PCA use for pain control after c-section

[Kayla.J.RN]

On the L&D unit where I work, post-op orders for pain management after c-sections typically include an order for IV PCA with morphine sulfate. Some of the nurses on my unit start the PCA in the recovery room before the pt is sent to postpartum regardless of whether the pt has complaints of pain or not. Others wait until the pt starts to feel onset of pain.

What is the right thing to do? Should the PCA be started before the pt has pain... or should I wait until the pt requests something for pain?

If anyone has advice or can cite research discussing this topic, I would greatly appreciate it. :)

[lovemyjoblandd]

What do the orders say to do?Usually by the time the patient is requesting something for pain ( and you know she will!) it's at a level where you r now trying to get it under control instead of simply managing it. We all know its harder to get pain under control rather than keeping it under control. On my floor we use pcea morphine or Demerol depending on the doc and we always start it ASAP coming from the or. After a major surgery the patient is going to hurt sooner or later, so why make her suffer when u have the means and orders to keep her comfortable from the start?

[PinkNBlue, BSN, RN]

Ideally I would think starting before the patient complains of pain would be most beneficial. It is way harder to bring it down once it's out of control. They usually end up needing more pain meds than they would have had they been given something before their pain went above where they're comfortable or when it's acceptable to them.

[Fyreflie]

What do your cs pts get in their spinal? On all three floors I've worked on our cs pts go to pp with orders for ibuprofen and Tylenol around the clock for 48 hours. Breakthrough is usually IV Toredol in the recovery room and prn for 6 doses after that. Only our general anesthetic a get a pca!

But if your floor does them for everyone I would say have it set up if you can and have them start using it if they need to. Definitely easier (and less use over the long term) if they stay on top of the pain rather than chasing it, which in return would allow them to return to function/ambulate/feed/bond more quickly :)

[klone, MSN, RN]

It's better and more effective to prevent pain, rather than try to control it after it takes effect. A woman who has just had major abdominal surgery and will be breastfeeding (severe cramping of the organ that was just cut open) *is* going to have pain. It's best to treat it before it becomes too strong.

That said, at my current facility, the anesthesiologists give Duramorph in their spinals, which generally lasts 12-24 hours. Thus, the post C/S patients generally don't need a PCA. At the other place I worked where Duramorph was not used, PCAs were definitely necessary.

[Elvish, BSN, DNP, RN, NP]

Most of our c/s moms get a Duramorph spinal as klone mentioned. Those who don't get a PCA, usually morphine. It is always preferable to have the PCA hanging asap after the section. Almost no one gets a basal rate anymore, it is almost always demand only, which seems to work alright if you can remind pts that it's there and to use it.

If you don't start it back in OR/recovery, you are (as previously mentioned) going to be trying to get pain under control once it has already gotten bad. That is much harder to do than heading it off as it first starts to exhibit.

[ndirishfanRNC]

We usually use duramorph in our spinals too with toradol Q6 for breakthrough pain. If a pt doesn't receive duramorph, we usually start the PCA at the beginning of recovery even if she is not in pain. Basal rates are not ordered and it is sometimes difficult for patients to remember that the only way they get pain medication is to push the button! I agree with others who have posted, it's better to stay ahead than catch up :)

[monkeybug]

We start it in recovery, with the goal to have it in place before they have pain. That way when they are hurting they don't have to wait on us to get it, set the pump up, have someone countersign with us. It's PCA, so if they aren't hurting, they don't have to hit the button. I experienced this personally. I had a section under general and the anesthesiologist forgot to sign the PCA orders. I awoke in agony with no PCA in place. It seemed like an eternity before they got orders signed and had the pump set up. It was hours before my pain was under control. Hours that I couldn't breastfeed, hours I couldn't hold my child, hours that I was a very upset patient.

[Kayla.J.RN]

Thank you everyone for responding. I guess I already knew the answer to my own question. I figured it would be better to start it as soon as possible to ensure that their pain in under control. However, on a busy day I have had co-workers who have said "oh she's not in pain or anything... they can start the PCA pump in postpartum." That didn't seem right to me because the postpartum nurse might also be busy... and it sometimes takes a while to find a PCA pump and set everything up. I don't want to fall into bad habits so I've been making it a priority to start the PCA pump in the recovery room. If I was in the pt's shoes.. I know I would want it to be started ASAP.