MULTIMODAL POST-CESAREAN ANALGESIA AND OPIOID CONSUMPTION REDUCTION: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS

Abstract

Cesarean section is the most commonly performed major surgery worldwide, with rates exceeding 55% in Brazil. Inadequate postoperative pain control impairs early ambulation, breastfeeding, and maternal-infant bonding, and increases the risk of postpartum depression and chronic pain. Multimodal analgesia, a cornerstone of Enhanced Recovery After Cesarean (ERAC) protocols, combines different pharmacological classes to achieve effective pain control with minimal opioid exposure. This study is a systematic review conducted according to PRISMA 2020 guidelines, restricted to randomized controlled trials (RCTs) published between 2019 and 2025 in PubMed/MEDLINE, SciELO, and BVS/LILACS databases. Risk of bias was assessed using the Cochrane RoB-2 tool and visualized via robvis. The initial search identified 312 records; after removal of 47 duplicates and exclusion of 258 records during screening and eligibility phases, 7 RCTs (total n = 890 parturients) composed the final sample. The included RCTs evaluated regional nerve blocks (TAP block, quadratus lumborum block, erector spinae plane block) and intrathecal morphine at different doses, always integrated with multimodal protocols containing acetaminophen and NSAIDs. Results demonstrated significant reduction in postoperative opioid consumption, prolonged time to first analgesic request, and lower pain scores, without increased maternal or neonatal adverse events. It is concluded that multimodal post-cesarean analgesia, based on regional blocks and optimized intrathecal morphine doses, represents a safe and effective strategy to reduce maternal opioid exposure.