1.1. Description of the condition
Cesarean delivery (CD) is the most common life-saving procedure for the mother and newborn when medically indicated(1, 2). Globally, the rates of cesarean section are increasing over the years in the last three decades particularly in developed nations (3–7).
World Health Organization estimate showed that more than 18 million cesarean sections are performed worldwide annually(6). However, more than 6 million cesarean sections were performed unnecessarily particularly in middle and high-income nations and from which China and Brazil alone accounted for 50% of unnecessary cesarean sections which is higher than the recommended rates of cesarean section for a nation, 10-15%(3, 5, 6).
A dramatic increase in the rates of cesarean section worldwide poses a significant challenge of postoperative pain management for health care workers(8). A number of postoperative pain management techniques were practiced over the years after cesarean section but they were associated with postoperative adverse events to the mother (9–15). The most commonly practiced postoperative pain management techniques include but not limited to systemic opioid and non-opioid drugs, regional blocks and local wound infiltration of different local anesthetics and other drugs(9–22).
Evidences showed that individual variability of pain is greatly influenced by sensitivity to pain gender, age, genetics, preoperative anxiety, preoperative pain, history of depressive symptoms, and history of substance use(8, 23–29).
Despite the advancement in the understanding of pathophysiology of postoperative pain introduction of different postoperative analgesic drugs and modalities, the prevalence of postoperative pain after cesarean section is persistently high which ranges from 25.5 to 80% due to individual variability and limitation from side effects of analgesic drugs or techniques employed (8, 23, 24, 27, 28, 30, 31).
The postoperative pain after cesarean section negatively affects ambulation, breastfeeding and maternal bonding(32). Besides, Inadequately managed acute postoperative pain is associated with different effects related to physiological and psychological implications which includes, postpartum depression, myocardial infarction, pulmonary infection, reduced gastric motility, nausea, vomiting oliguria, decreased immune function, and wound healing(23, 28, 29).
However, use of systemic and intrathecal opioid may lead to adverse reactions such as nausea, vomiting, itchiness and sedation(23, 32).
Recent works of peer reviewed published literatures revealed a number of local and regional postoperative pain management techniques after cesarean section including but not limited to epidural analgesia, Transverse abdominis plane (TAP) block, Quadratus lumborum block, and wound infiltrations(9, 11–14, 18, 21, 22, 32–37). However, wound infiltration techniques with local anesthetics, weak opioids, glucocorticoids, ketamine, magnesium, Nonsteroidal anti-inflammatory drugs, and alpha 2 agonists are getting popularity due to its novelty, simplicity and low complication profiles(10, 15–19, 21, 38–62). However, the superiority of each modalities is uncertain and a topic of debate.
1.2. Description of the intervention
Perioperative wound infiltration techniques after cesarean section has been employed recently due to its simplicity and feasibility in terms of cost effectiveness, techniques of administration, adverse effects. The techniques of wound infiltration with local anesthetics alone or combined with adjuvants were the most common approach(10, 13, 14, 18, 22, 42–46, 48, 52, 58, 61–64). However, recent studies comparing local anesthetics with glucocorticoids, opioids(15, 21, 41, 46, 47, 49, 50), ketamine(19, 40, 42, 44, 53–55), nonsteroidal anti-inflammatory agents(57), alpha 2 agonists(10, 38) and magnesium(48, 56, 60) are coming out.
1.4. Why is it important to do this review?
Different works of published literatures reported that the rate of cesarean section is growing rapidly worldwide. The prevalence of postoperative pain after cesarean section is very high which has a great challenge for health care workers. An inadequately managed postoperative management after cesarean section has a number of consequences including deep venous thrombosis, delayed breastfeeding, paralytic ileus, postpartum depression, pulmonary infection, delayed wound healing, increased in-hospital length of stay, chronic pain, and increased health care cost.
Different postoperative pain management modalities are practiced after cesarean section over the years. However, opioid based analgesics and land mark techniques have undesirable consequences, regional analgesia technique with ultrasound requires resource and expertise while different wound infiltration techniques are new techniques with minimal side effect and easy to administer. However, the effectiveness of each technique is uncertain and needs further investigation with systematic review with meta-analysis and trial sequential analysis. This systematic review will provide the most effective wound infiltration technique to prevent undesirable adverse effects of opioids and untreated pain. In addition, the output of this meta-analysis expected to contribute for the successful accomplishment of sustainable development goal (SDGs) article 3.2.2(79).