https://doi.org/10.14528/snr.2024.58.3.3256
2024. Obzornik zdravstvene nege, 58(3), pp. 185–195.
Key words: pain; delivery; 
opioid; mobilisation; nursing 
Ključne besede: bolečina; 
porod; opioid; mobilizacija; 
zdravstvena nega
1 University Medical Centre 
Ljubljana, Šlajmerjeva 4, 1000 
Ljubljana, Slovenia
2 University of Novo mesto, 
Faculty of Health Sciences, 
Na Loko 2, 8000 Novo mesto, 
Slovenia
3 University of Ljubljana, 
Faculty of Medicine, Zaloška 
cesta 4, 1000 Ljubljana, Slovenia
* Corresponding author/
Korespondenčni avtor: 
urosvisic@gmail.com
Pregledni znanstveni članek/Review article
Managing postcaesarean section pain with opioid analgesia and the effect on 
breastfeeding: A literature review
Obvladovanje bolečine po carskem rezu z opioidno analgezijo in vpliv na dojenje: 
pregled literature 
Uroš Višić1, 2, *, Miha Lučovnik1, 3
Received/Prejeto: 28. 8. 2023
Accepted/Sprejeto: 26. 7. 2024
© 2024 Avtorji/The Authors. Izdaja Zbornica zdravstvene in babiške nege Slovenije - Zveza strokovnih društev 
medicinskih sester, babic in zdravstvenih tehnikov Slovenije./Published by Nurses and Midwives Association 
of Slovenia. To je članek z odprtim dostopom z licenco CC BY-NC-ND 4.0./This is an open access article 
under the CC BY-NC-ND 4.0 license.
ABSTRACT
Introduction: Pain after caesarean section is an expected event that can affect the patient's recovery and 
first attempts at breastfeeding. The aim of this review was to determine the relationship between opioid pain 
management after caesarean section and support during the first breastfeeding attempts.
Methods: A descriptive method was used to conduct a literature search in the PubMed Central, ScienceDirect, 
and Google Scholar databases, which included literature published between 2013 and 2023. A combination 
of the following keywords was used in the search: "pain", "delivery", "opioid", "mobilisation" and "nursing". 
Primary sources were selected according to predefined inclusion and exclusion criteria. The search process 
and selection are illustrated using the PRISMA diagram. A thematic analysis was conducted by coding the 
data retrieved. 
Results: The literature search yielded nine articles addressing the status of opioid pain management and 
breastfeeding after caesarean section. The results of the literature search were critically appraised using 
the MML tool. The main content pertained to the outcomes of identifying different interventions for the 
management of postoperative pain and initiation of breastfeeding after caesarean section. 
Discussion and conclusion: In general, patients in different countries were found to be at higher risk of 
inadequate forms of pain management after caesarean section. We also identified the key research gaps that 
should be addressed to support further public health interventions for more appropriate pain management 
and the promotion of and support with breastfeeding after caesarean section. 
IZVLEČEK 
Uvod: Bolečina po carskem rezu je pričakovan dogodek, ki lahko vpliva na okrevanje otročnice in prvo 
dojenje. Namen tega pregleda je ugotoviti povezavo med obravnavo bolečine z opioidi po carskem rezu in 
podporo pri dojenju.
Metode: Izvedli smo pregled strokovne in znanstvene literature. Iskanje je potekalo po podatkovnih bazah 
PubMed Central, ScienceDirect in Google Scholar. Vključena je bila literature, objavljena med letoma 
2013 in 2023. Pri iskanju so bile uporabljene kombinacije ključnih besed: »bolečina«, »porod«, »opioid«, 
»mobilizacija« in »zdravstvena nega«. Primarni viri so bili izbrani v skladu z merili za vključitev in izključitev. 
Postopek iskanja in izbor sta prikazana s pomočjo PRISMA diagrama. Tematska analiza je bila izvedena s 
kodiranjem reziltatov. 
Rezultati: Identificirali smo 9 člankov, ki so obravnavali status obvladovanja bolečine z opioidi po carskem 
rezu. Rezultate smo kritično ovrednotili z orodjem PICO. Glavna vsebina so bili rezultati pri ugotavljanju 
različnih intervencij za obvladovanje pooperativne bolečine in za začetek dojenja po carskem rezu. 
Diskusija in zaključek: Na splošno velja, da so otročnice v različnih državah bolj izpostavljene tveganju 
neučinkovitih načinov obvladovanja bolečine po carskem rezu. Opredelili smo ključne vrzeli, ki bi lahko bile 
nadaljne področje raziskovanja za ustreznejše obvladovanje bolečine ter podpora dojenju po carskem razu.
186 Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
Introduction 
Pain management after caesarean section is critically 
important and a top priority for parturients undergoing 
caesarean section (Komatsu et al., 2022). Opioids are 
commonly prescribed for pain management as they 
reduce the intensity of pain signals (Brown, 2020). The 
introduction of opioid substitutes has made it possible 
to administrater lower doses of opioids during and 
after surgery (Boysen et al., 2023). However, managing 
breakthrough pain requires a standardised approach 
with planned non-opioid adjuncts and prescribed 
doses (Sangkum et al., 2021). The incidence of 
caesarean section varies widely around the world. In 
most European countries, the caesarean section rate 
is between 25% and 35% (Vila-Candel et al., 2020). 
In Slovenia, the rate has increased significantly over 
the years and has stabilised at around 21% (Visic et 
al., 2021). The highest rates have been observed in the 
Dominican Republic (56.4%). In the United States 
of America, caesarean section is the most common 
surgical procedure in hospitals, accounting for 31.9% 
of deliveries, while the global average for caesarean 
section deliveries is 18.6% (Landau et al., 2023). 
As with all surgical procedures, pain after a caesarean 
section is an expected event that can affect the patient's 
recovery (Carvalho & Butwick, 2017). While opioids 
provide adequate pain control, their side effects can 
negatively affect the mother-newborn bonding in 
the early postpartum period (Višić et al., 2022). 
Common side effects of opioid administration include 
sedation, dizziness, nausea, constipation, tolerance and 
respiratory depression (Daoust et al., 2020). While in 
some parturients with low analgesic requirements, a 
standard (non-opioid) analgesic regimen may lead 
to overmedication and analgesic-related side effects 
(Sangkum et al., 2021), this type of pain management 
enables early ambulation, breastfeeding, prevention 
of thromboembolic complications associated with 
caesarean section, as well as bonding between mother 
and newborn (Visic et al., 2021; Zipursky et al., 
2023). ERAC (Enhanced Recovery After Cesarean) 
uses an interdisciplinary approach in which the 
patient is part of the support system consisting of all 
healthcare professionals. Intraoperative anaesthesia and 
postoperative multimodal pain management are the 
simplest components of appropriate treatment. The 
postoperative course requires increasing involvement 
of nursing staff in the early postoperative period (Patel 
& Zakowski, 2021). 
Caesarean section requires optimal perioperative 
pain management, which not only enables early 
outpatient management, but also plays a key role 
in postoperative rehabilitation (Ismail et al., 2012). 
In a significant proportion of patients, it has been 
associated with moderate to severe postoperative pain, 
which can delay return to daily activities and also 
affect the first attempts at breastfeeding (Roofthooft 
et al., 2021). The issue of breastfeeding support after 
caesarean section that would also focus on maternal 
outcomes has not been addressed until recently 
(Ahmadi et al., 2015; Wen et al., 2015). Although 
it is generally recognised that caesarean section 
has a negative impact on breastfeeding, individual 
population-based studies examining the association 
between caesarean delivery and breastfeeding are 
inconsistent (Cohen et al., 2018). Early skin-to-skin 
contact has been shown to promote breastfeeding 
and is associated with physiological and psychological 
benefits for both mother and infant (Mary et al., 2021). 
The first postpartum hours are therefore crucial for 
the establishment and continuation of breastfeeding 
(Cohen et al., 2018; Gianni et al., 2020). 
Aims and objectives 
The aim of this systematic review was to determine 
the effects of opioid analgesia after caesarean section 
in the early postpartum period. The specific aim of 
this review was to investigate the association between 
opioid treatment of pain after caesarean section and 
its impact on ambulation and the early stages of 
breastfeeding. The following research questions were 
addressed: 
− What is the impact of opioid analgesia on activity 
performance in the early postcaesarean section 
period? 
− What is the outcome of opioid analgesia and 
breastfeeding after caesarean section?
Methods 
We conducted a literature review with quality 
assessment on the effect of pain management after 
caesarean section using only opioid analgesia on 
activity performance and breastfeeding initiation in 
the early postpartum period.
Review methods 
The PubMed Central, ScienceDirect, and Google 
Scholar databases were used for the electronic search 
for the primary literature, supplemented by a manual 
search. The inclusion and exclusion criteria listed in 
Table 1 were applied in the literature search. Based on 
the guidelines by Streubert & Carpenter (2011), the 
suitability of the identified literature for inclusion in 
the study was first assessed. The search results were 
analysed in several rounds. In the first round, the titles 
were carefully screened, and if the suitability of a record 
for inclusion in the study could not be determined 
on the basis of the title, the abstract was reviewed. In 
the second round, abstracts were read carefully, and 
in the third round, articles were read and assessed 
for eligibility for inclusion. We used the following 
inclusion criteria: patients undergoing caesarean 
187Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
section, pain management with opioid analgesia, fully 
accessible articles published in English or Slovene since 
2013. The following search strategy, consisting of a 
combination of keywords and Boolean operators, was 
used: ("caesarean section" OR "caesarean delivery") 
AND ("opioid analgesia" OR "opiate analgesia") AND 
("breastfeeding" OR "lactation"). The literature search 
took place in April 2023. We focused on the topic of 
opioid pain management after caesarean section and 
its impact on breastfeeding after caesarean section. 
The literature was screened for suitability for inclusion 
in the literature review using the guidelines described by 
Streubert & Carpenter (2011). We included publications 
that contained data on postcaesarean pain management 
with opioids for the defined population. We included 
publications with original results that were available as 
full text or comprehensive abstracts. Given the advances 
in the field of postcaesarean pain management, the 
literature search was limited to publications from the 
last 10 years. Relevant publications not yet found in 
the literature search and identified manually through 
other sources such as web browsers, organisations and 
citation searches, were included as additional records. 
All inclusion and exclusion criteria are listed in Table 1. 
Results of the review 
Our literature search yielded 37 records. After 
removing duplicates (n = 2) and adding records from 
other sources (n = 12), 23 records were screened for 
relevance. After removing irrelevant records (n = 9), 
the full texts of the publications were collected (n = 14). 
The literature review was conducted on the basis of nine 
(n = 9) relevant publications. The identified publications 
were categorised into two groups according to the 
reported outcome of the study: a) pain management 
after caesarean section with opioid use and b) 
breastfeeding after caesarean section with opioid use. 
Nine articles were included in the study, as shown in 
Figure 1. Table 3 shows the characteristics of each study 
included in our literature review. We carefully screened 
all selected publications and extracted the following 
information: description of the study period, study 
population, and results (outcomes related to opioid 
analgesia and breastfeeding after caesarean section). 
Quality assessment of the review and description 
of data processing
The results of the literature review included one 
qualitative and eight quantitative studies from different 
countries. The selected literature was included in the final 
review on the basis of relevance, topicality and accessibility. 
The typology of the nine sources retrieved and included 
in the final literature review was determined based on 
the hierarchy of evidence in scientific research (Polit & 
Beck, 2018). The inclusion of multi-methods research can 
address the complex aspects of healthcare services research 
that can not be analysed using a single method (Harrsion 
et al., 2021). Therefore, the reliability of the reviewed 
studies was determined based on a critical appraisal 
using the PICO model (P – patient, I – intervention, C – 
comparison, O – outcome), where we critically appraised 
the qualitative studies using a control (Brandt Eriksen & 
Faber Frandsen, 2018) and established that the selected 
studies were suitable for inclusion in the data analysis. The 
criteria for assessing the quality of the studies were the 
structure and coherence of the research and the reliability 
of the sources used. In the final phase, we identified nine 
studies, determined the codes and classified them into 
three categories according to their level of significance: A – 
excellent, B – good, C – sufficient (Table 2). 
Table 1: Inclusion and exclusion criteria
Tabela 1: Vključitvena in izključitvena merila
Type of criteria/
Vrsta meril 
Inclusion criteria/ 
Vključitvena merila
Exclusion criteria/ 
Izključitvena merila
Topic Caesarean section; opioid analgesia; breastfeeding. Vaginal birth, regional analgesia, addiction to 
opioids.
Type of research Literature review and meta-analysis, cohort study, 
prospective observational study, longitudinal study. 
Unpublished material, abstract, reports, and 
literature without professional content.
Observed population Patients after caesarean section with breastfeeding 
attempts. 
Patients after vaginal birth and no 
breastfeeding experience. 
Time frame Articles published since 2013. Articles published before 2013. 
Table 2: Level of evidence for the studies included in 
the review
Tabela 2: Stopnja dokazov pri vključenih študijah
Author, year, country /
Avtor, leto, država 
Level of evidence /
Stopnja dokazov 
Bjornstad & Reder, 2020, Norway A
Chao et al., 2019, USA B
Chang et al., 2022, Taiwan C
Fassoulaki et al., 2021, Greece A
Hooda et al., 2023, India B
Landau et al., 2021, USA A
O'Connor et al., 2022, USA B
Oommen et al., 2021, Norway B
Patzkowski et al., 2023, USA C
Legend/legenda: A – excellent/odlično; B – dobro/good; C – zadostno/
fair; USA - United States of America/Združene države Amerike
188 Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
Results 
Our literature review examined nine studies 
describing the effects of opioid treatment of 
postcaesarean section pain and breastfeeding 
initiation in developed countries around the world 
(United States of America – four studies; Norway – 
two studies; Greece – one study; India – one study; 
Taiwan – one study). Of the nine studies included in 
this review, six studies, namely Bjornstad & Reder 
(2020), Chao et al. (2019), Fassoulaki et al. (2021), 
O'Connor et al. (2022), Oommen et al. (2021), and 
Patzkowski et al. (2023), assess pain management 
with opioid analgesia. These studies also compare 
opioid analgesia and its side effects. Several studies 
report adverse effects such as nausea, vomiting, and 
dizziness. It can be assumed that the first attempt at 
breastfeeding after a caesarean section is unsuccessful. 
In this case, skin-to-skin contact is also prevented. 
Chao et al. (2019), Hooda et al. (2023), and Landau 
et al. (2021) compare different opioid pain regimens 
and breastfeeding outcomes after caesarean section. 
Most studies report on the prevalence of opioid use 
immediately after surgery. The reports indicate that 
patients experienced mild or severe problems in the 
initial postcaesarean period. The main findings were 
divided into thematic categories using codes, which 
were further divided into the following two clusters: 
Category I: Opioid analgesia after caesarean section 
and Category II: Breastfeeding support after induced 
opioid analgesia and are presented in Table 4.
Category I: Opioid analgesia after caesarean section
Bjornstad & Reder (2020) report on patients' high 
pain intensity on the visual analogue scale (VAS ≥ 
4‒7/10) and opioid requirement in the first 24 hours 
after caesarean section. Patients also received an 
additional opioid pain relief. In this study, low levels 
of ambulation were observed due to inadequate opioid 
pain relief and a high prevalence of side effects, such as 
fatigue, weakness and nausea. Patzkowski et al. (2023) 
report a mean VAS pain score of > 4/10 (in 72% of 
cases). Of all the patients included in this study, 96% 
Figure 1: Flow diagram of literature selection (Page et al., 2020)
Slika 1: Diagram pregleda selekcioniranja literature (Page et al., 2020)
In
cl
ud
ed
 
Sc
re
en
in
g 
 
Identification of new studies from databases and registers  
 
Records identified from: 
Pubmed Central (n = 13) 
ScienceDirect (n = 446) 
Google Scholar  
(n = 10500) 
Records removed 
before screening:  
Duplicate records 
removed (n = 4)  
Records screened
(n = 35)       
Reports sought for 
retrieval (n = 23) 
Reports assessed for 
eligibility (n = 14) 
Studies included 
 
in review (n = 9) 
Records included
(n = 23)       
Reports not 
retrieved (n = 9)     
Reports excluded
(n = 7):
Abstract (n = 4)
Study popula
 
tion
(n = 3) 
Identification using other methods  
Records identified from 
Websites (n = 55300) 
Organisations (n = 2030) 
Citation search (n = 16900) 
Reports 
sought for 
retrieval 
(n = 16355) 
Reports not 
retrieved 
(n = 16335) 
Reports 
assessed for 
eligibility 
(n = 20)      
Reports excluded
(n = 18):
Abstract (n = 4)
Study population
(n = 4)
Research (n = 10)  
Id
en
tif
ic
at
io
n 
189Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
Table 3: General characteristics of the studies included in the review
Tabela 3: Značilnosti vključenih raziskav
Author, year, 
country/Avtor, 
leto, država 
Research typology/
Raziskovalna 
tipologija
Data/
Podatki 
Research aim/
Raziskovalni cilj
Statistical analysis/
Statistična analiza 
Key findings/
Ključne ugotovitve 
Bjornstad & 
Reder, 2020, 
Norway
Retrospective 
cohort study 
50 patients 
included.
Pain 
management in 
elective CS.
The mean average VAS 
was 4 and the mean worst 
VAS pain intensity was 
7; 34 patients reported 
an average VAS ≥ 4, and 
seven reported a VAS 
pain intensity ≥ 7.
High pain intensity and 
need for opioids in the 
first 24 hours after CS; 
contribution to nausea 
and especially pruritus; 
low mobilisation rate 
on the postoperative 
day due to inadequate 
pain relief.
Chao et al., 
2019, 
USA
Retrospective 
cohort study
217 subjects 
in primary 
CS, and 37 
subjects in 
repeat CS.
Pain 
management 
with patients 
who underwent 
prior or repeat 
elective CS.
Opioid consumption was 
significantly lower in the 
repeat group compared 
to the primary CS group 
(p < 0.005); the repeat CS 
group had statistically 
significant lower opioid 
consumption in the 
postprocedure time 
intervals (0 – 72 h) (p 
< 0.005); the highest 
opioid consumption was 
recorded in the 25 – 48h.
None of the patients 
received additional 
regional analgesic 
procedures; CS 
recurrences were not 
treated differently in 
postoperative pain 
management allowing 
for BF / care for the 
newborn. 
Chang et al., 
2022,  
Taiwan 
Meta-analysis 
of randomised 
controlled trials 
23 studies 
with 2589 
parturients 
Effects of opioids 
administered 
through 
intravenous PCA 
in patients who 
have undergone 
CS.
Fentanyl had better 
analgesic effects after 4 
hours (MD = –0.75, 95% 
CI = 1.16; 0.34) and 8 
hours (MD = 0.93; 95% 
CI = –1.57; –0.28), and 
fentanyl was more likely 
to cause pruritis. 
Opioids cause opioid 
induced respiratory 
depression and 
sedation; delayed 
lactogenesis and BF 
decline; opioid-induced 
nausea, increased 
likelihood of developing 
pruritis after CS.
Fassoulaki  
et al., 2021, 
Greece
Cohort 
observational study
173 patients 
who 
underwent 
elective CS.
Comparing 
subcutaneus 
morphine in the 
postanaesthesia 
care unit.
Hospital opioid exposure 
(mean daily morphine 
equivalents) 10.7 
equivalents (95% CI = 
10.2 - 11.3).
Presence of persistent 
pain; 32% reported 
intermittent use of 
analgesic at home; 
lack of healthcare 
promotion for pain 
management; awareness 
of the impact on BF and 
its consequences.
Hooda et al., 
2023,  
India 
Prospective, 
double-blinded, 
randomised study
300 patients 
in elective 
CS.
Comparing the 
effect of different 
analgesic 
regimens 
(ambulation and 
BF) after CS.
In group 1 (diclofenac), 
the time taken to initiate 
BF was significantly 
shorter than in group 2 
(tramadol) (p = 0.028); in 
group 2, the time taken 
to initiate movement was 
significantly shorter (p 
< 0.001).
Adequate analgesia 
influences early 
BF performance 
and movement 
in the immediate 
postcaesarean period; 
patients report nausea, 
fatigue, refusal of first 
BF attempt.
Landau et al., 
2021,  
USA
Retrospective 
cohort study
2983 cases of 
elective CS.
Opioid-sparing 
analgesia during 
CS. 
Oxycodone users before 
intervention (32.7%; p 
< 0.001); the difference 
for non-opioid users 
is greater in academic 
hospitals (20.3%; 95% 
CI = 17.4 ± 23.1%) than 
in community hospitals 
(8.7%; 95% CI = 2.6 ± 
14.4%); CS.
Postoperative analgesic 
protocols were tailored 
to individual opioid 
use; pain scores were 
higher in patients 
prescribed an opioid; 
new methods of pain 
assessment resulted 
in a 30% reduction in 
hospital opioid use after 
CS.
Continues/Se nadaljuje
190 Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
received opioid analgesia and additional opioid pain 
relief with known side effects. In a study by O'Connor 
et al. (2022), patients treated with opioid analgesia 
reported significantly higher VAS pain scores of > 
4/10, which was considered statistically significant (p 
< 0.001). The study by Landau et al. (2021) concludes 
that postoperative analgesic protocols should be 
tailored to the individual patient due to the high 
prevalence of the most frequent side effects. Pain 
scores were higher in the opioid analgesia group than 
in the non-opioid group with a statistical significance 
of p < 0.001. The new standard for pain assessment 
significantly reduced in-hospital opioid use by 30% 
and promoted early adaptation in the postpartum 
period and initiation of breastfeeding. Oommen et al. 
(2021) compared opioid and non-opioid exposure and 
directly demonstrated the impact of fentanyl use on 
lower spontaneous suckling rates and breastfeeding 
difficulties at key moments. Fassoulaki et al. (2021) 
report on a lack of healthcare promotion and the 
impact of opioids in the postoperative period. Chao et 
al. (2019) found that opioid analgesia was associated 
with a statistically significant increase in the likelihood 
of developing pruritus (p < 0.005). All of these side 
effects raised patient concerns about breastfeeding 
outcomes in neonatal care. Hooda et al. (2023) 
demonstrate that the use of opioid analgesia has a 
statistically significant impact on early postpartum 
ambulation (p < 0.001) and breastfeeding initiation 
(p < 0.028) due to nausea and fatigue resulting from 
opioid-based postoperative pain relief. Chang et al. 
(2022) report adverse effects of all treatment modalities 
and conclude that that analgesic treatment should be 
individualised taking into account the known side 
effects of opioid analgesia and other pain treatment 
modalitiesopioid analgesia should be the treatment of 
choice, as they are aware of all side effects of opioids. 
The outcome of breastfeeding is often uncertain 
and places a high burden of stress on the mother. 
Patients with repeat caesarean section reported higher 
pain scores and requested a multiple dose of opioid 
analgesia, probably due to the psychological impact of 
the overall perception of the experience.
Author, year, 
country/Avtor, 
leto, država 
Research typology/
Raziskovalna 
tipologija
Data/
Podatki 
Research aim/
Raziskovalni cilj
Statistical analysis/
Statistična analiza 
Key findings/
Ključne ugotovitve 
O'Connor  
et al., 2022,  
USA 
Retrospective 
cohort study 
46 patients 
who 
underwent 
urgent/
elective CS.
Pain scores and 
opioid analgesic 
utilisation during 
hospitalisation 
in women 
delivering by CS.
The mean daily dose of 
opioid (buprenorphine) 
was 14.6 mg (4 – 32 mg); 
the mean pain score 
12 – 24 h after CS was 
5.03; patients receiving 
neuraxial opioid required 
more parenteral opioid 
than those who did 
not receive neuraxial 
analgesia (16.4 mg (SD 
= 21.1) vs 5.3 mg (SD = 
3.6), p = 0.42).
Buprenorphine 
should not inhibit 
the analgesic effect 
of a neuraxial opioid; 
14.4% of receiving 
buprenorphine had 
significantly increased 
pain; patients had mild 
to severe problems with 
nausea, drowsiness, 
fatigue and pruritus.
Oommen  
et al., 2021, 
Norway
Prospective 
observational study
1101 healthy 
patients.
Effect of 
intrapartum 
fentanyl 
administered 
intravenously or 
through epidural 
analgesia on 
early BF.
Fentanyl was four times 
more likely to cause non-
exclusive BF compared 
to no opioid exposure 
(OR = 4.20, 95% CI = 
2.49 ± 7.09, p < 0.001); a 
reduction in exclusive BF 
(81% vs. 89%; p = 0.014) 
and spontaneous suckling 
(68% vs. 83%; p < 0.001) 
was observed.
Spontaneous suckling 
was negatively 
associated with fentanyl 
use during labour (p 
< 0.001); known BF 
problems with lactation 
and first BF attempt and 
outcome.
Patzkowski  
et al., 2023, 
USA
Retrospective 
cohort study 
169 patients 
after elective 
CS.
Understanding 
postCS pain and 
opioid use.
In subarachnoid block, 
72% of patients received 
fentanyl and morphine 
(median fentanyl = 20 
mcg; MME = 0.15 mg), 
24% morphine alone 
(MME = 0.2 mcg), and 
3% fentanyl alone.
One in seven (14%) 
patients reported a 
mean VAS > 4/10, 
and 96% of these 
patients received opioid 
analgesia; including 
poor BF results.
Legend/legenda: CS – caesarean section/carski rez; PCA – patient controlled analgesia/nadzorovana analgezija; p – level of statistical significance/
stopnja statistične značilnosti; % – percentage/odstotek; MD – mean difference/mediana; SD – standard deviation / standardni odklon; MME 
– morphine miligram equivalents/ekvivalenti morfija; CI – confidence interval/interval zaupanja; OR – odds ratio/razmerja obetov; BF – 
breastfeeding/dojenje; VAS – visual-analogue scale/vizualno-analogna skala; USA - United States of America/Združene države Amerike
191Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
Category II: Breastfeeding support after induced 
opioid analgesia 
The findings of the authors of the studies included 
in this literature review can be summarised as follows. 
Some research results show that an appropriate 
theoretical approach and information on pain 
assessment (praise, encouragement, motivation, 
integration) in the early stages after caesarean 
section can increase breastfeeding by up to 45%. 
Breastfeeding after opioid-assisted pain management 
is very delicate, and early ambulation, contact with 
the newborn, and care for the newborn must be 
achieved. Breastfeeding as an intervention is the most 
important strategy for mother-newborn bonding in 
the postnatal period. According to Fassoulaki et al. 
(2021) and O'Connor et al. (2022) opioid analgesia 
and the first breastfeeding attempt and its outcomes 
in the early postcaesarean period depend on the basic 
nursing activities. Investigating the side effects and 
outcomes of breastfeeding and newborn care, and 
comparing opioid exposure to non-opioid exposure, 
Chang et al. (2022), Chao et al. (2019), and Oommen 
et al. (2021) demonstrated the impact of opioid use on 
lower spontaneous suckling rates and difficulties with 
breastfeeding. In this context, a statistically significant 
and worrying finding was the decrease in exclusive 
breastfeeding (p < 0.014) and spontaneous suckling 
(p < 0.001) that correlated with opioid analgesic use. 
Due to delayed lactogenesis, skin-to-skin contact and 
rooming-in with the newborn were recommended. 
Discussion 
Before the modernisation and upgrading of the 
concept of postoperative pain management, opioid 
analgesia was one of the key modalities of pain 
management. Modern treatment trends have been 
deliberately introduced to reduce opioid consumption 
and facilitate adaptation to the postcaesarean 
situation. The prevalence of opioid treatment of 
postcaesarean pain has a significant impact on 
postcaesarean nursing activities and breastfeeding. As 
noted by Chao et al. (2019), opioid analgesia causes 
opioid-induced nausea, vomiting, sedation, and a 
higher likelihood of pruritus. Health education and 
nursing interventions encourage skin-to-skin contact 
with the newborn and try to initiate the first attempt 
at breastfeeding as early as possible after caesarean 
section. We found that although all the studies 
included in our review aimed to improve the quality of 
patient care, they mainly focused on meeting physical 
needs rather than psychological support for successful 
adjustment to the early postcaesarean period. In the 
studies by Chang et al., (2022), Chao et al. (2019) and 
O'Connor et al. (2022), mainly physical deviations in 
opioid pain management after caesarean section were 
identified that resulted in nausea, vomiting, sedation, 
pruritus and a higher likelihood of developing delayed 
complications such as fatigue and drowsiness indicated 
by opioids. Loss of sensation and numbness were also 
reported in approximately 72% of cases. 
In most of the populations observed, it was not 
adequately defined whether the pain treatment was 
administered for a first or a repeat caesarean section. 
The results suggest that pain relief after elective 
caesarean section is inadequate with regard to acute 
pain management immediately after caesarean 
section. A more tailored approach may be required 
to optimise pain management after caesarean section. 
Additional strategies to reduce the risks of opioid use 
include multimodal approaches to pain management, 
using a combination of local pain relief techniques 
and systematic analgesics for a synergistic analgesic 
effect. The introduction of the computerised opioid 
bundle was associated with a reduction in the number 
of opioids prescribed and opioid consumption during 
inpatient treatment. The implementation of nursing 
activities influences confidence and self-assurance 
in early adjustment. Willingness to cooperate is 
also mainly related to treatment outcomes in the 
postcaesarean period. Various studies such as 
Bjornstad & Reder (2020), Chang et al. (2022), Chao et 
al. (2019), Fassoulaki et al. (2021), Hooda et al. (2023) 
and Oommen et al. (2021) have also addressed the 
issue of lactogenesis and breastfeeding after caesarean 
section, but have not presented definitive outcomes 
on breastfeeding in the early postpartum period. They 
described first attempts and attempts to establish 
contact with the newborn rather than describing and 
Table 4: Distribution of codes by category
Tabela 4: Razporeditev kod po kategorijah
Categories/Kategoriji Codes/Kode Author/Avtor
Category I – Opioid 
analgesia after caesarean 
section
Low levels of ambulation – inadequate opioid pain 
relief – known side effects – significantly higher VAS 
pain – postoperative analgesic protocols – individualised 
treatment of patients – lack of healthcare promotion – 
affecting early ambulation.
Bjornstad & Reder, 2020; Fassoulaki
et al., 2021; Hooda, 2023;  Landau 
et al, 2021; O'Connor et al, 2022; 
Oommen et al., 2021; Patzkowski et 
al, 2023
Category II – Breastfeeding 
support after induced 
opioid analgesia 
Late response to breastfeeding – exposure to opioids and 
suckling rates – delayed lactogenesis and skin-to-skin – 
bonding strategies – lower spontaneous suckling rates 
– lack of healthcare promotion.
Chang et al., 2022; Chao et al., 2019; 
Fassoulaki et al., 2021; O'Connor et 
al, 2022; Oommen et al., 2021
192 Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
defining support in terms of establishing nursing 
interventions. Dalili et al. (2020), Gianni et al. (2020), 
Kling Oms Lii et al. (2016), and Zanardo et al. (2010) 
report that surgery affects postpartum prolactin levels 
and slows lactation, which may have consequences. 
Zanardo et al. (2010) consider psychophysical and 
emotional support for women breastfeeding after 
a caesarean section to be essential for an effective 
initiation of breastfeeding after a caesarean section. 
Mary et al. (2021) and Wen et al. (2015) state that 
hospitals designated as breastfeeding-friendly, i.e. 
hospitals that offer breastfeeding-related interventions, 
provide women and their newborns with the best 
opportunities and intentions to support breastfeeding 
and promote optimal outcomes. These include 
hospital practices that support breastfeeding intention, 
professional and appropriate support for breastfeeding 
initiation, staff who do not formula feed newborns, 
and community resources that support breastfeeding. 
Dalili et al. (2020) found that among multiparous 
patients, promotion of breastfeeding and non-use 
of formula milk were important hospital practices. 
Among women who had given birth by caesarean 
section, breastfeeding initiation and rates of exclusive 
or any breastfeeding at six months were lower. As 
argued by Hobbs et al. (2016), a professional approach 
to supporting nursing interventions ultimately leads 
to effective breastfeeding.
Our literature review has several advantages. It 
is one of the few reviews that include the results of 
breastfeeding attempts after caesarean section in 
the early postpartum period. Most breastfeeding 
attempts after caesarean section are made in the early 
postpartum period, during hospitalisation, which 
is also a great achievement for the nursing staff. As 
concluded by Mary et al. (2021), developing suitable 
interventions to help more women breastfeed requires 
an understanding of the many factors that influence 
feeding choices. The benefits of our study suggest that 
breastfeeding outcomes after caesarean section are 
based on the doctrine of breastfeeding management 
according to the current standards and quality at a 
global level. Gianni et al. (2020) and Kling Oms Lii et 
al. (2016) agree that there is a notable need to identify 
interventions aimed at establishing and maintaining 
exclusive breastfeeding. Future studies should be 
strengthened by including data on patient-reported 
outcomes and measuring the initiation and duration 
of breastfeeding after caesarean section. 
Despite the strengths of our survey, there are certain 
limitations to its results. The first limitation is the 
inclusion of published literature from 2013 onwards 
due to advances in the field of pain management 
after caesarean section. The second limitation is the 
considerable heterogeneity of the studies included. 
In most cases, the limitations of the databases mainly 
emphasise a more medical approach to breastfeeding 
in terms of lactation. Different approaches, including 
initial and subsequent attempts at breastfeeding and 
meeting the emotional needs of both parties in the 
postcaesarean period tend to fall under the domain of 
nursing. 
Promoting supportive interventions in the antenatal 
and postnatal period has a significant impact on 
breastfeeding in the postcaesarean period. The 
findings define nursing as recognising the patient's 
psychophysiological needs and implementing 
solutions to achieve the set goals, regardless of the 
expected outcome. Hobbs et al. (2016) linked the 
implementation of theoretical knowledge to the 
importance of early skin-to-skin contact. This measure 
certainly helps with the initiation and outcomes of 
breastfeeding following a caesarean section. Hospital 
practices can design precise interventions (timing 
and modality) to facilitate evaluation of the nursing 
interventions implemented. 
Conclusion
This literature review emphasises the urgent need 
for further research, including a more extensive 
follow-up study on the benefits of non-opioid pain 
management and subsequent breastfeeding after 
caesarean section. The review shows a relatively high 
prevalence of adverse effects with opioid analgesia. 
Future studies should aim to increase the efficacy of 
different interventions (combining local pain relief 
techniques) with non-opioid analgesia to achieve a 
synergistic analgesic effect. Counselling by healthcare 
personnel is a key intervention to promote optimal 
breastfeeding practices after caesarean section. 
Promotion of optimal breastfeeding outcomes should 
be ensured across the continuum in different settings. 
Conflict of interest/Nasprotje interesov
The authors declare that no conflicts of interest 
exist./Avtorja izjavljata, da ni nasprotja interesov. 
Funding/Financiranje 
The study received no funding./Raziskava ni bila 
finančno podprta. 
Ethical approval/Etika raziskovanja 
The study required no special authorisation from 
the ethics committee. The study was conducted in 
accordance with the principles of the Helsinki-Tokyo 
Decleration (World Medical Association, 2013) and 
the Code of Ethics for Nurses and Nurse Assistants of 
Slovenia (2024)./Raziskava ni potrebovala posebnega 
dovoljenja komisije za etiko. Raziskava je pripravljena 
v skladu z načeli Helsinško-tokijske dekleracije (World 
Medical Association, 2013) in s Kodeksom etike v 
zdravstveni negi in oskrbi v Sloveniji (2024).
193Višić, U., & Lučovnik, M., (2024)/Obzornik zdravstvene nege, 58(3), pp. 185–195.
Author contribution/Prispevek avtorjev 
The first author, under thementorship ofthe second 
author, prepared the conceptual design of the study, 
conducted a selective literature review, data processing, 
and evaluation and justification of the results. The 
second author participated in the management of 
the content of the theoretical work, confirmed the 
methodology and evaluated the results./Prvi avtor je 
pod mentorstvom drugega avtorja pripravil idejno 
zasnovo, selektivni pregled literature, obdelavo 
podatkov te evalvacijo in utemeljite rezultatov. Soavtor 
je sodeloval pri usmerjanju vsebine teoretičnega 
dela, usmerjal je vsebine teoretičnega dela, potrdil 
metodologijo ter evalviral prikazane rezultate. 
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Cite as/Citirajte kot: 
Višić, U., & Lučovnik, M. (2024). Managing postcaesarean section pain with opioid analgesia and the effect on breastfeeding: A 
literature review. Obzornik zdravstvene nege, 58(3), 185–195. https://doi.org/10.14528/snr.2024.58.3.3256