The Comparison of Intraincisional Injection of Levobupivacaine versus Meloxicam on Post cesarean Section Pain Relief Randomized Controlled Trial

Abstract

SUMMARY D elivery by CS is becoming more frequent and is one of the most common operative procedures performed worldwide. Childbirth is an emotional experience for a woman and her family. The mother needs to bond with the new baby as early as possible and initiate early breastfeeding, which helps to contract the uterus and accelerates the process of uterine involution in the postpartum period. Any form of intervention that leads to improvement in pain relief can positively impact on early breastfeeding. Prompt and adequate postoperative pain relief is therefore an important component of cesarean delivery. Pain causes increase in the sympathetic response of body with subsequent rise in heart rate, cardiac work and oxygen consumption. Prolonged pain can reduce physical activity which leads to venous stasis and an increase risk of deep vein thrombosis and subsequent pulmonary embolism. In addition there can be wide spread effects on gut and urinary tract motility which may lead to post operative ileus, nausea, vomiting and urinary retention. These problems are unpleasant for the patients and may result in prolong hospital stay. Patients show variable threshold for pain, however, 75% of surgical patients have severe postoperative incisional pain. Pain relief may cause good psychological and physical effect on patients, which could lead to better recovery from surgical procedures and early mobilization of patients to prevent complications like deep vein thrombosis etc. Postoperative pain after CS is usually managed with opioids. These agents generally exert their analgesic effects through μ-receptors in the CNS, although there is evidence that opioids may also act at peripheral opioid receptors. Realistically, the analgesic efficacy of opioids is typically limited by the development of tolerance or opioid related side effects such as nausea, vomiting, sedation, or respiratory depression. Local anesthetics cause reversible blockade of impulse propagation along the nerve fibers by preventing the influx of Na+ through the cell membrane of the fibers. Several studies have reported on use of local anesthetics to relieve postoperative pain, with results ranging from being beneficial to conferring no benefit. The objectives of our study was to evaluate the impact of local levobupivacaine and meloxicam incision site infiltration in women undergoing cesarean sections, on postoperative pain and analgesic requirements. One hundred and fifty six parturient had participated in this study, recruited from Ain Shams Maternity Hospital and divided into three study groups, each group contains 52 women, group L (Levobupivacaine group) in which the wound was infiltrated with 20ml of levobupivacaine hydrochloride, group M (Meloxicam group) in which the wound was infiltrated with meloxicam 15 mg/3ml diluted in 20 ml of 0.9% normal saline and group P (Placebo group) in which the wound was infiltrated with 20ml of 0.9% normal saline. Post operative pain assessment was done using a 10 point visual analogue scale (VAS), after 1,4,6,12 and 24 hours postoperatively. All women received Diclofenac sodium 75mg IM on demand according to visual analogue scale. Postoperative pain scores, postoperative analgesic requirements and time to first rescue analgesia were assessed and statistically compared between the three groups. The study results showed that the VAS was significantly lower in the levobupivacaine group compared to the other two groups. The time to first rescue analgesia was significantly longer in the Levobupivacaine group compared to the other two groups and the number of rescue doses was significantly lower in the Levobupivacaine group. Also, the levobupivacaine group showed significantly the highest patient satisfaction rate among the three study groups with 90.4% (47 patients out of 52). No statistically significant post operative complications occurred with any of the three drugs.