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The impact of labor prior to cesarean delivery on postoperative pain and opioid consumption
Abstract Number: F-21
Abstract Type: Original Research
Introduction: Severe acute post-cesarean pain has been associated with an increased risk for persistent pain and postpartum depression . Identification of women at increased risk for pain can be used to optimize post-cesarean analgesia . To our knowledge, the impact of labor prior to cesarean delivery (CD) on acute post-operative pain has not been evaluated. We hypothesized that labor prior to CD, which has been associated with maternal exhaustion, affective distress related to an unexpected CD, and greater surgical trauma, would result in hypersensitization, higher postoperative pain scores and increased opioid intake.
Methods: Women undergoing CD at six academic medical centers in the United States between 9/2014 and 3/2016 were contacted by phone two weeks following discharge . Participants completed a structured interview that included questions about their postoperative pain scores and opioid utilization. They were asked to estimate their maximal pain score on an 11-point numeric rating scale at multiple time points, including day of surgery, during hospitalization, immediately after discharge, 1st week, and 2nd week following discharge. Pain scores over time were assessed utilizing a generalized linear mixed-effects model, with the patient identifier being a random effect, adjusting for an a priori defined set of confounders. A multivariate negative binomial model was utilized to assess the association between labor prior to CD and opioid utilization after discharge, also adjusting for the same confounders. In the context of non-random prescription distribution, this model was constructed with an offset for the number of tablets dispensed.
Results: A total of 720 women were enrolled, 392 with and 328 without labor prior to CD. Patients who labored prior to CD were younger, less likely to be undergoing repeat CD or additional surgical procedures, and more likely to experience a complication of CD.
Pain scores on the day of surgery were higher in women with labor prior to CD (median 6, IQR 4 to 8 versus 5, IQR 3 to 7; p<0.01) even after adjustment for confounders (p<0.01). Pain scores at other time points were not different between the two groups. Women with labor prior to CD consumed more opioid tablets following discharge than women without labor (median 20, IQR 10 to 30 versus 17, IQR 6 to 30; p<0.01). This association persisted after adjustment for confounders (incidence rate ratio 1.16, 95% CI 1.05 to 1.29; p<0.01).
Discussion: Women who labored prior to CD had worse pain on the day of surgery, but not other time points. Opioid requirements following discharge were modestly increased.
1)Eisenach et al, Pain. 2008 Nov;140(1):87-84
2)Booth et al, Anesth Analg. 2016 Apr;122(4):1114-9
3)Bateman et al, Pharmacoepidemiology and drug safety 2016; 25(Suppl. 3): 3–680.