The most common major surgical procedure performed worldwide is the caesarean section (CS).¹ Effective pain management is a priority for women undergoing this procedure, to reduce the incidence of persistent pain (a risk factor for postpartum depression), as well as optimising maternal-neonatal bonding and the successful establishment of breastfeeding after delivery. The reported incidence of persistent incisional pain or the need for analgesia beyond 6 months after a CS varies markedly, between 1% and 18%.² A prospective observational study at a regional hospital in Cape Town showed that the first 24 h after CS under spinal anaesthesia was the period with the highest incidence of moderate to severe pain (84%).³

Pain is a subjective phenomenon defined by the International Association for the Study of Pain as an ‘unpleasant sensory and emotional experience associated with actual, or resembling that associated with actual, or potential tissue damage’.^3,4,5 As a fifth vital sign, pain should be routinely assessed, managed (if indicated), and re-assessed. Given the subjectivity of pain, the gold standard for its assessment is a validated self-reporting tool. The most commonly used tools for evaluating pain intensity include the Likert-type numeric rating and the visual analogue scales.^3,6,7 Other pain assessment tools available include the Verbal Rating Scale (VRS), McGill Pain Questionnaire,⁸ Wong-Baker Faces Pain rating scale,⁹ and the Pain Quality Assessment Scale.³

The American Pain Society (APS) recommends that planning for post-operative pain management should begin in the preoperative period, and physicians should focus on individualising perioperative pain management using a multimodal approach.¹⁰ The 2016 Guidelines on the Management of Post-operative Pain,¹¹ provide several recommendations relevant to this audit, including that: (1) Clinicians conduct a preoperative evaluation including the assessment of medical and psychiatric comorbidities, concomitant medications, a history of chronic pain, substance abuse, and previous post-operative treatment regimens and responses, to guide perioperative pain management plans; (2) Clinicians adjust pain management plans based on the adequacy of pain relief and the presence of adverse events; (3) Clinicians use a validated assessment tool to track responses to post-operative pain treatments and adjust the treatment plans accordingly; (4) Clinicians offer multimodal analgesia, or the use of a variety of analgesia medications and techniques combined with non-pharmacological interventions, for the treatment of post-operative pain in children and adults.

Multimodal analgesia is the gold standard approach for post-CS analgesia management.¹² One strategy uses neuraxial morphine, scheduled non-steroidal anti-inflammatory drugs (NSAIDs), and paracetamol, and limits systemic opioids to the treatment of breakthrough pain.¹³ The South African Society of Anaesthesiologists (SASA) also recommends multimodal analgesia as the most effective way of alleviating acute pain post CS and that patients be discharged on oral pain medication and/or suppositories.¹⁴ Such analgesia options are appropriate for most parturients, but there are many women whose medical conditions require special consideration. Some conditions that will require alterations to pain management include: preeclampsia, side-effects to previously administered analgesic medications, pre-existing chronic pain, obstructive sleep apnoea, psychiatric comorbidities, and any contraindication to neuraxial anaesthesia.¹⁰

At present, no perioperative pain management protocols appear to be in existence for the management of patients presenting for CS at a regional hospital in South Africa. A protocol is defined as ‘a detailed written set of instructions to guide the care of a patient or to assist the practitioner in the performance of a procedure’.¹⁵ Protocols are useful tools to assist healthcare professionals translate guidelines into practice. Patients presenting to regional hospitals for CS would be expected to have a higher incidence of comorbidities than their counterparts in district-level hospitals, and healthcare professionals at these institutions potentially have access to a wider range of analgesic options. Therefore, regional hospitals’ specific protocols should include guideline-based information on the management of the higher risk patient presenting for CS.

Prior to making recommendations to develop and implement protocols, it is good practice to conduct an audit to describe current clinical practice. Clinical audits are used to improve patient care and evaluate outcomes as part of a continuous cycle essential in evidence-based medicine to optimise and update patient care.¹⁶ This audit aimed to review the folders of patients who underwent CS with particular reference to perioperative pain management guidelines for CS.

This audit was a query review¹⁷ which requires that at least 10% of cases or a minimum of 40 cases be reviewed. This study looked at patients who underwent CS over a 1-year period from 01 December 2017 to 31 November 2018. Approximately 220–250 CS are conducted per month at New Somerset Hospital, or 3000 per year. Therefore, 300 folders (10%) were reviewed. The principal author obtained the information from the theatre register for procedures done during that period and compiled a list of all patients who had undergone a CS using names and folder numbers. The list was then entered into a Microsoft Excel spreadsheet and their folder numbers were randomised using the inbuilt randomisation feature to generate a list of 300 random folders for the review.

This retrospective audit of 300 folders explored the documentation and implementation of pain assessment and management over a period of 1 year in women who had undergone CS at a regional hospital in Cape Town. The typical woman presenting to this hospital for this procedure was 30 years old and presenting for a second or third CS (52.3%). Our folder review showed consistency in the prescription of analgesia postoperatively with the use of more than one form of analgesic, mostly paracetamol and morphine. However, very few patients received NSAIDs, and no supplementary blocks, wound infusion catheters, or PCA devices were employed, such that the principle of multimodal analgesia was not followed. In addition, the prescribed medicines were not reliably administered. The subjective character of pain and the complexity of the feelings evoked by pain make reliable measurement by health professionals a key factor in successful management.¹⁸ However, limited documentation of pain assessment and reassessment was observed.¹⁹

The most used post-operative pain assessment tools are unidimensional and assess only pain intensity, which is just one aspect of the sensory dimension.²⁰ These include the Numerical Rating Scale (NRS) and the VRS. The McGill Pain Questionnaire is one of the most frequently used multidimensional pain assessment tools²¹ and measures aspects of pain including the physical and emotional characteristics.²⁰ In this study, the VRS was the only documented pain assessment method. According to Williamson,²² most patients prefer the VRS because it is easier to use compared to NRS and visual analogue scale (VAS) even though it lacks sensitivity and the data it captures can be misunderstood. On the day of surgery, the VRS was used in 31% of the folders. Since this is a retrospective chart review, it is possible that pain was assessed in more patients but was not documented. However, this lack of documented pain assessment provides a learning point for medical personnel and the development of a protocol. All pain should be regularly monitored and evaluated,²³ management should be documented and followed up. Poor documentation hinders periodic appraisal of clinical practice and has potential medico-legal implications.^3,24

Neuraxial anaesthesia techniques, specifically spinal anaesthesia, was the most commonly used method for CS in this chart review (93.3%). This is a strategy that is being adopted throughout the world as it has been associated with reduced rates of maternal mortality.²⁵ In addition, it has been shown that patients undergoing CS under GA have a higher frequency of pain than patients receiving spinal anaesthesia.^26,27 The most common practice at this hospital appeared to be intrathecal administration of 10 mg hyperbaric bupivacaine plus 10 mg fentanyl. Compared to GA, spinal anaesthesia provides for early assessment and engagement of the patient in the management of pain. In line with the SASA Acute Pain Guidelines,¹⁴ a patient has the right to be believed, to be properly assessed, to access appropriate effective pain management strategies, to be educated on the effective pain management options, and to be cared for by health professionals with training and experience in the management of pain. This approach provides for patient engagement and maintaining patient autonomy.

Multimodal analgesia should include scheduled NSAIDS and paracetamol with opioids reserved for severe breakthrough pain.²⁸ The APS guidelines recommend that pharmacological agents should include a neuraxial opioid in conjunction with non-opioid adjuncts such as scheduled NSAIDs and paracetamol, with additional opioids reserved for severe breakthrough pain.¹⁰ It has been suggested that intrathecal morphine be a gold standard for post-caesarean pain as it provides excellent and prolonged post-operative analgesia.²⁸ This folder review revealed that post-operatively, most patients received an analgesic regimen of mostly morphine and paracetamol. Of concern was a very low prescription rate for NSAIDs (4% – 5%), despite drugs like Ibuprofen being readily available as it is included in on the Standard Treatment Guidelines and Essential Medicines List for South Africa.²⁹ There is documented evidence that NSAIDs have opioid-sparing effects, with a consequent reduction in opioid-related side effects.³⁰ The combination of NSAIDs and morphine has been used extensively, and NSAIDs have been shown to reduce morphine use by 33% – 47%,³¹ when administered either as a single bolus or scheduled medication. Furthermore, the combined use of paracetamol with diclofenac resulted in a 38% reduction in the use of morphine, compared against patients receiving paracetamol only.³² Non-steroidal anti-inflammatory are mild-to-moderate analgesics which, when combined with paracetamol have synergistic anti-inflammatory properties and should form the backbone of pain management in these patients. The very low prescription rate for NSAIDs in this chart review despite numerous guidelines recommending their use is concerning. There is an urgent need to establish the reasons behind this finding.

Other analgesic modalities worth exploring include PCA, TAP blocks and wound infusion catheters. This review observed that none of the patients received PCA or TAP blocks, while only one patient had a wound infusion catheter (with local anaesthetic). This is not unusual in resource-limited settings were lack of adequate staffing, education, and post-operative monitoring facilities limit how much can be offered to a patient.³³ Bilateral TAP blocks and wound infusion catheters,^33,34 have been shown to reduce post-operative opioid consumption and nausea and vomiting, and are associated with lower post-operative pain scores. However, continuous wound infiltration via a catheter requires supplementary equipment (catheters, infusion pumps that may not be readily available),³³ while a portable ultrasound machine is required to safely perform TAP blocks. Disposable PCA devices, on the other hand, have the advantages in that they do not require electricity or battery usage, but remain expensive and not readily available compared with foxed-dose opioid prescriptions, coupled with the high volume of obstetric cases.³³

This review, as with many retrospective chart reviews, was fraught with many challenges. These highlight areas requiring further research, the need for training clinicians in better record keeping, pain evaluation and management, and the need to develop post-CS pain management protocols at this hospital. The South African Acute Pain (SAAP) guidelines recommend constituting a pain team and the need to document and evaluate.¹⁴ At this hospital, the practice appears to be that anaesthetists are only involved in the pain management of post-CS patients admitted to intensive care or high care unit. The development of a protocol with the relatively available drugs will provide the necessary guidance for institutions across the country where constituting such multidisciplinary teams may, for various reasons, be challenging.

Retrospective chart reviews are limited by convenience sampling, the inability to determine causation (only association), reliance upon the accuracy of written record, difficult to control bias and confounders,³⁵ misclassification bias, and temporal relationships often difficult to assess. A future prospective study would be more appropriate for the capture of relevant information in real time including pain assessment tools used, the socioeconomic status of the women, cultural and/or behavioural perspectives on pain and its management, challenges in assessment and recording of pain management by health professionals, and ward follow-up of patients. However, based on these findings in this review, a pain management protocol for CS specific for the type of anaesthesia that has been applied, and which includes scheduled NSAIDs is needed. This protocol should be developed with clear delineation of responsibilities between anaesthetists, obstetricians and nurses, and then implemented ensuing a quality improvement cycle with re-evaluation every 3–6 months to ascertain its utility and effect on patient outcomes.

Pain management is not merely about the reduction of pain; it is also about the optimisation of recovery through reliable and accurate assessment of pain.³ Effective post-operative pain management is imperative in increasing patient safety and satisfaction, and reducing costs to the healthcare services.^20,36 It is concerning that according to this chart review, post-CS patients are not being assessed for pain nor receiving adequate pain management. A significant proportion of the pain interventions appeared to be based on the professional knowledge of the practitioner and are not supported by evidence-based guidelines of pain management.¹¹ There is need for a post-CS nurse-led pain management protocol which specifies: (1) the roles of multidisciplinary team members, (2) appropriate assessment tools for setting and culture, and (3) multimodal analgesia. Hospitals should have pain teams responsible for pain management that conduct regular audits to ensure that protocols for quality improvement are in place, as well as ensure better patient care. Where such teams cannot be constituted for various reasons, practitioners can be guided by a national protocol based on readily available drugs, and safe alternative strategies.