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Rectus Muscles Closure at Cesarean Delivery Increases Post-operative Pain
Abstract Number: T-54
Abstract Type: Original Research
Introduction: Different surgical closure techniques for cesarean delivery, such as closure of the peritoneum, may impact post-operative pain and analgesic requirements.(1) The aim of this prospective study was to investigate whether closure of the rectus muscles at cesarean delivery increases post-operative pain and analgesic use.
Methods: Healthy women > 35 weeks undergoing primary cesarean delivery prior to labor were the study population for this IRB-approved, randomized, double-blind study. Patients were randomized either to closure of the rectus muscles (with three interrupted sutures), or non-closure. Intra-operative (spinal anesthesia with intrathecal bupivacaine, fentanyl and morphine) and post-operative pain management (multimodal analgesia with acetaminophen, NSAIDs and opioids) was standardized within the study protocol. The primary outcome was the combined opioid use and movement pain score using the Silverman Integrated Assessment (SIA) score.(2) Total opioid use was determined using standardized relative-potency conversion scales. Verbal numerical pain scores (0-10) were assessed at rest and with movement at 24, 48, 72 hours and 6 weeks post-operatively, and area-under-the-curve (AUC) 0-72 h was calculated. Maternal satisfaction with pain management was also assessed. Appropriate parametric and non-parametric statistics were applied with P<0.05 considered statistically significant.
Results: 63 women were enrolled and randomized into the study. Thirty five women underwent closure of the rectus muscles, and 28 underwent non-closure. Demographic and obstetric variables were similar between groups. The SIA combined opioid use and movement pain scores were higher in the rectus closure group (-31±78% vs. +15±100%; p = 0.043). Opioid use was 30 mg (18-45) and 20 mg (12-35) in the closure and non-closure groups respectively (p = 0.152). There were no significant differences in rest and movement pain scores at 24, 48 and 72 hours and 6 weeks between the groups. There was a trend toward lower AUC 0-72 h movement pain scores in the rectus closure group (p = 0.083). Maternal satisfaction was high in both groups; 85% (73-90) and 90% (75-100) in the closure and non-closure groups, respectively (p = 0.155).
Conclusion: Closure of the rectus muscles at cesarean delivery appears to increase combined post-operative movement pain and opioid use. Findings suggest that the cesarean technique should be considered when planning analgesic protocols and anticipating postoperative pain and analgesic requirements.
1. J Obstet Gynaecol. 2011; 31(4):307-10.
2. Anesth Analg 1993; 77:168-170.