More than just pain relief: A study of postpartum, post-caesarean pain management

AUbTRALIAN COLLEGE OF MIDWIVES INCORPORATED

MORE T H A N JUST PAIN RELIEF: A S T U D Y OF POSTPARTUM, POST-CAESAREAN PAIN MANAGEMENT P r e s e n t e d a t the A C M I 9 t h B i e n n i a l Conference, September, 1995 Marie Barton S R N SCM B E d (Nurs)

Introduction and Literature Review Achievement of effective control of acute and chronic pain, with minimal side effects, has been the subject of extensive research, particularly in the last decade. Prior to 1980, intramuscular narcotic injections were the main method of achieving relief of severe pain, particularly acute, post-operative pain. Since the first reports on intrathecal and epidural opioids in 1979, and the later development of reliable syringe infusion pumps, there has been an increase in the use of epidural opioids and intravenous narcotic infusions. This study examines maternal responses to post Caesarean analgesia, using self care and infant care goals as a means of comparing the effectiveness of methods of pain relief. The relationship between anaesthetic and maternal activities is also examined. The study also focuses on the amount of analgesia, including supplementary analgesia, received and aspects of medical and nursing management of post-operative pain in the subjects studied.

benefits of epidural morphine well outweighed the risks. These include the well established technique of epidural catheterisation, the duration and quality of analgesia, which is better than opioids given by other routes, and the absence of motor blockade which allows the patient to be more mobile. Epidural morphine has a slower onset (approximately 35 minutes) but is longer lasting than equianalgesic doses of other epidural narcotics and has a good dose related analgesic duration (Cousins and Mather, 1984). This makes it the drug of choice for postoperative analgesia, though there are wide individual difference in the duration of effective analgesia. Glynn (1987) attributes this to the wide variation in the amount of drug transferred across the dura to the cerebrospinal fluid. This is a disadvantage of epidural opioids, compared with intrathecal opioids.

In 1979, the first reports of the effective use (in humans) of morphine by the intrathecal (Wang et al, 1979) and epidural (Behar et al, 1979) routes, appeared. During the next few years many case reports were written, covering a diverse range of clinical applications of spinal and epidural opioids (Cousins and Mather, 1984). Side effects included nausea and vomiting (associated with all opioids), pruritis, urinary retention and respiratory depression, particularly with morphine (Cousins and Mather 1984; Glynn, 1987).

In 1982, the development of a special, programmable syringe pump enabled self administration of small preset doses of (intravenous) narcotic at frequent, regular, predetermined intervals patient controlled analgesia or PCA (Bennett et al, 1982, cited in Kleiman et al, 1987). Later syringe p u m p s allowed a b a c k g r o u n d infusion in addition to the bolus dose capability, overcoming the problem of incidental or breakthrough pain. PCA (with b a c k g r o u n d infusion) has the advantages of improved pain relief, less nursing staff time taken up with administration of analgesia and high patient satisfaction attributed to a sense of control over pain (McCaffery, 1987b). Steady pain relief may also be obtained via a continuous intravenous (IV) narcotic infusion, provided provision is made for adjustment of the infusion rate according to patient needs.

While the incidence of significant respiratory depression with epidural morphine is very low, respiratory changes may persist for up to 24 hours (Cousins and Mather, 1984), necessitating dose observation during this period. However, Glynn (1987) and others concluded that the

The long established method of intramuscular (IM) narcotic injections for pain control causes sharp rises and falls in serum narcotic levels, leading to what may be described as peaks of sedation and valleys of pain. This may be overcome to some degree by regular injections at

Methods of pain control

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fixed intervals. The more stable blood levels obtained by regular round-the-clock doses gives better pain control, reducing patient anxiety and may permit a lower dose (Goodinson, 1986). Hence, provided regular scheduled doses are given, IM narcotic injections should provide appropriate post-operative analgesia for surgery such as Caesarean section, where severe pain is unlikely to be a problem beyond 48 hours.

A follow up study of 130 past Caesarean patients randomly allocated to IM pethidine or infusion p u m p (PCA) found that the PCA group had overall better pain relief at higher, but still safe, doses of narcotic (Rayburn et al, 1988). There was less sedation and a higher level of activity in the PCA group. In order to provide more effective pain relief where IM narcotics are used, Macdonald (1990) suggests that they should be given 'on demand', and 'in anticipation' of pain, rather than waiting until the patient is in severe pain.

Post Caesarean analgesia Kotelko et aL (1984) studied 276 consecutive patients w h o received 5 mg epidural morphine following Caesarean delivery. The researchers looked at overall pain reliefl the time lapse to request for more analgesia and the incidence of adverse side effects. The major side effects were nausea (18%), vomiting (11%) and pruritus (68%) though only 28% requested treatment for the latter. No respiratory depression (<10 r.p.m.) was observed. Although 83.3% rated the quality of pain relief from the epidural narcotic as good or excellent, 48.2% requested additional analgesia within 24 hours, with 16.7% rating their pain relief as nil or poor, illustrating the wide variation in duration of analgesia described by Glynn. In what may be the most extensive 'clinical trial' epidural morphine bas been used successfully for postpartum, post surgical pain at the University of California San Francisco (UCSF) medical Centre since 1980 (Inturrisi et al, 1988). The authors stress that the focus in the postpartum period should be on resumption of activities of daily living and the care of the n e w b o r n . . .' not on maternal pain and discomfort. This can be achieved only with effective pain relief. Patients are assisted to mobilise and interact with their infants as soon as the epidural (local) anaesthetic wears off, usually within 1-2 hours. While staff at UCSF Medical Centre found that patients receiving epidural morphine postpartum require more frequent observation, this is balanced by the absence of time consuming interventions such as administration of other narcotics, the need for frequent turning, d e e p breathing and coughing, or trying to motivate sedated or undermedicated patients to ambulate. A random patients, analgesia, (1988) we JUNE IcX)O

prospective study of 60 post Caesarean with epidural, IV (PCA) e n d IM was conducted by Harrison and others received by the PCA and IM groups.

Pain In a review of current methods of pain relief following Caesarean Macdonald (1990) points out that pain is a subjective experience, involving anxieW, fear, fatigue and resentment, as well as physical discomfort. The fact that approximately o n e third will obtain relief f r o m p l a c e b o medication does not mean the pain is not real. It merely illustrates the complex nature of pain. Cohen (1980) interviewed 109 surgical patients and assessed the responses of 121 nurses in six surgical wards in five Illinois hospitals, to evaluate the adequacy of post-operative pain relief and the nurses' approach to analgesia for their patients. The patients had undergone uncomplicated, elective abdominal surgery, with no prior surgery, and had a PRN order for one or more narcotic analgesics. Moderate to marked distress due to pain was reported by 75.2%, supporting similar findings by Marks and Sachar (1976) and an earlier study by the same author (both cited in Cohen, 1980). Only four of the patients with marked pain distress had b e e n given analgesia equivalent to that prescribed, 87.6% experienced a return of pain prior to their next dose and 37.6% stated that they were in severe pain for an hour before receiving medication, Responses to the questionnaire s h o w e d that nurses were unduly concerned about the risks of addiction, choices of drugs and doses which were often inappropriate, and a lack of basic knowledge about the drugs m use. Other studies report similar findings. An Australian study (Chapman et al, 1987) looked at the attitudes and knowledge of 86 registered-nurses in relation to m a n a g e m e n t of post-operative pain. Whilst overall knowledge was sound, there were m a r k e d deficiencies in application of that

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knowledge. Donovan (1988) suggested that nurses were administering only one quarter of the analgesics prescribed and that pain was not being assessed properly. D o n o v a n also found that there was a mistaken belief that patients w h o were able to sleep were not in pain. Clemmson and Sharp (1986) suggest that nurses overestimate the degree of relief obtained with analgesia and underestimate the level of pain felt, while medical staff do not appreciate the variations in effective analgesic doses. The authors continue, as nurses have more sustained patient contact, they have a dual responsibility to plan/evaluate nursing care and to assess/report on the efficacy of treatments prescribed by others. McCaffery (1987a) warns that if the patient is already in pain, it's past time for the next injection. For those w h o would still hesitate, McCaffery concludes,

"If you feel it's unnecessary to give a scheduled analgesic w h e n the patient's not in pain, remind yourself that you wouldn't wait until a diabetic patient showed signs of coma before administering his daily insulin."

Background The Royal Women's Hospital Brisbane, a major teaching hospital and tertiary referral centre with 6000 deliveries per annum, has an average of 135 Caesarean births per month. Whilst a small number of anaesthetists used epidural morphine for their private patients from 1982, this form of post Caesarean analgesia only became the method of choice in recent years. Similarly, continuous IV narcotic infusions were not used on a regular basis. In 1990, 8 programmable syringe p u m p s and 6 Graseby PCAS (Patient Controlled Analgesic System) p u m p s were acquired. As these methods of post-operative analgesia have been used on a regular basis for some years, it seemed appropriate to attempt to evaluate their success. Studies reviewed focused on the effectiveness of past-surgical analgesia in terms of measured pain relief, patient satisfaction and the incidence of side effects. Only two (lnturrisi et al, 1988; Harrison et al, 1988) mentioned improved ability to resume self care activities and interaction with/care of their n e w b o r n as a reason for selection of a particular type of analgesia. Yet, PAGE 16

this seems the most assessing effectiveness,

appropriate

means

of

Methodology Subjects were all w o m e n undergoing Caesarean delivery over a four w e e k period. Those with significant morbidity (for example severe preeclampsia, concurrent major surgery such as hysterectomy, or post operative complications likely to affect mobility ) were excluded from the study. Following a literature review end discussion with senior staff in the areas involved, a pre-coded questionnaire was developed. This was distributed to the clinical areas concerned, together with written information about the p r o p o s e d study. After time for discussion, a one w e e k trial was conducted and minor modifications were made as a result of feedback from staff and problems detected by the researcher. The 50 item, pre-coded questionnaire was in three parts: part A covered relevant background information and details of surgery, anaesthesia and analgesia; parts B and C related to the first and second 24 hour periods post-operatively. Part A was completed by the nurse in charge of the case and parts B and C by the midwife caring for the patient each shift, during the first 48 hours post-operatively. Time was calculated from transfer from theatre to recovery room, a time normally recorded by theatre staff. Patient consent (verbal) was obtained by the primary nurse (midwife) caring for the patient. Selected self care goals recorded were: time of sitting out of bed, mobilising to the shower/toilet (with assistance, then independently) and passing urine. Infant care goals were: feeding infant (holding infant without assistance), attending to infant in cot (eg. n a p p y change) and picking up infant from cot. Additional information recorded included side effects such as nausea/vomiting, pruritus or respiratory depression, and extra medication required. Completed forms were placed in a ward folder and collected on a daily basis. If necessary, staff were asked to confirm or clarify items w h i c h a p p e a r e d incorrect or incomplete. At the conclusion of the study period, each patient's chart was examined in detail, particularly the anaesthetic, medication and observation sheets and progress notes, to check the information on the completed data sheets and

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to obtain more detailed information on medications, response to analgesia and any problems during the post-operative period.

Results One hundred and twenty one ( 1 2 1 ) Caesareans (C/S) were recorded during the study period, of these, 47 were primiparas. Seventeen (17) respondents were outside the inclusion criteria, leaving a sample of 104, with 65 elective and 39 immediate cases. Mean age was 29.3 (range 18-44). There were no differences in group means for age, whether cases were grouped according to type (elective C/S, i m m e d i a t e C/S) anaesthesia, analgesia or status (public or private patient). The majority of cases, 79 (76%), were performed under epidural anaesthesia (EPI), with 29 (18%) receiving a general anaesthetic (GA) and the remaining 6 (6%) receiving a variety of other methods (OTHER), alone or in combination, that is, epidural, spinal, general or local anaesthesia. Post-operative analgesia consisted of epidural morphine 60 (58%), IV narcotic 38 (36%) and 1M narcotic 6 (6%). Of the IV narcotic infusions, 14 were PCA (with background infusion) and 24 continuous infusions (with the rate able to be adjusted within a prescribed range). There were significant differences in achievement of self care goals with each type of anaesthesia, with only those patients w h o received epidural anaesthesia achieving these goals within 24 hours (37%), and 94% succeeding within 48 hours (X 2 = 27.41, DF = 4, p<.01). Similar findings were obtained w h e n analgesia and self care goals were examined (Table 1). Other anaesthetic/analgesia combinations and self care goals achieved are shown in Table 2, From this it seems that the combination of epidural anaesthetic with epidural analgesia was the most successful. In the 81 cases where the infant was admitted to the postnatal ward with the mother, both epidural anaesthesia and analgesia were associated with a significantly higher level of achievement of infant care goals than other forms of anaesthesia or analgesia (Tables 3, 4). Of the 23 infants admitted to special or intensive care nurseries, 14 were visited within 24 hours (and a further 6 within 48 hours). In two out of the three cases where the infant was not visited, the mother had received a GA. JUNE 1996

The type of Caesarean also affected the achievement of self care goals. While level of achievement was similar for the first 24 hours (27.7% for elective C/S and 28.2% for immediate C/S) only 7.7% of patients w h o had an elective C/S failed to achieve within 48 hours, c o m p a r e d with 25.7% of those w h o had an immediate C/S ( X 2 = 6.887, DF = 2, p<.05). However, there was no difference between type of Caesarean and achievement of infant care goals, with 63% in each group achieving these goals within 48 hours. N a u s e a o c c u r r e d m o r e f r e q u e n t l y with IV narcotics, 63% requiring anti-emetics in the first 24 hours and 26% during the second 24 hour period, c o m p a r e d with epidural narcotic (37%, 7%) and IM narcotic (33%, 16%) respectively. However, pruritus was more of a problem with those receiving the epidural narcotic, an incidence of 75%, with 58% receiving treatment with promethazine (Phenergan). The incidence was 8% (3% requiring treatment) with IV narcotics and nil with IM narcotics. There was only one reported case of mild respiratory depression, in a patient with IV analgesia (PCA morphine). This responded to a reduction in the bolus dose of narcotic available. Epidural morphine was the preferred analgesia for public patients, 79% of all cases c o m p a r e d with 58% of private eases. The majority of public patients (89%) received 3mg (one 2mg) epidural morphine, whereas private patients were more likely to receive 4-5rag (65%). During the first 24 hour period, 5% of public patients received additional narcotics c o m p a r e d with 17% of private patients. In the second 24 hour period this increased to 27% (public). 39% (private) and after 48 hours 13% (public), 26% (private). Of the 29 private patients w h o received IV narcotics, 22 were continuous infusions and 7 PCA (duration 14-63 hours). Continuous infusions were used for 2 public patients and 7 received PCA (duration 20-48 hours). Most infusions (55%) were continued for 24 to 36 hours. Three of the five whose infusion was ceased within 24 hours received additional narcotics during that period. The n u m b e r receiving additional IM narcotics in the 24-48 hour period, and for 48 hours, was similar for public and private patients, 33% (public) and 34% (private) in both cases. The latter included the two private patients w h o s e infusions were continued b e y o n d 48 hours,

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Only six patients, five of w h o m were private patients, received IM narcotics as their primary p o s t - o p e r a t i v e a n a l g e s i a . T h e n u m b e r of injections given ranged from 1-9 over the 48 hours post-operatively, with a m e a n interval of 6.06 hours between doses, excluding the patient w h o received the single dose (expressing a preference for oral medication). It is interesting to note that this patient did not achieve either self care or infant care goals during the 48 hour postoperative period and required IM narcotics on days three and four.

Discussion Using achievement of self care and infant care goals as the means of determining the effectiveness of post Caesarean analgesia, epidural morphine provided greater ability to mobilise and interact with the newborn, particularly w h e n it was combined with epidural anaesthesia for surgery, This was particularly evident during the first 24 hours post-operatively, w h e n only those w h o had an epidural anaesthetic were able to mobilise effectively (Table 2). This suggests that the type of anaesthetic is more likely to influence the ability to undertake self care activities, during the first postpartum day, than the type of postoperative analgesia. However, after 24 hours analgesia b e c o m e s more relevant. Whilst they may well be an effective form of pain relief, IV narcotics (continuous or PCA) were not as successful, in terms of facilitating self care and assisting the mother to care for her infant, as were other forms of analgesia. It may be that being attached to infusion tubing and the associated infusion a p p a r a t u s restricts mobility, either physically or because of fear of dislodging the IV caunula. Patients with IV narcotic infusions were more highly represented a m o n g those w h o did not achieve the selected self care goals within 48 hours than the epidural or IM narcotic group (Table 1). The IM narcotic group was too small to draw any conclusions about the effectiveness of IM narcotics. Only one of the six was unable to accomplish her self care goals, but three out of four (75%), whose infants were in the wards with them, did not achieve the selected infant care goals, suggesting that they may have been too uncomfortable to do so. PAGE 18

What is of more concern is the irregular, and mostly infrequent, administration of prescribed IM narcotic analgesia. Intervals between administration ranged from 3-17.3 hours, though over half the patients received oral analgesia (mainly Digesic) during the first 48 hours post-operatively. Nursing notes suggest that some patients were in pain with poor sleep and unwillingness to be disturbed recorded, yet analgesia was not given for up to 11 hours. It seems that ineffective pain assessment and under medication, as reported by Cohen and others, continues. Because of the dose related duration of analgesia with epidural morphine, it would be expected that f e w e r private patients w o u l d require additional, systemic narcotic analgesia than public patients, particularly in the first 24 hours. This was not the case. Despite the smaller dose of epidural morphine received, public patients received substantially less additional narcotic analgesia than private patients. It was observed that the majority of public patients did not have a written order for any additional post-operative analgesia during the recovery period. This is in contrast with private patients w h o had a range of analgesics prescribed, with orders that the anaesthetist was to be consulted prior to administration of any additional narcotic within the first 20-24 hours post-operatively. While this difference may be because of the ready availability of medical staff (for public. patients) the responsibility for assessing the need for additional pain relief, and contacting the anaesthetic registrar to obtain appropriate analgesia, rests with the midwife. And it is the midwife w h o is responsible for ensuring that pain relief is effective. This involves more than monitoring vital signs, checking infusions and drags administered and asking the patient if she is comfortable. It is suggested that observation of both self care and infant care taking activities will provide a more accurate assessment of the effectiveness of postpartum pain management. The achievement of quality pain relief, without undue sedation, is the goal whatever form of post-operative analgesia is employed. Patient safety, comfort and satisfaction with the level of pain relief achieved are all important. However, the post-partum, post Caesarean patient also needs to be able to interact with her infant and to begin those care taking activities which are so important to parent-infant attachment. Also, as

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90% o f m o t h e r s in t h i s s t u d y w e r e b r e a s t f e e d i n g , o r p l a n n i n g t o b r e a s t f e e d , a n y d e l a y in i n t e r a c t i n g w i t h t h e i r i n f a n t w o u l d b e likely t o a f f e c t t h e establishment of successful breastfeeding. Unlike other patients recovering from major surgery, the post Caesarean client does not have the luxury of caring only for herself. Without a d e q u a t e p a i n relief, r e s t a n d s l e e p in t h e e a r l y p o s t p a r t u m p e r i o d , h e r ability t o a c c o m p l i s h t h e d u a l g o a l s o f s e l f c a r e a n d i n f a n t c a r e will b e severely restricted.

References Behar M, Olshwang D, Magora F, Davidson JT, 1979, Epidural morphine m treatment of pain Lancet 1.527-529. Chapman PJ, Ganendran A, Scott RR, Basford KE, 1987, Attitudes and knowledge of nursing staff m relation to management of postoperative pare. Aust & N.Z Journal of Surgery 57 qq7-450 Clemmson E Sharp 8, 1986. Use of the London Hospital pain observation chart Nursing (Lond) 3 415-423. Cohen F, 1980, Postsurgical pare relief, patmnts, status and nurses, medication choices Pare 9 265-274.

TABLE 1 A n a l g e s i a a n d M o b i l i t y i n First 4 8 H o u r s

Cousins MJ Mather LE, 198q, Intrathecal and epldural administration of opiolds Anesthesiology 61.276-310

Analgesia

1st 24HRS

2nd 24HRS

Not Achieved

EPI (N=60) IV (N=38) IM (N=6) TOTAL 104

25 (41 7%) 3 ( 79 % ) 1 (167% 29

33 (55 0%5 23 (60.5%) 4 (666%) 60

2 (3.3%) 12 (31.6%5 1 (16.7%) 15

X2 = 22.907

DF =4

Donovan M, 1988, Pare control, too httle, too late.9 Nursing (USA) 18(q )'33 Goodinson SM. 1986, Pain r e h e f ' intetwennons Nurs,ng (Lond.) 3:395-q03

P. = 1.322E-0q (< 001)

TABLE 2 Anaesthetic/Analgesia Combinations and Mobility Anaes./Analg. 1st 24HRS

2nd 24HRS

EPI/EPl(N=57) EPI/IV(N=21) EPI/IM(N=I) GA/IV(N=16) GA/IM (N=3) OTH/EPI(N=3) OTH/IV( N= 1) OTH/IM(N=2)

31 (54 q%) 14 ((16 7%) 9 (56 3%) 2 (66 7%) 2 (66 7%5 2 (100%5

25 (43.9%) 3 (14 3°'0) 1 (100%) -

Not Achieved 1 4

(1 7%) (19%5

7 1 1 1

(43.7%) (33 3%) (33 3%5 ( 100%5

1st 24HRS

EPI (N=655 12 (18%) GA (N=12) 0 OTHER (N=4) 0 TOTAL 81 12 X2 14.524 DF =4 =

2nd 24HRS

Not Achieved

35 (54%) 18 (28%) 4 (33%) 8 (67%) 0 4 (100%) 39 30 P. = 5 799E-03 (.<.015

1st 24HRS

2nd 24HRS

10 (22%) 2 (6%) 0 12 D,F = 4

26 (56%) 10 (22%) 12 (39%) 17 (55%) 1 (25%) 3 (75%) 39 30 P = 0149 (<.05)

McCaffery M, 1987a, Giving mependine for pain. should it be so mechanical? Nursing (USA) 17(45:60-64. McCaffery M, 1987b, Patient controlled analgesia: more from a machine. Nursing (USA) 17( 11 ) 63-64.

Not Achieved Rayburn WF, Geramis BJ, Ramadei CA, Woods RE, Patll KD, 1988, Patient controlled analgesia for post-cesarean section pare Obstemcs and Gynecology 72 136-139

*23 babms were admitted to Special/Intenswe Care Nursery JUNE1996

Kotelko DM, Dalley PA, Shmder S, Rosen MA, Hughes SC, Bnzgys RV, 1984, Epldural morphine analgesia after cesarean dehvery Obstetrics and Gynecology 63 409-413 Macdonald R, 1990, Analgesia following Caesarean section Midwwes Chronicle and Nursing Notes, July.202-204.

TABLE 4 Infant Care by Analgesia (N=81)* EPI (N=465 IV (N=31) IM (N=45 TOTAL 81 X2= 12 349

Harrison DM, Sinatra R, Morgese L, Chung JH, 1988, Epidural narcotic and patient controlled analgesm for post-cesarean section pain relief. Anesthesiology 68 454457

Klmman RL, Llpman A, Hare BD, Macdonald SD, 1987, PCA versus regular IM intectlons for severe postoperative pain, American Journal of Nursing 87.1491-1492.

-

Analgesia

Glynn C J, 1987, Intrathecal and epidural administration of opiates Balliere's Chmcal Anaestheslology 1.915-931.

Inturnsl M, Carmenga CE Rosen M, 1988, Epldural morphine for relief of postpartum, postsurgical pain JOGNN 17:238-243.

TABLE 3 Infant Care by Anaesthetic (N=81) * Anaesthetic

pharmacological

Wang JK, Nouss LE, Thomas JE, 1979, Pain rehef by mtrathecally apphed morphine m man Anesthesiology 50.149-151.

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