Scheduled Oral Analgesia for Superior Pain Control in Postcesarean Women

nurse giving patient pills
nurse giving patient pills
Prescheduled pain management strategies after cesarean delivery are superior to receiving medications on-demand.

Prescheduled pain management strategies after cesarean delivery (CD) are superior to receiving medications on-demand, according to results of a new study published in the British Journal of Obstetrics and Gynaecology.1 Oral pain medications administered post-CD on a fixed time-interval basis resulted in significantly lower pain intensity and greater satisfaction with pain management than standard on-demand protocols.

A total of 214 women scheduled for CD at the Emek Medical Center in Afula, Israel, were randomly assigned to all receive the same medications for pain management during the 48 hours post-CD, delivered either according to a predetermined fixed schedule (n=108) or on-demand (n=106). The drug protocol for both groups included intravenous tramadol hydrochloride (100 mg), oral paracetamol (500 mg), and diclofenac (100 mg) tablets on arrival at the maternity ward after surgical delivery of the child.

For the fixed time schedule group, this treatment was followed by administration of 2 tablets of Zaldiar (containing 325 mg paracetamol and 35.5 mg tramadol) every 6 hours, and diclofenac (100 mg) at 12, 24, and 48 hours. The on-demand patients were given the same medications, but solely on request, and after meeting the same time thresholds as the scheduled group. Percocet (5 mg/325 mg paracetamol) was proposed to patients in either group as a rescue medication.

Pain scores assessed every 6 hours using the visual analog scale, with a score of 0 indicating no pain/greatest satisfaction and a score of 10 for worst pain/least satisfaction, indicated an improvement of scores in the fixed time schedule group compared with the on-demand group at all points, and up to 48 hours: mean pain, 2.8±0.84 vs 4.1±0.48, respectively (P <.0001), and satisfaction rate, 9.1±1.2 vs 8.3±1.5, respectively (P <.0001). Adverse events were minimal and similar in both groups.

Summary and Clinical Applicability

This study points to a clear advantage for fixed time over on-demand delivery of pain medications for post-CD patients. When asked what this might be attributed to, lead author, Enav Yefet, MD, PhD, from the Department of Obstetrics and Gynecology at Emek Medical Center, told Clinical Pain Advisor, “In my opinion, early treatment when the pain is not very intense, as well as anticipation of pain relief, contribute to the superiority of fixed time interval protocol over analgesia administration following demand. Those findings stress the fact that pain should be prevented, rather than treated.”


This study was conducted at a single institution.

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  1. Yefet E, Taha H, Salim R, et al. Fixed time interval compared with on-demand oral analgesia protocols for post-caesarean pain: a randomised controlled trial [published online February 25, 2017]. BJOG. doi:10.1111/1471-0528.14546