SpringerLink
Log in

Efficacy and Safety of Intrathecal Morphine for Cesarean Delivery: A Narrative Review

  • Chronic Pain Medicine (O Viswanath, Section Editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Pain management is a critical aspect of care during and following a cesarean delivery. Without proper control of pain, individuals can experience poor mobility, increased thromboembolic events, and difficulty caring for the neonate in the postpartum period. There have been multiple methods for pain management for cesarean delivery and intrathecal morphine (ITM) has emerged as a prominent option for post-operative analgesia due to its efficacy, safety, and potential benefits over other treatments. This review analyzes data on efficacy, side effects, and safety of ITM and the pain control alternatives.

Recent Findings

A comprehensive literature review was conducted to compare ITM with other analgesic techniques in post-cesarean patients. ITM was found to be as effective or better than other analgesic options, including bilateral quadratus lumborum block (QLB), opioid-free epidural analgesia (CSEA-EDA), and intravenous fentanyl. One study found that both ITM and oral analgesia were effective in pain control and that ITM caused fewer breakthrough pain events but had a longer duration and a greater rate of side effects than oral opioid analgesia. Commonly observed side effects of intrathecal opioids include nausea, vomiting, pruritus, and urinary retention, and it is thought that the adverse effects from intrathecal administration of opioids are short-lived.

Summary

ITM may provide a decreased risk of DVT and coagulation by decreasing lower extremity weakness and numbness, thereby decreasing recovery time and increasing mobility. ITM is a safe and effective option for post-cesarean analgesia, with comparable pain relief to alternative forms of pain control, and side effects that are generally manageable. Further research is warranted to explore beneficial combinations with other methods of pain management and optimal dosing strategies.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Availability of Data and Material

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

References

  1. Molina G, Weiser TG, Lipsitz SR, et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA. 2015;314(21):2263. https://doi.org/10.1001/jama.2015.15553.

    Article  CAS  PubMed  Google Scholar 

  2. Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. The Lancet. 2018;392(10155):1341–8. https://doi.org/10.1016/S0140-6736(18)31928-7.

    Article  Google Scholar 

  3. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6):e005671. https://doi.org/10.1136/bmjgh-2021-005671.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Gadsden J, Hart S, Santos AC. Post-cesarean delivery analgesia. Anesth Analg. 2005;101(5S):S62–9. https://doi.org/10.1213/01.ANE.0000177100.08599.C8.

    Article  CAS  PubMed  Google Scholar 

  5. Kessous R, Weintraub AY, Wiznitzer A, et al. Spinal versus general anesthesia in cesarean sections: the effects on postoperative pain perception. Arch Gynecol Obstet. 2012;286(1):75–9. https://doi.org/10.1007/s00404-012-2265-y.

    Article  PubMed  Google Scholar 

  6. Ring L, Landau R, Delgado C. The current role of general anesthesia for cesarean delivery. Curr Anesthesiol Rep. 2021;11(1):18–27. https://doi.org/10.1007/s40140-021-00437-6.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Bollag L, Lim G, Sultan P, et al. Society for obstetric anesthesia and perinatology: Consensus statement and recommendations for enhanced recovery after cesarean. Anesth Analg. 2021;132(5):1362–77. https://doi.org/10.1213/ANE.0000000000005257.

    Article  PubMed  Google Scholar 

  8. Lim G, Facco FL, Nathan N, Waters JH, Wong CA, Eltzschig HK. A review of the impact of obstetric anesthesia on maternal and neonatal outcomes. Anesthesiology. 2018;129(1):192–215. https://doi.org/10.1097/ALN.0000000000002182.

    Article  PubMed  Google Scholar 

  9. Hermanns H, Bos EME, Van Zuylen ML, Hollmann MW, Stevens MF. The options for neuraxial drug administration. CNS Drugs. 2022;36(8):877–96. https://doi.org/10.1007/s40263-022-00936-y.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Pangthipampai P, Dejarkom S, Poolsuppasit S, Luansritisakul C, Tangchittam S. Bilateral posterior Quadratus Lumborum block for pain relief after cesarean delivery: a randomized controlled trial. BMC Anesthesiol. 2021;21(1):90. https://doi.org/10.1186/s12871-021-01309-6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Siti Salmah G, Choy YC. Comparison of morphine with fentanyl added to intrathecal 0.5% hyperbaric bupivacaine for analgesia after caesarean section. Med J Malaysia. 2009;64(1):71–4.

    CAS  PubMed  Google Scholar 

  12. Suzuki H, Kamiya Y, Fujiwara T, Yoshida T, Takamatsu M, Sato K. Intrathecal morphine versus epidural ropivacaine infusion for analgesia after Cesarean section: a retrospective study. JA Clin Rep. 2015;1(1):3. https://doi.org/10.1186/s40981-015-0005-6.

    Article  PubMed  Google Scholar 

  13. Loane H, Preston R, Douglas MJ, Massey S, Papsdorf M, Tyler J. A randomized controlled trial comparing intrathecal morphine with transversus abdominis plane block for post-cesarean delivery analgesia. Int J Obstet Anesth. 2012;21(2):112–8. https://doi.org/10.1016/j.ijoa.2012.02.005.

    Article  CAS  PubMed  Google Scholar 

  14. Sharpe EE, Molitor RJ, Arendt KW, et al. Intrathecal morphine versus intrathecal hydromorphone for analgesia after cesarean delivery. Anesthesiology. 2020;132(6):1382–91. https://doi.org/10.1097/ALN.0000000000003283.

    Article  CAS  PubMed  Google Scholar 

  15. Yefet E, Nassar S, Carmeli J, et al. Oral analgesia in fixed-time interval administration versus spinal morphine for post-Cesarean pain: a randomised controlled trial. Arch Gynecol Obstet. 2022;305(4):893–901. https://doi.org/10.1007/s00404-021-06196-3. The study by Yefet, et al. was beneficial in this review due to its large number of patients involved in the randomized controlled trial, as well as its discussion of both efficacy and safety of the use of intrathecal morphine versus an alternative form of analgesia.

    Article  CAS  PubMed  Google Scholar 

  16. Sato I, Iwasaki H, Luthe SK, Iida T, Kanda H. Comparison of intrathecal morphine with continuous patient-controlled epidural anesthesia versus intrathecal morphine alone for post-cesarean section analgesia: a randomized controlled trial. BMC Anesthesiol. 2020;20(1):138. https://doi.org/10.1186/s12871-020-01050-6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Yan ZR, Chen LJ, Zhang SJ, et al. The transversus abdominis plane block in conjunction with intrathecal morphine use after cesarean section in women with severe pre-eclampsia: a randomized controlled trial. BMC Anesthesiol. 2023;23(1):100. https://doi.org/10.1186/s12871-023-02061-9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician. 2008;11(2 Suppl):S105-120.

    Article  PubMed  Google Scholar 

  19. Grape S, El-Boghdadly K, Albrecht E. Management of adverse effects of intrathecal opioids in acute pain. Best Pract Res Clin Anaesthesiol. 2023;37(2):199–207. https://doi.org/10.1016/j.bpa.2023.02.002.

    Article  PubMed  Google Scholar 

  20. Morphine - an overview | ScienceDirect Topics. Accessed February 27, 2024. https://www.sciencedirect.com/topics/neuroscience/morphine.

  21. Fei L, Shuai H, Chen Z, Jie Y, Zhefeng Q. Efficacy and safety of low-dose versus high-dose postoperative intrathecal morphine in 62 women undergoing elective cesarean section delivery at full term. Med Sci Monit. 2023;29:0–0. https://doi.org/10.12659/MSM.939567. The study by Fei, et al. was important to this review as it detailed some of the main adverse effects and safety concerns that are being considered when using intrathecal morphine during cesarean delivery.

    Article  Google Scholar 

  22. Gautier N, Lejeune D, Al Zein L, et al. The effects of intrathecal morphine on urinary bladder function and recovery in patients having a cesarean delivery - A randomized clinical trial. Anaesth Crit Care Pain Med. 2023;42(6):101269. https://doi.org/10.1016/j.accpm.2023.101269.

  23. Siti Salmah G, Choy YC. Comparison of morphine with fentanyl added to intrathecal 0.5% hyperbaric bupivacaine for analgesia after caesarean section. Med J Malays. 2009;64(1):71–4.

    CAS  Google Scholar 

  24. Fei L, Shuai H, Chen Z, Jie Y, Zhefeng Q. Efficacy and safety of low-dose versus high-dose postoperative intrathecal morphine in 62 women undergoing elective cesarean section delivery at full term. Med Sci Monit Int Med J Exp Clin Res. 2023;29:e939567–1–e939567–6. https://doi.org/10.12659/MSM.939567.

    Article  Google Scholar 

  25. Sun C, Wang YT, Dai YJ, Liu ZH, Yang J, Cheng ZQ, Dong DS, Wang CF, Zhao GL, Lu GJ, Song T, ** Y, Sun LL, Kaye AD, Urits I, Viswanath O, Sun YH. Intrathecal morphine delivery at cisterna magna to control refractory cancer-related pain: a prospective cohort study. Psychopharmacol Bull. 2020;50(4 Suppl 1):48–66. PMID: 33633417; PMCID: PMC7901124.

    PubMed  PubMed Central  Google Scholar 

  26. Herman JA, Urits I, Kaye AD, Urman RD, Viswanath O. Racial disparities in obstetric outcomes and anesthetic techniques for deliveries. J Clin Anesth. 2022;79:109989. https://doi.org/10.1016/j.jclinane.2020.109989. Epub 2020 Jul 24 PMID: 32718775.

    Article  PubMed  Google Scholar 

Download references

Funding

No funding or sponsorship was received for this study or publication of this article.

Author information

Authors and Affiliations

  1. Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA

    Alan D. Kaye

  2. School of Medicine, Louisiana State University Health Sciences Center at New Orleans, New Orleans, LA, 70112, USA

    Anne M. Lindberg & Rebecca J. Maitski

  3. School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA

    Shivam S. Shah, Emily B. Pendarvis & Jada F. Cooley

  4. Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA

    Sam Amarasinghe, Sagar Patel, Zachary Palowsky, Charles J. Fox, Shahab Ahmadzadeh & Sahar Shekoohi

  5. Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA

    Christopher L. Robinson

Authors
  1. Alan D. Kaye
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anne M. Lindberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shivam S. Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rebecca J. Maitski
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Emily B. Pendarvis
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jada F. Cooley
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sam Amarasinghe
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sagar Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Zachary Palowsky
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Charles J. Fox
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Shahab Ahmadzadeh
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Sahar Shekoohi
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Christopher L. Robinson
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Study Design: ADK, AML, SSS, RLM, EBP, JFC, SA, SP, ZP, CJF, SA, SS and CLR. Drafting of the manuscript: ADK, AML, SSS, RLM, EBP, JFC, SA, SP, ZP, CJF, SA, SS and CLR. Critical revision of the manuscript for important intellectual content: ADK, AML, SSS, RLM, EBP, JFC, SA, SP, ZP, CJF, SA, SS and CLR. All authors listed have made a direct and intellectual contribution to the work and approved for publication. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Sahar Shekoohi.

Ethics declarations

Competing Interests

CLR and ADK are section editors for current pain and headache reports.

Human and Animal Rights and Informed Consent

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kaye, A.D., Lindberg, A.M., Shah, S.S. et al. Efficacy and Safety of Intrathecal Morphine for Cesarean Delivery: A Narrative Review. Curr Pain Headache Rep (2024). https://doi.org/10.1007/s11916-024-01292-w

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11916-024-01292-w

Keywords

Search

Navigation