A C TA Obstetricia et Gynecologica

AOGS M A I N R E SE A RC H A R TI C LE

Risk factors for persistent pain and its influence on

maternal wellbeing after cesarean section
€
BOEL NIKLASSON1,2, SUSANNE GEORGSSON OHMAN 2,3 €
, MARTA SEGERDAHL4 & AGNETA BLANCK1
1
Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Obstetrics and Gynecology,
Karolinska Institute, Karolinska University Hospital, Stockholm, 2Sophiahemmet University, Stockholm, 3Department of
Women’s and Children’s Health, Karolinska Institute, Stockholm, and 4Department of Physiology and Pharmacology, Kar-
olinska Institute, Stockholm, Sweden

Key words Abstract

Cesarean section, postoperative pain,
persistent pain, risk factors, quality of life Objectives. To investigate the overall incidence and risk factors for persistent
pain and its interference with daily life after cesarean section. Design. Prospec-
Correspondence tive long-term follow-up study. Setting. Karolinska University Hospital, Stock-
Boel Niklasson, CLINTEC, Division of holm, Sweden. Population. 260 healthy women who underwent elective
Obstetrics and Gynecology, Karolinska
cesarean section. Methods. Information on demographics, medical history,
Institute, Karolinska University Hospital,
postoperative pain and analgesic requirements was collected. A questionnaire
Huddinge, 141 86 Stockholm, Sweden.
E-mail: [email protected] consisting of the Brief Pain Inventory was posted at 3, 6 and 12 months after
surgery. Women rated pain intensity as well as interference with factors related
Conflict of interest to general function and quality of life. Main outcome measures. The overall
The authors have stated explicitly that there incidence and risk factors for persistent postoperative pain at three time points.
are no conflicts of interest in connection with Persistent pain was considered a secondary outcome. Results. At 3, 6 and
this article. 12 months respectively 40, 27 and 22% of patients reported pain in one or
more locations, in the surgical site as well as in other areas. A psychological
Please cite this article as: Niklasson B,
€ indication, as well as a first cesarean section, increased the risk for pain at
Georgsson Ohman S, Segerdahl M , Blanck A.
Risk factors for persistent pain and its 3 months. Severe postoperative pain in the immediate postoperative period or
influence on maternal wellbeing after undergoing a first cesarean section were significant independent risk factors for
cesarean section. Acta Obstet Gynecol Scand the development of persistent pain up to 6 months after cesarean section.
2015; 94: 622–628. Parameters related to quality of life were significantly impaired in women with
persistent pain. Conclusion. Several factors, including severe postoperative pain,
Received: 22 September 2014 were shown to influence the risk for persistent pain after cesarean section.
Accepted: 13 February 2015
Long-term pain markedly affected women’s wellbeing.
DOI: 10.1111/aogs.12613
Abbreviations: CS, cesarean section; NRS, numerical rating scale.

Introduction
Persistent pain is a well known risk not only after major
surgery, such as limb amputation, breast and thoracic sur- Key Message
gery, but also following common surgery like groin hernia Severe postoperative pain, a first-time cesarean sec-
repair (1). This also applies to women undergoing gyneco- tion and if the operation was performed for psycho-
logical and obstetric surgery, e.g. cesarean section (CS) logical reasons were risk factors for developing
(2,3). The definition of chronic pain or persistent pain by persistent pain. Parameters related to quality of life
the International Association for the Study of Pain is pain were significantly impaired in women with long-term
that has lasted for 3 months or more, which has “persisted pain.
beyond the normal tissue healing time” (4).

622 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 622–628
 16000412, 2015, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.12613 by CAPES, Wiley Online Library on [17/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
B. Niklasson et al. Persistent pain and cesarean section

Several reports demonstrate that insufficient postopera- enrolled and randomized into the study when visiting the
tive pain management is common in patients subjected to clinic for preoperative assessment on the day before CS.
different types of surgery (5–7), including CS (2,3,8,9). Healthy women, 18–49 years old, with a medically nor-
Not only tissue damage but also other factors contribute mal pregnancy, scheduled for elective CS under spinal
to pain (9). Peripheral and central sensitizations are risk anesthesia from 38 full weeks of gestation and under-
factors for chronic postsurgical pain and are a current standing the Swedish language were considered eligible
topic for discussion. It may be that individuals whose for inclusion. Ongoing treatment for chronic pain or psy-
pain persists longer than what is considered normal have chiatric disorder, a history of illicit drug abuse and any
dysregulation of the pain inhibitory systems that leads to intolerance of opioids, local anesthetics or other analgesic
central sensitization (10). Prospective and detailed investi- drugs given in the study constituted exclusion criteria.
gation of the correlation between pain in the immediate The present investigation was a non-interventional
postoperative period and persistent pain in women long-term follow-up study with questionnaires posted to
undergoing CS has not been widely pursued. Earlier, we all women at 3, 6 and 12 months after the planned CS.
reported the effects of perioperative local anesthesia dur- To minimize loss to follow-up, a new questionnaire, with
ing CS and the present study is based on the same patient a reminder letter, was sent within 3 weeks after the first
group (11). questionnaire was sent. If necessary, a telephone call was
The primary aim of this follow-up study was to pro- made 5 weeks after mailing the first questionnaire. The
spectively investigate the overall incidence and risk factors second and third questionnaires (6 and 12 months) were
for persistent postoperative pain at 3, 6 and 12 months sent out even if no answer had been received to the pre-
after CS. The secondary aim was to characterize the pain vious questionnaire(s) and the same procedure to secure
as to intensity, body location and impact on daily life. answers was used as at 3 months. Previously recorded
baseline data on demographics and medical history, as
well as study data from the postoperative period of the
Material and methods
original randomized controlled study, were included in
The present study is a long-term follow-up of a previ- the analyses.
ously reported clinical trial (11). In that placebo-con- The questionnaire was sent to all patients from the
trolled double-blind randomized trial the effect on intervention and control groups in the previous study
postoperative pain and analgesic requirements of a subcu- (11). A pain assessment instrument, the Brief Pain Inven-
taneous injection of bupivacaine close to the fascia was tory, was used (Table 1). Women were asked if they
investigated. Morphine consumption and pain assessment experienced any pain at present and during the last week
using a Likert numerical rating scale (NRS) were docu- and also received instructions to mark their pain on the
mented throughout the hospital stay, with the women body map. They were asked to rate their worst, least,
rating their pain from 0 to 10 where 0 was “no pain at average and current pain intensity using an NRS. Pain
all” and 10 the “worst pain.” Mean and maximum (max) intensity was categorized as follows: NRS 1–3 was classi-
pain at rest and provoked pain (uterine palpation) were fied as mild pain, NRS 4–6 as moderate, NRS 7–8 corre-
recorded, as well as the number of occasions with break- sponded to severe and NRS 9–10 to very severe pain. The
through pain. The pain was assessed by regularly asking questionnaire also included questions about the extent to
the patient about pain, and breakthrough pain was diag- which pain interfered with the women’s daily life, with
nosed when the patient asked for rescue medication. In NRS 0–10 (0 “does not interfere,” 10 “interferes com-
accordance with departmental routines, patients were pletely”), regarding interference with seven functional
mobilized over a 24-h cycle, irrespective of the time of domains (general activity, mood, walking ability, normal
day at surgery. No differences were observed between the working capacity, relations with other people, sleep and
intervention and control groups, i.e. injection of bupiva- enjoyment of life) (12,13). The questionnaire was
caine-adrenaline or saline solution, regarding pain param- extended to include information about intake of analge-
eters recorded in the immediate postoperative period and sics, general wellbeing and with an open-ended question
pain at 3, 6 and 12 months. Therefore data from both where women could add more information (Table 1).
groups were pooled for all further calculations. The The free text responses were divided into nine categories;
demographic data collected included age, weight and pain, mobility, scar sensations, problems with carrying
body mass index at the time of surgery, indication for the child/children or other heavy things, sleeping difficul-
CS, parity and number of previous CS. ties, breast-feeding related problems, interruption of
The study was conducted between September 2006 and mood, problems with sex life or bowel function.
April 2008 at the obstetric unit, Karolinska University Approval was obtained from the Regional Ethics Com-
Hospital, Huddinge, Sweden. In all, 260 patients were mittee in Stockholm, Sweden (2006/628-31/1) and the

ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 622–628 623
 16000412, 2015, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.12613 by CAPES, Wiley Online Library on [17/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Persistent pain and cesarean section B. Niklasson et al.

Table 1. Three-, six- and 12-month questionnaires about severity and impact of pain after cesarean section. Pain assessment was performed
using the Brief Pain Inventory.

We want you to answer how the pain was when it was at its worse, least and average on a scale this last week. Most people experience
occasional pain from time to time, such as headache, toothache or sprains. Have you in the past week experienced a different kind of pain
than those mentioned above? Please mark on the body map where you have or have had pain the past week

 How strong has your pain been in the past week when it was at its worst?
 How strong has your pain been in the past week when it was at its lowest?
 How strong has your average pain been over the past week?
 How strong is your pain right now?

If you still have pain or pain that requires medication, please answer the following questions (regarding the past week). How much has pain
medication eased your pain during the last week? Please circle the percentages that best describe your experience
The Brief Pain Inventory also assesses the degree to which pain interferes with the patient’s function, to assess the impact of pain on some key
domains of daily living
For the following questions, please mark the number that best matches your experience during the last week

 Try to remember how the pain has interfered with your daily activities.
 To what extent has your mood been affected by pain?
 To what extent has your walking capacity been affected by pain?
 To what extent has your normal work been affected by pain?
 To what extent have your relations to others been affected by pain?
 To what extent has your sleep been disturbed by pain?
 To what extent has your enjoyment of life been affected by pain?
Open-ended question:
Have you got additional comments?

Swedish Medical Products Agency (151:2006/30029). Ver- ters related to quality of life, as assessed by the Brief Pain
bal and written informed consent was obtained from all Inventory, Spearman’s rank test was used. Correction for
participants. multiplicity was performed according to Bonferroni. In
all calculations, a level of p ≤ 0.05 was considered signifi-
cant.
Statistical analysis
The statistics software, IBM PASW Statistics, version 20.0
Results
(IBM Corp., Armonk, NY, USA), was used to conduct
the analyses. Pearson’s chi-squared test and two-tailed Demographic data and obstetric characteristics included
Student’s t-tests were used to compare the demographic age (median/range; 35/21–49), parity (1/0–4) and body
data. The sample size calculation was based on the mass index (29.1/20.3–45.3). In all, 125 women of 231
sample size for the previous randomized controlled trial had a previous CS (missing information for 22 women).
(11). Statistical analyses of factors possibly related to Fifty-one women were primiparous and 202 multiparous.
long-term pain at 3, 6 and 12 months were performed The response rate for the questionnaires was 91% (231/
by stepwise multiple logistic regression analysis, with 253) at 3 months, 90% (228/253) at 6 months and 85%
backward elimination of possible predictors. To avoid (215/253) at 12 months. The percentage of responders
confounders related to the pharmacological intervention who reported pain at any body location at 3 months was
in the randomized controlled study with local bupiva- 40%, at 6 months 27% and 1 year after the CS, 21%. The
caine versus placebo (11), pain at 12–24 h was used as same proportion of non-responders was seen in women
the baseline variable. The following co-variates were used reporting pain as in those without pain.
and analyzed separately: max NRS, mean NRS, number At 3 months, 56% of all responders with pain reported
of breakthrough pain episodes, parity (0/≥1), previous pain in and around the surgical site, and 32% of those
CS (no/yes) and psychological indication (yes/no) for the experiencing pain marked more than one location. At
CS. 6 months, 25% of the responders with pain marked more
Significance was calculated by Pearson’s chi-squared than one location on the body map. At that time point,
test. The proportion of women with pain at 3, 6 and 60% of the responders with pain marked it around the
12 months was compared in pairs using Fisher’s exact surgical site; the corresponding proportion at 12 months
test. To evaluate how persistent pain influenced parame- was 26%. The total number of women with pain localized

624 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 622–628
 16000412, 2015, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.12613 by CAPES, Wiley Online Library on [17/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
B. Niklasson et al. Persistent pain and cesarean section

Head 24% Table 2. Logistic regression analysis of risk factors for persistent pain
Neck/shoulder 22% Head
after planned cesarean section. Numerical rating scale represents pain
12 months Other 28% Neck/shoulder
Back/low back 46% parameters 12–24 h postoperatively.
Other
Abdomen 26%
Head 17% Back/low back Odds ratio 95% CI p ≤ 0.05
Neck/shoulder 8% Abdomen
6 months Other 22% 3 months
Back/low back 22%
Abdomen 59% Max NRS 1.04 0.95–1.15 n.s.
Head 12% Mean NRS 1.06 0.95–1.18 n.s.
Neck/shoulder 23% Breakthrough NRS 1.01 0.81–1.25 n.s.
3 months Other 26%
Back/low back 32% Psychological indication (yes/no) 2.04 1.15–3.70 0.02
Abdomen 56% Parity (0/≥1) 1.47 0.76–2.82 n.s.
0 10 20 30 40 50 60 Previous CS (no/yes) 1.96 1.11–3.44 0.02
6 months
Figure 1. Pain locations indicated in body charts by the women at 3, Max NRS 1.13 1.01–1.27 0.04
6 and 12 months after cesarean section. Percentage of women Mean NRS 1.14 1.01–1.31 0.04
reporting pain at each location is indicated in the bar charts. The Breakthrough NRS 1.25 0.99–1.60 n.s.
women could indicate pain at several locations. Total numbers of Psychological indication (yes/no) 1.42 0.73–2.78 n.s.
women reporting pain were 93 at 3 months, 63 at 6 months and 46 Parity (0/≥1) 1.98 0.99–3.92 n.s.
at 12 months. Previous CS (no/yes) 2.31 1.23–4.44 0.01
No explanatory variable was identified at 12 months
to the abdomen decreased over time from 52 (3 months),
CS, cesarean section; NRS, numerical rating scale; n.s., not significant.
to 37 (6 months) and finally to 12 (12 months)
(Figure 1). However, only 14 women reported abdominal
pain at both 3 and 6 months and another six women had related to function and quality of life showed a signifi-
pain at this location at all three time points. cant correlation (p ≤ 0.01) for all time points and
In a stepwise multiple logistic regression analysis we domains, with correlation coefficients ranging between
found that women undergoing a first CS had a signifi- 0.61 and 0.87.
cantly higher risk for persistent pain at 3 and 6 months. At 3 months, 26% (n = 24) of the women with pain
The three most common indications for elective CS were had sleeping difficulties (NRS 4–10). The corresponding
psychological/maternal request (36.5%), previous CS number at 6 months was 22% (n = 14) and at 12 months
(18.1%), breech presentation (17.7%) and previous 33% (n = 15). Inall, 22% (n = 20) of all patients with
sphincter/perineal rupture (13.1%). If the indication for pain at 3 months reported a moderate to very severe
CS was psychological (maternal request) a significantly (NRS 4–10) impact of pain on enjoyment of life. This
higher risk for persistent pain was observed at 3 months rate was essentially unchanged after 6 and 12 months
but not at later time points. High postoperative maxi- (Figure 2).
mum and mean NRS, but not the number of episodes
with breakthrough pain, significantly increased the risk
Discussion
for pain at 6 months. Expecting a first child had a ten-
dency to influence pain at 6 months (p = 0.051) The present study shows a relation between pain in the
(Table 2). No explanatory function was seen at 3 months immediate postoperative period and persistent pain for
for any of the pain-related parameters or parity and no up to 6 months. Other risk factors for persistent pain
explanatory variable at all could be identified at were a first-time CS and if the CS was performed for psy-
12 months. chological reasons. Pain after CS has been studied but, to
In the Brief Pain Inventory the intensity of the overall our knowledge, this is the first prospective long-term fol-
pain was rated by the NRS. The number of women with low-up study on the development of persistent pain and
pain at the different time points is presented in Table 3. the impact of pain on daily activities at three time points
A significantly higher proportion of women reported pain after elective CS. A strength of the study was that the
at 3 months than at 6 and 12 months. Responders with response rate was high, with 85% of the patients recruited
pain marked how much their pain interfered with activi- on the day before the CS remaining in the study by
ties of daily life, using the 0–10 NRS scale. The extent to answering and returning the questionnaire at 12 months.
which pain had a negative impact on daily life at Another strength was that the collection of the first set of
3 months was mainly moderate to severe, and pain was data was performed in close connection to the CS. In
mostly indicated in body locations other than the abdo- other studies investigating persistent pain after CS, the
men. The dependency between the variables pain inten- patients had to recall the memory of pain (8,9). A limita-
sity and interference with all seven functional domains tion of the study was that any history of chronic pain

ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 622–628 625
 16000412, 2015, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.12613 by CAPES, Wiley Online Library on [17/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Persistent pain and cesarean section B. Niklasson et al.

Table 3. Incidence and intensity of pain at 3, 6 and 12 months postoperatively. Assessment on the numerical rating scale (NRS) (% of women
with pain at the specific time point).

3 months 6 months 112 months

n = 231 n = 228 n = 215

Characteristics n % n % n %

Number of women reporting no pain 138 60 165 72 169 79

Number of women reporting pain 93 40 63a 28 46a 21
Mild pain (NRS 1–3) 31 33 25 40 15 33
Moderate pain (NRS 4–6) 54 58 25 40 18 39
Severe pain (NRS 7–8) 7 8 13 20 11 24
Very severe pain (NRS 9–10) 1 1 0 0 2 4

Significantly different from the proportion of women with pain at 3 months (Chi-square test p ≤ 0.05).
a

40

NRS 4 NRS 5 NRS 6 NRS 7 NRS 8 NRS 9 NRS 10

35 1
1

6
30
1 1
2 1
3
25 6
5 1
1 2 1
2 3 2
8 3
20
6 2 3
1 7 2 3 1 3
7 2
1 1
15 6 3 2 4 1 6
2 1 1 9 1 2 5
6 9 2 1 1 5 3 4 2
4 2 1 1 3
3 4 2 4 4 3
10 2 2
2 3 3 4
2 1 3 1 2 1
6 7 1 6 1 3 1
2 1 12 3 4 1
5 10 8 2 4 1 3 4 2
8 8 9 9 1 1 9
2 2 7 2
5 4 4 4 4 4 4 2
3 2 1 1
0 1 1 1 1
3 6 12 3 6 12 3 6 12 3 6 12 3 6 12 3 6 12 3 6 12
Impact on acvies of Impact on Impact on walking Impact on working Disturbed relaons with Sleep disturbance Impact on enjoyment
daily life mood capacity capacity others of life

Figure 2. Impairment of function and quality of life items from the Brief Pain Inventory due to pain at 3, 6 and 12 months in women reporting
pain with numerical rating scale (NRS) >3/10. Numbers in boxes indicate number of responders.

before the CS was not recorded, which might have inter- factors for persistent pain have not previously been
fered with the evaluation of persistent pain after CS. reported. It is tempting to speculate that both these fac-
This set of prospective data confirms previous retro- tors could be related to psychological elements, in anal-
spective studies, indicating that high pain scores during ogy with the previously mentioned preoperative anxiety
the first postoperative day are a risk factor for chronic which has been shown to increase the risk for chronic
pain (2,8,9). General anesthesia, preoperative anxiety as pain.
well as a history of previous persistent pain have also In the present study 22% of the responders still experi-
been suggested as predictors for development of chronic enced pain at 12 months. The most common location
postoperative pain after CS (8,14). Interestingly, Johansen was back or low-back pain, reported by 46% (n = 21) of
and coworkers found co-morbid pain to be strongly asso- these women. These findings are in accordance with other
ciated with persistent pain in the surgical site (15). studies regarding pain after childbirth (16–18). Several
To our knowledge our findings regarding first-time CS studies report that women have health problems, such as
and psychological indications for the operation as risk fatigue, tiredness, headaches, backaches, abdominal or

626 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 622–628
 16000412, 2015, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.12613 by CAPES, Wiley Online Library on [17/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
B. Niklasson et al. Persistent pain and cesarean section

pelvic pain after childbirth (16,17,19–22). There are about the long-term risks associated with abdominal sur-
inconsistent data regarding pain after CS compared with gery in young healthy women. Even if the proportion of
vaginal deliveries (23–25). When comparing mode of women reporting pain at 12 months corresponding to the
delivery, both Deqlercq et al. (26) and Kainu et al. (3) proportion in the general population, it is unambiguous
found that persistent pain was more common after CS that a significantly higher proportion of women report
than after vaginal birth. pain 3 months after the CS. Scar sensations not con-
In a survey about chronic pain in Europe, Breivik et al. nected to pain were reported by many of the responders.
found that 19% of adult Europeans suffer from long-last- It is relevant to inform the women that numbness and
ing pain of moderate to severe intensity which seriously lack of sensory perception in the skin after the CS is not
affects their daily activities and social life. In the Swedish uncommon and that these symptoms usually decrease
part of the Breivik study, the overall prevalence of pain over time. Protocols for postoperative pain management
was 18%. In that group, 54% were women and 40% of vary in different parts of the world, not only with respect
these were between 18 and 40 years of age (27). Pain at to analgesic drugs used or available, but also regarding
12 months in the present study is not necessarily related mode of administration and duration of treatment. How-
to the CS. Few women had abdominal pain at this time ever, we believe that pain treatment has some level of
point and the pain reported could just as well be consis- generalizability, irrespective of the specific protocol used.
tent with health status in women previously giving birth, Our data support that optimal pain control after CS is
regardless of mode of delivery, or it could reflect the essential for the women’s wellbeing for an extended per-
health condition observed in women of childbearing age iod of time after surgery.
in general. The data regarding persistent pain observed
here are in a similar range as in other studies (3,8). In Acknowledgments
Kainu’s report, pain was mostly related to negative sensa-
tions at the site of the scar (3). Our data show that We are grateful to Dr. Henry Nisell for valuable support
abdominal pain was present in 5.6% of women respond- and advice. We would also like to thank Magnus Backhe-
ing to the questionnaire at 12 months. Similar findings den, MSc, Medical Statistics Unit, Karolinska Institute,
were reported by Liu and coworkers, who found an inci- for expert statistical support.
dence of 4.2% at the same time point (28).
The majority of women reporting pain at the three time Funding
points experienced mild to moderate pain (≤NRS 6). How-
ever, it is worth noting that 9% of the women with pain at The study was supported by a grant from the Stockholm
3 months described the pain to be severe to very severe. It County Council (grant no. 2006023) and funding from
is even more striking that as many as 28% of the women the Sophiahemmet University, Stockholm.
who still experienced pain after 1 year graded their pain to
be severe or very severe and that nearly 20% reported that References
their pain interfered with enjoyment of life, as could be
1. Ravindran D. Chronic postsurgical pain: prevention and
expected. There was a significant difference, for all three
management. J Pain Palliat Care Pharmacother.
time periods, between patients with pain and patients with
2014;28:51–3.
no pain, as to the impact on different kinds of physical
2. Loos MJ, Scheltinga MR, Mulders LG, Roumen RM. The
activity, mood, relations to others and enjoyment of life.
Pfannenstiel incision as a source of chronic pain. Obstet
Schytt et al. found that one in four women had sleeping
Gynecol. 2008;111:839–46.
problems 1 year after childbirth irrespective of mode of 3. Kainu JP, Sarvela J, Tiippana E, Halmesmaki E, Korttila
delivery (17). Tiredness related to, among other things, KT. Persistent pain after caesarean section and vaginal
sleeping problems, is often reported after childbirth birth: a cohort study. Int J Obstet Anesth. 2010;19:4–9.
(17,18,21). In the present study, 7% of all responders 4. Harstall C, Ospina M. How prevalent is chronic pain? Pain
reported sleep disturbances 1 year after the CS. This was Clin Updates. 2003;11:1–4.
less than reported by Schytt et al. (17). However, the num- 5. Warfield CA, Kahn CH. Acute pain management.
ber of women reporting sleeping problems might have Programs in U.S. hospitals and experiences and attitudes
been higher if the question about sleep had not been put among U.S. adults. Anesthesiology. 1995;83:1090–4.
forward only in relation to pain. 6. Kehlet H, Wilmore DW. Multimodal strategies to improve
The indications for CS vary in different settings. It is surgical outcome. Am J Surg. 2002;183:630–41.
rather common that women request CS for non-medical 7. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative
reasons and it is important to be able to inform them pain experience: results from a national survey suggest

ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 622–628 627
 16000412, 2015, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/aogs.12613 by CAPES, Wiley Online Library on [17/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Persistent pain and cesarean section B. Niklasson et al.

postoperative pain continues to be undermanaged. Anesth 19. Borders N. After the afterbirth: a critical review of
Analg. 2003;97:534–40, table of contents. postpartum health relative to method of delivery. J
8. Nikolajsen L, Sorensen HC, Jensen TS, Kehlet H. Chronic Midwifery Womens Health. 2006;51:242–8.
pain following Caesarean section. Acta Anaesthesiol Scand. 20. Thompson JF, Roberts CL, Currie M, Ellwood DA.
2004;48:111–6. Prevalence and persistence of health problems after
9. Sng BL, Sia AT, Quek K, Woo D, Lim Y. Incidence and childbirth: associations with parity and method of birth.
risk factors for chronic pain after caesarean section under Birth. 2002;29:83–94.
spinal anaesthesia. Anaesth Intensive Care. 2009;37:748–52. 21. Brown S, Lumley J. Maternal health after childbirth: results
10. Landau R, Bollag L, Ortner C. Chronic pain after of an Australian population based survey. BJOG.
childbirth. Int J Obstet Anesth. 2013;22:133–45. 1998;105:156–61.
11. Niklasson B, Borjesson A, Carmnes UB, Segerdahl M, 22. Webb DA, Bloch JR, Coyne JC, Chung EK, Bennett IM,
Ohman SG, Blanck A. Intraoperative injection of Culhane JF. Postpartum physical symptoms in new
bupivacaine-adrenaline close to the fascia reduces mothers: their relationship to functional limitations and
morphine requirements after cesarean section: a emotional well-being. Birth. 2008;35:179–87.
randomized controlled trial. Acta Obstet Gynecol Scand. 23. Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte
2012;91:1433–9. GM. Caesarean section for non-medical reasons at term.
12. Tan G, Jensen MP, Thornby JI, Shanti BF. Validation of Cochrane Database Syst Rev. 2012;3:CD004660.
the Brief Pain Inventory for chronic nonmalignant pain. J 24. Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung
Pain. 2004;5:133–7. R, Willan A, et al. Outcomes at 3 months after planned
13. Klepstad P, Loge JH, Borchgrevink PC, Mendoza TR, cesarean vs planned vaginal delivery for breech
Cleeland CS, Kaasa S. The Norwegian brief pain inventory presentation at term: the international randomized Term
questionnaire: translation and validation in cancer pain Breech Trial. JAMA. 2002;287:1822–31.
patients. J Pain Symptom Manage. 2002;24:517–25. 25. Hannah ME, Whyte H, Hannah WJ, Hewson S,
14. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Amankwah K, Cheng M, et al. Maternal outcomes at
risk factors and prevention. Lancet. 2006;367:1618–25. 2 years after planned cesarean section versus planned
15. Johansen A, Schirmer H, Stubhaug A, Nielsen CS. vaginal birth for breech presentation at term: the
Persistent post-surgical pain and experimental pain international randomized Term Breech Trial. Am J Obstet
sensitivity in the Tromso study: comorbid pain matters. Gynecol. 2004;191:917–27.
Pain. 2014;155:341–8. 26. Declercq E, Young R, Cabral H, Ecker J. Is a rising
16. MacArthur C, Lewis M, Knox EG. Health after childbirth. cesarean delivery rate inevitable? Trends in industrialized
BJOG. 1991;98:1193–5. countries, 1987 to 2007. Birth. 2011;38:99–104.
17. Schytt E, Lindmark G, Waldenstrom U. Physical 27. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D.
symptoms after childbirth: prevalence and associations Survey of chronic pain in Europe: prevalence, impact on
with self-rated health. BJOG. 2005;112:210–7. daily life, and treatment. Eur J Pain. 2006;10:287–333.
18. Glazener CM, Abdalla M, Stroud P, Naji S, Templeton A, 28. Liu TT, Raju A, Boesel T, Cyna AM, Tan SG. Chronic
Russell IT. Postnatal maternal morbidity: extent, causes, pain after caesarean delivery: an Australian cohort. Anaesth
prevention and treatment. BJOG. 1995;102:282–7. Intensive Care. 2013;41:496–500.

628 ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 622–628