Short Report| Volume 52, 103592, November 2022

Download started.


Respiratory depression after administration of single-dose neuraxial morphine for post-cesarean delivery analgesia: a retrospective cohort study

Published:August 24, 2022DOI:


      • Neuraxial morphine is a cornerstone of post-cesarean analgesia.
      • Significant respiratory depression after low- and high-dose morphine is rare.
      • Monitoring for respiratory depression may interfere with maternal-baby bonding.
      • Consideration of relaxation of monitoring guidelines may be warranted.



      Neuraxial administration of long-acting opioid is the “gold standard” for the management of postoperative pain following cesarean delivery. Respiratory depression, however, remains a concerning complication.


      This retrospective single-center study of 4963 patients evaluated the frequency of respiratory depression after neuraxial morphine administration in a post-cesarean delivery population. The spinal dose of morphine varied from 100 to 450 µg intrathecally, and from 3 to 5 mg epidurally. The primary outcome was the initiation of a Rapid Response Team (RRT) event for respiratory failure due to neuraxial opioid in the 24 h following morphine administration. Secondary outcomes studied included oxygen desaturation events (SpO2 <90%), initiation of oxygen therapy and naloxone administration.


      There were no respiratory RRT events within the study period (95% confidence interval [CI] 0 to 7 per 10 000). There were no desaturation events recorded and no patients received supplemental oxygen therapy or naloxone (95% CI 0 to 7 per 10 000).


      Clinically significant respiratory depression is rare among patients receiving neuraxial morphine for post-cesarean delivery analgesia.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to International Journal of Obstetric Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fuller J.G.
        • McMorland G.H.
        • Douglas M.J.
        • Palmer L.
        Epidural morphine for analgesia after caesarean section: a report of 4880 patients.
        Can J Anaesth. 1990; 37: 636-640
        • Sharawi N.
        • Carvalho B.
        • Habib A.S.
        • Blake L.
        • Mhyre J.M.
        • Sultan P.
        A systematic review evaluating neuraxial morphine and diamorphine-associated respiratory depression after cesarean delivery.
        Anesth Analg. 2018; 127: 1385-1395
        • Weiniger C.F.
        • Akdagli S.
        • Turvall E.
        • Deutsch L.
        • Carvalho B.
        Prospective observational investigation of capnography and pulse oximetry monitoring after cesarean delivery with intrathecal morphine.
        Anesth Analg. 2019; 128: 513-522
        • Wong C.A.
        • Dyer R.A.
        Enough but not too much: monitoring for neuraxial morphine-associated respiratory depression in obstetric patients.
        Anesth Analg. 2019; 129: 330-332
        • Crowgey T.R.
        • Dominguez J.E.
        • Peterson-Layne C.
        • Allen T.K.
        • Muir H.A.
        • Habib A.S.
        A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia.
        Anesth Analg. 2013; 117: 1368-1370
        • Kato R.
        • Shimamoto H.
        • Terui K.
        • Yokota K.
        • Miyao H.
        Delayed respiratory depression associated with 0.15 mg intrathecal morphine for cesarean section: a review of,cases.
        J Anesth. 1915; 2008: 112-116
        • Ladha K.S.
        • Kato R.
        • Tsen L.C.
        • Bateman B.T.
        • Okutomi T.
        A prospective study of post-cesarean delivery hypoxia after spinal anesthesia with intrathecal morphine 150 mcg.
        Int J Obstet Anesth. 2017; 32: 48-53
        • Bauchat J.R.
        • Weiniger C.F.
        • Sultan P.
        • et al.
        Society for Obstetric Anesthesia and Perinatology Consensus Statement: monitoring recommendations for prevention and detection of respiratory depression associated with administration of neuraxial morphine for cesarean delivery analgesia.
        Anesth Analg. 2019; 129: 458-474
        • Ramsay M.A.
        • Savege T.M.
        • Simpson B.R.
        • Goodwin R.
        Controlled sedation with alphaxalone-alphadolone.
        Br Med J. 1974; 2: 656-659
      1. WHO Consultation on Obesity (1997: Geneva, Switzerland), World Health Organization. Division of Noncommunicable Diseases & World Health Organization. Programme of Nutrition, Family and Reproductive Health. (1998). Obesity: preventing and managing the global epidemic: report of a WHO Consultation on Obesity, Geneva, 3-5 June 1997. World Health Organization. Available at: Accessed July 25, 2022.

        • Terada S.
        • Irikoma S.
        • Yamashita A.
        • Murakoshi T.
        Incidence of respiratory depression after epidural administration of morphine for cesarean delivery: findings using a continuous respiratory rate monitoring system.
        Int J Obstet Anesth. 2019; 38: 32-36
        • Bauchat J.R.
        • McCarthy R.
        • Fitzgerald P.
        • Kolb S.
        • Wong C.A.
        Transcutaneous carbon dioxide measurements in women receiving intrathecal morphine for cesarean delivery: a prospective observational study.
        Anesth Analg. 2017; 124: 872-878
        • Ende H.B.
        • Dwan R.L.
        • Freundlich R.E.
        • et al.
        Quantifying the incidence of clinically significant respiratory depression in women with and without obesity class III receiving neuraxial morphine for post-cesarean analgesia: a retrospective cohort study.
        Int J Obstet Anesth. 2021; 47: 103187
        • Abouleish E.
        • Rawal N.
        • Rashad M.N.
        The addition of 0.2 mg subarachnoid morphine to hyperbaric bupivacaine for cesarean delivery: a prospective study of 856 cases.
        Reg Anesth. 1991; 16: 137-140
        • Sultan P.
        • Gutierrez M.C.
        • Carvalho B.
        Neuraxial morphine and respiratory depression: finding the right balance.
        Drugs. 2011; 71: 1807-1819
        • Bornstein E.
        • Husk G.
        • Lenchner E.
        • et al.
        Implementation of a standardized post-cesarean delivery order set with multimodal combination analgesia reduces inpatient opioid usage.
        J Clin Med. 2020; 10
        • Herbert K.A.
        • Yurashevich M.
        • Fuller M.
        • Pedro C.D.
        • Habib A.S.
        Impact of a multimodal analgesic protocol modification on opioid consumption after cesarean delivery: a retrospective cohort study.
        J Matern Fetal Neonatal Med. 2021; : 1-7