Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief

Anthony A Bamigboye; G Justus Hofmeyr

doi:10.1002/14651858.CD006954.pub2

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Analysis 1.1

Comparison 1 Wound infiltration with local anaesthetic only versus control, Outcome 1 Total morphine consumption as defined by trial author in the first 24 hours.

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Analysis 1.2

Comparison 1 Wound infiltration with local anaesthetic only versus control, Outcome 2 Visual analogue scale (0‐10) at 24 hours.

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Analysis 1.3

Comparison 1 Wound infiltration with local anaesthetic only versus control, Outcome 3 Total morphine consumption as defined by trial author, in the first 12 hours.

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Analysis 2.1

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 1 Need for pethidine rescue within 1 hour of delivery.

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Analysis 2.2

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 2 Numerical pain score (0‐10) at 1 hour.

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Analysis 2.3

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 3 Numerical pain score (0‐10) at 8 hours.

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Analysis 2.4

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 4 Numerical pain score at 24 hours.

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Analysis 2.5

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 5 Total pethidine consumed 24 hours postdelivery.

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Analysis 2.6

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 6 Experience of severe pain 15 minutes after delivery.

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Analysis 2.7

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 7 Experience of severe pain 2 hours postcaesarean section delivery.

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Analysis 2.8

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 8 Experience of severe pain 4 hours after caesarean delivery.

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Analysis 2.9

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 9 Experience of severe pain (0‐10) 8 hours after caesarean delivery.

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Analysis 2.10

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 10 Experience of severe pain 16 hours postcaesarean delivery.

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Analysis 2.11

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 11 Experience of severe pain 24 hours after caesarean delivery.

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Analysis 2.12

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 12 Amount of tramacet (375 mg paracetamol+150 tramadol) tablet used.

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Analysis 2.13

Comparison 2 Wound infiltration with local anaesthetic and peritoneal spraying versus placebo, Outcome 13 Amount of rescue voltaren (mg) used during hospitalisation.

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Analysis 3.1

Comparison 3 Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control, Outcome 1 No of attempts to activate PCA.

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Analysis 3.2

Comparison 3 Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control, Outcome 2 Total morphine (mg) used in the first 18 hours.

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Analysis 3.3

Comparison 3 Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control, Outcome 3 Need for antiemetic.

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Analysis 3.4

Comparison 3 Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control, Outcome 4 Patient satisfaction‐good/excellent.

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Analysis 3.5

Comparison 3 Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control, Outcome 5 Nausea.

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Analysis 3.6

Comparison 3 Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control, Outcome 6 Pruritus.

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Analysis 4.1

Comparison 4 Abdominal nerve blocks with local anaesthetic versus placebo block or no block, Outcome 1 Mean visual analogue scale at 24 hours.

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Analysis 4.2

Comparison 4 Abdominal nerve blocks with local anaesthetic versus placebo block or no block, Outcome 2 Postoperative opioid use (mg) (as defined by trial authors).

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Analysis 4.3

Comparison 4 Abdominal nerve blocks with local anaesthetic versus placebo block or no block, Outcome 3 No of times mother breast fed in 24 hours.

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Analysis 5.1

Comparison 5 Wound infiltration with local anaesthetic versus local anaesthetic + narcotics, Outcome 1 Mean visual analogue score at 2 hours.

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Analysis 5.2

Comparison 5 Wound infiltration with local anaesthetic versus local anaesthetic + narcotics, Outcome 2 Mean visual analogue score at 12 hours.

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Analysis 5.3

Comparison 5 Wound infiltration with local anaesthetic versus local anaesthetic + narcotics, Outcome 3 Mean visual analogue score at 24 hours.

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Analysis 6.1

Comparison 6 Wound infiltration with local anaesthetic versus local anaesthetic + ketamine, Outcome 1 Total morphine consumed in the first 6 hours.

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Analysis 6.2

Comparison 6 Wound infiltration with local anaesthetic versus local anaesthetic + ketamine, Outcome 2 Patient satisfaction, good/excellent.

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Comparison 1. Wound infiltration with local anaesthetic only versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total morphine consumption as defined by trial author in the first 24 hours Show forest plot	3	126	Std. Mean Difference (IV, Random, 95% CI)	‐1.72 [‐2.35, ‐1.09]

1.1 General anaesthesia	0	0	Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Regional anaesthesia	3	126	Std. Mean Difference (IV, Random, 95% CI)	‐1.72 [‐2.35, ‐1.09]
2 Visual analogue scale (0‐10) at 24 hours Show forest plot	2	56	Mean Difference (IV, Fixed, 95% CI)	‐0.39 [‐1.72, 0.94]

2.1 Regional anaesthesia	2	56	Mean Difference (IV, Fixed, 95% CI)	‐0.39 [‐1.72, 0.94]
2.2 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Total morphine consumption as defined by trial author, in the first 12 hours Show forest plot	1	28	Mean Difference (IV, Fixed, 95% CI)	‐0.39 [‐0.68, ‐0.10]

3.1 General anaesthesia	1	28	Mean Difference (IV, Fixed, 95% CI)	‐0.39 [‐0.68, ‐0.10]
3.2 Regional anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Wound infiltration with local anaesthetic only versus control

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Comparison 2. Wound infiltration with local anaesthetic and peritoneal spraying versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Need for pethidine rescue within 1 hour of delivery Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.38, 0.69]

1.1 General anaesthesia	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.38, 0.69]
1.2 Local anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Numerical pain score (0‐10) at 1 hour Show forest plot	1	100	Mean Difference (IV, Fixed, 95% CI)	‐1.46 [‐2.60, ‐0.32]

2.1 General anaesthesia	1	100	Mean Difference (IV, Fixed, 95% CI)	‐1.46 [‐2.60, ‐0.32]
2.2 Regional anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Numerical pain score (0‐10) at 8 hours Show forest plot	1	100	Mean Difference (IV, Fixed, 95% CI)	‐0.58 [‐3.29, 2.13]

3.1 General	1	100	Mean Difference (IV, Fixed, 95% CI)	‐0.58 [‐3.29, 2.13]
3.2 Regional	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Numerical pain score at 24 hours Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	0.19 [‐0.67, 1.05]

4.1 General anaesthesia	1	97	Mean Difference (IV, Fixed, 95% CI)	0.19 [‐0.67, 1.05]
4.2 Regional	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Total pethidine consumed 24 hours postdelivery Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	‐44.0 [‐108.31, 20.31]

5.1 General anaesthesia	1	97	Mean Difference (IV, Fixed, 95% CI)	‐44.0 [‐108.31, 20.31]
5.2 Regional	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Experience of severe pain 15 minutes after delivery Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.09, 0.42]

6.1 General anaesthesia	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.09, 0.42]
6.2 Regional anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Experience of severe pain 2 hours postcaesarean section delivery Show forest plot	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	0.31 [0.11, 0.88]

7.1 General anaesthesia	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	0.31 [0.11, 0.88]
7.2 Regional anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Experience of severe pain 4 hours after caesarean delivery Show forest plot	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.28, 1.19]

8.1 General anaesthesia	1	98	Risk Ratio (M‐H, Fixed, 95% CI)	0.58 [0.28, 1.19]
8.2 Regional anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Experience of severe pain (0‐10) 8 hours after caesarean delivery Show forest plot	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.35, 1.45]

9.1 General anaesthesia	1	100	Risk Ratio (M‐H, Fixed, 95% CI)	0.71 [0.35, 1.45]
9.2 Regional anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Experience of severe pain 16 hours postcaesarean delivery Show forest plot	1	96	Odds Ratio (M‐H, Fixed, 95% CI)	0.35 [0.11, 1.11]

10.1 General anaesthesia	1	96	Odds Ratio (M‐H, Fixed, 95% CI)	0.35 [0.11, 1.11]
10.2 Regional anaesthesia	0	0	Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Experience of severe pain 24 hours after caesarean delivery Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.27, 2.50]

11.1 General anaesthesia	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.27, 2.50]
11.2 Regional anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Amount of tramacet (375 mg paracetamol+150 tramadol) tablet used Show forest plot	1	95	Mean Difference (IV, Fixed, 95% CI)	‐2.35 [‐3.62, ‐1.08]

12.1 General anaesthesia	1	95	Mean Difference (IV, Fixed, 95% CI)	‐2.35 [‐3.62, ‐1.08]
12.2 Regional anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Amount of rescue voltaren (mg) used during hospitalisation Show forest plot	1	95	Mean Difference (IV, Fixed, 95% CI)	‐43.79 [‐66.95, ‐20.63]

13.1 General anaesthesia	1	95	Mean Difference (IV, Fixed, 95% CI)	‐43.79 [‐66.95, ‐20.63]
13.2 Regional anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 2. Wound infiltration with local anaesthetic and peritoneal spraying versus placebo

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Comparison 3. Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 No of attempts to activate PCA Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	‐15.0 [‐30.22, 0.22]

1.1 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Regional anaesthesia	1	60	Mean Difference (IV, Fixed, 95% CI)	‐15.0 [‐30.22, 0.22]
2 Total morphine (mg) used in the first 18 hours Show forest plot	1	60	Mean Difference (IV, Fixed, 95% CI)	‐7.4 [‐9.58, ‐5.22]

2.1 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Regional anaesthesia	1	60	Mean Difference (IV, Fixed, 95% CI)	‐7.4 [‐9.58, ‐5.22]
3 Need for antiemetic Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.17, 0.83]

3.1 General anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Regional anaesthesia	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.17, 0.83]
4 Patient satisfaction‐good/excellent Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [1.02, 1.55]

4.1 General anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 Regional anaesthesia	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	1.26 [1.02, 1.55]
5 Nausea Show forest plot	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.90, 2.16]

5.1 General anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 Regional anaesthesia	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.90, 2.16]
6 Pruritus Show forest plot	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	1.81 [1.01, 3.23]

6.1 General anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Regional anaesthesia	1	40	Risk Ratio (M‐H, Fixed, 95% CI)	1.81 [1.01, 3.23]

Comparison 3. Wound infiltration with local anaesthetic + nonsteroidal anti‐inflammatory drugs versus control

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Comparison 4. Abdominal nerve blocks with local anaesthetic versus placebo block or no block

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean visual analogue scale at 24 hours Show forest plot	2	83	Mean Difference (IV, Fixed, 95% CI)	‐1.82 [‐2.74, ‐0.90]

1.1 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Regional anaesthesia	2	83	Mean Difference (IV, Fixed, 95% CI)	‐1.82 [‐2.74, ‐0.90]
2 Postoperative opioid use (mg) (as defined by trial authors) Show forest plot	4	175	Mean Difference (IV, Random, 95% CI)	‐25.80 [‐50.39, ‐1.21]

2.1 General anaesthesia	0	0	Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Regional anaesthesia	4	175	Mean Difference (IV, Random, 95% CI)	‐25.80 [‐50.39, ‐1.21]
3 No of times mother breast fed in 24 hours Show forest plot	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.2 [0.02, 1.61]

3.1 General anaesthesia	1	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.2 [0.02, 1.61]
3.2 Regional anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 4. Abdominal nerve blocks with local anaesthetic versus placebo block or no block

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Comparison 5. Wound infiltration with local anaesthetic versus local anaesthetic + narcotics

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean visual analogue score at 2 hours Show forest plot	1	50	Mean Difference (IV, Fixed, 95% CI)	0.69 [‐0.08, 1.46]

1.1 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Regional anaesthesia	1	50	Mean Difference (IV, Fixed, 95% CI)	0.69 [‐0.08, 1.46]
2 Mean visual analogue score at 12 hours Show forest plot	1	50	Mean Difference (IV, Fixed, 95% CI)	0.18 [‐0.59, 0.95]

2.1 Regional anaesthesia	1	50	Mean Difference (IV, Fixed, 95% CI)	0.18 [‐0.59, 0.95]
2.2 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Mean visual analogue score at 24 hours Show forest plot	1	50	Mean Difference (IV, Fixed, 95% CI)	‐0.15 [‐0.92, 0.62]

3.1 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Regional anaesthesia	1	50	Mean Difference (IV, Fixed, 95% CI)	‐0.15 [‐0.92, 0.62]

Comparison 5. Wound infiltration with local anaesthetic versus local anaesthetic + narcotics

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Comparison 6. Wound infiltration with local anaesthetic versus local anaesthetic + ketamine

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total morphine consumed in the first 6 hours Show forest plot	1	50	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐2.74, 2.94]

1.1 General anaesthesia	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Regional anaesthesia	1	50	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐2.74, 2.94]
2 Patient satisfaction, good/excellent Show forest plot	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	1.2 [0.42, 3.43]

2.1 General anaesthesia	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	1.2 [0.42, 3.43]
2.2 Regional anaesthesia	0	0	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 6. Wound infiltration with local anaesthetic versus local anaesthetic + ketamine

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