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MULTIMODAL APPROACH TO POST CAESAREAN SECTION PAIN MANAGEMENT: THE ROLE OF RECTAL DICLOFENAC COMBINED WITH INTRATHECAL BUPIVACAINE AND PETHIDINE
ABSTRACT
Caesarean section often affords the advantage of an increased chance of a healthy
mother and baby, it may however bear the disadvantage of severe post operative
pain. This pain could be severe and distressing if poorly managed, causing
significant discomfort to the mother and predisposing her to an increased danger of
thromboembolism from immobilisation. Mother to child bonding and the quality of
maternal care are also compromised. Evidence abound that post Caesarean section
pain continues to be undermanaged. With the soaring Caesarean section rates
across the world, there is an increasing need to continuously evolve strategies to
combat this malady.
There is a trend towards the use of multimodal approach to post Caesarean section
pain management, and this has proven to be an improvement over traditional forms
of pain management. In a resource poor setting such as ours, there is need to
evolve effective pain management strategies with cheap and readily available
analgesic agents, hence the evaluation of diclofenac suppository combined with
intrathecal bupivacaine and pethidine.
This is a prospective randomised placebo controlled trial, which was approved by the
University of Benin Teaching Hospital Research and Ethics Committee. Ninety four
ASA I and II subjects aged between 16 and 42 years were drawn from women
scheduled for elective Caesarean section. Patients were randomised into two groups
to receive 100mg diclofenac suppository or placebo at the end of surgery. After
preloading of patients’ circulation with 15ml/kg of 0.9% saline, Spinal anaesthesia
was established. This was achieved with intrathecal injection of 2.2ml hyperbaric
bupivacaine and 7.5mg pethidine and surgery was allowed to commence when
adequate analgesia was ascertained.
At the end of surgery, 100mg diclofenac suppository was inserted and pain scores
recorded hourly until the time of first request for analgesia by the patient. The time of
request for analgesia and the corresponding pain scores were recorded. At the time
of first request for analgesia intravenous tramadol at 1mg/kg 4 – 6 hourly was
commenced. Other complications observed in the perioperative period included
hypotension, shivering, nausea and vomiting, these were managed as they occurred.
A total of 94 patients were randomised equally into the diclofenac and placebo
groups. The socio-demographic characteristics of patients in both groups were
similar. The duration of effective analgesia (time to first request for analgesia) was
significantly longer in the diclofenac group with a mean of 399.9±72.9 compared with
248.45±32.42 in the placebo group (P <0.0001). Pain scores at 2, 3 and 4 hours
from the time of establishing the sub arachnoid block i.e before the time to first
request for analgesia were lower in the diclofenac group (P < 0.0001 for all time
lines). Patient satisfaction with pain relief was significantly better in the diclofenac
group (P <0.0001 using the Chi Square test).
This study showed that rectal diclofenac when used as an adjunct to spinal
bupivacaine and pethidine improves the quality and prolongs the duration of post
Caesarean section analgesia with minimal side effects. The mothers who received
rectal diclofenac were very satisfied with their post operative pain control. It is thus
suggested that rectal diclofenac should be offered to women who have caesarean
section with spinal bupivacaine.
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