (1 6).
been case reports of disastrous equipment and Paracetamol toxicity is related to the production of
human errors when running continual epidural highly reactive metabolites, which result in hepatic
infusions in ward settings (4). necrosis. Current guidelines recommend that doses
 J. MONACLE
ET AL 171

should not exceed 90 mglkglday. Our patients 3. Cohen SE, Suback LL and Brose WG. Analgesia after cesarean
received 5,000 mg a day. Excretion of paracetamol in delivery: patient evaluations and cost of five opiod techniques.
Reg Anesth 1991; 16: 141-149.
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Results from this study showed acceptable analgesia Intens Care 1995; 23: 650-651.
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7. Luthan J, Kay NH and White JB. The morphine sparing effect
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incidence of side-effects with this regimen. Patients are anaesthesia. Internat Obstet Anaesth 1994; 3: 82-86.
able to mobilize early, with 18 out of 20 reporting no 8. Souter AJ, Fredman B and White PF. Controversies in the
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morphine. All morphine requests occurred within the Tuimala R. Diclofenac and ketoprofen for pain treatment after
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This may be due to a delay in oral medications Serum salicylate levels in a breast-fed infant. Ann Rheum Dis
reaching adequate plasma levels prior to resolution of 1987; 46: 638-639.
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There was a high level of satisfaction, with 18 of 20 Anaesthesia 1993; 48: 616-625.
12.Orlowski JP, Gillis J, Kdham HA. A Catch in the Reye.
being very satisfied with their postoperative analgesia. Paediatrics 1987; 80: 638-642.
Our experience of combining oral medications in a 13. Schoenfeld A, Bar Y, Merlob P, Ovadia Y. NSAIDs: maternal
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technique with a high level of satisfaction and analgesic effect of codeine and paracetamol can be detected in
acceptance by staff and most importantly patients. strong, but not moderate, pain after caesarean section. Baseline
pain-intensity is a determinant of assay-sensitivity in a
postoperative analgesic trial. Acta Anaesthesiol Scand 1996; 40:
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