Postoperative Pain Management after Caesarean Section
With the rising number of cesarean deliveries, postoperative pain management poses as a major clinical challenge. Various methods of pain management have been introduced in an effort to relief cesarean patient’s pain due to factors related to related possible complications as well as for neonatal and maternal wellbeing. Despite the advances made in development of new delivery and analgesic techniques and on pathophysiology of postoperative pain, most patients still suffer from moderate to severe postoperative pain. The United States surveys indicate that 50-70% of women have a high likelihood of experiencing moderate to severe pain after a C-section (Gilmour, 2005). The high risk factor is associated with poor pain management by clinical personnel as well as negative attitude towards pain by the patients. Postoperative pain presents unique risks as opposed to other surgeries as there is increased risk of thromboembolic events which may cause immobility. This is caused by excessive sedation from Opiods or inadequate pain control. The need for adequate pain control should also be emphasized as to enable the mother to be energetic for the care of her new born. Surgical pain is the result of inflammation caused by tissue trauma or direct tissue injury (Carvalho, et al 2011). Tissue trauma can result from dissection, surgical incision and burns while nerve injury maybe the result of nerve stretching, compression or transection. Pain in felt via the afferent pain pathway and can be altered through several pharmacologic agents. The Visual analogue scale (VAS) is used to assess and manage pain in the postoperative period. The objective of this paper is to provide evidence based review of various methods that can be used to relieve off postoperative pain by understanding the causes of the pain and postpartum pain management (Tagaloa, Butwick and Carcalho, 2009 p.1).
Pain is defined as a bio psychosocial and complex phenomenon occurring amongst a diverse group of patients including expectant mothers. Pain is a sensation that serves to protect the body from further damage. If postoperative pain is poorly managed, it could lead to complications resulting in reduced quality of life for the patient, physical and emotional stress. It may also cause hypoxia, hypothermia, and delay in wound healing besides predisposing the wound to infection. According to the Joint Commission on Accreditation of healthcare Organizations (2001) commissioned pain management standards in which the body emphasized the need for appropriate care and management of pain on the basis that it is a patient’s right. Reports by the World Health Organization in 2003 reported that pain remains the leading cause of disease burden and death in the world. While childbearing is supposed to be a pleasant time, postoperative pain may make the event unpleasant. Few studies have been conducted in recent years to investigate the different methods of pain relief in CS patients. According to JCAHO the team responding to acute pain in patients should include nurses, surgeons, physiotherapist and anesthesiologist. The process by which pain is conveyed is known as nociception; a process that begins with the activity of neurotransmitters leading to the production of agents such as potassium, bradykinin and substance P. From the point of injury three phases of the pain process ensue: transduction, transmission and perception (Abdo, 2008; JCAHO, 2001).
Instruments of pain assessment
Several assessment instruments have been developed due to the unique nature of pain. One such instrument is the visual analogue scale. The horizontal version of the scale is 10cm long where the left hand anchor represents “no pain” while the right anchor represents “intense pain.” This is an ordinal scale with a sample pain intensity scale of between 1 and 10, “no pain” to “worst pain possible.” The second version is a face pain scale which contains six facial expressions depicting the level of distress due to pain. The scale is administered to a patient where one is asked to point the face that bests describe the intensity of their pain (Ismail, Shahzad and Shafiq, 2012).
According to Diane Gilmour, 2005, in his production of Perioperative care, effective pain management begins with pre-empting pain. Although pain is subjective, it is crucial to accurately assess its severity to each patient. This may be hampered if the patient is drowsy, crying or confused. Recovery nurses should then resort to non-verbal cues such as the degree of restlessness or hyperventilation (Avidan, 2003). Effective pain management also involves prior discussions on the possibility of pain after surgery and the duration and likely intensity of the pain. According Wee and Reynolds (2005), pain may be reduced based on the patient’s perception and expectation of the pain. While there are pharmacological methods of dealing with the pain, investigations have revealed that other non-pharmacological therapies are available such as foot and hand massaging among others (Gilmour, 2005). Analgesics are administered through various routes such as injection, intravenous patient controlled analgesia (PCA), intravenous bolus or rectally. PCA is common with clinicians as it gives the patient control over the pain (Gilmour, 2005).
Pain management modalities
A systematic search of various journals such as Nurse Media, Journal of anesthesiology clinical pharmacology, medical publications such as the National Guideline clearing house, books and online sources has been conducted on various pain modalities. There has been considerable evolution of pain management after a cesarean section. Many of the institutions which conduct intravenous PCA and neuraxial opioids have shifted away from opioids based therapies to multimodal approaches. A multimodal approach involves the use of opioids based regimen and PCA in combination with other classes of analgesic drugs (Tagaloa, Butwick & Carcalho, 2009 p.1). A multimodal approach reduces the side effects associated with one class of analgesics due to the fact that smaller doses of each drug are administered. This approach also synergized reduction of pain. However, the transition stage by the patient from the high potent opioids dependency into oral analgesics complicates pain relief strategies despite the advances (Jacques, 2009; Tagaloa, Butwick & Carcalho, 2009 p.1). All of these medications have life threatening side effects that include respiratory complication, nausea and vomiting, urinary complications that decrease urinary output, constipation and hypertension. The nurse should look out for these side effects in patients and advance non-pharmacological therapies (Carvalho, Stetka and Sullivan 2011). Complimentary therapies such as foot and hand massages, music and guided imagery can be applied (Good 2001 p. 61 -70; Khoshtarash, 2012). The non-pharmacological therapies can be conducted independently by the nurse without the need to consult.
- Nonsteroidal Anti-inflammatory Drugs (NSAIDS)
NSAIDS work by inhibiting cyclo-oxygenase (COX). This is an enzyme that regulates the production of Prostagladin which results from inflammation or trauma on tissue. COX is of two types: COX-1 which is involved in causing prostaglandin formation (Kogler, Bandic et al. 2009) . Prostaglandin maintains physiologic functions of platelet formation and increasing gastric mucosal blood flow. Intravenous administration of these drugs starts 30-60 minutes before the estimated end of the C-section. It is highly dangerous to administer intramuscular analgesic as a post-operative measure due to the pain caused by the injection as well as the variability of the concentration level of serum drug. NSAIDS decrease the need for the administration of opioids (Jacques, 2009 p.1)
- Opioids
These are safe and used as a first line postoperative treatment of acute pain. These can be administered orally, intravenously, rectally, through transdermal, intraspinal and intranasal routes. The choice of the route of administration is unique to each patient (Jacques, 2009 p.1). Methadone is one of the most commonly opioids to be administered due to its analgesic properties. It has a long plasma half-life and can be used on hospitalized patients as it is considered relatively safe (Daesh, Ghaedi, and Jabalameli. 2012 p. 143-7). The use of opioids should anticipate side effects with the key principle for effectiveness being achieving a titration of pain relief and reducing its effects. The neurological and behavioral effects on the newborn and ease of elimination from the body should be considered before administration of opioids (National Guidance Clearinghouse, 2013; Daesh, Ghaedi, and Jabalameli. 2012 p. 143-7; NICE). Patient controlled Analgesia. PCAs are used to manage chronic pain while allowing the patient to control the administration of their own medication based on predetermined limits. This approach can be used with opioids as well as Oral Analgesics for effective pain relief. Systematic intravenous administration of PCAs improves patient satisfaction while reducing chances of respiratory complication.
- Epidural analgesia
Neural stimuli and activation of the nervous system releases endocrine-metabolic responses. Regional continuous techniques lead to reduction of surgical stress. Epidural analgesia such as patient controlled epidural analgesia (PCEA), relieve postoperative pain excellently while reducing the need for use of opioids. This intervention is common as it permits individualization of medication; it decreases the use of drugs while providing greatest patient satisfaction (National Guideline clearinghouse, 2013 p.1)
- Paracetamol can be singly used to alleviate mild pains. Its use in pain management reduces opioids consumption.
- Metamizole is also used for mild pain and renal colic though it is prohibited in most European countries and in the USA; it continues to be used in other countries. Prolonged use of the drug should be avoided.
In recent years, there have been studies into complementary therapies of pain management that include relaxation, music and reflexology therapies. Particularly, foot and hand massage is used an alternative pain relief therapy by encouraging relaxation, promoting sleep, reduces swelling and increases oxygen circulation in the blood.
According to Wang and Keck 2004, Classical massage techniques involve effleurage, pertrissage, friction and kneading applied to the feet and hands of the patient. Effleurage refers to a gliding manipulation of superficial tissue by spreading lubricant and warming the surface layer of the tissue. Stroking is then done with the effect on easy blood circulation to the heart and to the skin. Skin temperature increases and causes the subcutaneous tissues to be stretched thus preventing formation of fibrosis. It also stimulates the flow of lymph liquid hence enhancing drainage of waste products (Abdo, 2008). Secondly, petrissage generally includes kneading, skin rolling, compression, wringing and squeezing
This technique uses finger to make circles on the patient’s hands. The message should be conducted for at least 5 minutes on each hand and leg while making sure to avoid catheter areas. The pillow support ought to be removed to aid in relaxation. Similar research interventions have been conducted by (Degirmen et al, 2010 and McDonald, Mitchell and Kreutz 2012); with the common finding that foot and hand massage and relaxation lead to the reduction in the intensity of patients enrolled in their studies.
Mechanism of foot massage on acute postoperative pain
Postoperative pain results from the release of chemical mediators such as histamine and bradykinin cytokines among others. The pain impulses are transmitted through A-Delta and C nerve fibers and eventually activate the T-cells. Foot massage activates primary afferents through the stimulation of cutaneous mechanoreceptors. Afferents releases endorphins which serve to inhibit the transmission of neurotransmitters. Massage also causes second transmission neurons to be blocked thus preventing noceptive information reaching consciousness. The pain is the result of impulse transmission from the small and large diameter nerve fibers. When massage is applied the tactile stimulation produced moves very fast through the large diameter fibers. This is deemed a race with the brain as the fibers carry a faster signal. Pain sensations to the brain are blocked since massage sensation have already closed the gate (Degirmen et al, 2010 p. 41 and McDonald, Mitchell and Kreutz 2012 p. 23, and National Guideline Clearinghouse, 2013). This is the gate theory.
According to the review on literature and evidences, postoperative pain following a cesarean section remains an unresolved consequence for clinical practitioners. Postoperative pain may adversely affect the wellbeing of the newborn and the mother. To the mother, it may result in respiratory complications, ambulation impairment, thromboembolism and atelectasis. It may also affect the newborn’s feeding. In this study we have examined various pain management strategies for cesarean recovering patients. The role of nurses is to ensure control and relief of acute postoperative pain through pharmacological and non-pharmacological interventions. The use of oral opioids in pain management is common in the United States and European countries. PCAs are also common among practitioners as it does not use injections and can be quickly administered without delay. Non-pharmacological interventions have also been seen to help in relieving pain in patients. Massages, music and other mind-body techniques are effective in pain management. Ongoing monitoring and assessment of pain relief efficacy evidenced by the patient’s ability to take deep breaths, feel less stressed or anxious, stand and walk (Gilmour, 2005 p. 12).
References
Abdo, R 2008, Factors affecting pain intensity post cesarean section in Government Hospitals in the West Bank-Palestine, An-Najah National University, Palestine.
Carvalho, B, Stetka, B & Sullivan 2011, A proven Approach to reduce Post cesarean Pain, Retrieved from <http://www.medscape.com/viewarticle/736231>
Daesh, S A, Ghaedi, S & Jabalameli, M 2012, Pain relief after cesarean section: Oral Methadone vs. Intramuscular pethidine, Med science 2012 17(2).
Degirmen, N, Ozerdogan, N, Sayiner, D, Kosgeroglu, N & Ayranci, U 2010, Effectiveness of foot and hand massage in post cesarean pain control in a group of Turkish pregnant women, Applied Nursing Research, 23, 153-158.
Gilmour, D 2005, The basis of surgical care: Perioperative care
Good, M, Anderson, C G, Hicks, S M, & Makii, M 2002, Relaxation and music after gynecologic surgery, Journal Pain Management Nursing, 3.
Ismail S, Shahzad, K & Shafiq, F 2012, Observational study to assess the effectiveness of postoperative pain management of patients undergoing elective cesarean section, J Anaesthesiol Clin Pharmacol vol 28(1).
Jacques, D 2009, Impact of opioids rescue medication for breakthrough pain on the efficacy and tolerability of long acting opioids in patients with chronic non-malignant pain, British journal of Anaesthesia.
Joint Commission on Accreditation of healthcare Organizations (JCAHO) 2001, Facts about Pain Management, The Joint Commission.
Kogler, M V, Bandic, D et al. 2009, Effect of postoperative pain therapy on surgical outcome, University Hospital Center Zagreb, Croatia.
Khoshtarash, M, Ghanbari, A, Reza, M, Kazemnejhad, E, Rezasoltani, P 2012, Effects of foot reflexology on pain and physiological parameters after cesarean section. A Koomesh Journal, 14(1).
McDonald, R, Mitchell, L & Kreutz, G 2012, Music Health and Wellbeing, Oxford University Press, Oxford.
National Guideline Clearinghouse 2013, Postoperative pain management, In: Guidelines on pain management, Retrieved from <http://www.guideline.gov/content.aspx?id=23897>
Wee, M Y K, Brown, H Reynolds, F 2005, The National Institute of Clinical Excellence (NICE) guidelines for cesarean sections: implications for the anaesthetists. International Journal of Obstetric Anaethesia 14 (147-158).
Tagaloa, A, Butwick, A & Carcalho, 2009, A survey of Perioperative and postoperative anaesthetic practices for cesarean delivery, Anaesthesiology research and practice, Retrieved from http://www.hindawi.com/journals/arp/2009/510642/
