Following Evidence-Based Recommendations for Perioperative Pain Management after Cesarean Section Is Associated with Better Pain-Related Outcomes: Analysis of Registry Data

Abstract

Women who have had a Cesarean Section (CS) frequently report severe pain and pain-related interference. One reason for insufficient pain treatment might be inconsistent implementation of evidence-based guidelines. We assessed the association between implementing three elements of care recommended by guidelines for postoperative pain management and pain-related patient-reported outcomes (PROs) in women after CS. The analysis relied on an anonymized dataset of women undergoing CS, retrieved from PAIN OUT. PAIN OUT, an international perioperative pain registry, provides clinicians with treatment assessment methodology and tools for patients to assess multi-dimensional pain-related PROs on the first postoperative day. We examined whether the care included [i] regional anesthesia with a neuraxial opioid OR general anesthesia with wound infiltration or a Transvesus Abdominis Plane block; [ii] at least one non-opioid analgesic at the full daily dose; and [iii] pain assessment and recording. Credit for care was given only if all three elements were administered (= “full”); otherwise, it was “incomplete”. A “Pain Composite Score-total” (PCStotal), evaluating outcomes of pain intensity, pain-related interference with function, and side-effects, was the primary endpoint in the total cohort (women receiving GA and/or RA) or a sub-group of women with RA only. Data from 5182 women was analyzed. “Full” care was administered to 20% of women in the total cohort and to 21% in the RA sub-group. In both groups, the PCStotal was significantly lower compared to “incomplete” care (p < 0.001); this was a small-to-moderate effect size. Administering all three elements of care was associated with better pain-related outcomes after CS. These should be straightforward and inexpensive for integration into routine care after CS. However, even in this group, a high proportion of women reported poor outcomes, indicating that additional work needs to be carried out to close the evidence-practice gap so that women who have undergone CS can be comfortable when caring for themselves and their newborn.

Keywords: anti-inflammatory agents non-steroidal; caesarean section; pain; patient reported outcomes; registry.

Figure 1

Study flow chart.

Figure 2

Presents a summary of dichotomized patient-reported outcome measures that form the Pain Composite Score and two additional outcomes. Results are shown separately for women who received “full” care (blue bars) compared to “incomplete” care (yellow bars). The capped lines indicate the 95% confidence intervals. ‘Satisfaction with results of pain care’ and ‘Would have liked more pain treatment’ are not part of the Pain Composite Score but are included here to provide additional information about women’s responses to the surgery and treatment.

Figure 3

Results of the regression analyses. Regression weights (differences in covariate adjusted means), with 95% confidence intervals for each care group The “incomplete” group served as a reference. Significant differences between the “incomplete” group and other groups (intra-operative [green bars], post-operative [petrol bars], and full care [purple bars]) are marked with asterisks. All p-values were corrected using the Bonferroni-Holm procedure. The Pain Composite Score (and sub-scores) were z-standardized before modeling. Thus, mean differences can be interpreted in terms of standard deviations (absolute values ≥ 0.2 for small effect sizes, ≥ 0.5 for medium effect sizes, and ≥ 0.8 for large effect size). The broken vertical line at −0.2 level on the x-axis marks the level of a small effect size. Negative values indicate “better” outcomes compared to the “incomplete” group. Results for the total cohort are shown in (A) and results for women receiving only regional anesthesia in (B). * p < 0.05, ** p < 0.01, *** p < 0.001.