Cesarean Section (CS) is considered to be one of the most common major surgical procedures worldwide [1]. Delivery of effective post-operative analgesia after CS is crucial for many reasons. Firstly, pain is ranked of highest importance in women undergoing cesarean delivery [2]. Secondly, acute post- operative pain may develop into persistent pain, which may result in hampered functional recovery, increase opioid use and increase risk of postpartum depression [3]. Lastly, ensuring adequate post-operative analgesia improves bonding between mother and child [4].

An ideal method of pain relief after CS should be cost effective, safe for mother and baby, have minimal side effects, requires minimal monitoring and use of drugs that are not secreted into breast milk. The mother should not be over sedated or hampered by equipment that prevents her from moving freely and caring of the newborn. Drug availability, maternal health conditions, availability of resources and medical expertise, patient preference and trained support staff also play a role in the choice of analgesia method [5].

Although advances have been made in the understanding of post-operative pain pathophysiology and development of new analgesics and delivery techniques, many patients still suffer from moderate to severe post-operative pain [6]. Results from United State National Survey reported that a patient has 50-70% possibility of having moderate to severe pain after surgery [7]. Many studies have attributed the reason for this issue to the lack of knowledge and poor attitude of patients and health workers towards pain and lack of well-developed pain service [8].

In spite of advances in post-operative pain management, post-operative pain relief and patient satisfaction is still not adequate in some patients due to individual variation and limitation from drug side effects or   techniques   [6]. Using  Visual Analogue Scale (VAS) is essential for assessment of post-operative pain and improves pain service. Regular audits are critical in improving patient care and pain management service. 

There is a study in 2012 on the satisfaction level after CS pain. Unfortunately, this study suffers from several handicaps such as including only elective cases, did not mention if there is any difference in post-operative pain perception with different anesthesia technique and no specified inclusion/ exclusion criteria. We feel that these variables could have a profound effect on the study outcome and reduce its cause-and-effect relationship and needs further evaluation.

The aim of our study was to assess the efficacy of existing pain management strategy used at Khoula hospital for patients undergoing elective and emergency CS under spinal anesthesia. The primary objective of the study was to determine patient satisfaction with their post Cesarean section pain control. The secondary objectives were to determine the effect of pain control on patient’s sleep pattern, mood and daily activity over the first 24 hours.

After approval by Departmental Management Board and verbal informed consent, we enrolled 132 patients ASA I-III scheduled for elective/emergency cesarean section under spinal anesthesia from December 2020 to February 2021 for this prospective observational study. Exclusions criteria were patient refusal, technical difficulty, patients unable to give informed consent due to language barrier, mental retardation or any reduction in own ability to understand or give informed consent, patients with thrombocytopenia less than 50,000/dL or International Normalized Rate (INR) greater than 1.5 and patients with known ischemic heart disease/ heart failure/ valvular heart disease. 

On the day of the procedure, a predesigned proforma was filled that included patient hospital number, age, gravity status, post-operative pain orders as advised by the obstetrician and adequacy of anesthesia counseling offered preoperatively. Anesthetist followed patient in first 24 hours of procedure. Severity of pain, patient satisfaction and complications were noted. Visual Analogue Scale (VAS) was used to assess pain severity (0- no pain, 1-3 mild pain, 4-6 moderate pain and 7-10 severe pain). We also recorded patient’s mood/ sleep pattern, patient activity and common complications like nausea, vomiting, drowsiness, headache, backache, pruritus, sedation, respiratory depression, urinary retention, muscle weakness and inability to walk. One investigator reviewed all patients for postoperative pain relief, social behavior and complications, if any.

The data were entered and analyzed in SPSS program (version 26). In all cases a p-value <0.05 was considered as statistically significant (95% confidence interval). Results are shown as percentage and mean (SD) for normally distributed parameters. Chi-Square test was used for categorical variables.

One hundred and thirty-two patients underwent elective or emergency CS during two months of the study period. Sixty-five patients (49.2%) underwent elective CS while sixty-seven patients (50.8%) underwent emergency CS under spinal anesthesia. Overall, seventy-five patients (56.8%) received pre-operative counseling prior to spinal anesthesia, while fifty-seven (43.2%) did not receive counseling prior to spinal anesthesia. Twenty-two patients were primi-gravida (16.7%), while one hundred and ten were multigravida (83.3%). The mean age of the patients was nearly identical in both the groups. Table 1 showed these patient demographics.

The overall rate of pre-operative counseling prior to spinal anesthesia was 56.8%, the elective CS patients showed a greater percentage of counseling compared to emergency CS (44 patients vs 31 patients, 67.7% vs 46.3%, respectively p = 0.015).

The overall rate of happy mood was 92.4%, sad mood 6.8% and despair mood 0.8%. Emergency CS patients showed marginally better mood compared to elective CS. Only 1 patient reported despair mood, 0% vs 1.5% and p = 0.450). 89.3% patients who were counseled showed happy mood (Table 2).

The overall rate of good and average sleep was nearly identical in patients undergoing elective and emergency CS (p = 0.409). Table 3 showed the relationship between sleep, nature of procedure and counseling.

The overall rate of normal activity was 81.8%, restricted activity was 16.7% and absent activity was 1.5%. Patients with counseling had a higher incidence of normal activity in both the groups (Table 4).

The post-operative analgesia regimen was started and followed up by obstetric team in 100% of patients. Multimodal analgesia was the commonest modality of post-operative pain management used in our hospital for patients undergoing caesarean section. Patients were administered diclofenac (75 mg Intramuscularly (IM)) or paracetamol (1 g Intravenously (IV)) alone or in combination at regular intervals of 6-8 hours. For breakthrough pain, it was largely pethidine that was given in doses ranging from 50-100 mg from once in few patients to three times in the first 24 hours. Tramadol 100 mg was administered by intramuscular route in one patient only as shown in Table 5. Post-operatively, all patients were followed up by obstetric team, which included management of inadequate pain relief. 

Analysis of overall pain score since the time of surgery till 24 hours post-operative showed mild pain 29.5% (VAS 0-3), moderate pain 55.3% (VAS 4-6) and severe pain in 15.15% (VAS 7-10). Patient’s opinion regarding pain management was satisfactory in 84.8% (n-112), while 15.15 % (n-20) were not satisfied. Out of 20 patients not satisfied about pain management, 2 (10%) had severe pain. Upon further look at VAS scores of these patients, we found 2 patients with VAS 10, 2 with VAS 9, 12 with VAS 8 and 4 with VAS 7. 8 patients not satisfied with pain management had restricted activity (6 patients), absent activity (1 patient), average sleep (2 patients), sad mood (2 patients), drowsiness (4 patients), headache (1 patient) and shortness of breath (1 patient).

Table 1: Patients Baseline Characteristics

SD : Standard Deviation, VAS : Verbal Analogue Scale

Table 2: Patients in Relation to Mood, Nature of Procedure and Counseling

n: Number of Patients

Table 3: Patients in regard of sleep, nature of procedure and counseling

n: Number of Patients

Table 4: Patients in Regard of Activity, Nature of Procedure and Counseling

n: Number of Patients

Table 5: Patients Receiving Different Types of Opioids as Intramuscular Injection (n=132)

Table 6: Percentage Of Patients with Different Complications

Table 7: Percentage of Patients with Complications, Nature of Procedure, Counseling and There and Probability

12.8% of patients (n = 17) complained of different complications. Back pain was present in 5.3% (n = 7), drowsiness in 3.8% (n = 5), headache in 1.5% (n = 2), vomiting in 1.5% (n = 2) and shortness of breath in 0.8% (n = 1). This is shown in Table 6. 

Table 7, highlights the nature of procedure, counseling and their probability. Incidence of complication was higher in patients who had undergone elective CS. This could be a chance finding due to small sample size. In total, 17 patients reported one or more complications.

Effective pain management is critical after CS to promote early recovery, care of newborn and return to daily functional activity. Women who undergo CS delivery rank avoidance of pain as their highest priority [2]. Despite advances in post-operative pain management, post-operative pain relief and patient satisfaction is still in-adequate in some patients due to individual variations and limitation from drug side effects or techniques [6].

More than 80% of patients who undergo surgery of diverse nature report moderate, severe or extreme post-operative pain [10]. Many studies have attributed the reason for this issue to the lack of knowledge and poor attitude of patients and health workers towards pain and lack of well-developed pain service [8].

In our study, the incidence of pre-operative counseling prior to spinal anesthesia was significantly higher (p = 0.015) in patients undergoing elective compared to emergency CS. This could be attributed to limited time available for counseling emergency CS patients. In contrast, previous study shows no clear documentation of the incidence of pre-operative counseling [9].

Inadequate post-operative pain management is associated with a broad range of negative consequences, including increased morbidity, impaired physical and psychological function and recovery from surgery, development of chronic post-operative pain, prolonged opioids use and increased medical cost. Our study showed effect of pain on social maternal behavior in regard to mood, sleep and physical activity. Emergency CS patients showed marginally better mood, sleep and activity compared to those undergoing elective CS (p = 0.450, p = 0.409, p = 0.997 respectively). This may be a chance finding. Patients with pre-spinal counseling had better mood, sleep and activity. Previous study did not assess effect of counseling, social maternal behavior on pain perception [9].

Our study shows that the overall incidence of patient satisfaction of pain management is 84.8%. In comparison, a previous study reported a slightly higher incidence of 91.6%. This could be partly attributed to the management of post-operative pain solely by our obstetricians unlike previous study [9]. 

High quality post-operative pain management can be provided by establishing a proper anesthesiology based acute pain service. Anil et al., in 2011 [11], showed that setting up of the acute pain service based on evidence-based approach within available resources and accountability provides a good perioperative pain management and is associated with less mortality and morbidity. The issue of cost, availability of the drugs, regional anesthesia and individual preferences are the main barriers for effective post- operative pain management.

Regional anesthesia provides a good post-operative analgesia. It improves maternal comfort in the post-operative period and is cost effective as compared to general anesthesia provided there is no contradiction. It can be conducted using different techniques like single shot spinal anesthesia, epidural and combined spinal epidural. The administration of epidural or intrathecal opioids is a popular means of intraoperative anesthesia and optimizing post-operative pain [12]. In our hospital the most common method is single shot spinal anesthesia for elective and emergency CS using intrathecal fentanyl and heavy bupivacaine 0.5%. All our patients underwent spinal anesthesia for elective and emergency CS. However, in previous study [9], only elective CS patients were included and either spinal or general anesthesia was administered.

Administration of opioids for analgesia remains the gold standard for post-operative CS pain [13]. The incorporation of non-opioid analgesics in post-operative CS pain regimen helps to decrease incidence of opioid induce side effects. Other modalities including patient controlled intravenous infusions, wound infiltration and transversus abdominis plane and quadratus lumborum blocks have also been reported [13]. Patient Controlled Analgesia (PCA) provides effective, safe and consistent high patient satisfaction. In our hospital, we have limited availability of PCA pumps and hence are not regularly utilized.

In our institution, obstetrician prescribed and nurses administered intravenous paracetamol and intramuscular non-steroid anti-inflammatory drugs at regular interval every 6-8 hr alone or in combination. Opioids were given only for breakthrough pain one to three times a day. Majority of our patients received pethidine in doses ranging from 50-100 mg intramuscularly based on body weight. Intramuscular tramadol was administered to one patient. In an earlier study also intravenous opioids mainly pethidine supplemented anti-inflammatory analgesics as their postoperative pain management regimen [9].

We reviewed different outcome such as effectiveness, safety and tolerability. Effectiveness was assessed based on pain score and patient satisfaction. Satisfaction was assessed by asking patient if they were satisfied or not with the provided pain management strategy. Safety and tolerability were assessed based on side effects occurrence. Safety was assessed by incidence of excessive sedation, hypotension, inability to walk, muscle weakness and respiratory depression. Occurrence of other side effects like back pain, headache, itching, nausea, vomiting was used to assess for tolerability of post-operative pain management regimen.

One patient reported subjective shortness of breath which did not need active management. Otherwise, none of patient had any drop in desaturation, hypotension, muscle weakness or respiratory depression which indicative that our post-operative management is safe. 12.5% of patient experienced some complication such as back pain, drowsiness, headache and vomiting, which responded to simple analgesics and antiemetic and did not require additional treatment, further investigations or prolonged hospitalization.

There are few drawbacks of our study. First, pain perception was different between individuals although they had the same procedure and anesthesia technique. The education level and socio-economic status may have influenced their pain perception. However, level of education and socio-economic status was not included in our study. Future study is needed to assess these factors. Second, we do not have any record whether any of our patients received intra-operative analgesics. Lastly, the study aimed to assess overall effectiveness with current pain management protocol in our hospital for the first 24 hours only.

In conclusion, our post-operative pain management strategy was adequate in term of patient safety. However, relief of pain was suboptimal as pain score was moderate in severity as reported by 55.3% patients highlighting the need for improvement of our acute post CS pain relieving service. We have a few recommendations that include setting a proper acute pain service that is nurse based, anesthesiologist supervised and surgeon cooperated. Adequate training of staff nurse is crucial to assess pain intensity, analgesia administration, monitor efficiency and side effects. Providing brochures on different anesthesia techniques including spinal anesthesia to all patient attended obstetric clinics may decrease pain perception.

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