Perioperative Anaesthesia Management and Enhanced Recovery after Cesarean Delivery: A Systematic Review

Background: Cesarean delivery is associated with significant postoperative pain, which may interfere with maternal mobilization, breastfeeding, satisfaction, and overall recovery. Intrathecal morphine provides effective analgesia but may cause opioid-related adverse effects. Regional techniques such as transversus abdominis plane (TAP), quadratus lumborum (QL), and erector spinae plane (ESP) blocks, together with multimodal analgesia and enhanced recovery after cesarean (ERAC/ERAS) pathways, have therefore gained increasing attention. The objective is to systematically evaluate the evidence regarding perioperative anesthesia and analgesic strategies for cesarean delivery, with particular emphasis on intrathecal morphine, TAP, QL and ESP blocks, multimodal analgesia, and ERAC/ERAS pathways, and to assess their effects on postoperative pain, opioid consumption, adverse effects, and maternal recovery. Material and Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. PubMed/MEDLINE, Scopus, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies published between 2012 and 2026. Original comparative clinical studies involving women undergoing cesarean delivery were eligible. Randomized controlled trials and prospective or retrospective comparative studies evaluating neuraxial opioids, regional/fascial-plane blocks, multimodal analgesia, or ERAC/ERAS pathways were included. The primary outcomes were postoperative pain intensity and opioid/rescue analgesic consumption. Secondary outcomes included time to rescue analgesia, duration of analgesia, postoperative nausea and vomiting, pruritus, mobilization, breastfeeding, maternal satisfaction, quality of recovery, and length of hospital stay. Results: Twenty-four original comparative studies were included, predominantly randomized controlled trials. Intrathecal morphine generally provided reliable and prolonged postoperative analgesia, although higher doses were associated with greater opioid-related adverse effects in some studies. TAP, QL, and ESP blocks provided effective postoperative analgesia and reduced rescue opioid requirements in selected settings, particularly when intrathecal morphine was not used. However, adding a QL block to intrathecal morphine did not consistently reduce 24-hour opioid consumption. Multimodal analgesia, including scheduled non-opioid medications, reduced opioid requirements and supported the use of lower intrathecal morphine doses in some protocols. ERAC/ERAS pathways consistently improved broader recovery outcomes, including length of hospital stay, early functional recovery, breastfeeding, pain, and quality of recovery, although opioid reduction was not uniform across studies. Conclusion: Current evidence supports a multimodal and individualized approach to perioperative anesthesia management for cesarean delivery. Intrathecal morphine remains an effective analgesic option, while TAP, QL, and ESP blocks provide useful opioid-sparing alternatives or adjuncts in selected patients. ERAC/ERAS pathways appear to provide the broadest recovery benefits by integrating analgesia with early mobilization, breastfeeding, and other components of maternal recovery.

Keywords: Cesarean Delivery, Perioperative Anaesthesia, Enhanced Recovery After Cesarean, Obstetric Anaesthesia, Multimodal Analgesia, Postoperative Recovery, Maternal Outcomes, ERAC.