PROSPECT guideline for elective caesarean section: updated systematic review and procedurespecific postoperative pain management recommendations

Caesarean section is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and patient satisfaction as well as breastfeeding success and mother-child bonding. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after elective caesarean section under neuraxial anaesthesia. A systematic review utilising procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language between 1 May 2014 and 22 October 2020 evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane databases. Studies evaluating pain management for emergency or unplanned operative deliveries or caesarean section performed under general anaesthesia were excluded. A total of 145 studies met the inclusion criteria. For patients undergoing elective caesarean section performed under neuraxial anaesthesia, recommendations include intrathecal morphine 50-100 g or diamorphine 300 g administered pre-operatively; paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone administered after delivery. If intrathecal opioid was not administered, single-injection local anaesthetic wound infiltration; continuous wound local anaesthetic infusion; and/or fascial plane blocks such as transversus abdominis plane or quadratus lumborum blocks are recommended. The postoperative regimen should include regular paracetamol and non-steroidal anti-inflammatory drugs with opioids used for rescue. The surgical technique should include a Joel-Cohen incision; non-closure of the peritoneum; and abdominal binders.

## Why was this guideline developed?
Caesarean section is associated with moderate-to-severe postoperative pain which may influence recovery, psychological maternal well-being, breastfeeding and mother-child bonding. The aim of this guideline is to provide clinicians with updated evidence for optimal pain management following elective caesarean section under neuraxial anaesthesia.
What other guidelines are available on this topic?

# Introduction
Caesarean section is associated with moderate-to-severe postoperative pain in a significant proportion of women, which may delay recovery and return to activities of daily living; impair mother-child bonding; impact maternal psychological well-being; and may complicate breastfeeding [bib_ref] Predicting severity of acute pain after Cesarean delivery: a narrative review, Gamez [/bib_ref]. Furthermore, inadequate postoperative pain relief may lead to hyperalgesia and persistent postoperative pain [bib_ref] Persistent pain after caesarean section and vaginal birth: a cohort study, Kainu [/bib_ref].
Pain after caesarean section is often under-treated due to unfounded fears that analgesic drugs or interventions might induce maternal and neonatal side-effects and because the severity of post-caesarean section pain is often underestimated. Based on a systematic review performed in 2014 [bib_ref] A review of enhanced recovery after surgery principles used for scheduled Caesarean..., Huang [/bib_ref] , the PROSPECT Working Group [bib_ref] Procedure-specific pain management (PROSPECT) -an update, Lee [/bib_ref] 

# Results
A total of 145 studies were included, of which 126 were randomised controlled trials and 19 were systematic reviews and meta-analyses . The [fig_ref] Table 2: Analgesic interventions that are not recommended for pain management in patients undergoing... [/fig_ref].

## Systemic non-opioid and opioid analgesics
When paracetamol was administered pre-operatively rather than at the end of surgery, only minor differences were noted [bib_ref] Preoperative caesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized..., Towers [/bib_ref]. In one study, rectal paracetamol was shown to be superior to pre-operative oral paracetamol combined with i.v. paracetamol at the end of surgery [bib_ref] Study to compare the effect of oral, rectal and intravenous infusion of..., Mahajan [/bib_ref]. In one study, opioid consumption was reduced with i.v. paracetamol compared with placebo but there was no difference in pain scores [bib_ref] Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control, Altenau [/bib_ref]. In another study, no differences in opioid consumption and pain scores were noted with i.v.
paracetamol [bib_ref] The analgesic efficacy of IV acetaminophen for acute postoperative pain in C-section..., Bernstein [/bib_ref].
A meta-analysis concluded that systemic NSAIDs reduced pain scores, decreased opioid consumption, reduced opioid-related side-effects and increased patient satisfaction [bib_ref] The analgesic efficacy of nonsteroidal anti-inflammatory agents (NSAIDs) in patients undergoing cesarean..., Zeng [/bib_ref]. A Cochrane review evaluated oral analgesics, comprising primarily but not exclusively [bib_ref] Efficacy of a single 40-mg intravenous dose of parecoxib for postoperative pain..., Inthigood [/bib_ref]. Three studies compared an NSAID with an opioid and demonstrated equally effective or superior analgesia with NSAIDs [bib_ref] Comparison of morphine suppository and diclofenac suppository for pain management after elective..., Mahdavi [/bib_ref] [bib_ref] Comparison of efficiacy and safety of intramuscular piroxicam and tramadol for postoperative..., Thippeswamy [/bib_ref] [bib_ref] Comparison of preemptive effect of ketorolac versus meperidine on postoperative shivering and..., Khezri [/bib_ref]. The addition of rectal diclofenac to pentazocine was also associated with better analgesia then pentazocine alone [bib_ref] Pentazocine versus pentazocine with rectal diclofenac for postoperative pain relief after caesarean..., Olajetu [/bib_ref].
Four randomised controlled trials [bib_ref] A perioperative course of gabapentin does not produce a clinically meaningful improvement..., Monks [/bib_ref] [bib_ref] Effect of preoperative pregabalin on post-caesarean delivery analgesia: a dose-response study, El Kenany [/bib_ref] [bib_ref] The effect of gabapentin versus intrathecal fentanyl on postoperative pain and morphine..., Najafi Anaraki [/bib_ref] [bib_ref] The comparative preemptive analgesic efficacy of addition of vitamin B complex to..., Khezri [/bib_ref] and a metaanalysis [bib_ref] Perioperative gabapentin and post cesarean pain control: a systematic review and metaanalysis..., Felder [/bib_ref] evaluated pre-operative gabapentinoids for analgesia after caesarean section. No significant benefits were reported with gabapentin when added to a multimodal analgesia regimen [bib_ref] A perioperative course of gabapentin does not produce a clinically meaningful improvement..., Monks [/bib_ref]. The multimodal regimen consisted of intrathecal morphine, rectal and oral paracetamol and i.v. and oral NSAID [bib_ref] A perioperative course of gabapentin does not produce a clinically meaningful improvement..., Monks [/bib_ref]. Administration of pregabalin combined with intramuscular diclofenac, but without intrathecal morphine, was associated with lower pain scores and reduced opioid requirements [bib_ref] Effect of preoperative pregabalin on post-caesarean delivery analgesia: a dose-response study, El Kenany [/bib_ref]. In another study, gabapentin provided superior analgesia compared with intrathecal fentanyl [bib_ref] The effect of gabapentin versus intrathecal fentanyl on postoperative pain and morphine..., Najafi Anaraki [/bib_ref]. In the two latter studies, basic analgesia consisted of diclofenac [bib_ref] Effect of preoperative pregabalin on post-caesarean delivery analgesia: a dose-response study, El Kenany [/bib_ref] [bib_ref] The effect of gabapentin versus intrathecal fentanyl on postoperative pain and morphine..., Najafi Anaraki [/bib_ref]. In a study conducted on patients who did not receive any basic analgesia, adding vitamin B complex to gabapentin reduced pain scores and opioid consumption compared with the use of gabapentin alone [bib_ref] The comparative preemptive analgesic efficacy of addition of vitamin B complex to..., Khezri [/bib_ref]. A systematic review Flow diagram of studies included in this systematic review.
reported a clinically significant reduction in 24-h pain scores with pre-operative gabapentin. Side-effects such as sedation and dizziness were reported in several of the included studies [bib_ref] Perioperative gabapentin and post cesarean pain control: a systematic review and metaanalysis..., Felder [/bib_ref].
Adding i.v. lidocaine to i.v. patient-controlled analgesia (PCA) with morphine did not improve pain scores or opioid consumption [bib_ref] The effect of adding lidocaine to patient controlled analgesia with morphine on..., Habibi [/bib_ref]. One randomised controlled trial evaluated the effects of i.v. ketamine on postoperative analgesia [bib_ref] The effect of low-dose intravenous ketamine on postoperative pain following Cesarean section..., Rahmanian [/bib_ref]. A bolus of i.v. ketamine after delivery of the fetus reduced pain and rescue analgesics in the first 12 h after caesarean section [bib_ref] The effect of low-dose intravenous ketamine on postoperative pain following Cesarean section..., Rahmanian [/bib_ref]. In the latter study, no basic analgesia or additional baseline analgesia was given [bib_ref] The effect of low-dose intravenous ketamine on postoperative pain following Cesarean section..., Rahmanian [/bib_ref]. A meta-analysis on the i.v. use of ketamine demonstrated marginal improvements in pain scores and a mild reduction in morphine consumption [bib_ref] Impact of ketamine on pain management in Cesarean section: A systematic review..., Wang [/bib_ref].
Compared with sufentanil PCA alone, the addition of dexmedetomidine to a sufentanil PCA in the postoperative period was associated with lower pain scores, reduced sufentanil consumption, reduced need for rescue analgesia and a higher patient satisfaction. However, the improved pain scores were not clinically relevant [bib_ref] Dexmedetomidine added to sufentanil patient-controlled intravenous analgesia relieves the postoperative pain after..., Nie [/bib_ref]. In the latter study, no basic or additional baseline analgesia was given [bib_ref] Dexmedetomidine added to sufentanil patient-controlled intravenous analgesia relieves the postoperative pain after..., Nie [/bib_ref].
Four randomised controlled trials evaluated the use of i.v. dexamethasone [bib_ref] To study the efficacy of intravenous dexamethasone in prolonging the duration of..., Shalu [/bib_ref] [bib_ref] The effect of a single intraoperative dose of intravenous dexamethasone 8 mg..., Ituk [/bib_ref] [bib_ref] Comparison of local and intravenous dexamethasone on postoperative pain and recovery after..., Maged [/bib_ref] [bib_ref] Postoperative analgesia using bupivacaine wound infiltration with intravenous tramadol or dexamethasone following..., Edomwonyi [/bib_ref]. Use of i.v. dexamethasone was associated with better pain scores; prolongation of analgesic effect [bib_ref] To study the efficacy of intravenous dexamethasone in prolonging the duration of..., Shalu [/bib_ref] ; a reduction in opioid consumption [bib_ref] The effect of a single intraoperative dose of intravenous dexamethasone 8 mg..., Ituk [/bib_ref] ; and a reduced need for postoperative anti-emetics [bib_ref] Comparison of local and intravenous dexamethasone on postoperative pain and recovery after..., Maged [/bib_ref]. One study reported better analgesia when dexamethasone was administered as wound infiltration as opposed to i.v. administration [bib_ref] Postoperative analgesia using bupivacaine wound infiltration with intravenous tramadol or dexamethasone following..., Edomwonyi [/bib_ref]. Intravenous dexamethasone was not as effective as i.v. tramadol [bib_ref] Postoperative analgesia using bupivacaine wound infiltration with intravenous tramadol or dexamethasone following..., Edomwonyi [/bib_ref].
Several studies compared various systemic opioids (oxycodone; sufentanil; tramadol; dezocine; butorphanol; hydromorphone; tapentadol) [bib_ref] Oral oxycodone for pain after caesarean section: a randomized comparison with nurse..., Niklasson [/bib_ref] [bib_ref] Comparison of patient-controlled intravenous analgesia with sufentanil versus tramadol in postcesarean section..., Chi [/bib_ref] [bib_ref] Effect of oxycodone patientcontrolled intravenous analgesia after cesarean section: a randomized controlled..., Nie [/bib_ref] [bib_ref] Comparison of the analgesic effects of dezocine, tramadol and butorphanol after cesarean..., Zhu [/bib_ref] [bib_ref] The analgesic effect of tramadol combined with buorphanol on uterine cramping pain..., Cai [/bib_ref] [bib_ref] Patient-controlled intravenous tramadol versus patient-controlled intravenous hydromorphone for analgesia after secondary cesarean..., Duan [/bib_ref] [bib_ref] A randomized controlled trial comparing tapentadol with oxycodone in non-breastfeeding women post-elective..., Ffrench [/bib_ref] [bib_ref] Oral versus patient-controlled intravenous administration of oxycodone for pain relief after cesarean..., Makela [/bib_ref]. No individual drug was clearly superior in terms of analgesia or side-effect profile compared with any other opioid.

## Neuraxial adjuvant drugs
One meta-analysis [bib_ref] The effect of intrathecal morphine dose on outcomes after elective Cesarean delivery:..., Sultan [/bib_ref] and three randomised controlled trials [bib_ref] Dose-response of intrathecal morphine when administered with intravenous ketorolac for post-cesarean analgesia:..., Berger [/bib_ref] [bib_ref] A randomized controlled trial comparing two multimodal analgesic techniques in patients predicted..., Booth [/bib_ref] [bib_ref] Neuraxial anesthesia for pain control after cesarean section: a prospective randomized trial..., Kaufner [/bib_ref] evaluated the administration of intrathecal morphine. The meta-analysis compared low (50-100 g)
and high (> 100 g) doses of intrathecal morphine and concluded that high doses increase the duration of analgesia but were more likely to be associated with sideeffects. Pain scores were similar in both groups [bib_ref] The effect of intrathecal morphine dose on outcomes after elective Cesarean delivery:..., Sultan [/bib_ref]. A doseresponse study of intrathecal morphine showed that 50 g doses were as effective as 100 g and 150 g, with a similar requirement for rescue opioids. The risk of pruritus was lowest after 50 g morphine [bib_ref] Dose-response of intrathecal morphine when administered with intravenous ketorolac for post-cesarean analgesia:..., Berger [/bib_ref]. In patients with an anticipated high pain intensity (such as patients with chronic pelvic pain), pain scores with movement were lower in patients receiving 300 g vs. those receiving 150 g intrathecal morphine [bib_ref] A randomized controlled trial comparing two multimodal analgesic techniques in patients predicted..., Booth [/bib_ref]. In a comparative study, intrathecal morphine provided better analgesia compared with epidural morphine and patient-controlled epidural analgesia of ropivacaine with sufentanil [bib_ref] Neuraxial anesthesia for pain control after cesarean section: a prospective randomized trial..., Kaufner [/bib_ref]. In two studies, women were offered to choose the analgesic strategy and select either no intrathecal morphine or a low or high dose of intrathecal morphine [bib_ref] Impact of patient choice for different analgesic protocols on opioid consumption: a..., Carvalho [/bib_ref] [bib_ref] Patient choice compared with no choice of intrathecal morphine dose for caesarean..., Carvalho [/bib_ref]. Having a choice did not impact on rescue opioid consumption, but women were very good in predicting their actual opioid needs. Choosing high-dose intrathecal morphine was associated with increased rescue analgesia and more vomiting [bib_ref] Impact of patient choice for different analgesic protocols on opioid consumption: a..., Carvalho [/bib_ref] [bib_ref] Patient choice compared with no choice of intrathecal morphine dose for caesarean..., Carvalho [/bib_ref]. Apart from one study [bib_ref] Neuraxial anesthesia for pain control after cesarean section: a prospective randomized trial..., Kaufner [/bib_ref] , all studies used basic analgesia with NSAIDs [bib_ref] Dose-response of intrathecal morphine when administered with intravenous ketorolac for post-cesarean analgesia:..., Berger [/bib_ref] [bib_ref] A randomized controlled trial comparing two multimodal analgesic techniques in patients predicted..., Booth [/bib_ref] [bib_ref] Patient choice compared with no choice of intrathecal morphine dose for caesarean..., Carvalho [/bib_ref] or a combination of NSAIDs and paracetamol [bib_ref] Impact of patient choice for different analgesic protocols on opioid consumption: a..., Carvalho [/bib_ref]. Intrathecal morphine was similar to intrathecal hydromorphone in a recent trial by Sharpe et al. [bib_ref] Intrathecal morphine versus intrathecal hydromorphone for analgesia after caesarean delivery, Sharpe [/bib_ref].
Ten trials evaluated the neuraxial administration of 2agonists such as clonidine and dexmedetomidine [bib_ref] The impact of neuraxial clonidine on postoperative analgesia and perioperative adverse effects..., Allen [/bib_ref] [bib_ref] Clonidine effect on pain after Cesarean delivery: a randomized controlled trial of..., Fernandes [/bib_ref] [bib_ref] Randomized study of postcesarean analgesia with intrathecal morphine alone or combined with..., Carvalho [/bib_ref] [bib_ref] Comparison of postoperative analgesic effect of intrathecal clonidine and fentanyl added to..., Khezri [/bib_ref] [bib_ref] Effect of mini-dose epidural dexmedetomidine in elective cesarean section using combined spinal-epidural..., Yousef [/bib_ref] [bib_ref] Comparison of intrathecal dexmedetomidine with morphine as adjuvants in Cesarean sections, Qi [/bib_ref] [bib_ref] Low dose of dexmedetomidine as an adjuvant to bupivacaine in cesarean surgery..., Bi [/bib_ref] [bib_ref] Effect of different doses of intrathecal dexmedetomidine as an adjuvant combined with..., Bi [/bib_ref] [bib_ref] Addition of dexmedetomidine to epidural morphine to improve anesthesie and analgesia for..., Yang [/bib_ref] [bib_ref] Intrathecal dexmedetomidine versus magnesium sulphate for postoperative analgesia and stress response after..., Mostafa [/bib_ref].
A meta-analysis showed that neuraxial clonidine increased the duration and quality of analgesia and reduced morphine consumption [bib_ref] The impact of neuraxial clonidine on postoperative analgesia and perioperative adverse effects..., Allen [/bib_ref]. However, more side-effects such as hypotension and intra-operative sedation were noted. No improvements in analgesia were reported with intrathecal or i.v. clonidine, whether administered alone [bib_ref] Clonidine effect on pain after Cesarean delivery: a randomized controlled trial of..., Fernandes [/bib_ref] or in combination with intrathecal morphine [bib_ref] Randomized study of postcesarean analgesia with intrathecal morphine alone or combined with..., Carvalho [/bib_ref]. One study demonstrated the superiority of intrathecal clonidine to intrathecal fentanyl [bib_ref] Comparison of postoperative analgesic effect of intrathecal clonidine and fentanyl added to..., Khezri [/bib_ref]. Addition of epidural dexmedetomidine to combined spinal-epidural anaesthesia resulted in improved intra-operative and postoperative analgesia and less requirements for opioid rescue [bib_ref] Effect of mini-dose epidural dexmedetomidine in elective cesarean section using combined spinal-epidural..., Yousef [/bib_ref]. A comparison of intrathecal dexmedetomidine with intrathecal morphine did not demonstrate any significant differences in duration of analgesia, pain scores or need for rescue analgesia. However, both intrathecal morphine and intrathecal dexmedetomidine provided better analgesia when compared with isobaric bupivacaine [bib_ref] Comparison of intrathecal dexmedetomidine with morphine as adjuvants in Cesarean sections, Qi [/bib_ref]. Administration of intrathecal dexmedetomidine resulted in improved postoperative analgesia when compared with isobaric bupivacaine or ropivacaine alone [bib_ref] Low dose of dexmedetomidine as an adjuvant to bupivacaine in cesarean surgery..., Bi [/bib_ref] [bib_ref] Effect of different doses of intrathecal dexmedetomidine as an adjuvant combined with..., Bi [/bib_ref]. Intrathecal dexmedetomidine combined with intrathecal magnesium sulphate or intrathecal morphine improved analgesia which was of longer duration than analgesia produced by magnesium sulphate alone [bib_ref] Addition of dexmedetomidine to epidural morphine to improve anesthesie and analgesia for..., Yang [/bib_ref] [bib_ref] Intrathecal dexmedetomidine versus magnesium sulphate for postoperative analgesia and stress response after..., Mostafa [/bib_ref].
Adding intrathecal fentanyl to bupivacaine improved initial analgesia [bib_ref] Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand..., Weigl [/bib_ref]. However, when morphine is also added to the intrathecal mixture, fentanyl might induce acute opioid tolerance and result in greater opioid consumption [bib_ref] Perioperative analgesia after intrathecal fentanyl and morphine or morphine alone for cesarean..., Weigl [/bib_ref].
Intrathecal buprenorphine [bib_ref] Intrathecal hyperbaric bupivacaine with varying doses of buprenorphine for postoperative analgesia after..., Ravindran [/bib_ref] and epidural hydromorphone [bib_ref] Postoperative analgesic effects of different doses of epidural hydromorphone coadministered with ropivacaine..., Yang [/bib_ref] resulted in improved postoperative analgesia and reduced opioid consumption compared with intrathecal bupivacaine or ropivacaine alone.
A meta-analysis evaluating the effect of neuraxial magnesium on postoperative analgesia demonstrated a longer duration of sensory block, lower pain scores and reduced rescue analgesia requirements then neuraxial mixtures of local anaesthetic without magnesium [bib_ref] Neuraxial magnesium sulfate improves postoperative analgesia in Cesarean section delivery women: a..., Wang [/bib_ref].
The use of intrathecal midazolam was evaluated in several studies [bib_ref] Effects of adding midazolam and sufentanil to intrathecal bupivacaine on analgesia quality..., Abdollahpour [/bib_ref] [bib_ref] Intrathecal midazolam as an adjuvant in pregnancy-induced hypertensive patients undergoing an elective..., Dodawad [/bib_ref]. A comparative study demonstrated that intrathecal magnesium and intrathecal sufentanil were superior to intrathecal midazolam [bib_ref] Effects of adding midazolam and sufentanil to intrathecal bupivacaine on analgesia quality..., Abdollahpour [/bib_ref]. Intrathecal midazolam prolonged the duration of spinal anaesthesia when compared with placebo [bib_ref] Intrathecal midazolam as an adjuvant in pregnancy-induced hypertensive patients undergoing an elective..., Dodawad [/bib_ref]. Intrathecal ketamine prolonged analgesia when compared with fentanyl [bib_ref] Comparison of postoperative analgesic effect of intrathecal ketamine and fentanyl added to..., Khezri [/bib_ref] [bib_ref] Addition of low-dose ketamine to midazolam and low-dose bupivacaine improves hemodynamics and..., Basuni [/bib_ref].
A meta-analysis showed that intrathecal neostigmine improved analgesia after caesarean section, although it was associated with an increased risk of nausea and vomiting [bib_ref] A systematic review of the effects of adding neostigmine to local anesthetics..., Cossu [/bib_ref]. A study showed that a faster speed of intrathecal injection of fentanyl and local anaesthetic results in improved postoperative analgesia with a more sustained duration [bib_ref] Sequential intrathecal injection of fentanyl and hyperbaric bupivacaine at different rates: does..., Hussien [/bib_ref].

## Local and regional analgesia techniques
Intraperitoneal local anaesthetic instillation resulted in lower early pain scores [bib_ref] Intraperitoneal installation of lidocaine improves postoperative analgesia at cesarean delivery: a randomized,..., Patel [/bib_ref] , and reduced pain scores at 24 h in a sub-group in which the peritoneum was closed [bib_ref] Intraperitoneal installation of lidocaine improves postoperative analgesia at cesarean delivery: a randomized,..., Patel [/bib_ref]. The use of topical analgesia (e.g. eutectic mixture of local anaesthetic cream) failed to reduce pain scores at 24 and 48 h [bib_ref] Topic anaesthesia with a eutectic mixture of lidocaine/ prilocaine cream after elective..., Grosse-Steffen [/bib_ref].
Three studies demonstrated that local anaesthetic wound infiltration reduced pain scores and the need for rescue analgesia during the first 24 h after caesarean section [bib_ref] Effect of high volume systematic local infiltration analgesia in Caesarean section: a..., Larsen [/bib_ref] [bib_ref] Local lidocaine 2% in postoperative pain management in Cesarean delivery, Ghenaee [/bib_ref] [bib_ref] Local wound infiltration with ropivacaine for postoperative pain control in Caesarean section, Nasir [/bib_ref] , while one study showed only limited benefits [bib_ref] Continuous wound infiltration with ropivacaine for analgesia after caesarean section: a randomized..., Reinikainen [/bib_ref]. Apart from one study [bib_ref] Local lidocaine 2% in postoperative pain management in Cesarean delivery, Ghenaee [/bib_ref] , basic analgesia with ibuprofen and paracetamol was provided. Another two studies which used multimodal analgesia showed improved pain scores, less morphine consumption and higher breastfeeding comfort with continuous wound infusion compared with no infusion [bib_ref] Cesarean analgesia using levobupivacaine continuous wound infiltration: a randomized trial, Jolly [/bib_ref] [bib_ref] Continuous ropivacaine subfascial wound infusion compared with intrathecal morphine for postcesarean analgesia:..., Lalmand [/bib_ref]. Local anaesthetic wound infusion resulted in similar analgesic effects as intrathecal morphine [bib_ref] Continuous ropivacaine subfascial wound infusion compared with intrathecal morphine for postcesarean analgesia:..., Lalmand [/bib_ref]. A meta-analysis confirmed that both singleshot local anaesthetic wound infiltration and continuous wound infusion reduce postoperative opioid consumption and mildly improve pain scores [bib_ref] Local anaesthetic wound infiltration for postcaesarean section analgesia, Adesope [/bib_ref]. Pain scores were similar whether the catheter was placed preperitoneal or subcutaneously [bib_ref] Continuous wound infiltration of bupivacaine at two different anatomical planes for caesarean..., Thomas [/bib_ref]. Adding ketorolac improved analgesia of wound infiltration and reduced opioid consumption [bib_ref] Efficacy of continuous in-wound infusion of levobupivacaine and ketorolac for post-caesarean section..., Wagner-Kovacec [/bib_ref].
In a recent study, ketorolac added to wound infiltration did not improve analgesia but intrathecal morphine was administered in both groups [bib_ref] Ropivacaine and ketorolac wound infusion for postcesarean delivery analgesia, Barney [/bib_ref]. Magnesium and dexmedetomidine as adjuvants to wound infiltration reduced pain scores [bib_ref] Efficacy of magnesium sulphate as an adjunct to ropivacaine in local infiltration..., Kundra [/bib_ref] [bib_ref] Comparison of local wound infiltration with ropivacaine alone or ropivacaine plus dexmedetomidine..., Bhardwaj [/bib_ref].
A rectus sheath block provides no additional analgesic benefit when added to multimodal analgesia which also includes intrathecal morphine [bib_ref] A randomized, controlled trial of rectus sheath bupivacaine and intrathecal morphine, vs..., Liu [/bib_ref]. Adding a field block after caesarean section to intrathecal morphine also did not improve analgesia after caesarean section [bib_ref] Direct field block with 40 mL of 0.125% bupivacaine in conjunction with..., Triyasunant [/bib_ref].
There were five studies that compared transversus abdominis plane (TAP) blocks against placebo or no TAP block [bib_ref] Transversus abdominis plane block does not improve early or late pain outcomes..., Mckeen [/bib_ref] [bib_ref] Transversus abdominis plane block in the management of acute postoperative pain syndrome..., Fusco [/bib_ref] [bib_ref] Role of ultrasound guided transversus abdominis plane block as a component of..., Jadon [/bib_ref] [bib_ref] The analgesic efficiency of transversus abdominis plane (TAP) block after caesarean section, Kupiec [/bib_ref] [bib_ref] Evaluate the feasibility of surgical transversus abdominis plane block for postoperative analgesia..., Kakade [/bib_ref]. Apart from one study [bib_ref] Transversus abdominis plane block does not improve early or late pain outcomes..., Mckeen [/bib_ref] , all studies noted that TAP blocks improved pain relief, increased patient satisfaction and resulted in a reduction of rescue analgesia.
A comparison between lateral and posterior approaches concluded that the posterior approach resulted in better pain scores which was only clinically relevant at 12 h postoperatively. This approach also resulted in reduced need for rescue analgesia [bib_ref] Comparison of ultrasound-guided posterior transversus abdominis plane block and lateral transversus plane..., Faiz [/bib_ref]. Comparison between surgeon-administered and anaesthetist-administered TAP blocks did not show any differences in postoperative analgesia [bib_ref] A randomized trial comparing surgeonadministered intraoperative transversus abdominis plane block with anesthesiologist-administered..., Narasimhulu [/bib_ref].
Several studies evaluated the role of local anaesthetic adjuvants for TAP blocks. Pain scores, opioid consumption and duration of analgesia were significantly improved when dexamethasone was added to local anaesthetic for TAP blocks [bib_ref] Effect of dexamethasone as an adjuvant to ropivacaine on duration and quality..., Gupta [/bib_ref]. Fentanyl added to TAP blocks failed to improve the quality of analgesia [bib_ref] Analgesic efficacy of transverse abdominal plane block after elective cesarean delivery -bupivacaine..., John [/bib_ref]. The addition of 2-agonists (clonidine or dexmedetomidine) prolonged the duration of analgesia, reduced the need for rescue drugs and improved patient satisfaction [bib_ref] Addition of clonidine to bupivacaine in transversus abdominis plane block prolongs postoperative..., Singh [/bib_ref] [bib_ref] Comparative analysis of duration of postoperative analgesia between levobupivacaine and levobupivacaine with..., Acharya [/bib_ref] [bib_ref] Comparison of efficacy of bupivacaine with dexmedetomidine versus bupivacaine alone for transversus..., Parameswari [/bib_ref]. However, mild sedation was noted in some patients [bib_ref] Addition of clonidine to bupivacaine in transversus abdominis plane block prolongs postoperative..., Singh [/bib_ref] [bib_ref] Comparative analysis of duration of postoperative analgesia between levobupivacaine and levobupivacaine with..., Acharya [/bib_ref] [bib_ref] Comparison of efficacy of bupivacaine with dexmedetomidine versus bupivacaine alone for transversus..., Parameswari [/bib_ref].
Several studies compared TAP blocks with alternative regional anaesthesia techniques [bib_ref] The analgesic efficacy of transverse abdominis plane block versus epidural block after..., Canakci [/bib_ref] [bib_ref] Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery:..., Jarraya [/bib_ref] [bib_ref] The impact of a transversus abdominis plane block including clonidine vs intrathecal..., Dereu [/bib_ref] [bib_ref] The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis..., Kwikiriza [/bib_ref] [bib_ref] Transversus abdominis plane block vs wound infiltration in Caesarean section: a randomized..., Telnes [/bib_ref] [bib_ref] Postoperative analgesia after caesarean section with transversus abdominis plane block or continuous..., Klasen [/bib_ref] [bib_ref] Transversus abdomionis plane block versus wound infiltration for analgesia after cesarean delivery:..., Tawfik [/bib_ref]. In a comparison of TAP blocks with epidural analgesia which included highdose epidural morphine, improved analgesia with the epidural analgesia was noted [bib_ref] The analgesic efficacy of transverse abdominis plane block versus epidural block after..., Canakci [/bib_ref]. Three studies compared intrathecal morphine with TAP blocks [bib_ref] Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery:..., Jarraya [/bib_ref] [bib_ref] The impact of a transversus abdominis plane block including clonidine vs intrathecal..., Dereu [/bib_ref] [bib_ref] The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis..., Kwikiriza [/bib_ref]. In two of these, there was better analgesia with intrathecal morphine and a reduced requirement for rescue analgesia. However, postoperative mobilisation and return of gastro-intestinal function was better with TAP blocks [bib_ref] Subarachnoid morphine versus TAP blocks for enhanced recovery after caesarean section delivery:..., Jarraya [/bib_ref] [bib_ref] The impact of a transversus abdominis plane block including clonidine vs intrathecal..., Dereu [/bib_ref]. The third study could not discriminate between the two techniques in terms of pain relief and other clinical outcomes [bib_ref] The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis..., Kwikiriza [/bib_ref]. Three randomised controlled trials compared TAP blocks with continuous local anaesthetic wound infusion and noted no differences in postoperative analgesia [bib_ref] Transversus abdominis plane block vs wound infiltration in Caesarean section: a randomized..., Telnes [/bib_ref] [bib_ref] Postoperative analgesia after caesarean section with transversus abdominis plane block or continuous..., Klasen [/bib_ref] [bib_ref] Transversus abdomionis plane block versus wound infiltration for analgesia after cesarean delivery:..., Tawfik [/bib_ref].
Three meta-analyses confirmed the efficacy of TAP blocks for analgesia after caesarean section but concluded that they do not confer any benefit over intrathecal morphine [bib_ref] Transversus abdominis plane block for analgesia after Cesarean delivery. A systematic review, Fusco [/bib_ref] [bib_ref] Clinical effectiveness of transversus abdominis plane (TAP) blocks for pain relief after..., Champaneria [/bib_ref] [bib_ref] High-dose versus low-dose local anaesthetic for transversus abdominis plane block post-Caesarean delivery..., Ng [/bib_ref]. A combination of ilioinguinal and iliohypogastric nerves block with TAP blocks vs. no blocks resulted in less rescue opioid consumption and lower pain scores [bib_ref] a triple-blind, placebocontrolled randomized trial of the ilioinguinal-transversus abdominis plane (I-TAP) nerve..., Staker [/bib_ref]. Adding dexmedetomidine to a ropivacaine bilateral ultrasound-guided TAP block resulted in lower postoperative pain scores and less rescue opioid [bib_ref] Ultrasound-guided transversus abdominis plane block using ropivacaine and dexmedetomidine in patients undergoing..., Qian [/bib_ref].
Quadratus lumborum blocks were evaluated in 11 trials [bib_ref] Quadratus lumborum block for postoperative pain after caesarean section, Blanco [/bib_ref] [bib_ref] The analgesic effect of ultrasound-guided quadratus lumborum block after Cesarean delivery: a..., Krohg [/bib_ref] [bib_ref] Ultrasoundguided transmuscular quadratus lumborum block for elective cesarean section significantly reduces postoperative..., Hansen [/bib_ref] [bib_ref] Evaluation of the effectiveness of the quadratus lumborum block type I using..., Mieszkowski [/bib_ref] [bib_ref] Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after..., Blanco [/bib_ref] [bib_ref] Comparison of transversus abdominis plane block and quadratus lumborum block for post-caesarean..., Verma [/bib_ref] [bib_ref] Postoperative analgesic effects of various quadratus lumborum block approaches following cesarean section:..., Kang [/bib_ref] [bib_ref] A tripleblinded randomized trial comparing spinal morphine with posterior quadratus lumborum block..., Tamura [/bib_ref] [bib_ref] Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after..., Salama [/bib_ref] [bib_ref] The effectiveness of the intramuscular quadratus lumborum block in postoperative analgesia after..., Yoshida [/bib_ref] [bib_ref] Quadratus lumborum block for analgesia after caesarean section: a randomised controlled trial, Irwin [/bib_ref]. Compared with a sham block, quadratus lumborum blocks produced better analgesia. In two trials quadratus lumborum blocks were found to be superior to a TAP blocks [bib_ref] Quadratus lumborum block versus transversus abdominis plane block for postoperative pain after..., Blanco [/bib_ref] [bib_ref] Comparison of transversus abdominis plane block and quadratus lumborum block for post-caesarean..., Verma [/bib_ref] [bib_ref] The effectiveness of the intramuscular quadratus lumborum block in postoperative analgesia after..., Yoshida [/bib_ref] [bib_ref] Quadratus lumborum block for analgesia after caesarean section: a randomised controlled trial, Irwin [/bib_ref]. In one study, quadratus lumborum blocks were less effective than a single epidural bolus of local anaesthetic [bib_ref] Postoperative analgesic effects of various quadratus lumborum block approaches following cesarean section:..., Kang [/bib_ref]. Adding quadratus lumborum blocks to intrathecal morphine did not improve analgesia [bib_ref] A tripleblinded randomized trial comparing spinal morphine with posterior quadratus lumborum block..., Tamura [/bib_ref]. However, in a direct comparison, a quadratus lumborum block was similar to intrathecal morphine [bib_ref] Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after..., Salama [/bib_ref]. Two recent meta-analyses evaluated TAP blocks, wound infusion and quadratus lumborum blocks with or without intrathecal morphine and concluded that all three regional anaesthetic techniques are superior to no regional technique in the absence of intrathecal morphine [bib_ref] Transversus abdominis plane block compared with wound infiltration for postoperative analgesia following..., Sultan [/bib_ref] [bib_ref] Quadratus lumborum block versus transversus abdominis plane block for caesarean delivery: a..., El-Boghdadly [/bib_ref]. When intrathecal morphine is administered, adding these techniques confers no further advantages.
Two studies recently evaluated the erector spinae plane block (ESP) compared with TAP block and intrathecal morphine and in both studies the ESP block improved analgesia [bib_ref] Comparison of analgesic effect between erector spinae plane block and transversus abdominis..., Boules [/bib_ref] [bib_ref] Analgesic efficacy of erector spinae plane block compared with intrathecal morphine after..., Hamed [/bib_ref].

## Patient-controlled epidural analgesia
Patient-controlled epidural analgesia added to intrathecal morphine resulted in a further lowering of postoperative pain scores and less need for rescue opioid [bib_ref] Comparison of intrathecal morphine with continuous patient-controlled epidural anesthesia versus intrathecal morphine..., Sato [/bib_ref]. Adding fentanyl to patient-controlled epidural analgesia with levobupivacaine did not improve analgesia [bib_ref] Patient-controlled epidural levobupivacaine with or without fentanyl for post-cesarean section pain relief, Chen [/bib_ref].

## Postoperative interventions
Several investigators reported on the beneficial effects of transcutaneous electrical nerve stimulation on pain scores, rescue analgesia use and patient satisfaction [bib_ref] Pulsed electromagnetic fields for postsurgical pain management in women undergoing cesarean section...., Khooshideh [/bib_ref] [bib_ref] Evaluation of percutaneous electrical nerve stimulation of the auricle for relief of..., Chakravarthy [/bib_ref]. A study demonstrated that self-administered oral opioid analgesia was as effective as parenteral nurse-administered drugs [bib_ref] Patient-controlled oral analgesia versus nurse-controlled parenteral analgesia after caesarean section: a randomized..., Bonnal [/bib_ref]. A comparison of a fixed time-interval with ondemand oral analgesia concluded that the latter was associated with better pain scores [bib_ref] Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain:..., Yefet [/bib_ref]. One study evaluated the use of relaxation sounds intra-or postoperatively and showed improved pain scores [bib_ref] Comparative effect of nature-based sounds intervention and headphones intervention on pain severity..., Farzaneh [/bib_ref].
One study evaluated the use of early skin-to-skin contact between mother and baby and noted no differences in postoperative pain scores [bib_ref] Early skin-toskin contact after cesarean section: a randomized clinical pilot study, Kollmann [/bib_ref].
Three studies evaluated the use of elastic abdominal binders after caesarean section [bib_ref] Randomized controlled trial of abdominal binders for postoperative pain, distress and blood..., Ghana [/bib_ref] [bib_ref] Elastic abdominal binders reduce cesarean pain postoperatively: a randomized controlled pilot trial, Gustafson [/bib_ref] [bib_ref] Influence of abdominal binder usage after cesarean delivery on postoperative mobilization, pain..., Karaca [/bib_ref]. In all three, a clinically-relevant reduction in pain scores and rescue analgesia was noted [bib_ref] Randomized controlled trial of abdominal binders for postoperative pain, distress and blood..., Ghana [/bib_ref] [bib_ref] Elastic abdominal binders reduce cesarean pain postoperatively: a randomized controlled pilot trial, Gustafson [/bib_ref] [bib_ref] Influence of abdominal binder usage after cesarean delivery on postoperative mobilization, pain..., Karaca [/bib_ref]. Two studies evaluated the application of manual cervical dilation at the end of caesarean section and compared it with no cervical dilation and came to conflicting conclusions [bib_ref] Dilatation of the cervix at non-labour caesarean section: does it improve the..., Sakinci [/bib_ref] [bib_ref] Routine cervical dilatation at caesarean section and its influence on postoperative pain..., Alalfy [/bib_ref]. One study noted improved pain scores until 7 days postoperatively [bib_ref] Dilatation of the cervix at non-labour caesarean section: does it improve the..., Sakinci [/bib_ref] while the other did not report any pain reduction [bib_ref] Comparison of the analgesic effects of dezocine, tramadol and butorphanol after cesarean..., Zhu [/bib_ref].
Pre-operative vaginal cleansing resulted in minor but statistically significant reductions in postoperative pain scores [bib_ref] Effect of vaginal cleansing on postoperative factors in elective caesarean sections: a..., Goymen [/bib_ref].

## Surgical interventions
A systematic review [bib_ref] Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and..., Gizzo [/bib_ref] confirmed the superiority of the Joel-Cohen (also called modified Misgav-Ladach) incision compared with Pfannenstiel incision in reducing postoperative pain [bib_ref] Diathermy versus scalpel in transverse abdominal incision in women undergoing repeated cesarean..., Elbohoty [/bib_ref]. No differences in pain scores were noted between using a scalpel vs. diathermy for the skin incision [bib_ref] Diathermy versus scalpel in transverse abdominal incision in women undergoing repeated cesarean..., Elbohoty [/bib_ref].
A blunt fascial opening resulted in less postoperative pain [bib_ref] Postoperative pain and neuropathy after caesarean operation featuring blunt or sharp opening..., Yilmaz [/bib_ref]. The older technique of extraperitoneal section was associated with better pain scores up to 48 h postoperatively [bib_ref] Fetus delivery time in extraperitoneal versus transperitoneal cesarean section: a randomized trial, Yapca [/bib_ref]. In one study, the absence of making a bladder flap at opening the uterus resulted in clinicallyrelevant improvements in postoperative pain scores [bib_ref] Comparing formation or non-formation of bladder flap at cesarean section on perioperative..., Akhlagi [/bib_ref]. A comparison between uterine exteriorisation and in situ closure of the uterus showed more postoperative pain with exteriorised uteri [bib_ref] A randomized controlled trial of uterine exteriorization versus in situ repair of..., El-Khayat [/bib_ref]. However, one meta-analysis did not show any difference in postoperative pain between the two modalities of uterine closure [bib_ref] Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic..., Zaphiratos [/bib_ref].
A comparison between two techniques of pyramidalis muscle dissection found no differences in postoperative pain [bib_ref] Two techniques of pyramidalis muscle dissection in Pfannenstiel incision for cesarean section, Skret-Magierlo [/bib_ref]. Reduced pain scores when the peritoneum was not closed were reported [bib_ref] Effects of closure versus non-closure of the visceral and parietalperitoneum at cesarean..., Eken [/bib_ref]. One study reported a significant reduction in postoperative pain scores when the rectus muscle was not re-approximated [bib_ref] The effect of rectus muscle re-approximation at cesarean delivery onpain perceived after..., Omran [/bib_ref]. A Cochrane review noted minimal evidence for reduced pain scores when the peritoneum was not closed after caesarean section [bib_ref] Closure versus non-closure of the peritoneum at caesarean section: short-and long-term outcomes, Bamigboye [/bib_ref]. When applying laser irradiation to the caesarean section wound at the end of surgery, less pain during the first 24 h postoperatively was noted [bib_ref] The effect of low-level laser on postoperative pain after elective cesarean section, Poursalehan [/bib_ref] [bib_ref] Albuquerque Barbosa Cabral Micussi MT. Lowlevel laser therapy improves pain in postcesarean..., Pires De Holanda [/bib_ref].
No differences in pain scores were noted between interrupted and continuous wound suturing [bib_ref] Subcuticular interrupted versus continuous skin suturing in elective cesarean section in obese..., Maged [/bib_ref]. Similarly, two meta-analyses did not show any difference in pain scores whether skin closure was performed with sutures or staples [bib_ref] Suture versus staples for skin closure after cesarean: a metaanalysis, Mackeen [/bib_ref] [bib_ref] Subcuticular sutures versus staples for skin closure after cesarean delivery: a metaanalysis, Wang [/bib_ref].

# Discussion
The Various local anaesthetic techniques such as TAP blocks, quadratus lumborum blocks and local anaesthetic wound infiltration are effective in reducing pain scores and opioid requirements. Given that the potential side-effects of these regional analgesic techniques are limited, they are recommended.
However, the additional value of any of these techniques when combined with intrathecal morphine appears to be minimal. Therefore, these blocks may be administered if intrathecal morphine is not used. Overall recommendations for pain management in patients undergoing elective caesarean section.

## Pre-operatively
- Intrathecal long-acting opioid (e.g. morphine 50-100 g or diamorphine up to 300 g) (Grade A). Epidural morphine 2-3 mg or diamorphine up to 2-3 mg may be used as an alternative, for example, when an epidural catheter is used as part to concerns about side-effects such as sedation and respiratory depression [bib_ref] Multimodal analgesic therapy with gabapentin and its association with postoperative respiratory depression, Cavalcante [/bib_ref]. Furthermore, it is not clear if gabapentinoids add to our current recommendations of basic analgesia, i.v. dexamethasone and regional analgesia.
Several intra-operative interventions are not recommended due to inconsistent or limited or lack of procedure-specific evidence and/or concerns of sideeffects [fig_ref] Table 2: Analgesic interventions that are not recommended for pain management in patients undergoing... [/fig_ref]. For example, intra-operative dexmedetomidine infusion has been shown to provide improved postoperative pain relief; however, it is not recommended because its benefits on top of basic analgesia remain unknown, and due to concerns of side- effects including hypotension and bradycardia which can be prolonged and might impede ambulation [bib_ref] Intraoperative analgesia with remifentanil vs. dexmedetomidine: a systematic review and meta-analysis with..., Grape [/bib_ref].
Similarly, although, a sub-anaesthetic dose of i.v. ketamine has demonstrated positive effects on postoperative pain scores [bib_ref] Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial, Bauchat [/bib_ref] , it is not recommended because its benefits over basic analgesia are unknown, and concerns of sideeffects such as hallucinations that might impair the recollection of the birth experience and mother-child bonding [bib_ref] Low-dose ketamine with multimodal postcesarean delivery analgesia: a randomized controlled trial, Bauchat [/bib_ref] [bib_ref] Postcesarean delivery analgesia, Carvalho [/bib_ref].
Intrathecal or epidural administration of buprenorphine, hydromorphone, midazolam, 2adrenergic agonists, neostigmine and ketamine has been reported to prolong the analgesic duration of morphine.
However, they cannot be recommended due to inconsistent procedure-specific evidence and due to the potential sideeffects such as hypotension or sedation. Additionally, in most studies, hypotension occurs as frequently as sedation.
Peritoneal instillation of local anaesthetics cannot be recommended due to a lack of procedure-specific evidence. Similarly, topical local anaesthetic cream application is not recommended due to a lack of procedurespecific evidence.

## Supporting information
Additional supporting information may be found online via the journal website. . Quality assessment and level of evidence assigned to the randomised trials included in the review for analgesia after caesarean section.
[fig] : Intravenous paracetamol if not administered pre-operatively (Grade A) Intravenous non-steroidal anti-inflammatory drugs (Grade A) Intravenous dexamethasone (Grade A) If intrathecal morphine not used, local anaesthetic wound infiltration (single-shot) or continuous wound infusion and/or regional analgesia techniques (fascial plane blocks such as transversus abdominis plane blocks and quadratus lumborum blocks) (Grade A) Postoperative Oral or intravenous paracetamol (Grade A) Oral or intravenous non-steroidal anti-inflammatory drugs (Grade A) Opioid for rescue or when other recommended strategies are not possible (e.g. contra-indications to regional anaesthesia) (Grade D) Analgesic adjuncts include transcutaneous electrical nerve stimulation (Grade A) Surgical technique Joel-Cohen incision (Grade A) Non-closure of peritoneum (Grade A) Abdominal binders (Grade A) Surgical techniques that have been shown to be beneficial and are therefore recommended include Joel-Cohen incision and avoidance of peritoneum closure. Using abdominal binders postoperatively is recommended with sufficient procedure-specific evidence being identified. Analgesic adjuncts such as listening to music via headphones and use of transcutaneous electrical nerve stimulation may be associated with improved pain relief and are recommended when available. Although pre-operative gabapentinoids were recommended previously, they are no longer recommended despite positive studies of their benefits due [/fig]
[table] Table 2: Analgesic interventions that are not recommended for pain management in patients undergoing elective caesarean section.PostoperativeSkin-to-skin contact Limited procedure-specific evidence Intravenous lidocaine Lack of procedure-specific evidence Patient controlled epidural analgesia Limited procedure-specific evidence and concerns of side-effects Type of pyramidalis muscle dissection Lack of procedure-specific evidenceRectus muscle re-approximation Limited procedure-specific evidence TAP, transversus abdominis plane block. [/table]
[table] Table S2: Summary of key results from studies evaluating systemic analgesics, analgesics adjuncts, regional anaesthesia and surgical procedures used to support the recommended interventions in patients after caesarean section. [/table]
[table] Table S3: Summary of key results from studies evaluating systemic analgesics, analgesics adjuncts, regional anaesthesia and surgical procedures used to support the interventions that are not recommended in patients undergoing caesarean section. [/table]