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Determinants of satisfaction with acute pain therapy during and after childbirth

Einflussfaktoren auf die Zufriedenheit mit der peripartalen Schmerztherapie

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Abstract

Background

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.

Methods

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).

Results

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.

Discussion

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.

Zusammenfassung

Hintergrund

Eine zentrale Aufgabe in der Geburtshilfe ist es, Patientinnen nach Spontanpartus (SP) und insbesondere nach Kaiserschnitt (KS) eine adäquate peripartale Schmerztherapie anzubieten. Ziel der vorliegenden Studie war es, Schmerzintensitäten nach einer Geburt zu erfassen sowie Einflussfaktoren auf die Zufriedenheit mit der Schmerztherapie während und nach der Geburt zu identifizieren.

Methodik

Die vorliegende Sekundäranalyse einer prospektiven Längsschnittstudie umfasste 210 Patientinnen. Diese füllten pränatal, einen Tag, 3 sowie 6 Monate nach Geburt einen Fragebogen aus. Als primäre Endpunkte fungierten die Schmerzintensitäten in Ruhe und bei Belastung (Median [Interquartile Range, IQR]), die Zufriedenheit mit der Schmerztherapie sowie der Wunsch nach mehr Schmerztherapie während der Geburt und am ersten postpartalen Tag.

Ergebnisse

Einen Tag nach einem KS zeigten sich sehr hohe Schmerzintensitäten (mediane Schmerzintensität bei Belastung: 8 NRS-Punkte [6–9]). 28 % der Frauen erhielten nach einem KS retardierte Opioide. 7,4 % aller Mütter gaben Schmerzen zu allen Zeitpunkten an, wobei die Schmerzintensität nach 3 bzw. 6 Monaten niedrig war (mediane Intensität in Ruhe: 2 NRS-Punkte [0–3]) Als wichtigster Einflussfaktor für die Zufriedenheit mit der Schmerztherapie konnte in der Kohorte eine stärkere Schmerzlinderung identifiziert werden.

Diskussion

In der vorliegenden Studie bestätigten sich hohe Schmerzintensitäten nach KS im Gegensatz zu niedrigeren Schmerzintensitäten nach SP sowie eine Inzidenz von 7 % mit chronischen postoperativen Schmerzen – aber von geringer Intensität. Eine ungenügende Schmerzlinderung war der wichtigste Einflussfaktor für eine geringere Zufriedenheit und einen stärkeren Wunsch nach mehr Schmerztherapie. Eine suffiziente multimodale Schmerzbehandlung (retardierte Opioide, Regionalanästhesieverfahren, nichtmedikamentöse Verfahren) mit Fokus auf eine adäquate Schmerzlinderung könnte einen Beitrag zu Verbesserung der Zufriedenheit leisten.

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Abbreviations

COS:

Core outcome set

CS:

Cesarean section

D1:

First day after vaginal delivery and cesarean section

IQR:

Interquartile range

M:

Median

3M:

3 months after vaginal delivery and cesarean section

6M:

6 months after vaginal delivery and cesarean section

NRS:

Numeric rating scale

P:

Pregnant

PCS:

Pain catastrophizing scale

PRO (M):

Patient-related outcome (measures)

VD:

Vaginal delivery

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Authors and Affiliations

  1. Department of Medical Psychology and Psychotherapy, Medical Sociology and Rehabilitation Sciences, Julius-Maximilians-University Wuerzburg, Wuerzburg, Germany

    Kathrin Schnabel

  2. Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Albert-Schweitzer Campus 1A, 48149, Muenster, Germany

    Kathrin Schnabel &  Alexander Schnabel MD

  3. Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany

    Ann-Marie Drusenbaum, Peter Kranke, Patrick Meybohm &  Alexander Schnabel MD

  4. Department of Obstetrics and Gynecology, University Hospital of Wuerzburg, Wuerzburg, Germany

    Achim Wöckel

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  1. Kathrin Schnabel
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  3. Peter Kranke
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  4. Patrick Meybohm
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  6. Alexander Schnabel MD
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Corresponding author

Correspondence to Alexander Schnabel MD.

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Conflict of interest

K. Schnabel, A.-M. Drusenbaum, P. Kranke, P. Meybohm, A. Wöckel and A. Schnabel confirm that there is no conflict of interest.

All procedures performed in studies involving human participants or on human tissue were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Additional information

The authors K. Schnabel and A.-M. Drusenbaum contributed equally to this work.

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Schnabel, K., Drusenbaum, AM., Kranke, P. et al. Determinants of satisfaction with acute pain therapy during and after childbirth. Anaesthesiologie 72, 325–331 (2023). https://doi.org/10.1007/s00101-023-01260-w

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  • DOI: https://doi.org/10.1007/s00101-023-01260-w

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