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Caesarean section wound infiltration with local anaesthetic for postoperative pain relief--any benefit?

Delivery by caesarean section (CS) is becoming more frequent and is one of the most common major operative procedures performed worldwide. In the USA a CS rate of 26% for all births is reported. (1) The rate approaches 25% in Canada and is over 20% in England, Wales and Northern Ireland. (2) In the private health sector in South Africa, one study noted a much higher figure of 57%. (3)

Childbirth is an emotional experience for a woman and her family. The mother needs to bond with the new baby as early as possible and initiate early breastfeeding, which helps to contract the uterus and accelerates the process of uterine involution in the postpartum period. (4) Any form of intervention that leads to improvement in pain relief can positively impact on early breastfeeding. Prompt and adequate postoperative pain relief is therefore an important component of caesarean delivery that can make the period immediately after the operation less uncomfortable and more emotionally gratifying. Postoperative pain after CS is usually managed with opioids in combination with other forms of analgesics.

CS is performed under spinal anaesthesia, spinal epidural, epidural block or general anaesthesia. Short-or mediumacting sedatives, narcotics and local anaesthesia have been employed during the operation as an adjunct to anaesthesia or to alleviate postoperative pain. Local anaesthetics cause reversible blockade of impulse propagation along the nerve fibres by preventing the influx of sodium ions through the cell membrane of the fibres. Several studies have reported on use of pre-emptive local anaesthetics (local anaesthetic given during the operation to prevent or reduce pain afterwards) to relieve postoperative pain, with results ranging from being beneficial (5,6) to conferring no benefit. (7,8)

The local anaesthetic may be administered by pre-or post-incisional abdominal nerve block (local anaesthetic injected to block the nerves before cutting the skin at the beginning of the operation, or after closing the skin at the end (9)) or pre-or post-incisional abdominal wound infiltration. (5,10) It may also be administered by continuous wound irrigation. (11) Commonly used local anaesthetic agents have side-effects, although these are very rare, ranging from allergy to cardiovascular and central nervous system effects. Local anaesthetics eventually get absorbed systemically and secreted in breastmilk, but their effects on breastfed babies have not yet been documented. This is in sharp contrast to morphine or pethidine, both of which have significant transfer to breastmilk and may have a sedative effect on the baby. (4)

It is also important to consider the cost implications of local anaesthetic administration. Should it prove to be of benefit, the actual cost of the local anaesthetic and the additional time needed to carry out the procedure may be justified, considering the long-term sequelae of pain and immobility immediately after CS.

Objectives

The objectives of the study were to assess the effects of local anaesthetic agent wound infiltration/irrigation and/or abdominal nerve blocks on pain relief after CS, on the mother's physical, social and mental well-being, and on her ability to meet the physical, psychological and nutritional needs of the baby.

Methods

Prospective randomised controlled trials in women undergoing CS, either electively or as an emergency, were considered for inclusion in the review.

The types of interventions that were sought were local anaesthetic agent wound infiltration versus placebo/no infiltration, ilio-inguinal/iliohypogastric nerve block versus placebo/no treatment, local anaesthetic agent versus other methods of pain relief, and comparisons of different local anaesthetic agent techniques. Outcome measures assessed included postoperative pain scores, postoperative analgesia requirement, time to first rescue analgesia, postoperative fever, duration of CS, onset of mobilisation, onset of breastfeeding, duration of breastfeeding, duration of exclusive breastfeeding, side-effects of the local anaesthetic, duration of hospital stay, postoperative wound infection, women's satisfaction with regard to pain relief, occurrence of postnatal depression or neurotic/psychotic disorders, chronic pelvic pain, and caregiver satisfaction.

Studies were searched for and identified through the Cochrane Pregnancy and Childbirth Group's Trials Register by contacting the Trials Search Co-ordinator (April 2009). Details of the search strategies for CENTRAL and MEDLINE, the list of hand-searched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the 'Specialized Register' section in the editorial information about the Cochrane Pregnancy and Childbirth Group. (12) There was no language restriction. We assessed for inclusion all potential studies we identified via the search strategy, and designed a form to extract data. No major discrepancies were identified. We used the Review Manager software (13) to double-enter all the data, assessed the validity of each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions, (14) and described methods used for generation of the randomisation sequence for each trial.

For each individual study we described the method used to generate allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups. We assessed the method as either adequate (any truly random process, e.g. random number table; computer random number generator), inadequate (any non-random process, e.g. odd or even date of birth; hospital or clinic record number), or unclear. Method of allocation concealment (checking for possible selection bias), blinding, completeness of data and selective reporting bias were all assessed.

We carried out statistical analysis using the Review Manager software. (13) We used fixed-effect meta-analysis for combining data in the absence of significant heterogeneity if trials were sufficiently similar. When heterogeneity was found, we used random-effects analysis. For dichotomous data, we presented results as summary risk ratios (RRs) with 95% confidence intervals (CIs), and for continuous data we used the mean difference if outcomes were measured in the same way between trials. We used the standardised mean difference to combine trials that measured the same outcome but used different methods.

We applied tests of heterogeneity between trials, if appropriate, using the [I.sup.2] statistic. In the event of significant heterogeneity, we used a random-effects meta-analysis as an overall summary if we determined that this was appropriate. Subgroup analysis was for women who had general anaesthesia versus regional analgesia. We excluded studies of poor quality (those rating B, C or D) in order to assess for any substantive difference to the overall result.

Results

We identified 40 studies. Twenty studies, involving 1 150 women, carried out in both developed and developing countries and spanning almost two decades, met the inclusion criteria (Table I). The outcome of interventions is shown in Table II.

Wound infiltration with local anaesthetics only v. control

Women who underwent CS under regional anaesthesia and had wound infiltration had a decrease in morphine consumption at 24 hours (3 studies, 126 participants; standardised mean difference (SMD) -1.70 mg; 95% CI -2.75 to -0.94) compared with placebo. There was no difference in visual analogue pain.

Peritoneal spraying/instillation and abdominal wound infiltration involving all layers

Women who underwent CS under general anaesthetic, who had the wound infiltrated and peritoneal spraying with local anaesthetic (1 study, 100 participants), had a reduced need for opioid rescue (RR 0.51; 95% CI 0.38 to 0.69). The numerical pain score (0-10) within the first hour was reduced (MD -1.46 mg; 95% CI -2.60 to -0.32).

The amount of oral Tramacet (375 mg paracetamol + 150 mg tramadol) consumed was reduced in the local anaesthetic group compared with controls who received saline (MD -2.35 mg; 95% CI -3.62 to -1.08).

Local anaesthetic v. local anaesthetic and nonsteroidal anti-inflammatory drug (NSAID) mixture

Women operated on under regional anaesthesia and who had a local anaesthetic and NSAID cocktail wound infiltration consumed less morphine in the first 18 hours (1 study, 60 participants; MD -7.40 mg; 95% CI -9.58 to -5.22) compared with controls who received a local anaesthetic only. There was no difference in the occurrence of vomiting or reduction in anti-emetic use (RR 1.40 mg; 95% CI 0.90 to 2.16).

Anterior abdominal nerve block with local anaesthetic v. control

Women who had regional anaesthesia and an abdominal nerve block had decreased opioid consumption (4 studies, 175 participants; MD -25.80 mg; 95% CI -50.39 to -5.37) but no difference in visual analogue pain score (0-10) (2 studies, 83 participants; MD -1.82 (95% CI -2.74 to -0.90)).

Local anaesthetics v. local anaesthetics + narcotics

In terms of the visual analogue scale over 24 hours, no advantage was demonstrated in the single study of 50 participants who had wound infiltration with a mixture of local anaesthetic and narcotics versus local anaesthetic.

Local anaesthetics v. local anaesthetics + ketamine

Addition of ketamine to the local anaesthetic in women receiving regional anaesthesia does not confer any advantage in terms of narcotic consumption or patient satisfaction (1 study, 50 participants).

Discussion

Minimising pain after CS is best achieved using a multimodal approach. Local anaesthetics, from lidocaine to the more recent ropivacaine, have been used as pre-emptive analgesics since the 1980s. Clinical trials were only published in the early 1990s. Local anaesthetic has been used in women receiving general anaesthesia and regional anaesthesia, and rarely local anaesthesia alone has been used when other anaesthesia was unavailable or unsafe. Various routes of administration have been tested, such as subcutaneous wound infiltration, infiltration through all layers of the abdomen, continuous wound instillation or iliohypogastric/ilio-inguinal nerve blocks. Ultrasound-guided nerve blocks may soon be explored. Local anaesthesia has been used alone and in combination with NSAIDs or ketamine.

This review showed that women undergoing CS under regional analgesia who had local anaesthetic infiltration or abdominal nerve block had a reduced need for postoperative opioids. Addition of NSAIDs to the local anaesthetic for wound infiltration conferred additional advantage, perhaps because these analgesics have a different mode of action. Opioid consumption may not be the optimal method of pain assessment because of being influenced by patient fear of dependency, but this effect is balanced by the randomisatio process. Significant results must be regarded with caution because of testing at multiple times, and the results are mostly based on single trials involving few women. None of the trials addressed chronic pelvic pain or cost implications.

Conclusions

In general, we conclude that local anaesthesia is of benefit in women having a CS because it reduces opioid consumption. It can be recommended as part of the multimodal approach to pain relief, but in terms of affordability a cost-benefit analysis is needed as theatre time will be increased and there is a cost attached to the local anaesthetic and accessories. This cost increase may be offset by less use of postoperative analgesia. A pharmacokinetic study of local anaesthetic absorption after wound and peritoneal infiltration is necessary. Ultrasound-guided direct block of the anterior abdominal wall nerves in CS should be explored. An important field of investigation will also be the effect of the intervention on chronic pelvic pain.

The authors acknowledge support from the Postgraduate School and Effective Health Care Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, and University of Fort Hare, East London.

After a pre-publication editorial process by the Cochrane Pregnancy and Childbirth Group, the review was published in its full format in the Cochrane Library. (31)

Accepted 28 September 2009.

References

(1.) Centers for Disease Control and Prevention. Rate of cesarean delivery among Puerto Rican women: Puerto Rico and the U.S. mainland 1992-2002. MMWR Morb Mortal Wkly Rep 2006; 55(3): 68-71.

(2.) Royal College of Obstetricians and Gynaecologists. Clinical Effectiveness Study Support Unit. The National Sentinel Caesarean Section Audit Report. London: RCOG, 2001.

(3.) Tshabangu KC, de Jong MA, de Villiers DJ, Du Toit JJ, Sha SMH. Incidence and outcome of caesarean section in the private sector--3-year experience at Pretoria Gynaecological Hospital. S Afr Med J 2002; 92(12): 956-959.

(4.) Novy MJ. 1991; The normal pueperium. In: Pernoll ML, ed. Current Obstetrics & Gynecologic Diagnosis and Treatment. Connecticut: Appleton & Lange;p. 260. Author: Please provide name/s of editor/s

(5.) Ganta R, Samra SK, Maddineni VR, Furness G. Comparison of the effectiveness of bilateral ilioinguinal nerve block and wound infiltration for postoperative analgesia after caesarean section. Br J Anaesth 1994; 72: 229-230.

(6.) Johanssen B, Hallerback B, Stubberod A, et al. Preoperative local infiltration with ropivacaine for postoperative pain relief after inguinal hernia repair. A randomised controlled trial. Eur J Surg 1997; 163(5): 371-378.

(7.) Adams WJ, Avramovic J, Barraclough BH. Wound infiltration with 0.25% bupivacaine not effective for postoperative analgesia after cholecystectomy. Aust NZ J Surg 1991; 61(8): 626-630

(8.) Friedman B, Zohar E, Tarabykin A, et al. Bupivacaine wound instillation via an electronic patient-controlled analgesia device and a double-catheter system does not decrease postoperative pain or opioid requirements after major abdominal surgery. Anesth Analg 2000; 93(2): 514.

(9.) Trotter TN, Hayes-Gregson P, Robinson S, Cole L, Coley S, Fell D. Wound infiltration of local anaesthetic after lower segment caesarean section. Anaesthesia 1991; 46(5): 404-407.

(10.) Kumar Das A, Wig J, Dhaliwal L. Preincisional local infiltration of bupivacaine and a mixture of bupivacaine and morphine for pain following lower segment cesarean section (a comparative evaluation). J Anaesthesiol Clin Pharmacol 1999; 15: 317-320.

(11.) Givens VA, Lipscomb GH, Meyr NL. A randomized trial of postoperative wound irrigation with local anesthetic for pain after cesarean delivery. Am J Obstet Gynecol 2002; 186: 1188-1191.

(12.) Cochrane Pregnancy and Childbirth Group. http://www.mrw.interscience.wiley.com/ cochrane/clabout/articles/PREG/frame.html (accessed 21 May 2008).

(13.) Review Manager (RevMan) [Computer program]. Version 5.0. Copenhagen: Nordic Cochrane Centre, Cochrane Collaboration, 2008.

(14.) Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 [updated September 2008]. Cochrane Collaboration, 2008. Available from www. cochrane-handbook.org

(15.) Bamigboye AA, Hofmeyr GJ. Ropivacaine wound infiltration and peritoneal spray for post caesarean section pain relief. Int J Gynecol Obstet 2008; 102(2): 160-164.

(16.) Bell EA, Jones BP, Olufolabi AJ, et al. Iliohypogastric-ilioinguinal peripheral nerve block for post-cesarean delivery analgesia decreases morphine use but not opioid-related side effects. Can J Anesth 2002; 49(7): 694-700.

(17.) Caulry C, Roelants F, Waterloos H, Yamgnane A, Lavand'homme P. Continuous wound irrigation with ropivacaine or diclofenac for postoperative analgesia after cesarean section. Reg Anesth Pain Med 2003; 28(5 Suppl 1): 49.

(18.) Chen C, Seah YS, Ng YT, Chuah EC, Tan PP. Ilioinguinal nerve blockade with or without epinephrine for analgesia after caesarean section. Ma Tsui Hsueh Tsa Chi 1990; 28: 351-355.

(19.) Kuppuvelumani P, Jaradi H, Delilkan A. Abdominal nerve blockade for postoperative analgesia after caesarean section. Asia-Oceania Journal of Obstetrics and Gynaecology 1993; 19(2): 165-169.

(20.) Lacrosse D, Roelants F, Mercier V, Waterloos H, Lavand'homme P. Continuous wound irrigation with ropivacaine or diclofenac after cesarean: immediate and delayed benefits. Int J Obstet Anesth 2004; 13(3): S20.

(21.) Lavand'homme PM, Roelants F, Waterloos H, De Kock MF. Postoperative analgesic effects of continuous wound infiltration with diclofenac after elective cesarean delivery. Anesthesiology 2007; 106(6): 1220-1225.

(22.) Marbaix C, Roelants F, Mercier V, Waterloos H, Lacrosse D, Lavand'homme P. Post cesarean section analgesia with continuous local infusion of ropivacaine or diclofenac. Int J Obstet Anesth 2004; 13(3): S19.

(23.) McDonnell JG, Curley G, Carney J, et al. The analgesic efficacy of transversus abdominis plane block after cesarean delivery: a randomized trial. Anesth Analg 2008; 106(1): 186-191.

(24.) Mecklem DW, Humphrey MD, Hicks RW. Efficacy of bupivacaine delivered by wound catheter for post-caesarean section analgesia. Aust NZ J Obstet Gynaecol 1995; 35(4): 416-421.

(25.) Pavy TJG, Gambling DR, Kliffer AP, Munro A, Merrick PM, Douglas MJ. Effect of preoperative skin infiltration with 0.5% bupivacaine on postoperative pain following cesarean section under spinal anesthesia. Int J Obstet Anesth 1994; 3: 199-202.

(26.) Pirbudak L, Balat O, Karadasli H, Ugur MG, Oner U. Single perioperative wound infiltration with combination of bupivacaine, tramadol, and tenoxicam for pain relief after cesarean delivery with spinal anesthesia. Pain Clinic 2004; 16(3): 287-291.

(27.) Rosaeg OP, Lui AC, Cicutti NJ, Bragg PR, Crossan ML, Krepski B. Peri-operative multimodal pain therapy for caesarean section: analgesia and fitness for discharge. Can J Anaesth 1997; 44(8): 803-809.

(28.) Solak M, Yildirim S, Senel AC, Erciyes N. The effects of preincisional bupivacaine infiltration on surgical stress response and postoperative analgesia in caesarean section [Sezaryen operasyonlarinda insizyon oncesi bupivakain infiltrasyonunun serum kortizol ve postoperatif agri ulzerine etkisi]. Turk Anesteziyoloji Ve Reanimasyon 1999; 27: 182-185.

(29.) Zohar E, Luban I, Zunser I, Shapiro A, Jedeikin R, Fredman B. Patient-controlled bupivacaine wound instillation following cesarean section: the lack of efficacy of adjuvant ketamine. J Clin Anesth 2002; 14: 505-511.

(30.) Zohar E, Shapiro A, Eidinov A, Fishman A, Fredman B. Postcesarean analgesia: the efficacy of bupivacaine wound instillation with and without supplemental diclofenac. J Clinl Anesth 2006; 18(6): 415-421.

(31.) Bamigboye AA, Hofmeyr GJ. Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief. Cochrane Database Syst Rev 2009; 3: CD006954.

Anthony Akinloye Bamigboye, George Justus Hofmeyr

Department of Obstetrics and Gynaecology, University of the Witwatersrand, and Sandton Medi-Clinic, Johannesburg, and Visiting Consultant Gynaecologist, University Teaching Hospital, Ado Ekiti, Nigeria

Anthony Akinloye Bamigboye, FCOG (SA)

Effective Care Research Unit, University of the Witwatersrand, Johannesburg, and University of Fort Hare, East London, E Cape

George Justus Hofmeyr, MRCOG

Corresponding author: A A Bamigboye (bami@medinet.co.za)
Table I. Characteristics of included studies

Author Methods Participant

Bamigboye Randomised 100 consenting
et al. (15) double-blind, women, elective CS
 placebo-
 controlled trial

Bell et Randomised 59 women,
al. (16) double-blind randomised
 placebo- to receive nerve
 controlled trial block or saline
 placebo

Caulry et Randomised 30 women, spinal
al. (17) placebo- anaesthesia, randomised
 controlled trial into 10 each of saline,
 ropivacaine and
 diclofenac

Chen et Randomised 36 women, randomised into
al. (18) clinical trial 12 no treatment, 12 plain
 Marcaine and 12 Marcaine
 with adrenaline

Ganta et Randomised 62 women, elective CS
al. (5) single-blind under general anaesthesia
 placebo-
 controlled trial

Givens et Randomised 36 women, planned CS
al. (11) double-blind
 placebo-
 controlled trial

Kumar et Randomised 50 ASA I and II women,
al. (10) controlled trial elective CS

Kuppuvelumani Randomised 60 women, CS under
et al. (19) controlled trial general anaesthesia

Lacrosse et Prospective 55 healthy parturients,
al. (20) randomised trial CS under spinal
 anaesthesia

Lanvand'homme Randomised 90 women randomly
et al. (21) double-blind allocated to receive
 placebo- saline, diclofenac or
 controlled trial 0.2% ropivacaine,
 30 in each group

Marbaix et Randomised 55 healthy parturients,
al. (22) prospective trial elective CS under
 spinal anaesthesia

McDonnell et Randomised 50 women, CS under
al. (23) controlled trial spinal anaesthesia

Mecklem et Randomised 79 women, CS under
al. (24) double-blind spinal analgesia
 placebo-
 controlled trial

Pavy et Randomised trial 40 women for elective CS
al. (25)

Pirbudak et Randomised 60 women, CS under
al. (26) double-blind spinal anaesthesia

Rosaeg et Randomised 40 women, elective CS
al. (27) controlled trial

Solak et Randomised trial 30 women, elective CS
al. (28)

Trotter et Randomised 28 women, elective CS
al. (9) double-blind trial

Zohar et Prospective 50 term parturients,
al. (29) randomised CS under spinal
 double- anaesthesia
 blind study

Zohar et Prospective, 90 parturients
al. (30) randomised, (ASA 1 & 2), elective CS
 double-blind,
 placebo-
 controlled trial

Author Intervention Outcome

Bamigboye 50 women received 225 mg Postoperative
et al. (15) ropivacaine if 64 kg or pethidine, diclofenac
 more and 3 mg/kg if less. injection and Tramacet
 Controls received an
 equivalent volume of
 saline.
 All layers of anterior
 abdominal incision
 infiltrated, including
 peritoneum

Bell et 31 women had ilio- Postoperative morphine
al. (16) inguinal-iliohypogastric use and visual analogue
 nerve block with 0.5% pain scores
 bupivacaine with
 adrenaline and 28 had
 saline placebo

Caulry et Wound irrigation in Visual analogue pain
al. (17) each group scores and use of
 morphine

Chen et Ilio-inguinal nerve Pain, times of pethidine
al. (18) block after CS injection, first time and
 dosage of pethidine
 injection, postpartum
 haemorrhage and uterine
 atony

Ganta et 21 women had bilateral Visual analogue scale
al. (5) ilioinguinal nerve block pain scores in first 24
 with 0.5% bupivacaine, 20 hours and mean morphine
 had wound infiltration consumption in 24 hours
 with 0.5% bupivacaine,
 and 21 received no local
 anaesthetic

Givens et 20 women with wound Postoperative morphine
al. (11) irrigation with 0.25% use and visual analogue
 bupivacaine v. 16 with pain scores
 normal saline solution
 irrigation

Kumar et 24 women received pre- Visual analogue pain
al. (10) incisional 0.5% scores at different hours
 bupivacaine 40 ml v. 26 in the first 24 hours and
 receiving bupivacaine 40 side-effects of vomiting,
 ml and 2 mg morphine nausea and pruritus
 mixture

Kuppuvelumani Mixture of 0.5% Time to breastfeeding,
et al. (19) bupivacaine with total pethidine
 adrenaline with 1% requirement over 24 hours
 xylocaine injected to and duration of action of
 block the ilio-inguinal/ the block
 iliohypogastric nerve in
 30 women v. 30 controls
 who did not receive
 abdominal nerve block

Lacrosse et 19 women had wound Local ropivacaine wound
al. (20) irrigation with 300 mg infiltration superior to
 diclofenac for 48 hours, diclofenac only in the
 18 had ropivacaine 0.2%, first 24 hours, but
 18 controls had saline diclofenac has a better
 opioid-sparing effect

Lanvand'homme Continuous wound Postoperative morphine
et al. (21) infiltration with the consumption, parietal and
 allocated interventions visceral visual analogue
 pain scores

Marbaix et 19 women had wound Visual analogue pain
al. (22) irrigation with 300 mg scores and morphine
 diclofenac for 48 hours, consumption
 18 had ropivacaine 0.2%,
 18 controls had saline

McDonnell et 1.5 mg/kg ropivacaine per Morphine requirement,
al. (23) side injected into the prolonged and superior
 transversus abdominis analgesia up to 36 hours
 plane (TAP) versus saline postoperatively
 TAP block

Mecklem et Patients allocated to Visual analogue pain
al. (24) receive either saline or scores, morphine
 0.25% bupivacaine consumption and gastro-
 intestinal side-effects

Pavy et 20 patients received 0.5% Pain scores, pruritus
al. (25) bupivacaine, 20 received and nausea
 saline

Pirbudak et 40 ml 0.25% bupivacaine + Reduction in
al. (26) 100 mg tramadol + 20 mg postoperative analgesic
 tenoxicam v. normal use and prolongation of
 saline analgesic requirement
 time

Rosaeg et Experimental group Visual analogue pain
al. (27) received intrathecal scores at rest and at
 morphine, incisional mobilisation. Time to
 bupivacaine and ibuprofen first walking, eating,
 and acetaminophen, v. IVI bowel movement and
 morphine weaned to voiding
 acetaminophen and
 codeine. Both groups
 received 0.75%
 bupivacaine spinal
 analgesia

Solak et Patients randomised to Visual analogue pain
al. (28) receive either 20 ml 0.5% scale scores, analgesic
 bupivacaine or saline requirement and cortisol
 level

Trotter et 0.5% bupivacaine v. Morphine consumption,
al. (9) saline pain scores, sedation
 level and nausea

Zohar et A multi-holed device was Visual analogue scale for
al. (29) placed in the wound and pain, rescue morphine,
 connected to a patient- patient satisfaction
 controlled pump.
 Bupivacaine v.
 bupivacaine combined with
 ketamine

Zohar et 30 women had wound Rescue analgesic
al. (30) instillation with 0.25% required, visual analogue
 bupivacaine and 75 mg pain scale, nausea and
 intravenous diclofenac patient satisfaction
 via a patient-controlled
 analgesic infusion pump,
 30 only bupivacaine
 instillation, 30 only
 diclofenac infusion

Table II. Data and analyses

Outcome or subgroup Studies Participants

Wound infiltration with
local anaesthetic only v. control
Total morphine consumption as 3 126
defined by trial author
in the first 24 hours
 General anaesthesia 0 0
 Regional anaesthesia 3 126
Visual analogue scale
(0-10) at 24 hours 2 56
 Regional anaesthesia 2 56
 General anaesthesia 0 0
Total morphine consumption
as defined by trial author,
in the first 12 hours 1 28
 General anaesthesia 1 28
 Regional anaesthesia 0 0
Wound infiltration with local
anaesthetic and peritoneal
spraying v. placebo
Need for pethidine rescue
within 1 hour of delivery 1 100
 General anaesthesia 1 100
 Regional anaesthesia 0 0
Numerical pain score
(0-10) at 1 hour 1 100
 General anaesthesia 1 100
 Regional anaesthesia 0 0
Numerical pain score
(0-10) at 8 hours 1 100
 General anaesthesia 1 100
 Regional anaesthesia 0 0
Numerical pain score at 24 hours 1 97
 General anaesthesia 1 97
 Regional anaesthesia 0 0
Total pethidine consumed
24 hours after delivery 1 97
 General anaesthesia 1 97
 Regional anaesthesia 0 0
Severe pain 15 minutes after
delivery 1 100
 General anaesthesia 1 100
 Regional anaesthesia 0 0
Severe pain 2 hours after delivery 1 98
 General anaesthesia 1 98
 Regional anaesthesia 0 0
Severe pain 4 hours after delivery 1 98
 General anaesthesia 1 98
 Regional anaesthesia 0 0
Severe pain (0-10) 8 hours
after delivery 1 100
 General anaesthesia 1 100
 Regional anaesthesia 0 0
Severe pain 16 hours after delivery 1 96

 General anaesthesia 1 96
 Regional anaesthesia 0 0
Severe pain 24 hours after delivery 1 97
 General anaesthesia 1 97
 Regional anaesthesia 0 0
Number of Tramacet (375 mg para-
cetamol + 150 tramadol) tablets
used 1 95
 General anaesthesia 1 95
 Regional anaesthesia 0 0
Amount of rescue diclofenac
(mg) used during hospitalisation 1 95
 General anaesthesia 1 95
 Regional anaesthesia 0 0
Wound infiltration with local
anaesthetic + NSAIDs v. control
No. of attempts to activate PCA 1 60
 General anaesthesia 0 0
 Regional anaesthesia 1 60
Total morphine (mg)
used in the first 18 hours 1 60
 General anaesthesia 0 0
 Regional anaesthesia 1 60
Need for anti-emetic 1 60
 General anaesthesia 0 0
 Regional anaesthesia 1 60
Patient satisfaction good/excellent 1 60
 General anaesthesia 0 0
 Regional anaesthesia 1 60
Nausea 1 40
 General anaesthesia 0 0
 Regional anaesthesia 1 40
Pruritus 1 40
 General anaesthesia 0 0
 Regional anaesthesia 1 40
Abdominal nerve blocks with
local anaesthetic v. placebo
block or no block
Mean visual analogue
scale at 24 hours 2 83
 General anaesthesia 0 0
 Regional anaesthesia 2 83
Postoperative opioid use (mg),
as defined by trial authors 4 175
 General anaesthesia 0 0
 Regional anaesthesia 4 175
No. of times mother
breastfed in 24 hours 1 60
 General anaesthesia 1 60
 Regional anaesthesia 0 0
Wound infiltration with
local anaesthetic v.
local anaesthetic + narcotics
Mean visual analogue score
at 2 hours 1 50
 General anaesthesia 0 MD (IV, fixed, 95% CI)
 Regional anaesthesia 1 50
Mean visual analogue score
at 12 hours 1 50 MD (IV, fixed, 95% CI)
 Regional anaesthesia 1 50
 General anaesthesia 0 0
Mean visual analogue
score at 24 hours 1 50 MD (IV, fixed, 95% CI)
 General anaesthesia 0 0
 Regional anaesthesia 1 50
Wound infiltration with local
anaesthetic v. local anaesthetic
+ ketamine
Total morphine consumed in
the first 6 hours 1 50
 General anaesthesia 0 0
 Regional anaesthesia 1 50
Patient satisfaction good/excellent 1 50
 General anaesthesia 1 50
 Regional anaesthesia 0 0

Outcome or subgroup Statistical method

Wound infiltration with
local anaesthetic only v. control
Total morphine consumption as SMD (IV, random, 95% CI)
defined by trial author
in the first 24 hours
 General anaesthesia SMD (IV, random, 95% CI)
 Regional anaesthesia SMD (IV, random, 95% CI)
Visual analogue scale
(0-10) at 24 hours MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
Total morphine consumption
as defined by trial author,
in the first 12 hours MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Wound infiltration with local
anaesthetic and peritoneal
spraying v. placebo
Need for pethidine rescue
within 1 hour of delivery RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Numerical pain score
(0-10) at 1 hour MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Numerical pain score
(0-10) at 8 hours MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Numerical pain score at 24 hours MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Total pethidine consumed
24 hours after delivery MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Severe pain 15 minutes after
delivery RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Severe pain 2 hours after delivery RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Severe pain 4 hours after delivery RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Severe pain (0-10) 8 hours
after delivery RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Severe pain 16 hours after delivery Odds ratio (OR)
 (M-H, fixed, 95% CI)
 General anaesthesia OR (M-H, fixed, 95% CI)
 Regional anaesthesia OR (M-H, fixed, 95% CI)
Severe pain 24 hours after delivery RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Number of Tramacet (375 mg para-
cetamol + 150 tramadol) tablets
used MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Amount of rescue diclofenac
(mg) used during hospitalisation MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Wound infiltration with local
anaesthetic + NSAIDs v. control
No. of attempts to activate PCA MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Total morphine (mg)
used in the first 18 hours MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Need for anti-emetic RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Patient satisfaction good/excellent RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Nausea RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Pruritus RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Abdominal nerve blocks with
local anaesthetic v. placebo
block or no block
Mean visual analogue
scale at 24 hours MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Postoperative opioid use (mg),
as defined by trial authors MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
No. of times mother
breastfed in 24 hours RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)
Wound infiltration with
local anaesthetic v.
local anaesthetic + narcotics
Mean visual analogue score
at 2 hours MD (IV, fixed, 95% CI)
 General anaesthesia Not estimable
 Regional anaesthesia MD (IV, fixed, 95% CI)
Mean visual analogue score
at 12 hours 1 0.18 (-0.59 to 0.95)
 Regional anaesthesia MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
Mean visual analogue
score at 24 hours 1 -0.15 (-0.92 to 0.62)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Wound infiltration with local
anaesthetic v. local anaesthetic
+ ketamine
Total morphine consumed in
the first 6 hours MD (IV, fixed, 95% CI)
 General anaesthesia MD (IV, fixed, 95% CI)
 Regional anaesthesia MD (IV, fixed, 95% CI)
Patient satisfaction good/excellent RR (M-H, fixed, 95% CI)
 General anaesthesia RR (M-H, fixed, 95% CI)
 Regional anaesthesia RR (M-H, fixed, 95% CI)

Outcome or subgroup Effect estimate

Wound infiltration with
local anaesthetic only v. control
Total morphine consumption as -1.72 (-2.35 to -1.09)
defined by trial author
in the first 24 hours
 General anaesthesia Not estimable
 Regional anaesthesia -1.72 (-2.35 to -1.09)
Visual analogue scale
(0-10) at 24 hours -0.39 (-1.72 to 0.94)
 Regional anaesthesia -0.39 (-1.72 to 0.94)
 General anaesthesia Not estimable
Total morphine consumption
as defined by trial author,
in the first 12 hours -0.39 (-0.68 to -0.10)
 General anaesthesia -0.39 (-0.68 to -0.10)
 Regional anaesthesia Not estimable
Wound infiltration with local
anaesthetic and peritoneal
spraying v. placebo
Need for pethidine rescue
within 1 hour of delivery 0.51 (0.38 to 0.69)
 General anaesthesia 0.51 (0.38 to 0.69)
 Regional anaesthesia Not estimable
Numerical pain score
(0-10) at 1 hour -1.46 (-2.60 to -0.32)
 General anaesthesia -1.46 (-2.60 to -0.32)
 Regional anaesthesia Not estimable
Numerical pain score
(0-10) at 8 hours -0.58 (-3.29 to 2.13)
 General anaesthesia -0.58 (-3.29 to 2.13)
 Regional anaesthesia Not estimable
Numerical pain score at 24 hours 0.19 (-0.67 to 1.05)
 General anaesthesia 0.19 (-0.67 to 1.05)
 Regional anaesthesia Not estimable
Total pethidine consumed
24 hours after delivery -44.00 (-108.31 to 20.31)
 General anaesthesia -44.00 (-108.31 to 20.31)
 Regional anaesthesia Not estimable
Severe pain 15 minutes after
delivery 0.19 (0.09 to 0.42)
 General anaesthesia 0.19 (0.09 to 0.42)
 Regional anaesthesia Not estimable
Severe pain 2 hours after delivery 0.31 (0.11 to 0.88)
 General anaesthesia 0.31 (0.11 to 0.88)
 Regional anaesthesia Not estimable
Severe pain 4 hours after delivery 0.58 (0.28 to 1.19)
 General anaesthesia 0.58 (0.28 to 1.19)
 Regional anaesthesia Not estimable
Severe pain (0-10) 8 hours
after delivery 0.71 (0.35 to 1.45)
 General anaesthesia 0.71 (0.35 to 1.45)
 Regional anaesthesia Not estimable
Severe pain 16 hours after delivery
 0.35 (0.11 to 1.11)
 General anaesthesia 0.35 (0.11 to 1.11)
 Regional anaesthesia Not estimable
Severe pain 24 hours after delivery 0.82 (0.27 to 2.50)
 General anaesthesia 0.82 (0.27 to 2.50)
 Regional anaesthesia Not estimable
Number of Tramacet (375 mg para-
cetamol + 150 tramadol) tablets
used -2.35 (-3.62 to -1.08)
 General anaesthesia -2.35 (-3.62 to -1.08)
 Regional anaesthesia Not estimable
Amount of rescue diclofenac
(mg) used during hospitalisation -43.79 (-66.95 to -20.63)
 General anaesthesia -43.79 (-66.95 to -20.63)
 Regional anaesthesia Not estimable
Wound infiltration with local
anaesthetic + NSAIDs v. control
No. of attempts to activate PCA -15.00 (-30.22 to 0.22)
 General anaesthesia Not estimable
 Regional anaesthesia -15.00 (-30.22 to 0.22)
Total morphine (mg)
used in the first 18 hours -7.40 (-9.58 to -5.22)
 General anaesthesia Not estimable
 Regional anaesthesia -7.40 (-9.58 to -5.22)
Need for anti-emetic 0.38 (0.17 to 0.83)
 General anaesthesia Not estimable
 Regional anaesthesia 0.38 (0.17 to 0.83)
Patient satisfaction good/excellent 1.26 (1.02 to 1.55)
 General anaesthesia Not estimable
 Regional anaesthesia 1.26 (1.02 to 1.55)
Nausea 1.40 (0.90 to 2.16)
 General anaesthesia Not estimable
 Regional anaesthesia 1.40 (0.90 to 2.16)
Pruritus 1.81 (1.01 to 3.23)
 General anaesthesia Not estimable
 Regional anaesthesia 1.81 (1.01 to 3.23)
Abdominal nerve blocks with
local anaesthetic v. placebo
block or no block
Mean visual analogue
scale at 24 hours -1.82 (-2.74 to -0.90)
 General anaesthesia Not estimable
 Regional anaesthesia -1.82 (-2.74 to -0.90)
Postoperative opioid use (mg),
as defined by trial authors -25.80 (-50.39 to -1.21)
 General anaesthesia Not estimable
 Regional anaesthesia -25.80 (-50.39 to -1.21)
No. of times mother
breastfed in 24 hours 0.20 (0.02 to 1.61)
 General anaesthesia 0.20 (0.02 to 1.61)
 Regional anaesthesia Not estimable
Wound infiltration with
local anaesthetic v.
local anaesthetic + narcotics
Mean visual analogue score
at 2 hours 0.69 (-0.08 to 1.46)
 General anaesthesia
 Regional anaesthesia 0.69 (-0.08 to 1.46)
Mean visual analogue score
at 12 hours 1
 Regional anaesthesia 0.18 (-0.59 to 0.95)
 General anaesthesia Not estimable
Mean visual analogue
score at 24 hours 1
 General anaesthesia Not estimable
 Regional anaesthesia -0.15 (-0.92 to 0.62)
Wound infiltration with local
anaesthetic v. local anaesthetic
+ ketamine
Total morphine consumed in
the first 6 hours 0.10 (-2.74 to 2.94)
 General anaesthesia Not estimable
 Regional anaesthesia 0.10 (-2.74 to 2.94)
Patient satisfaction good/excellent 1.20 (0.42 to 3.43)
 General anaesthesia 1.20 (0.42 to 3.43)
 Regional anaesthesia Not estimable

PCA = patient-controlled analgesia; IV = inverse variance, used
when analysis model is random effect;
statistical method, used when analysis model is fixed effect.
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Title Annotation:Original Articles
Author:Bamigboye, Anthony Akinloye; Hofmeyr, George Justus
Publication:South African Medical Journal
Article Type:Report
Geographic Code:6NIGR
Date:May 1, 2010
Words:6158
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