Predicting Severity of Acute Pain After Cesarean Delivery: A Narrative Review

Abstract

Cesarean delivery is one of the most common surgical procedures in the United States, with over 1.3 million performed annually. One-fifth of women who undergo cesarean delivery will experience severe pain in the acute postoperative period, increasing their risk of developing chronic pain and postpartum depression, and negatively impacting breastfeeding and newborn care. A growing body of research has investigated tools to predict which patients will experience more severe pain and have increased analgesic consumption after cesarean delivery. These include quantitative sensory testing, assessment of wound hyperalgesia, response to local anesthetic infiltration, and preoperative psychometric evaluations such as validated psychological questionnaires and simple screening tools. For this review, we searched MEDLINE, the Cochrane database, and Google Scholar to identify articles that evaluated the utility of various tools to predict severe pain and/or opioid consumption in the first 48 hours after cesarean delivery. Thirteen articles were included in the final review: 5 utilizing quantitative sensory testing, including patient responses to pressure, electrical, and thermal stimuli; 1 utilizing hyperalgesia testing; 1 using response to local anesthetic wound infiltration; 4 utilizing preoperative psychometric evaluations including the State-Trait Anxiety Inventory, the Pain Catastrophizing Scale, the Pittsburgh Sleep Quality Index, the Hospital Anxiety and Depression Scale, and simple questionnaires; and 2 utilizing a combination of quantitative sensory tests and psychometric evaluations. A number of modalities demonstrated statistically significant correlations with pain outcomes after cesarean delivery, but most correlations were weak to modest, and many modalities might not be clinically feasible. Response to local anesthetic infiltration and a tool using 3 simple questions enquiring about anxiety and anticipated pain and analgesic needs show potential for clinical use, but further studies are needed to evaluate the utility of these predictive tests in clinical practice.

Application of preoperative assessment of pain induced by venous cannulation in predicting postoperative pain in patients under laparoscopic nephrectomy: a prospective observational study

“…There are some limitations to the present study. Known risk factors of postoperative pain are female gender, lower age, preoperative pain, intraoperative factors and psychological factors, and so on [8,[19][20][21]. Furthermore, it was reported that psychological factors were correlated with venous cannulation-induced pain score [22].…”

Application of preoperative assessment of pain induced by venous cannulation in predicting postoperative pain in patients under laparoscopic nephrectomy: a prospective observational study

“…Numerous studies have been developed to predict postoperative pain in the last decade. The pain intensity of QST stimuli, including pressure, electric, and thermal stimulus, have been reported to correlate with the intensity of postoperative pain [6][7][8][14][15][16][17]. Werner et al [18] reported that QST assessments might predict up to 54% of the variance in the postoperative pain experience.…”

“…There are some limitations to the present study. Known risk factors of postoperative pain are female gender, lower age, preoperative pain, intraoperative factors and psychological factors, and so on [8,[19][20][21]. Furthermore, it was reported that psychological factors were correlated with venous cannulation-induced pain score [22].…”

“…Numerous studies have tried to identify patients who are at risk for postoperative pain in the preoperative period and evaluated the role of psychological factors and experimental pain tests or quantitative sensory tests (QST) [4][5][6][7][8]. However, none of those prediction methods has been used as a routine for prediction of postoperative pain, mainly because expensive equipment, much time and effort are required outside routine preoperative procedures.…”

Comparison of Postoperative Opioid Consumption and Pain Scores in Primary Versus Repeat Cesarean Delivery in Opioid Naïve Patients

“…However, it is still common for anesthesiologists and obstetricians to prescribe opioids postoperatively, as severe pain after CD is a predictor for poor outcomes including chronic pain, post-partum depression, and difficulty with breastfeeding and infant care [3][4][5]. Given this disconnect between recommended guidelines and current clinical practice, identifying factors that may link to higher pain scores and opioid consumption is of particular importance [8,9].…”