Persistent Pain Following Delivery
Anesthesia providers are responsible for anesthesia care, critical care medicine and pain management.1 In particular, pain management involves providing medicine or nonpharmaceutical alternatives for acute2 or chronic3 pain. Anesthesia providers may need to treat a variety of types of pain, including chronic pain, injury-induced pain, fibromyalgia, postoperative pain, myofascial pain syndrome, pain from youth sports, knee pain, back pain and labor pain.4 Improper treatment of acute pain, such as labor or postpartum pain, may lead to chronic pain.5 Anesthesia providers should be familiar with the complexities of delivery, persistent pain and postpartum analgesia.
Pregnancy and giving birth are life-changing experiences.6 Pregnancy affects a patient’s medical symptoms6 and psychology, including changes in body image.7 Additionally, the journey through labor and delivery can be powerful and intense.8 Giving birth involves a patient’s changing circumstances and expectations; a sense of self including the sense of being in a private world, the sense of control, the need for caring and understanding and the need for a sense of security; the physical aspects of labor and delivery; and the first hours of motherhood.8 Both vaginal and Cesarean delivery are associated with significant tissue damage.9 Vaginal deliveries involve uterine contractions, dilation of the cervix and lower uterine segment, stretching and compression of pelvic and perineal structures, inflammation of cervical tissue and tears in the birth canal.9 On the other hand, tissue damage during Cesarean section is related to incisions on the lower segment of the uterus and the skin, as well as traction on abdominal muscles and nerves.9 Overall, giving birth has psychological and physiological implications.
Acute postoperative pain is followed by persistent pain in many individuals after common procedures, such as groin hernia repair, breast and thoracic surgery, leg amputation, coronary artery bypass surgery and knee arthroplasty.10,11 Delivery, whether vaginal or Cesarean, is also associated with persistent pain.9 Though high-quality data are lacking, psychosocial factors, preoperative pain, poorly controlled postoperative pain and nerve injury may be associated with persistent postoperative pain.{Niraj, 2011 #2099} While some researchers have found that higher preoperative pain sensitivity was associated with greater persistent postoperative pain,{Granot, 2009 #2100} others link persistent postoperative pain to inadequate postoperative pain relief.{Joshi, 2005 #2101} Although childbirth is considered a natural event, some deliveries require instrumentation or surgical intervention,{Lavand’homme, 2013 #2102} and all are associated with tissue damage.9 Thus, childbirth, like other procedures, may lead to acute and chronic postoperative pain.9
Anesthesia providers are crucial in the prevention and management of persistent pain after delivery.{Kainu, 2010 #2103} Some researchers have investigated the relationship between type of delivery and risk of persistent pain, with conflicting results.9{Liu, 2013 #2104}{Kainu, 2010 #2103} Degree of tissue trauma does not seem to impact the risk of persistent pain, either.{Lavand’homme, 2013 #2102} On the other hand, acute postpartum pain levels may be associated with persistent pain. Eisenach et al. found that severity of acute postpartum pain was related to persistent postpartum pain and depression.{Eisenach, 2008 #2105} Sng et al. also found that higher pain score recalled in the immediate postoperative period served as an independent risk factor for pain three months after Cesarean section.{Sng, 2009 #2106} According to Sutton and Carvalho, severe pain after Cesarean section is associated with persistent pain, greater opioid use, delayed functional recovery and increased postpartum depression.{Sutton, 2017 #2107} There appears to be no influence of the type of anesthesia used during delivery on persistent pain, as regional versus general anesthesia{Liu, 2013 #2104} or substances like remifentanil9 and ketamine{Bilgen, 2012 #2108} do not influence risk. Researchers suggest that optimal pain management after Cesarean delivery involves multimodal anesthesia including intrathecal morphine, scheduled nonsteroidal anti-inflammatory drugs and acetaminophen; wound instillation with local anesthetics; and other options such as nerve blocks, dexamethasone, gabapentin and ketamine.{Carvalho, 2017 #2109}{Sutton, 2017 #2107} Because 81 percent of women in the United States initiate breastfeeding during the postpartum period, anesthesia providers must consider the possible drug effects on both the mother and infant.5 Though more research is needed to establish the exact causes of persistent pain after delivery, it is clear that acute postpartum pain management is crucial to the mother’s long-term health.
Anesthesia providers are responsible for preventing and treating acute and chronic pain. Patients who undergo significant trauma, such as vaginal delivery or Cesarean section, are at risk for developing persistent pain. In order to avoid chronic pain issues in their patients, anesthesiology practitioners should aim to reduce severity of acute postpartum pain. Future research is needed to investigate the risk factors and treatments for persistent pain after delivery.
1.American Society of Anesthesiologists. Role of Physician Anesthesiologist. When Seconds Count… Physician Anesthesiologists Save Lives 2020; https://www.asahq.org/whensecondscount/anesthesia-101/role-of-physician-anesthesiologist/.
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3.American Society of Regional Anesthesia and Pain Medicine. The specialty of chronic pain management. 2020; https://www.asra.com/page/44/the-specialty-of-chronic-pain-management.
4.American Society of Anesthesiologists. Types of Pain. When Seconds Count… Physician Anesthesiologists Save Lives 2020; https://www.asahq.org/whensecondscount/pain-management/types-of-pain/.
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