Efficacy of Single Wound Infiltration With Bupivacaine and Adrenaline During Cesarean Delivery for Reduction of Postoperative Pain

Abstract

ImportanceMost women report moderate to severe pain after cesarean delivery. The extent of the ability of surgical wound infiltration with local anesthetic agents during cesarean delivery for the reduction of postoperative pain is uncertain.ObjectiveTo examine the efficacy of single wound infiltration with bupivacaine and adrenaline during cesarean delivery for the reduction of postoperative pain.Design, Setting, and ParticipantsThis randomized clinical trial was conducted between January 25, 2018, and May 30, 2020, at a university teaching hospital in Afula, Israel. A total of 288 women with singleton pregnancy who were scheduled for a planned cesarean delivery at term were randomized to receive single wound infiltration with bupivacaine and adrenaline during cesarean delivery (intervention group) or no single wound infiltration (control group) at a 1:1 ratio.InterventionsIn the intervention group, the subcutaneous layer was infiltrated on both sides of the wound by a mixture of bupivacaine and adrenaline before wound closure. Other perioperative techniques were similar between the groups.Main Outcomes and MeasuresThe primary outcome was mean pain intensity over the course of 24 hours after the operation, as measured by a visual analog scale (VAS) score ranging from 0 to 10 (with higher scores indicating greater pain intensity). To detect a mean (SD) reduction of 1 (3) points in the VAS score in the intervention group, 286 women were needed in total. Secondary outcomes included VAS score greater than 4 (indicating moderate pain) at 2 hours after the operation, use of rescue opioids, maternal satisfaction with the pain management procedure (using a scale of 1-5, with higher scores indicating greater satisfaction), duration of the operation, scar complications (hematoma, infection, and separation), and length of stay.ResultsAmong 288 women (mean [SD] age, 32.5 [5.1] years; all of Arab or Jewish ethnicity), 143 were randomized to the intervention group, and 145 were randomized to the control group. Demographic and obstetric variables were similar between groups. The primary outcome (VAS pain score) was significantly lower in the intervention group (mean [SD], 2.21 [0.56]) compared with the control group (mean [SD], 2.41 [0.73]; P = .02). In the intervention group, 11 women (7.7%) had a VAS score greater than 4 at 2 hours compared with 22 women (15.2%) in the control group (odds ratio, 0.47; 95% CI, 0.22-1.00; P = .05). In addition, compared with the control group, the intervention group had significantly lower postpartum use of rescue opioid analgesics (19 women [13.3%] vs 37 women [25.5%]; P = .009) and greater satisfaction with pain management (mean [SD] score, 4.65 [0.68] vs 4.44 [0.76]; P = .007). In the intervention vs control groups, duration of the operation, scar complications (hematoma, infection, or separation), and length of stay were comparable.Conclusions and RelevanceIn this study, wound infiltration with a single administration of bupivacaine and adrenaline during cesarean delivery reduced postoperative pain and opioid use and may have improved maternal satisfaction with pain management. These findings suggest the technique is efficacious, safe, and easy to perform.Trial RegistrationClinicalTrials.gov Identifier: NCT03395912

Postoperative Analgesia and Cesarean Section under General Anesthesia: Multicenter Study

“…Our result is not isolated, the randomized study by Garmi [11] comparing scar infiltration and absence of infiltration found a superiority of infiltration on the post-operative pain score and the use of emergency analgesia. In 2009, A Cochrane database review [12] revealed that wound infiltration with local anesthesia was associated with decreased opioid consumption at 24 hours after cesarean delivery but did not reduce VAS scores Meta-analyses from 2016 [13] and 2021 concluded that wound infiltration with local anesthesia was associated with reductions in opioid consumption only among patients who did not receive intrathecal morphine.…”

Analgesia after cesarean section – what is new?

“…Several regional anesthesia techniques have been investigated to assess their potential analgesic benefit for postcesarean pain. These include lumbar paravertebral block, transversus abdominis plane block (TAP), quadratus lumborum (QL) blocks with different approaches, ilioinguinal-iliohypogastric (II-IH) nerve block, erector spinae plane (ESP) block [16], and surgical wound infiltration [17,18]. When compared to intrathecal morphine, none of these provide superior analgesia [19].…”

Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients

“…Both TAP blocks and local wound infiltration, whether by single shot or continuous catheter technique, have been shown to decrease 24-hour opioid consumption and provide significant analgesia when compared to control in the absence of neuraxial opioid. 58,59,70 However, a meta-analysis of 42 RCTs comparing TAP to wound infiltration and wound catheter found no statistically significant difference in 24-hr opioid consumption, 24-hour pain scores, or time to first supplementary analgesic between the two techniques. 63 A second meta-analysis reproduced the same results; TAP blocks may have small to no significant advantage in post-operative pain reduction when compared to wound infiltration of local anesthetic by a surgeon.…”