Management and impacts of acute post-cesarean section pain in a usual-risk maternity hospital: cross-sectional study

Pereira, Milena Santos; Silva, Daniele Oliveira; Carvalho, Fábia Laís Dias; Teles, Juliana Santos; Santos, Guilherme Reis de Santana; Ribeiro, Caíque Jordan Nunes

doi:10.63231/2595-0118.20250013-pt

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ORIGINAL ARTICLE • Brazilian Journal of Pain 8 • 2025 • https://doi.org/10.63231/2595-0118.20250013-en linkcopy

Management and impacts of acute post-cesarean section pain in a usual-risk maternity hospital: cross-sectional study

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND AND OBJECTIVES Pain management during labor has been extensively explored, but few studies investigate acute postoperative pain following the cesarean section (APPC). The objective of this study was to analyze the management and impacts of APPC among postpartum women in the immediate postoperative period.

METHODS This was a cross-sectional and analytical study, which employed questionnaires and documentary analysis. It was conducted between March and July 2023 in a philanthropic maternity hospital for low-risk pregnancies in Northeast Brazil, affiliated with the Brazilian Public Health System (SUS), and included postpartum women in the immediate postoperative period of cesarean section. This study outcomes were inadequate management of APPC and its impacts on the well-being and activities of postpartum women. Chi-square, Fisher's Exact tests, MANOVA, Friedman's ANOVA, Bonferroni post-hoc test, and Poisson regression were used for data analysis.

RESULTS A total of 321 puerperal women were included, 232 of whom (72.3%) reported APPC. Both the prevalence of moderate to severe APPC and analgesic inadequacy was 38% (n=122). Painful experience in previous deliveries was independently associated with an 88% higher prevalence of analgesic inadequacy of the APPC (95% CI: 1.32-2.69; p=0.001), when adjusted for the age of the puerperae. Moderate to severe pain had an impact on activities such as sitting/standing, dressing, bathing, intimate hygiene, walking, breastfeeding, sleep, mood and the ability to enjoy life.

CONCLUSION Inadequate management of APPC was associated with previous painful childbirth experience and negatively impacted the well-being and daily activities of postpartum women.

Keywords:
Caesarean section; Postoperative pain; Obstetric nursing; Pain management

HIGHLIGHTS

Analgesic inadequacy for acute post-cesarean pain (APPC) can impact surgical recovery

The adequacy of pharmacological analgesia was estimated using the Pain Management Index (PMI)

Moderate to severe APPC had a negative impact on the puerperal women's activities of daily living

Previous pain experience was associated with the analgesic inadequacy of APPC

GRAPHICAL ABSTRACT

Scores	Analgesic power	Pain intensity
0	Absence of analgesic drug	Painless (VNS = 0)
1	Simple analgesic or non-steroidal anti-inflammatory drug	Mild pain (VNS ≤ 4)
2	Weak opioids (codeine, tramadol)	Moderate pain (5 ≤ VNS ≤ 7)
3	Strong opioids (morphine, meperidine)	Severe pain (VNS ≥ 8)

Variables		Analgesic inadequacy				Total (n=321)		PR (CI 95%)	p-value
		Yes [PMI < 0] (n=122)		No [PMI ≥ 0] (n=199)		Total (n=321)
		n	%	n	%	n	%
City of origin	Lagarto^[ref]	40	55.6	50	44.4	90	28.0	0.80 (0.60-1.07)	0.138
City of origin	Other	82	35.5	149	64.5	231	72.0	0.80 (0.60-1.07)	0.138
Age	< 35 years^[ref]	98	37.8	161	62.2	259	80.7	1.02 (0.72-1.45)	0.899
Age	≥ 35 years	24	38.7	38	61.3	62	19.3	1.02 (0.72-1.45)	0.899
Skin color	White^[ref]	19	50.0	19	50.0	38	11.8	1.37 (0.97-1.96)	0.105
Skin color	Non-white	103	36.4	180	63.6	283	88.2	1.37 (0.97-1.96)	0.105
Marital status	With a partner^[ref]	96	37.8	158	62.2	254	79.1	0.97 (0.69-1.37)	0.879
Marital status	Without a partner	26	38.8	41	61.2	67	20.9	0.97 (0.69-1.37)	0.879
Work	Yes^[ref]	25	37.3	42	67.2	67	20.9	1.02 (0.72-1.45)	0.896
Work	No	97	38.2	157	61.8	254	79.1	1.02 (0.72-1.45)	0.896
Government aid	Yes^[ref]	71	37.8	117	62.2	188	58.6	1.01 (0.77-1.35)	0.916
Government aid	No	51	38.3	82	61.7	133	41.4	1.01 (0.77-1.35)	0.916
Number of people in the household	< 4 people^[ref]	73	34.6	138	65.4	211	65.7	1.29 (0.97-1.70)	0.081
Number of people in the household	≥ 4 people	49	44.5	61	55.5	110	34.3	1.29 (0.97-1.70)	0.081
Area of residence	Countryside^[ref]	55	40.1	82	59.9	137	42.7	0.91 (0.69-1.20)	0.496
Area of residence	Urban	67	36.4	117	63.6	184	57.3	0.91 (0.69-1.20)	0.496
Type of home	Owned^[ref]	83	37.7	137	62.3	220	68.5	1.02 (0.76-1.38)	0.879
Type of home	Rented	39	38.6	62	61.4	101	31.5	1.02 (0.76-1.38)	0.879
Schooling (years of study)	< 12 years	49	34.8	92	65.2	141	43.9	0.86 (0.64-1.14)	0.288
Schooling (years of study)	≥ 12 years^[ref]	73	40.6	107	59.4	180	56.1	0.86 (0.64-1.14)	0.288
Access to health services	Public-dependent	96	39.5	147	60.5	243	75.7	1.18 (0.83-1.68)	0.328
Access to health services	Supplement/private^[ref]	26	33.3	52	66.7	78	24.3	1.18 (0.83-1.68)	0.328
Comorbidity	Yes	34	47.2	38	52.8	72	22.4	1.34 (0.99-1.80)	0.067
Comorbidity	No^[ref]	88	35.3	161	64.7	249	77.6	1.34 (0.99-1.80)	0.067
Previous abdominal surgery	Yes	4	28.6	10	71.4	14	4.4	0.74 (0.32-1.72)	0.457*
Previous abdominal surgery	No^[ref]	118	38.4	189	61.6	307	95.6	0.74 (0.32-1.72)	0.457*
Previous gynecological surgery	Yes	19	52.8	17	47.2	36	11.2	1.46 (1.03-2.06)	0.053
Previous gynecological surgery	No^[ref]	103	36.1	182	63.9	285	88.8	1.46 (1.03-2.06)	0.053
Number of pregnancies	1	50	35.5	91	64.5	141	43.9	0.89 (0.67-1.18)	0.406
Number of pregnancies	≥ 2^[ref]	72	40.0	108	60.0	180	56.1	0.89 (0.67-1.18)	0.406
Number of deliveries	1	56	34.6	106	65.4	162	50.5	0.83 (0.63-1.10)	0.200
Number of deliveries	≥ 2^[ref]	66	41.5	93	58.5	159	49.5	0.83 (0.63-1.10)	0.200
Number of abortions	None^[ref]	98	37.5	163	62.5	261	81.3	1.07 (0.75-1.51)	0.724
Number of abortions	≥ 1	24	40.0	36	60.0	60	18.7	1.07 (0.75-1.51)	0.724
Previous cesarean section	Yes	41	39.0	64	61.0	105	32.7	1.18 (0.83-1.68)	0.351
Previous cesarean section	No^[ref]	39	33.1	79	66.9	118	36.8	1.18 (0.83-1.68)	0.351
Previous instrumental delivery	Yes	10	58.8	7	41.2	17	5.3	1.70 (1.09-2.65)	0.048*
Previous instrumental delivery	No^[ref]	63	34.6	119	65.4	182	56.7	1.70 (1.09-2.65)	0.048*
Pain in previous births	Yes	33	51.6	31	48.4	64	19.9	1.71 (1.22-2.40)	0.003
Pain in previous births	No^[ref]	47	30.1	109	69.9	156	48.6	1.71 (1.22-2.40)	0.003
Planned gravity	Yes^[ref]	47	37.0	80	63.0	127	39.6	1.04 (0.78-1.39)	0.766
Planned gravity	No	75	38.7	119	61.3	194	60.4	1.04 (0.78-1.39)	0.766
Number of prenatal consultations	< 7	14	28.6	35	71.4	49	15.3	0.72 (0.45-1.15)	0.139
Number of prenatal consultations	≥ 7^[ref^]	108	39.7	164	60.3	272	84.7	0.72 (0.45-1.15)	0.139
Duration of cesarean section (in minutes)	≤ 60^[ref]	110	37.5	183	62.5	293	91.3	1.39 (0.90-2.15)	0.177*
Duration of cesarean section (in minutes)	> 60	11	52.4	10	47.6	21	6.5	1.39 (0.90-2.15)	0.177*

Pain Impact	Pain intensity (n=232) Median			p-value
	Mild	Moderate	High
	(n=110)	(n=75)	(n=47)
General activity	3 (0; 5)	5 (1; 8)	4 (0; 9)	0.004
Mood	0 (0; 3)	1 (0; 5)	2 (0; 8)	0.016
Walking	3 (1; 5)	4 (2; 7)	6 (0; 8)	0.003
Interpersonal relationships	0 (0; 0.25)	0 (0; 1)	0 (0; 4)	0.108
Sleep	1 (0; 5)	3 (0; 7)	5 (0; 8)	0.003
Ability to appreciate life	0 (0; 0)	0 (0; 2)	0 (0; 6)	<0.001
Sitting down and standing up	4 (3; 6.25)	6 (4; 9)	8 (4; 10)	<0.001
Urination	0 (0; 3)	0 (0; 5)	0 (0; 6)	0.491
Defecation	0 (0; 4)	0 (0; 5)	0 (0; 5)	0.827
Intimate hygiene	0 (0; 2)	0 (0; 5)	1 (0; 7)	0.010
Bathing	0 (0; 3)	1 (0; 5)	3 (0; 7)	0.008
Dressing	2 (0; 4)	4 (0; 7)	3 (0; 9)	0.003
Feeding	0 (0; 0)	0 (0; 1)	0 (0; 1)	0.307
Breastfeeding	0 (0; 3)	0 (0; 4)	2 (0; 6)	0.045
Changing diapers	0 (0; 0)	0 (0; 1)	0 (0; 1)	0.050
Holding the NB	0 (0; 1.25)	0 (0; 4)	0 (0; 6)	0.031

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[1] VNS = verbal numeric scale.