Expert / 25 July, 2022 / My Baba
Did you know that up to one out of every five women can be left with chronic pain following a Caesarean section? C-section pain post op is common, and Caesarean sections are one of the most common operations performed. It is one of the safest surgeries that can be offered to facilitate childbirth for a variety of reasons. However, we now realise that up to one out of every five C-section patients can be left with chronic pain due to a number of reasons after surgery. This kind of pain is often referred to as neuropathic pain indicating that there is likely to be some form of nerve damage as a result of the incision or sometimes during the process of healing that can trap very tiny nerves in the scar tissue. Either way, this can leave a young mother with significant pain which will impact not only her own quality of life but also affects her ability to look after her newborn.
It is accepted that recovery after a Caesarean section is likely to be more painful as it is major abdominal surgery. More than 25% of all deliveries in the United Kingdom are born by Caesarean section so this is a very common surgery that is performed in most NHS hospitals. Acute pain is often most severe in the first few days and does respond to painkillers like paracetamol and nonsteroidal anti-inflammatory (NSAIDs) medications like Nurofen. Medications such as codeine or stronger opioids such as tramadol or morphine may be required for some patients but it is unusual for this to be needed after discharge. Pain often settles in the first few weeks but when pain continues to persist beyond 12 weeks and cannot be explained by any other processes such as infection or fever then it is most likely to be chronic post-surgical neuropathic pain.
Anything that puts stress on the incision such as bending forward or sitting can cause discomfort and worsen the pain in the immediate few days after surgery. At this time use simple non-drug techniques such as a pillow to splint the incision site when you laugh or cough. Using loose-fitting clothing and avoiding any other pressure on the incision site can also help in healing quicker.
Using medication such as paracetamol and codeine is often the most common way to help pain at the incision site. When the pain is severe, they can take stronger drugs belonging to the morphine class to help reduce or manage pain.
There are now studies that point to the fact that when people are more anxious as a baseline personality or they already have pain in another area, then their pain experience is likely to be amplified in such circumstances after C-section surgery. People who sustain an infection at the scar site or deeper inside are also at risk.
One challenge of giving stronger medication is the willingness of new mothers to take such medication which can have many side effects like drowsiness, lightheadedness and nausea. We also have to be careful with stronger medication if the mother is considering breastfeeding as there can be a transfer with these drugs through breast milk.
In most patients, the acute pain experienced after a Caesarean section does tend to reduce in the first few weeks and responds to simple pain medication such as paracetamol and codeine and sometimes slightly stronger medication such as tramadol. Anti-inflammatories can also be used in some patients with great effect. However, when the pain lasts beyond 12 weeks it can then referred to as post-surgical neuropathic pain after Caesarean section.
The common reasons in the acute post-operative period can be infection or nerve damage. Infection can be in the superficial scar because of the stitches or it can be in the inner layers below the skin, which can be in the muscles or even the lining around the intestine. There can be a deeper infection within the pelvis. Another reason for pain can be nerve damage that can occur at the site of surgery.
Usually, acute pain stops after two to four weeks. However, when pain persists longer than 12 weeks, then this becomes known as chronic pain. This is usually due to a nerve hypersensitivity at the site of the surgery. This nerve hypersensitivity can be because of the nerve being irritated by the scar or by an infection or it can be a hypersensitive nerve after being cut during surgery.
It is important to know what kind of pain is likely to be responsible for the continuing discomfort after 12 weeks. As I mentioned, if there is an ongoing infection, then it is important to address the source of the infection. You may need to be seen by your specialist and further investigations including scans of blood tests may be required.
If an infection is known to be present, then it may require antibiotics or a surgical clearance depending on how deep or superficial the infection is. In the presence of infection. it is likely that drugs like paracetamol or even opioids like morphine, or even anti-inflammatories are likely to work.
However, if nerve damage is known to have occurred, or the pain is due to nerve hypersensitivity, then this is not likely to respond to the usual medications like paracetamol codeine / Tramadol. This may require stronger medication such as amitriptyline or Gabapentin which are specifically meant for calming the nerves down.
It is important to use a framework when the pain is not just due to infection. If it’s due to nerve hypersensitivity, then calming the nerves can be achieved by many other strategies and not just medication.
My framework goes by the acronym of MINDSET. In this, the M stands for medications.
Often put these strategies together to form your own toolkit. In many cases, using a combination of these techniques can help in reducing the pain significantly with fewer side effects. Creating a toolkit that can be of benefit and hopefully more personalised should be the aim of helping overcome pain.
Expert article by Dr. Deepak Ravindran, @drdeepakravindran
Dr. Deepak Ravindran is a multi-award-winning pain expert focussed on educating people and debunking myths. He is the best-selling author of The Pain-Free Mindset.