[CG] Analgesia following caesarean section or 3rd/4th degree tear repair

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This algorithm is intended for patients who have had a spinal/epidural anaesthetic with neuraxial opioid.

First 24h

  • PARACETAMOL 1g qds
    • reduce dose to 500mg if bodyweight <50kg
  • DICLOFENAC 50mg tds
    • starting 8-12h after 100mg diclofenac suppository
    • omit if genuine contraindication to NSAIDs (eg true allergy, previous gastric ulcer, asthmatics with known NSAID intolerance)
    • prescribe PPI/H2 antagonist if history of gastritis with NSAIDs
  • MST 20mg one dose (two 10mg tablets)
    • prescribe as once-only dose on front of kardex
    • at least four hours after spinal opioid
    • timed to fit in with drug rounds (0800, 1400, 1800, 2200)
    • reduce dose to 10mg if bodyweight <50kg
  • MST 10mg one dose (one 10mg tablet)
    • prescribe as once-only dose on front of kardex
    • approximately 12 hours after the previous dose
  • Morphine Sulphate (Immediate Release)*10mg as required (*(SEVREDOL brand name in GCC)
    • up to once hourly (first dose AT LEAST two hours after MST)
    • if more than 3 doses requested, consider medical review
  • Prescribe LAXIDO (1 sachet once or twice per day)
  • Please also prescribe at least one anti-emetic

Second 24h

  • NO FURTHER MST
  • STOP Morphine Sulphate before discharge
  • Continue regular PARACETAMOL and DICLOFENAC
  • If the patient has a genuine contraindication to NSAIDs, or a history of chronic pain, or is still has inadequately controlled pain consider adding DIHYDROCODEINE 4 hourly as required

For discharge

  • Aim for discharge on PARACETAMOL and DICLOFENAC only
  • NO PATIENT will be discharged home on morphine sulphate
  • Patients being discharged on day 1 or 2 who have a genuine contraindication to NSAIDs, or pre-existing chronic pain issues or who still have moderate pain may need a small supply of DIHYDROCODEINE 4 hourly as required

Last reviewed: 04 November 2019

Next review: 30 November 2022

Author(s): Dr Drew Smith, Consultant Anaesthetist, PRM on behalf of Obstetrics Guidelines Group – SLWG on Postoperative analgesia

Version: 2.1

Approved By: Dr Catrina Bain, Clinical Director, Obstetrics GGC