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.
The problem of C-section-related pain
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.
Challenges of traditional methods of pain relief after C-section
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.
Who can be at risk of getting post-surgical 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.
Challenges of using medication
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.
Reasons for C-section pain after your operation
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.
Ways to manage C-section pain
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.
- Medications as mentioned earlier can be simple anti-inflammatories/paracetamol/codeine if there’s an infection, but we may also need to start some stronger nerve medication. However, this needs to be tailored alongside the ongoing issues of breastfeeding and the side effects of these drugs. It is better to consult with a specialist to decide if such medication will be required or not.
- I for interventions. When the pain is due to a scar-related irritation of the nerve or is due to a numbness or tingling or superficial pain along the scar, then there may be a role for injections or even steroid-like injections in and around the scar. This again will require you to be reviewed by your specialist to see if that is an option. Deeper infections may require further imaging.
- The N stands for neuroscience and stress management. This specifically refers to the fact that when the nerve sensitivity is ongoing, then signals are often transferred from the scar area. And they are often processed by the brain. And in this situation, other factors that activate the stress system can also amplify the existing pain pathways. So, therefore, it would be useful to then try other stress-relieving strategies that can be helpful in calming the pain down.
- Use of diet and microbiome in the post-natal phase, it is often easier sometimes to opt for processed foods. However, with breastfeeding and considerations around healthy eating, another advantage is the need for focusing on healthy foods and an anti-inflammatory diet. Such a diet can also help in calming the sensitive nerves and an anti-inflammatory diet essentially refers to food that is predominantly whole food plant based consisting of unprocessed foodstuffs with vitamin and mineral supplements as appropriate, alongside an elimination diet predominantly aiming to reduce sugars, dairy or gluten. These are simple strategies that can be done by most people without any harm. However, if you do have any further dietary allergies or intolerances, then it is worth seeking and advice from a specialist before you proceed further in using that strategy.
- Sleep. Another very useful strategy for reducing the sensitivity of the nerves is optimising sleep. This is easily said than done when you have a newborn baby to take care of. However, if you have post-surgical pain, where the nerves are hypersensitive then it is important to seek help and support from family if possible, to ensure that you can optimise your sleep as much as you can. There is now a good understanding that sleep and pain can be often bi-directional, so poor sleep can worsen the pain in the same manner as increasing pain reduces your hours of sleep. One could have a sleep tracker to see which phase of sleep is getting impacted. The aim should be to try improving the REM phase of sleep as this is going to be useful for reducing the sensitivity of your nervous system.
- E is for exercise and physical activity. We all know it is important to keep active after surgery and to start mobilising. This is not just important for good blood flow to your pelvic muscles. This increased blood flow can also help in improving nutrition to the nervous system and can help rewire the nervous system circuits in such a way so as to reduce sensitivity. Hopefully, this will over time, start to show some effect.
- T is for Therapies of Mind and Body. Now there are therapies of mind and body in the sense that calming the nervous system down using non-drug strategies like breathing techniques, yoga, pilates, and CBT can be very useful in other ways of reducing the sensitivity of the nerves. This helps in rewiring the nerve circuits and can helpfully reduce the pain over time.
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.