I’ve had two children – now 19 and 16, and wonderful. At the time of their delivery I can remember both times thinking ‘as long as they’re healthy’ and being not at all worried about having medical intervention if it was needed. My eldest was born with epidural anaesthesia, and my youngest was born completely naturally.
And I am one of those people who ended up with an exacerbation of my chronic pain after delivery, in fact quite specific chronic pain in the area where the epidural was inserted. I recall asking my GP about 12 months later how long the pain was supposed to last, and she was quite surprised I had any pain at all! But now I’ve been reviewing some of the literature around childbirth, and I realise how common having persistent pain can be in women postnatally.
Today’s paper is an editorial discussing the incidence of pelvic pain and other chronic pain after what is described as ‘the most common operation worldwide’ – caesarean delivery. A couple of things surprised me when I read that – I had no idea caesarean delivery was the most common operation (even more than vasectomy?), and I hadn’t realised that the first paper on chronic pain after caesarean was written in 2004. The feminist in me shrugs and says ‘well, it’s only women’s pain and who writes about women’s pain?’ but as I look more into the topic I can see some of the other reasons for the delay in reporting.
Firstly, women often believe that having pain from ‘women’s troubles’ is both normal and to be endured. How many women have at least one day a month with serious cramping from menstruation? Childbirth is meant to be ‘natural’ and women are supposed to be infused with that rosy glow from having successfully brought a life into the world so that any discomfort is overridden with joy and wonder. (…erm can you tell it’s been a while since I had ’em?!) So many women are incredibly busy simply keeping up with feeding, changing, sleeping that personal pains are ignored – and then if pain is reported, what pharmacologic solutions are available that don’t interfere with breastfeeding?
This editorial points out several other problems associated with assessing chronic post-surgical pain in women – the definition of chronic post-surgical pain is pain that has persisted for 2 – 3 months after the procedure. Recall of pain is not especially accurate, and especially the intensity and impact of pain if it is retrospectively collected. Despite this, one study found that 18% of women reported pain 12 months after caesarean, while 10% reported pain after vaginal birth.
At first glance this prevalence looks reasonably low – after all, postamputation pain affects up to 50% of patients. However, as the editorial points out, as childbirth is so common, small percentages add up to a significant number of women. And these women are carrying out some of the most important (and fatiguing) work in the world – raising kids. Two studies are used to identify that pain at 2 months post-delivery affects 20 – 25% of women carrying out daily activities, and continues to interfere with daily activities in 14-15% at one year or longer.
What are the risk factors for chronic pain in women after childbirth? It seems that reporting high levels of pain in the first few days after delivery (6/10 or more) increases the risk of persistent pain, and this increased the risk of postpartum depression compared with mild pain after delivery.
Severe, poorly managed postoperative pain after any surgery is a risk for developing chronic pain. Other risk factors for postsurgical chronic pain include having chronic pain prior to surgery, regular use of analgesics, and anxiety. Perioperative risk factors include the depth of anaesthesia – spinal anaesthesia is more effective at reducing central sensitisation (so yes, I want my epidural!), and intrathecal anaesthesia for elective caesarean is also associated with less pain in the first 24 hours compared with epidural anaesthesia.
There doesn’t seem to be a great difference between having vaginal birth or caesarean delivery in terms of developing chronic pain, but ‘uterine exteriorisation’ increases visceral pain during the first 24 hours after surgery compared to in situ repair. Parietal peritoneum closure also increases postoperative pain and is associated with persistent pain and discomfort 8 months after caesarean delivery.
Really good postoperative pain management seems to be one of the best ways to reduce the risk of chronic pain after surgery. This is difficult if women don’t want to take medications that might interfere with breastfeeding (or cost too much in financial terms or in side-effects) It’s perhaps time that midwives and others worked hard to help women not only access pain medication, but more importantly, to use nonpharmacologic coping strategies to help cope.
I would love to read about a study in the future showing that midwives and others routinely help women to cope with post-partum pain in the same way they prepare women for delivery – they’re skills that are portable, free, have no calories – and the side effects are minimal.
Lavand’homme, P. (2009). Chronic pain after vaginal and cesarean delivery: a reality questioning our daily practice of obstetric anesthesia International Journal of Obstetric Anesthesia DOI: 10.1016/j.ijoa.2009.09.003