Post–Cesarean Delivery Pain
As a primary analgesic method after cesarean delivery, an
NSAID-based regimen has the benefit of low cost and a
superior side effect profile to some systemic opioid methods
(e.g., IM meperidine or oral codeine)127–129 or oral tramadol
regimens,130 but the analgesia is frequently inadequate.131,132
In contrast, as adjuncts within a multimodal analgesic
regimen, NSAIDs are frequently of benefit. The addition
of an NSAID improves IV tramadol or opioid analgesia
and/or reduces opioid dose requirements after epidural,133
general,134–136 or spinal anesthesia.137–142 There may be a
benefit from combining an NSAID with acetaminophen,143,144
although this appears to depend on what concurrent
analgesic method is used. As adjuncts to a primary method
of systemic opioid, such as IV morphine patient-controlled
analgesia, ketorolac, parecoxib, celecoxib, or ibuprofen
show similar analgesic effectiveness or opioid dose-sparing
effects.145–147 IV diclofenac can augment analgesia achieved
with continuous bupivacaine wound infusion.148
When neuraxial opioid techniques are the primary
method of postoperative analgesia, the benefits of NSAIDs
are much less consistent among both non-obstetric and
obstetric surgical populations. Three studies have reported
improved analgesia from low-dose epidural morphine with
the addition of either diclofenac or ketorolac.131,149,150 Rectal
NSAIDs prolonged the time until request for additional
analgesia after spinal morphine.151,152 In contrast, after spinal
morphine 100 μg, neither IV ketorolac153 nor oral valdecoxib154
had beneficial effects, and celecoxib 300 mg did not
improve analgesia.155 Although some studies have found
a small dose-sparing effect, pain relief is not improved by
combining diclofenac with patient-controlled epidural local
anesthetic and opioid.156 Neither IV ketorolac, nor parecoxib
followed by oral celecoxib, improved meperidine patientcontrolled
epidural analgesia or reduced opioid consumption
(M. Paech, unpublished data).157
Failure to demonstrate improved analgesia when an
NSAID is used with a neuraxial opioid technique likely
reflects the high quality of analgesia achieved with the
primary method. Subsequently however, as postoperative
pain wanes, there may be a role for NSAIDs. Twenty-four
hours after spinal morphine, regular oral naproxen reduced
incisional pain, cramping pain, and worst pain compared
with placebo and modestly reduced rescue opioid requirements,
although the incidence of inadequate pain control
was not reduced.158
An opioid dose-sparing effect is of no clinical benefit
unless the lower opioid dose translates to a better patient
outcome because of fewer opioid-induced side effects.
One small single-blinded randomized trial found that the
intraoperative, postdelivery administration of NSAID
(flurbiprofen) was more effective in producing transient
improvement in emetic symptoms compared with metoclopramide
or droperidol,159 but the finding has not been replicated,
and an etiology for this effect is unclear.
There is no information about the incidence of adverse
effects in women after short-term postpartum administration
of NSAIDs; in particular, safety data with respect to
events such as acute gastric ulceration, acute renal impairment,
or exacerbation of hypertension are lacking. A 1991
case series160 describes 3 women with the rare complication
of necrotizing fasciitis of their abdominal wall after cesarean
delivery, all of whom were receiving an NSAID. The
authors postulated that there might be a possible causal
relationship because NSAIDs impair chemotaxis, phagocytosis,
and granulocyte bactericidal activity,161 but there have
been no similar reports in the past 20 years.