PERIODICUM BIOLOGORUM UDC 57:61

VOL. 113, No 2, 239–241, 2011 CODEN PDBIAD

ISSN 0031-5362

Original scientific paper/new guidelines

Persistent post-partum pain after vaginal birth and

cesarean section

Abstract
LADA KALAGAC FABRIS
Purpose of review: Labor pain remains under evaluated and under
Department of Anaesthesiology and managed while evidence is growing that post partum treatments stron-
Intensive Care, General Hospital Pula,
A.Negri 4, 52100 Pula, Croatia
gly influence patients’ outcome. The present review examines the recent
E-mail: [email protected] developments in mechanisms underlying labor and delivery pain and
questions current understanding of post-partum pain features observed
Key words: Cesarean section, labor pain, in patients.
peripartum pain, chronic pain, multimodal
analgesia Recent findings: Different strategies to approach acute labor pain have
been developed. Chronic pain after labor and delivery has not been studied
so extensively. Prevalence rates of chronic pain after cesarean section are be-
tween 6 and 18% and after vaginal delivery they are between 4 and 10%.
Predictors for chronic pain after cesarean section and delivery are previous
chronic pain, general anesthesia and higher post delivery pain. As labor pain
is rated as one of the most serious kinds of acute pain we speculate that effec-
tive treatment of this pain with peripartum epidural analgesia could pre-
vent the development of chronic pain.
Conclusion: Treatment of acute pain during labor and delivery is neces-
sary to prevent chronic pain. Effective perioperative block of nociceptive in-
puts from the wound as well as use of antihyperalgesic and analgesic drugs
in combination seem the best way to control postoperative pain and specifi-
cally to prevent central sensitization. Future studies should focus on the
long-term effects of different analgesic regimens on the development of
chronic pain after labor and delivery.

INTRODUCTION

A painful labor is a universal fear experienced by pregnant women as

they approach term. Pain should be considered one of these unde-
sirable events because optimal pain management is mandatory for early
rehabilitation after labor. In modern obstetrics, alleviation of labor
pains by simple, safe and effective means is possible, but still remain
under evaluated and poorly treated (1).
Recent surveys suggest that 80% of patients experience pain after
surgery, 11% having severe pain, and that pain delays recovery in 24%
of patients undergoing ambulatory surgery (2, 3). Furthermore, recog-
nition is growing that peri-operative treatments have long-term conse-
quences on patients’ outcome and quality of life; specifically, unre-
Received April 20, 2011.
lieved acute pain favors the occurrence of postoperative cognitive im-
pairment (4), and chronic post surgical pain (5).
Lada Kalagac Fabris Pain after vaginal birth and cesarean section

Peri-operative pain management is currently a chal- of perineal pain, back pain and pelvic gridle pain that af-
lenging area in which anaesthesiologists should be in- fects women’s recovery from childbirth ranging from
volved and take responsibility (6). The present review ex- 5–43% for 6 month after delivery (15).
amines recent developments in labor and delivery pain
mechanisms and questions the current understanding of Chronic pain and cesarean section
post partum pain features observed in patients.
Cesarean section are usually performed through a
Acute pain during and after vaginal Pfannenstiel or vertical skin incision and a transverse
delivery lower uterine segment incision. Depending on haemo-
stasis, the uterine wound is closed in one or two layers of
The amount of pain experienced during labor is the continuous absorbable suture, the peritoneum and mus-
result of complex processing of multiple physiologic and cles are left open and the fascia is closed with a running
psychosocial factors on a woman’s individual interpreta- continuous suture of absorbable material. The skin is
tion of nociceptive labor stimuli (7). In the 1980s, Mel- closed with non absorbable individual stiches that are re-
zack et al. (8) determined that about 65–68% of pri- moved on day five or six. The patients ambulate 8–10 h
miparas and multiparas rated their labor pain as 'severe' after cesarean section.
or 'very severe'; moreover, 23% of primiparas and 11% of
multiparas rated their pain as 'horrible'. Labor pain sco- Surgical injury causes flare formation around the
res are found to be higher than average pain scores re- wound and results in two different types of hyperalgesia.
ported by patients with chronic low-back pain, pain in Primary hyperalgesia occurs for both thermal and me-
non-terminal cancer patients, arthritic pain and other chanical stimuli applied to damaged tissues close to the
forms of chronic and acute pain that are universally ac- site of injury (16). The underlying mechanism involves
knowledged to be severe (9). peripheral sensitization of primary afferent nociceptors
by algogenic mediators locally released. Although in-
Labor pain arises from contraction of the myome- flammation certainly participates in incisional pain, its
trium against the resistance of the cervix and perineum, cause and its role are different from these in other models
progressive dilatation of the cervix and lower uterine seg- of tissuelar injury (17). In contrast, ischemia may play an
ment, as well as stretching and compression of pelvic and important role and local acidosis parallels postoperative
perineal structures (10). Pain during the first stage of la- pain behaviors and hyperalgesia (18). Low pH activates
bor is mostly visceral pain resulting from uterine contrac- several ion channels susceptible to transduce pain, i.e.
tions and cervical dilatation. During this phase, T10-L1 acid-sensing ion channels, vanilloid receptors, puriner-
dermatomes are involved. The visceral afferent fibers re- gic receptors, and potassium channels. Surgical injury
sponsible for labor pain travel with sympathic nerve fi- also induces hypersensitivity in adjacent tissues, called
bers to the uterine and cervical plexuses, through the secondary hyperalgesia and observed only for mechani-
hypogastric and aortic plexuses, before entering the spi- cal stimuli applied to uninjured tissues surrounding the
nal cord with the T10-L1 nerve roots (10). The onset of wound (16). Secondary mechanical hyperalgesia is con-
perineal pain at the end of the first stage signals the be- sidered a consequence of central sensitization and results
ginning of fetal descent and the second stage of labor. from enhanced response of dorsal horn neurons to pe-
Stretching and compression of pelvic and perineal struc- ripheral inputs, with magnitude and duration related to
tures intensifies the pain. Sensory innervation of the per- the degree of tissue injury (19).
ineum is provided by the pudendal nerve (S2–4), so pain
during the second stage of labor involves the T10-S4 der- Post-cesarean patients differ from the general surgical
matomes (10). population because of concerns of exposure to analgesic
drugs to the newborns and because of a need for early
Pain is defined as 'an unpleasant sensory and emo- physical request to care for their baby. Pain treatment af-
tional experience associated with actual or potential tis- ter childbirth may even be less adequate than after sur-
sue damage, or described in terms of such damage' by the gery. This is because of the restraint to use non-steroidal
International Association for the Study of Pain. Chronic anti-inflammatory drugs or adequate doses of opioids
pain is defined as pain that persists beyond the usual cour- during breastfeeding (20).
se of an acute disease or after a reasonable time for healing
to occur. This period can vary from 2 to 6 months (11). Persistent pain after cesarean section has been investi-
gate in the Danish study by Nikolajsen et al. (21). They
Klein et al. reported that both episiotomy and perineal reported that 12.3% of the parturients experience persis-
laceration are strongly associated with the presence of tent pain at the end of a follow-up period ranging from 6
perineal pain during the immediate postpartum period to 18months. Daily pain was reported in 5.9% of the pa-
and at 3 months for 11%of women (12). Similarly, Mac- tients. In that study, the risk factors for persistent pain
arthur et al. found that 36% of 96 women with episio- were cesarean section under general anaesthesia, as well
tomy described their pain as distressing or worse on post- as previous pains problems, and recall of severe acute
partum day 1 and 6 percent reported the same pain levels postoperative pain (21).
on postpartum day 7 (13). In the HOOP study, 7.3% of
women reported pain at 3 months; however, validated The type of anaesthesia was found to be a predictor of
pain scales were not used (14). The reported prevalence chronic pain, showing that patients undergoing cesarean

240 Period biol, Vol 113, No 2, 2011.

Pain after vaginal birth and cesarean section Lada Kalagac Fabris

section under general anaesthesia had a higher frequency operative pain continues to be under managed. Anesthesia & Analge-
sia 97: 534–540
of pain than patients receiving spinal anaesthesia (21).
3. PAVLIN D J, CHEN C, PENALOZA D et al.2002 Pain as a factor
Almeida et al. (22) found that 67% of women with complicating recovery and discharge after ambulatory surgery. Anes-
chronic pelvic pain had a history of cesarean section. In thesia & Analgesia 95: 627–634
4. VAURIO L E, SANDS L P, WANG Y et al. 2006 Postoperative delir-
an Asian study, the incidence of chronic pain after 3 ium: the importance of pain and pain management. Anesthesia &
months was 9.2% after elective cesarean section under Analgesia 102: 1267–1273
spinal anaesthesia. Higher recalled pain scores postoper- 5. PERKINS F M, KEHLET H 2000 Chronic pain as an outcome of
atively, the presence of pain elsewhere and non-private surgery: a review of predictive factors. Anesthesiology 93:1123–1133
insurance status were found to be independent risk fac- 6. GOTTSCHALK A, RAJA S N 2004 Severing the link between
acute and chronic pain: the anesthesiologist’s role in preventive
tors (23). medicine. Anesthesiology 101: 1063–1065
A study from Finland found a significant difference in 7. LOWE N K 2002 The nature of labor pain. American Journal of Ob-
stetric Gynecology 186: S16–S24
persistent pain 1 year after delivery between cesarean
8. MELZACK R, KINCH R A, DOBKIN P et al.1984 Severity of labor
section (44/229, 18%) and vaginal delivery (20/209, 10%). pain: influence of physical as well as psychologic variables. Canadian
The persistent pain was mild in 55% of the women in Medical Association Journal 130: 579–584.
both groups, and intense or unbearable in four women 9. MELZACK R 1984 The myth of painless childbirth (the John J.
after cesarean sections and in six women after vaginal Bonica lecture) Pain 19: 321–337
10. McMAHON S, KOLTZENBURG M 2006 Wall and Melzack’s
births. Persistent pain was significantly more common in textbook of pain. 5th ed. Elsevier/Churchill Livingstone, Philadel-
women with previous pain, previous back pain and any phia, p 794–795
chronic disease. The women with persistent pain re- 11. MERSKEY H, BOGDUK N 1994 Classification of chronic pain:
called significantly more pain on the day after cesarean description of chronic pain syndromes and definitions of pain terms.
IASP Press, Seattle.
section and vaginal birth than those who did not report
12. KLEIN M C, GAUTHIER R J, ROBBINS J M et al.1994 Relation-
persistent pain (24). ship of episiotomy to perineal trauma and morbidity, sexual dysfunc-
Eisenach et al. (25) recently compared the occurrence tion, and pelvic floor relaxation. American Journal of Obstetric Gyne-
cology 171: 591–598
of chronic pain after cesarean section and after vaginal 13. MACARTHUR A J, MACARTHUR C 2004 Incidence, severity, and
delivery. The prevalence of severe acute pain within 36 h determinants of perineal pain after vaginal delivery: A prospective
postpartum was found to be 10.9% and persistent pain cohort study. American Journal of Obstetric Gynecology 191: 1199–1204
after 8 weeks was found to be 9.8%.Severity of acute 14. ALBERS L, GARCIA J, RENFREW M et al.1999 Distribution of
genital tract trauma in childbirth and related postnatal pain. Birth
postpartum pain was independently related to the risk of 26: 11–17
persistent postpartum pain, whereas no relation was ob- 15. WANG S M, DEZINNO P, MARANETS I et al. 2004 Low back
served concerning mode of delivery. Women with severe pain during pregnancy: prevalence, risk factors, and outcomes. Ob-
acute postpartum pain had a 2.5-fold increased risk of stetric Gynecology 104: 65–70
persistent pain. 16. ZAHN P K, BRENNAN T J1999 Primary and secondary hy-
peralgesia in a rat model for human postoperative pain. Anesthesiol-
The few presented studie’s are agree that drugs com- ogy 90: 863–872
binations – multimodal or balanced analgesia – are man- 17. LEONARD P A, ARUNKUMAR R, BRENNAN T J 2004 Brady-
kinin antagonists have no analgesic effect on incisional pain. Anes-
datory to achieve satisfactory and effective pain relief thesia & Analgesia 99: 1166–1172
with reduced side effects. Effective perioperative block of 18. WOO Y C, PARK S S, SUBIETA A R, BRENNAN T J 2004
nociceptive input from the wound by means of regional Changes in tissue pH and temperature after incision indicate acido-
anesthesia and the administration of analgesic drugs sis may contribute to postoperative pain. Anesthesiology 101: 468–475
19. POGATZKI E M, NIEMEIER J S, BRENNAN T J 2002 Persistent
may prevent central sensitization and reduce develop- secondary hyperalgesia after gastrocnemius incision in the rat. Euro-
ment of chronic pain. pean Journal of Pain 6: 295–305
20. LAVAND’HOMME P 2006 Postcesarean analgesia: effective strate-
gies and association with chronic pain. Current Opinion in Anaesthe-
CONCLUSION siology 19: 244–248
We conclude that persisten pain is more common af- 21. NIKOLAJSEN L, SORENSEN H C, JENSEN T S, KEHLET H
2004 Chronic pain following caesarean section. Acta Anaesthesiolo-
ter cesarean section that vaginal birth, although the pain gica Scandinava 48: 111–116
was usually. In all study the persistent pain was associ- 22. ALMEIDA E C S, NOGUEIRA F J, CANDIDO DOS REIS F J,
ated with a history of previous pain, chronic disease and ROSA DE SILVA J C 2002 Cesarean section as a cause of chronic
pain in peri-partum time. A more extensive prospective pelvic pain. International Journal of Gynaecology & Obstetrics 79:
101–104
study are needed to examine risk factors for persistent 23. SONG B L, SIA A T H, QUEK K et al. 2009 Incidence and risk fac-
pain after cesarean section and vaginal delivery. tors for chronic pain after caesarean section under spinal anaesthe-
sia. Anaesth Intensive Care 37: 748–752
24. KAINU J P, SARVELA J, TIIPPANA E et al. 2010 Persistent pain af-
REFERENCES ter caesarean section and vaginal birth: a cohort study. Int J Obstet
1. KEHLET H 2005 Postoperative opioid sparing to hasten recovery: Anesth 19: 4–9
what are the issues? Anesthesiology 102: 1083–1085 25. EISENACH J C, PAN P H, SMILEY R et al. 2008 Severity of acute
2. APFELBAUM J L, CHEN C, MEHTA S S, GAN T J 2003 Postop- pain after childbirth, but not type of delivery, predicts persistent pain
erative pain experience: results from a national survey suggest post- and postpartum depression. Pain 140: 87–94

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