Department of Medical Psychology and Psychotherapy, Medical Sociology and Rehabilitation Sciences, Julius-Maximilians-University Wuerzburg, Wuerzburg, Germany.
Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1A, 48149, Muenster, Germany.
Anaesthesiologie. 2023 May;72(5):325-331. doi: 10.1007/s00101-023-01260-w. Epub 2023 Feb 17.
An important task in obstetrics is to offer patients adequate pain management after vaginal delivery (VD) and after cesarean section (CS). The aim of the present analysis was to assess pain intensity at the day after childbirth, after 3 and 6 months in women after VD and after CS. Additionally, it was planned to identify determinants of maternal satisfaction with acute pain therapy following VD and CS.
This secondary analysis of a single-center prospective cohort study included 210 parturients. The women gave birth in the University Hospital of Wuerzburg. They completed a survey before childbirth (P), on the first day (D1), 3 and 6 months after VD and CS. The survey included questions about the expected pain, the experienced pain, the birth, the pain afterwards and also psychological questionnaires. In addition, information was collected from the patient records. Women with planned CS received spinal anesthesia. A secondary CS was performed with an epidural, spinal or general anesthesia. Pain therapy on the ward was standardized. The primary outcomes were acute and chronic pain intensity at rest, during movement, determinants of satisfaction with pain therapy and the wish to have received more pain medication during and after VD and CS (D1).
A total of 175 women completed the survey at all time points and were available for the analysis (drop-out 16.8%). The results confirmed high pain levels at D1 after CS (median pain intensity during movement: 8 NRS points, interquartile range, IQR 6-9 points). After VD pain scores were much lower (median pain intensity during movement: 4 points, IQR 2-5 points). Of the mothers 7.4% reported pain at rest at all time points after VD or CS but pain intensity was low after 3 and 6 months (median pain intensity at rest: 2 points, IQR 0-3 points), 28% received extended-release opioids after CS and 33% of women (VD and CS) had an epidural. The most important influencing factor for lower satisfaction with pain therapy after CS or VD was inadequate pain relief. Women with VD who had an epidural, were more satisfied during delivery than women without but there was no difference at D1.
This study confirmed high acute pain levels following CS and an incidence of chronic pain of around 7% but pain intensity was low and one third received strong opioids after CS. Around 11% of women after primary CS (8% epidural, 3% combined spinal/epidural) and around 55% of women after secondary CS had an epidural, which could be used for pain therapy after birth. Women without an epidural or without opioids may not have had good pain management. The received pain relief appeared to be the most relevant predictor for satisfaction and the wish to have received more pain medication. Mothers having a VD with an epidural catheter were more satisfied with pain therapy during birth than those without. Therefore, a better multimodal pain management (including opioids, epidural and nonopioids) might provide better pain relief and might improve overall satisfaction with pain treatment following CS. Finally, the received pain relief might be a better patient-related outcome measure for satisfaction with pain treatment after childbirth than pain intensity alone.
在妇产科中，一项重要任务是在阴道分娩（VD）和剖宫产（CS）后为患者提供充分的疼痛管理。本分析的目的是评估 VD 和 CS 后产妇在分娩后一天、第 3 个月和第 6 个月的疼痛强度。此外，还计划确定 VD 和 CS 后产妇对急性疼痛治疗满意度的决定因素。
这是一项单中心前瞻性队列研究的二次分析，纳入了 210 名产妇。这些女性在维尔茨堡大学医院分娩。她们在分娩前（P）、分娩后第 1 天（D1）、第 3 个月和第 6 个月完成了一项调查。该调查包括关于预期疼痛、实际疼痛、分娩以及产后疼痛的问题，还包括心理问卷。此外，还从患者记录中收集了信息。计划行 CS 的产妇接受了脊髓麻醉。二次 CS 采用硬膜外、脊髓或全身麻醉进行。病房内的疼痛治疗是标准化的。主要结局是 D1 时的急性和慢性静息疼痛强度、疼痛治疗满意度的决定因素以及在 VD 和 CS 期间和之后希望接受更多疼痛药物治疗的愿望（D1）。
共有 175 名女性在所有时间点完成了调查并可进行分析（失访率 16.8%）。结果证实 CS 后 D1 时疼痛程度较高（运动时中位数疼痛强度：8 NRS 点，四分位距 IQR 6-9 点）。VD 后疼痛评分要低得多（运动时中位数疼痛强度：4 点，IQR 2-5 点）。在 VD 或 CS 后，7.4%的母亲在所有时间点都报告有静息疼痛，但 3 个月和 6 个月后疼痛强度较低（静息时中位数疼痛强度：2 点，IQR 0-3 点），28%的 CS 后患者接受了缓释阿片类药物，33%的女性（VD 和 CS）接受了硬膜外麻醉。CS 或 VD 后疼痛治疗满意度较低的最重要影响因素是疼痛缓解不足。接受硬膜外麻醉的 VD 产妇在分娩过程中比未接受硬膜外麻醉的产妇更满意，但在 D1 时没有差异。
本研究证实 CS 后急性疼痛程度较高，慢性疼痛发生率约为 7%，但疼痛强度较低，三分之一的 CS 后患者接受了强阿片类药物。初次 CS 后（8%硬膜外，3%联合脊髓/硬膜外）约 11%的女性和二次 CS 后约 55%的女性接受了硬膜外麻醉，可用于产后疼痛治疗。未接受硬膜外麻醉或未接受阿片类药物的女性可能没有得到良好的疼痛管理。所接受的疼痛缓解似乎是满意度和希望接受更多疼痛药物治疗的最相关预测因素。接受硬膜外导管的 VD 产妇在分娩过程中比未接受硬膜外导管的产妇更满意疼痛治疗。因此，更好的多模式疼痛管理（包括阿片类药物、硬膜外和非阿片类药物）可能提供更好的疼痛缓解，并可能改善 CS 后整体疼痛治疗的满意度。最后，与疼痛强度相比，接受的疼痛缓解可能是产后疼痛治疗满意度的更好的患者相关结局测量指标。
