Background and Aims Caesarean section (CS) is associated with postoperative pain, which can influence recovery, satisfaction, breastfeeding success, mother-child bonding and can lead to persistent pain (1,2,3). Pain after CS is often undertreated due to fears that analgesia might induce maternal/neonatal side-effects. The aim is to develop recommendations for pain management after elective CS under neuraxial anaesthesia.

Methods A systematic review, utilising the PROSPECT methodology (4), was performed, evaluating the effects of analgesic/anaesthetic and surgical interventions during CS. Randomised controlled trials (RCT’s), systematic reviews and meta-analyses published between 1 May 2014 and 22 October 2020 were retrieved from MEDLINE, Embase, PubMed and Cochrane databases.

Results Included were 145 studies (126 RCT’s and 19 systematic reviews and meta-analyses). For patients undergoing elective CS performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50–100 micrograms or diamorphine 300 micrograms administered pre-operatively. Paracetamol, NSAIDs and intravenous dexamethasone administered after delivery. If intrathecal opioids were not administered, local anaesthetic wound infiltration or fascial plane blocks (transversus abdominis plane block or quadratus lumborum block) are recommended. The postoperative regimen should include regular paracetamol and NSAIDs with opioids used for rescue. The surgical technique should include a Johel-Cohen incision, non-closure of the peritoneum and abdominal binders. Transcutaneous electrical nerve stimulation could be an analgesic adjunct.

Conclusions Recommendations were made to optimize postoperative pain management after elective CS performed under neuraxial anaesthesia. The PROSPECT recommendations for postoperative analgesia after CS are a multimodal approach with pre-, intra- and postop analgesic strategies which combined with certain surgical procedures and adjuvant techniques may provide excellent analgesia.