The most common major surgical procedure performed worldwide is the caesarean section (CS). 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 optimise maternal-neonatal bonding and the successful establishment of breastfeeding. Multimodal analgesia is the gold standard for post-CS analgesia. At present, no perioperative pain management protocols could be identified for the management of patients presenting for CS at regional hospitals in South Africa. This audit aimed to review the folders of patients who underwent CS, with particular reference to perioperative pain management guidelines for CS.
A descriptive, retrospective, cross-sectional audit was conducted. Three hundred folders (10% of the annual number of caesarean procedures performed) from New Somerset Hospital, a regional hospital in Cape Town, South Africa were reviewed.
The women were a mean age of 30 years (standard deviation [s.d.]: 6.2). Median gravidity was 3 (interquartile range [IQR]: 2–3) and parity was 1 (IQR: 1–2); 52% had previously undergone a CS. In 93.3% cases, spinal anaesthesia was employed for CS. Pain assessment was poor, with only 55 (18%) patients having their pain assessed on the day of the operation. Analgesia was prescribed in over 98% of the patients, however, medication was only administered as prescribed in 32.6%. Non-steroidal anti-inflammatory drugs (NSAIDs) were prescribed in < 5% of cases. None of the patients received a patient-controlled analgesia (PCA), transversus abdominis plane (TAP) block, or wound infusion catheter as supplementary strategies.
Pain management for post-CS patient at this hospital is lacking. There is the need for the implementation of a structured assessment tool to improve administration of analgesics in these patients. In addition, the reasons for the omission of NSAIDs from the analgesia regimen requires investigation. Hospital requires post-CS pain protocols to guide management especially in resource-limited settings.
The most common major surgical procedure performed worldwide is the caesarean section (CS).
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’.
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.
Multimodal analgesia is the gold standard approach for post-CS analgesia management.
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’.
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.
This audit was a query review
The information obtained from the folders included sociodemographic and health information, management of the CS, and the modalities of post-operative pain assessment and management. The REDCap software (version 3.8.4) data collection tool was used to upload the information, with password protection. A pilot trial of 20 folders was done initially to test the usability of the tool and subsequently discarded. As illustrated in
Flow chart of folder selection process to obtain 300 random folders.
The work presented in this article was granted ethical approval by the University of Cape Town, Faculty of Health Sciences, Human Research Ethics Committee (HREC reference: 703/2018) and the Western Cape Government Health Research Department (reference: WC_201901_008).
As seen in
Sociodemographic and health profile of patients (
Activity | Mean | (s.d.) | Median | range | IQR |
---|---|---|---|---|---|
Age (years) | 29.96 | 6.20 | - | - | - |
Hypertensive disorders of pregnancy | 27 | 9.00 | - | - | - |
Asthma | 12 | 4.00 | - | - | - |
HIV | 53 | 17.70 | - | - | - |
Epilepsy | 4 | 1.30 | - | - | - |
Depression | 3 | 1.00 | - | - | - |
Eczema | 1 | 0.33 | - | - | - |
Syphilis | 1 | 0.33 | - | - | - |
Avascular necrosis of the hip | 1 | 0.33 | - | - | - |
Gravidity | - | - | 3 | 1–9 | 2–3 |
Parity | - | - | 1 | 0–6 | 1–2 |
Previously had a CS | - | - | - | - | - |
Median number of CS ( |
157 | 52.3 | 1 | 1–3 | 1–2 |
Previously experienced a miscarriage | 90 | 30.00 | - | - | - |
Median number of miscarriages ( |
- | - | 1 | 1–6 | 1–1 |
s.d., standard deviation; IQR, interquartile range; CS, caesarean section; HIV, human immunodeficiency virus.
Spinal anaesthesia was used in 93.3% of the patients for the management of CS. Based on the folder review, common practice at this hospital during the study period was the intrathecal administration of 10 mg of 0.5% hyperbaric plus 10 mg of fentanyl. This was sometimes supplemented with one or more of the following agents: intravenous (IV) paracetamol, ketamine, and fentanyl. Patients who required general anaesthesia (GA) received a combination of morphine, IV paracetamol and fentanyl for pain relief. Other analgesic agents included ketamine, alfentanil and local infiltration with plain bupivacaine. However, only one patient received a wound infusion catheter while none had transversus abdominis plane (TAP) blocks employed. Details of intraoperative management appear in
Management of current caesarean section (
Activity | % | |
---|---|---|
Foetal | 103 | 34.33 |
Foetal and maternal | 77 | 25.67 |
Maternal | 120 | 40.00 |
General | 20 | 6.70 |
Spinal | 280 | 93.30 |
IV/IM morphine | 16 | 80.00 |
IV paracetamol | 17 | 85.00 |
IV ketamine | 3 | 15.00 |
IV fentanyl | 10 | 50.00 |
IV NSAIDs | 0 | 0.00 |
IV alfentanil | 7 | 35.00 |
Local anaesthesia infiltration (0.25% Plain Bupivacaine) | 5 | 25.00 |
Wound infusion catheter | 0 | 0.00 |
Peripheral nerve block | 0 | 0.00 |
IV/IM morphine | 6 | 2.14 |
IV paracetamol | 20 | 7.14 |
IV ketamine | 13 | 4.60 |
IV fentanyl | 11 | 3.92 |
IV NSAIDs | 4 | 1.42 |
IV alfentanil | 0 | 0.00 |
Local anaesthesia infiltration (0.25% Plain Bupivacaine) | 16 | 5.71 |
Wound infusion catheter | 1 | 0.36 |
Peripheral nerve block | 0 | 0.00 |
IM, intramuscular; IV, intravenous; NSAIDS, non-steroidal anti-inflammatory drugs; CS, caesarean section; GA, general anaesthesia.
The most common indications for CS were maternal (40.0%), namely previous CS, declining vaginal birth after CS (VBAC), and hypertensive disorders of pregnancy, especially preeclampsia. Other indications included: foetal (34.3%) and both foetal and maternal (25.6%). Of the 300 live births (280 spinal, 20 GA), 288 of the neonates went straight to their mothers following delivery, and 12 required Neonatal Intensive Care Unit (NICU) care (11 GA, 1 spinal anaesthetic).
Spinal anaesthesia was the most common modality used for the management of CS (93.3%). This technique should allow the opportunity for earlier and better establishment of pain control in the post-operative recovery area, as patients are wide-awake immediately after their procedures and regression of the spinal block can be assessed. A pain assessment was recorded as having been conducted based on the presence of any form of documented pain assessment in either the doctors’ or nurses’ notes, for example, ‘mild pain’ or ‘patient complaining of pain’. The VRS was the only scoring system used for the assessment of pain during the period under review. The rate of documented follow-up of the response to pain management was low, with 13 of the 55 patients who had their pain assessed on the day of surgery (day 1), having their pain reassessed after administration of analgesia (24%) (
Frequency and method of pain assessment and reassessment.
Activity | Day 1 |
Day 2 |
Day 3 |
|||
---|---|---|---|---|---|---|
% | % | % | ||||
55 | 18 | 33 | 11 | 30 | 10 | |
VRS | 17 | 31 | 26 | 79 | 21 | 70 |
Patient complained of pain | 38 | 69 | 7 | 21 | 9 | 30 |
13 | 24 | 21 | 64 | 13 | 43 | |
Consistent reassessment | 2 | 0 | 3 | 0 | 2 | 0 |
Intermittent reassessment | 11 | 0 | 18 | 0 | 11 | 0 |
VRS, Verbal Rating Scale.
Method of assessment day 1:
In the chart review, data was extracted on what analgesics were prescribed, and what analgesics were administered based on documented evidence of administration. Analgesia was prescribed in over 98% of the patients, with the medication administered as prescribed in 32.6% of patients on the first day and 37% on the second day (
Prescription and administration of analgesia.
Activity | Day 1 |
Day 2 |
Day 3 |
|||
---|---|---|---|---|---|---|
% | % | % | ||||
299 | 99.67 | 300 | 100.00 | 296 | 98.67 | |
Yes | 98 | 32.67 | 113 | 37.67 | 98 | 32.67 |
No | 4 | 1.34 | 1 | 0.33 | 4 | 1.34 |
Intermittent | 193 | 64.34 | 186 | 62.00 | 190 | 63.33 |
Declined | 4 | 1.34 | - | - | 4 | 1.34 |
Medicine not obtained from pharmacy | 1 | 0.33 | - | - | 1 | 0.33 |
Oral paracetamol | 299 | 99.67 | 298 | 99.33 | 293 | 97.67 |
Oral NSAID | 5 | 1.67 | 4 | 1.33 | 4 | 1.33 |
IV/IM morphine | 246 | 82.00 | 184 | 61.33 | 168 | 56.00 |
PCA | 0 | 0.00 | 0 | 0.00 | 0 | 0.00 |
IV/IM pethidine | 0 | 0.00 | 0 | 0.00 | 0 | 0.00 |
IV, intravenous; NSAID, non-steroidal anti-inflammatory drug; IV/IM, intravenous/intramuscular; PCA, patient-controlled analgesia.
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.
The most used post-operative pain assessment tools are unidimensional and assess only pain intensity, which is just one aspect of the sensory dimension.
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.
Multimodal analgesia should include scheduled NSAIDS and paracetamol with opioids reserved for severe breakthrough pain.
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.
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.
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,
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.
The authors would like to thank Margot Flint, Agya Prempeh, and Lizel Loo for the assistance rendered during data collection, analysis and preparation of this document.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
All authors contributed to the design of this study, analysis and interpretation of the data. E.F.M. and R.P. drafted the original manuscript, while D.v.D. provided critical revision.
This review was not supported by any grants or other funding.
The data that support the findings of this study are not publicly available due to ethical restrictions.
The views expressed in this article are those of the authors and not an official position of the New Somerset Hospital or the University of Cape Town.