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A Comprehensive Description of Postpartum Pain after Cesarean Delivery Emily G. Chin, Catherine Vincent, and Diana Wilkie

Correspondence Emily G. Chin, PhD, RNC, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1006, Chicago, IL 60660, [email protected]

ABSTRACT

Keywords Postpartum pain Cesarean delivery PAINReportIt McGill Pain Questionnaire

Setting: Large, university-based, midwestern medical center.

Objective: To describe women’s experiences with the perception of, evaluation of, and response to postpartum pain after cesarean delivery through the sensory, affective, cognitive, and behavioral dimensions of pain. The secondary aim of this research was to differentiate pain described with nociceptive and neuropathic pain descriptors. Design: Longitudinal, concurrent mixed methods design.

Participants: Convenience sample of 30 low-risk women scheduled for cesarean deliveries. Methods: The PAINReportIt, a computerized version of the McGill Pain Questionnaire, was administered in person to participants at two visits: between 24 and 48 hours postcesarean delivery and at 6 weeks postpartum. Descriptive statistics, t tests, and χ2 tests were calculated from these data and pain descriptor selections were compared with established nociceptive and neuropathic pain descriptor lists. Results: Pain was reported in all dimensions at both visits. The abdomen was most frequently selected for pain location; mean intensity was 2.75/10 at the first visit, 1.1/10 at the 6-week visit. Pain in the sensory and cognitive dimensions decreased significantly between visits. Affective dimension pain decreased, but the difference was not significant. Participants reported activities that increased and decreased pain in the behavioral dimension. Pain descriptors indicative of nociceptive (e.g., tender, sore) and neuropathic (e.g. aching) pain were selected at both visits. Conclusion: Postpartum pain after cesarean delivery is multidimensional and has been described with words indicative of nociceptive and neuropathic pain. Nurses should complete a thorough and comprehensive pain assessment throughout the postpartum for patients experiencing cesarean deliveries.

JOGNN, 43, 729-741; 2014. DOI: 10.1111/1552-6909.12483 Accepted May 2014

Emily G. Chin, PhD, RNC, is an assistant professor, Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL.

The authors report no conflict of interest or relevant financial relationships.

esarean deliveries occurred at a record high in 2009, and pain is a frequent sequela. There were more than 3.9 million births in the United States in 2012 of which 32.8% were cesarean deliveries (Martin, Hamilton, Osterman, Curtin, & Mathews, 2013). Pain following this event is one of the most frequently reported problems by postpartum women (Lansakara, Brown, & Gartland, 2010). Postcesarean pain is considered major for as many as one third of the women (Declercq, Cunningham, Johnson, & Sakala, 2008), and this pain has a negative effect on breastfeeding and infant care (Karlstrom, EngstromOlofsson, Norbergh, Sjoling, & Hildingsson, 2007; Karlstrom, Engstrom-Olofsson, Nystedt, Sjoling, & Hildingsson, 2010). Despite this effect, in previous postpartum pain studies, investigators have not comprehensively described this experience and have failed to examine postpartum pain after cesarean delivery in terms of dimension and type. In this study, we described postpartum pain in terms

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 C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

Catherine Vincent, PhD, RN, is an associate professor, Department of Women, Children, and Family Health Science, University of Illinois at Chicago, Chicago, IL.

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C

of the sensory, affective, cognitive, and behavioral pain dimensions and the nociceptive and neuropathic pain types.

Background Pain is a common experience after all births. As many as 92% of women report pain after childbirth (Andrews, Thakar, Sultan, & Jones, 2008), and as many as 78% of women rate their postpartum pain intensity as moderate to severe (Karlstrom et al., 2007). Postpartum pain has detrimental implications for the infant and mother. Women experiencing postpartum pain took longer to initiate interactions with their infants (Karacam & Eroglu, 2003) and reported that pain negatively affected breastfeeding (East, Dube, & Perreault, 2007; Karlstrom et al., 2007; Karlstrom et al., 2010) and interfered with infant care (Borg-Stein & Dugan, 2007; Gustafsson & Nilsson-Wikmar, 2008; Karlstrom et al., 2010). Postpartum pain

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Postpartum pain research lags behind other pain research areas due to an inconsistent description of pain in terms of type and dimension.

following cesarean delivery compared to vaginal delivery has been reported as more intense (Schindl et al., 2003), longer lasting (Kainu, Sarvela, Tiippana, Halmesmaki, & Korttila, 2010), and with a greater effect on activities of daily living, including infant care (Declercq et al., 2008; Karlstrom et al., 2007) and breastfeeding exclusivity (Sayyah Melli et al., 2007). It is for these reasons that we focused this research on the experience of pain after a cesarean delivery. There are two types of pain, nociceptive and neuropathic, experienced when pain pathways are triggered. Nociceptive pain arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors, and neuropathic pain is caused by a lesion or disease of the somatosensory nervous system (Loeser, 2012). Although peripheral nerves are damaged by the cesarean incision, nociceptive and neuropathic pain have not been differentiated in postpartum research.

Diana Wilkie, PhD, RN, FAAN, is a professor, Department of Biobehavioral Health Science, University of Illinois at Chicago, Chicago, IL.

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In addition to these two types of pain, there are also four dimensions: sensory, affective, cognitive, and behavioral (Ahles, Blanchard, & Ruckdeschel, 1983). The main focus of postpartum research has been the sensory dimension of pain, centering on pain intensity and location, primarily through the use of the Visual Analogue Scale (VAS) or a similar instrument (Goodman et al., 2005; Gustafsson & Nilsson-Wikmar, 2008). Only two research teams examined the affective dimension of pain with a formal instrument (Dodd, Hedayati, Pearce, Hotham, & Crowther, 2004; Kindberg, Stehouwer, Hvidman, & Henriksen, 2008). The cognitive dimension of pain was measured to a limited extent by investigators examining pain management satisfaction expectations (Dodd et al., 2004; Karlstrom et al., 2007; Kindberg et al., 2008). Investigators have examined the behavioral dimension of pain by observing pain’s effect on activities of daily living (e.g., walking, sitting, voiding, or passing stool) and infant care tasks (e.g., breastfeeding, lifting infant) (Eisenach et al., 2008; Gustafsson & Nilsson-Wikmar, 2008; Karlstrom et al., 2007).

of pain in terms of type and dimension. A better understanding of the type of pain will provide direction for therapies and options for pain management. The negative effects of pain have been established on mother/infant interaction (Karacam & Eroglu, 2003), breastfeeding (East et al., 2007; Karlstrom et al., 2007; Karlstrom et al., 2010; Sayyah Melli et al., 2007), infant care (Borg-Stein & Dugan, 2007; Declercq et al., 2008; Gustafsson & Nilsson-Wikmar, 2008; Karlstrom et al., 2007, 2010), and sleep/rest (Lee & Lee, 2007); it is possible that better postpartum pain management can alleviate some of these poor outcomes. Although investigators have included some elements of the pain dimensions, the sensory, affective, cognitive, and behavioral dimensions have not been addressed comprehensively with a psychometrically sound instrument. Furthermore, the effect of postpartum pain on mothers and infants has not been well established. The University of California San Francisco symptom management theory guided this descriptive study. Model concepts include symptom experience, symptom management, and symptom outcome (Figure 1). Symptom experience— this study’s focus, consists of three components: symptom perception (noticing a change), evaluation (judgments about symptoms), and response (feelings, thoughts, and behaviors secondary to symptoms). The two types of pain and the four dimensions of pain can be conceptualized within the symptom experience components. The primary aim of this research was to describe women’s experiences with the perception of, evaluation of, and response to postpartum pain through the sensory, affective, cognitive, and behavioral dimensions of pain after a cesarean delivery. The secondary aim of this research was to differentiate pain described with nociceptive and neuropathic pain descriptors.

Methods Design

Postpartum pain research lags behind other pain research areas due to an inconsistent description

We used a longitudinal, concurrent mixed methods design (Giddings & Grant, 2006; Sandelowski, 2000) to better describe women’s experience of postpartum pain. We used PAINReportIt (Huang et al., 2003; Wilkie et al., 2003), a computerized version of the McGill Pain Questionnaire (MPQ) (Melzack, 1975), to gather descriptors of the sensory, affective, evaluative (renamed as cognitive; Melzack, 2005), and

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Chin, E. G., Vincent, C., and Wilkie, D.

Figure 1. Conceptual model of the University of California San Francisco symptom management theory. The researchers focused on the symptom experience concept. Dodd, M., Janson, S., Facione, N., Faucett, J., Forelicher, E. E., Humphreys, J., . . . Taylor, D. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33(5), 668–676. Used with permission from John Wiley & Sons.

behavioral dimensions of pain. In this article we report our quantitative findings. Approvals from appropriate Institutional Review Boards were obtained prior to the start of the research. Participants were recruited from one provider group attending births at a large, university-based, midwestern medical center. Once, between 24- and 48-hours postcesarean delivery during the inpatient postpartum period, women were asked to complete the PAINReportIt (Huang et al., 2003; Wilkie et al., 2003). At 6 weeks, the traditional end of the postpartum period, this measure was repeated at a location scheduled at the convenience of the mother (i.e., the participant’s home, the primary provider’s office, or public meeting places).

Sample A convenience sample of 30 participants was recruited. Inclusion criteria were women at least age 18 years, scheduled for cesareans, and experiencing a singleton pregnancy. Exclusion criteria were women who had any prior labor with this pregnancy or any pregnancy complicated by risk factors such as multiple gestation, preterm labor, preeclampsia, and diabetes.

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The number of recruited participants was intended to capture the variation in the experience of postpartum pain and provide a representative description of the phenomenon. The sample was not intended to meet statistical requirements, but rather to fulfill informational requirements of the phenomenon of interest (Sandelowski, 1995).

Measures PAINReportIt. The PAINReportIt (Huang et al., 2003; Wilkie et al., 2003) is a computerized version of the MPQ (Melzack, 1975), driven by a touch screen. The PAINReportIt covers the paper-and-pencil version of the instrument in 13 screens, and an additional 21 items that measure pain goals, satisfaction, and expectations (Huang et al., 2003). The equivalence of the PAINReportIt and the MPQ as well as the reliability of the PAINReportIt have been supported through focus groups and sequential completion of the paper and electronic versions of instruments (Wilkie et al., 2003). The computerized PAINReportIt has been demonstrated as a useable version of the MPQ, with 86% of participants indicating it was a good way to report pain to their provider (Huang et al., 2003; Wilkie et al., 2003), and 93% of participants reporting it was easy to use (Huang et al.,

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2003). Mean completion time of the PAINReportIt by this study’s participants was 13.2 minutes (SD = 3.9, range = 7.5 – 26.9). The McGill Pain Questionnaire. This instrument is a four-page, four-part, multidimensional measurement of pain, measuring the sensory, affective, cognitive, and behavioral dimensions of pain (Melzack, 1975). All four parts of the instrument are described below. Part 1. Participants answer the question, “where is your pain?” (Melzack, 1975), measuring the sensory (location) dimension of pain in Part 1 of the instrument. This part of the instrument includes a line drawing of a body outline. Participants are instructed to mark the places where pain is felt and indicate if the pain felt at that location is internal, external, or both. The total number of places marked is tallied and indicates the spatial distribution of the pain experienced. Part 2. Participants answer the question, “what does your pain feel like?” (Melzack, 1975), measuring the sensory (quality), affective, and cognitive dimensions of pain in Part 2. This part of the instrument includes a list of 78 pain descriptor words, separated into 20 groups; each consisting of two to six descriptor words. Groups 1 to 14 include sensory pain, 11 to 15 include affective pain, 16 includes cognitive pain, and groups 17 to 20 include miscellaneous pain descriptors. In the PAINReportIt, participants are instructed to select as many words as necessary to describe their pain. For analysis, each group’s individual words are assigned a rank value, indicating increasing pain with subsequent words. For example, Group 2 includes jumping, flashing, and shooting, listed in this order (Melzack, 1975). Jumping is assigned a value of 1, flashing is assigned a value of 2, and shooting is assigned a value of 3. When these values are summed for each of the 20 groups, the Pain Rating Index (PRI) scores are obtained. Scores for the PRI-Total range from 0 to 78; 0 indicating the minimum and 78 the maximum pain rating score. The PRI-Total score represents the comprehensive score of all of the pain descriptors and the rank values associated with these pain qualities (Melzack, 1983).

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values for Groups 11–15) reflects affective qualities (tension, fear, and autonomic) of the pain experience (Melzack, 1975). The PRI-Evaluative score (sum of values for Group 16) reflects the subjective intensity of the pain experience and considers the person’s cognitive ability to make a judgment about the pain experience (Melzack & Torgerson, 1971). The PRI-Miscellaneous score (sum of values for Groups 17–20) reflects additional descriptors, including words such as spreading, radiating, penetrating, and piercing (Melzack, 1975). An additional score for part 2 of the MPQ is obtained by tallying the number of words chosen (NWC) for the 20 groups. Number of words chosen is a measure of pain quality without the influence of intensity (Wilkie et al., 2010). Scores range from 0, indicating no pain descriptors were employed, to 20, indicating that at least one word per category was chosen by the participant. Part 3. Participants answer the question, “how does your pain change with time?” (Melzack, 1975), measuring the sensory (temporal) dimension of pain in Part 3 of the instrument. Part 3 includes three groups of three words that describe the pain pattern experienced. For example, one group includes the descriptors rhythmic, periodic, or intermittent (Melzack, 1975). Participants are instructed to choose the word or words that best describe their pain. Two additional open-ended questions solicit information regarding activities that relieve or increase pain, measuring the behavioral dimension of pain. These are open-ended questions for participants to provide responses. Examples of the relieving or increasing factors could include movement, heat/cold, and social interaction. No numerical scores are obtained from these open-ended questions; however, the information collected provides context for understanding the participant’s pain.

The PRI-Total can be divided. The PRI-Sensory score (sum of values for Groups 1–14) reflects the sensory qualities of the pain experience, including: temporal, spatial, pressure, and thermal (Melzack, 1975). The PRI-Affective score (sum of

Part 4. Participants answer the question, “how strong is your pain?” (Melzack, 1975), measuring the sensory (intensity) dimension of pain in Part 4 of the instrument. Using a 0 to 10 scale where 0 represents no pain and 10 represents pain as bad as it can be, six questions solicit current, least, and worst pain in the past 24 hours and baseline pain comparisons for the participant (worst toothache, worst headache, and worst stomach-ache). The last three questions give context for the individual participant’s general pain ratings, indicating the

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Chin, E. G., Vincent, C., and Wilkie, D.

severity of pain this participant has experienced in the past. Internal consistency reliability of the MPQ is supported by the correlation between the PRI and the number of words chosen (r = .89) (Melzack, 1975). Factor analysis revealed the three dimensions: sensory, affective, and cognitive were found to be intercorrelated (r = .64 – .81) and measured the same pain concept (Turk, Rudy, & Salovey, 1985). Test–retest reliability resulted in a mean consistency of 70.3% over a 3- to 7-day span (Melzack, 1983) and mean consistency of 66% to 80.4% was achieved over four administrations of the MPQ, each a week apart (Graham, Bond, Gerkovich, & Cook, 1980). Construct validity was supported by several investigators (Dubuisson & Melzack, 1976; Klepac, Dowling, & Hauge, 1981; Turk et al., 1985).

Data Analysis The PAINReportIt records responses in a computerized database from each participant. Descriptive statistics, t tests, and χ2 tests were calculated from these data for data collection points (inpatient and at 6-weeks postpartum) and summarized to describe the symptom experience of postpartum pain after cesarean delivery. The secondary aim of this research was to differentiate pain described with nociceptive and neuropathic pain descriptors. Pain descriptor word selection frequency were analyzed and compared with established lists of nociceptive and neuropathic pain descriptors (Wilkie, 2001; Wilkie, Huang, Reilly, & Cain, 2001).

Results

This is the first study in which the sensory, affective, cognitive, and behavioral dimensions of postpartum pain have been measured and complete findings reported.

Overall pain intensity decreased from the inpatient visit to the 6-week visit. It should be noted that participants were on a postpartum medication protocol and likely consuming analgesics. Participants’ reported current mean pain scores of 2.75 +/-1.8 (mild pain, on a scale of 0 – 10) at the inpatient visit, and by 6 weeks, the mean pain decreased to 1.1 +/–2.4 (mild pain), a statistically significant difference, t(29) = 4.18, p < .001. Median current pain decreased from 2 to 0 from the inpatient visit to the 6-week visit. In regard to worst pain in the last 24 hours, participants reported means of 5.8+/–2.2 (moderate pain) at the inpatient visit; by the 6-week visit, the mean decreased to 1.5+/– 2.9 (mild pain), a statistically significant difference, t = 9.07 (29), p < .001. Worst headache, stomachache, and toothache were reported to place postpartum pain intensity in context. See Table 2 for a complete report of pain intensity scores. Regarding pain quality, of a possible maximum score of 42, participants reported mean PRISensory score of 15.1 +/–5.0 at the inpatient visit. The PRI-Sensory score was 11.0 +/–6.2 at 6 weeks, a statistically significant difference from the inpatient visit, t = 3.56 (29), p = .001. When participants were asked to select words to describe how pain changes with time, they most often reported an intermittent pain pattern; 12 (40%) participants chose this pattern at both visits. Complete pain pattern frequencies are shown in Table 2.

Sample Characteristics Participant characteristics are reported in Table 1. This sample was largely White, educated, affluent, and experiencing a second birth.

Pain Dimensions

Affective. As shown in Table 2, out of a possible maximum score of 14, participants reported mean PRI-Affective scores of 1.2 +/–1.5 at the inpatient visit and 0.9 +/–1.6 at the 6-week visit. This difference was not statistically significant.

Sensory. The sensory dimension of pain includes location, intensity, quality, and pattern of pain. Participants reported that pain occurred in a number of locations as shown in Table 2. All participants experienced a low transverse cesarean delivery; the abdomen was the most common location for pain at both visits (97% & 93%, respectively), followed by the upper back, and the chest. The lower back was the only pain location not selected during either visit.

Cognitive. The cognitive dimension of pain includes the PRI-Evaluative score, pain goal, pain expectations, and pain satisfaction. As shown in Table 2, out of a possible maximum score of 5, the mean PRI-Evaluative scores decreased from the inpatient visit (4.6 +/–0.5) to the 6-week (1.7 +/–1.9) visit, a statistically significant difference, t = 8.11 (29), p < .001.

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Table 1: Demographic Characteristics of Participants Variable

Number(%)

Mean (SD)

Min-Max

35.4 (3.7)

28–45

Education

17.4 years (2.7)

12–23 years

Income

$113,577 ($69,770)

$25,000–350,000

Age Race/Ethnicity White

20 (66)

Black, not of Hispanic origin

5 (17)

Hispanic

2 (7)

Asian/Pacific Islander

3 (10)

Cesarean 1st nd

6 (20)

2

21 (70)

3rd or more

3 (10)

Primary Indication Repeat

24 (80)

Malpresentation

3 (10)

Other

3 (10)

When asked to provide a goal for pain level, as shown in Table 3, participants reported an optimal pain mean score of 0.6 (+/–0.9) out of 10 at the inpatient visit. Participants’ responses decreased to 0.1 (+/–0.4), a statistically significant difference from the inpatient to the 6-week visits, t = 2.9 (29), p = .007. When asked about pain expectation, five (17%) participants reported that pain was worse than expected at the inpatient visit. The remaining participants at the inpatient visit and all participants at the 6-week visit reported their pain was the same or not as bad as expected. Complete pain expectation scores are shown in Table 3. Also shown in Table 3, 23 (77%) participants reported satisfaction with their pain level at the inpatient visit. This report increased to 29 (97%) participants by the 6-week visit. Behavioral. At the inpatient visit, sleep or rest relieved pain for eight (27%) participants. Walking was an activity that relieved pain for seven (23%) participants, but increased pain for four (13%) participants. Common activities that increased pain included: getting in and out of bed or positioning (sitting/standing) (13 [43%]) and moving too much, or too quickly (7 [23%]). At the 6-week visit, rest was the most commonly chosen activity that relieved pain, selected by 20 (67%) participants, whereas lifting, carrying, or picking up

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items (including the baby) was the most common activity that increased pain, selected by 18 (60%) participants. Participants identified the importance of sleep and rest in their pain management during the 6-week recovery period. Early on, simple activities like position change were most troublesome, but as the postpartum period lengthened, activities of daily living became sources of pain.

Pain Descriptors From possible scores ranging from 0 to 20, the mean number of words chosen at the inpatient visit was 8.3 +/–3.0 and 6.5 +/–2.9 at the 6week visit. This difference was significant, t = 2.88 (29), p = .007. Nociceptive pain, pain that is experienced with somatic or visceral injury (Bonica, 1991; Portenoy, 1989), is represented by 26 nociceptive descriptors such as cramping, tender, and sharp. The mean number of nociceptive words chosen by participants decreased significantly from 5.8 (+/–2.3) to 4.6 (+/–2.7), t = 2.30 (29), p = .029, from the inpatient to the 6-week visits. All 30 participants selected at least one nociceptive descriptor at both visits. Neuropathic pain, pain that is experienced with nerve injury (Bonica, 1991; Portenoy, 1989), is represented by 28 neuropathic descriptors such as

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Min-Max

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0 (0)

0 (0)

0 (0)

0 (0)

Right Leg

Left Leg

Head

Lower Back 1.9 (1.0)

1–4 sites

0–10

6.8 (2.2) 6.5 (3.0)

Worst ever stomachache

15.1 (5.0) 1.2 (1.5) 4.6 (0.5) 3.4 (3.8) 24.3 (8.7)

PRI-S: Sensory(0–42 possible)

PRI-A: Affective(0–14 possible)

PRI-E: Evaluative(0–5 possible)

PRI-M: Miscellaneous(0—17 possible)

PRI-T: Total(0–78 possible)

Quality Pain Rating Index (PRI)

Worst ever toothache

2–10.

6.6 (2.5)

Worst ever headache

3–10.

11–44.

0–14

4–5.

0–6

5–24

1–10.

0–6

5.8 (2.2) 1.7 (1.6)

Worst pain in last 24 hours

0–6

Least pain in last 24 hours

2.75 (1.8)

Current Pain

Intensity (0–10 possible)

Number of pain sites

1 (3)

Left Arm

0 (0)

3 (10)

1 (3)

2 (7)

0 (0)

1 (3)

3 (10)

6 (20)

2 (7)

Chest

10 (33)

Upper Back

Right Arm

4 (13)

29 (97)

28 (93)

No(%)

Mean (SD)

No (%)

Abdomen

Location

2nd Visit

1st Visit

Table 2: Sensory Pain Characteristics

16.1 (9.2)

2.5 (2.5)

1.7 (1.9)

0.9 (1.6)

11.0 (6.2)

6.3 (3.2)

7.0 (2.3)

7.0 (2.0)

0.5 (1.5)

1.5 (2.8)

1.1 (2.4)

1.7 (0.9)

Mean (SD)

4–47

0–9

0–5

0–6

4–35.

0–10

4–10.

2–10.

0–6

0–10

0–10

1–4 sites

Min-Max

0.07

0.37

3.61

0.07

χ 2

0.79

0.54

0.06

0.79

p value

NS

NS

NS

NS

0.66

−0.44

4.78

1.47

8.11

0.79

3.56

(Continued)

< .001

0.15

< .001

0.44

0.001

0.69

0.24

−1.2

0.41

0.002

< .001

0.0002

0.29

p value

3.39

9.07

4.18

1.07

t Test Value

Two-tailed

Chin, E. G., Vincent, C., and Wilkie, D.

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5 (17)

2 (7)

0 (0)

5 (17)

Transient group

Constant/Intermittent

Constant/Transient

Intermittent/Transient

Transient

1 (3)

12 (40)

Intermittent group

Constant/Intermittent/

5 (17)

Constant group

Pain pattern

(0–28 possible)

Number of Neuropathic words chosen

(0–26 possible) 3.5 (2.3)

5.8 (2.0)

8.3 (3.0)

0–10.

2–10.

4–14.

1 (3)

4 (13)

1 (3)

3 (10)

3 (10)

12 (40)

6 (20)

No(%)

Min-Max

No (%)

Mean (SD)

2nd Visit

1st Visit

Number of Nociceptive words chosen

possible)

Number of words chosen (0–20

Pain words

Table 2: Continued

2.5 (2.1)

4.6 (2.7)

6.5 (2.9)

Mean (SD)

0–10

1–15.

2–15.

Min-Max

66.46

χ 2

0.00

p value

2.60

2.30

2.88

t Test Value

Two-tailed

0.014

0.029

0.007

p value

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Tolerable pain level

11 (37)

Not as bad as expected

4 (13)

Not sure

10 (33) 8 (27) 3 (10) 9 (30)

0–6 hours

7–12 hours

13–18 hours

19–24 hours

Number of hours in last 24 that pain was less than tolerable level

23 (77) 3 (10)

Yes

No

Satisfaction with Pain Level

5 (17) 14 (47)

Worse than expected

Same as expected

Pain Expectation

Min-Max

1–6

0–3

22 (73)

2 (7)

0 (0)

6 (20)

0 (0)

1 (3)

29 (97)

15 (50)

15 (50)

0 (0)

No(%)

Mean (SD)

No (%)

Optimal goal for pain level

Goal for Pain Management

2nd Visit

1st Visit

Table 3: Cognitive Pain Characteristics

2.9 (1.3)

0.1 (0.4)

Mean (SD)

0–6

0–2

Min-Max

2.56

9.31

8.64

χ 2

0.862

0.010

0.013

p value

0.8

2.9

test value

Two-tailed

0.43

0.007

p value

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aching, itchy, or shooting. The mean number of neuropathic descriptor words chosen by participants decreased significantly from 3.5 (+/–1.2) to 2.5 (+/–2.1), t = 2.60 (29), p = .014, from the inpatient to the 6-week visits. At the inpatient and 6-week visits, 29 (97%) and 26 (87%) participants, respectively, selected neuropathic descriptors. Figures 2 through 4 (available as supplemental material published online) show the frequency of neuropathic, nociceptive, and other pain descriptors selected by participants at both visits. The six pain descriptors participants selected most frequently at the inpatient visit were a mix of nociceptive and neuropathic words. At the inpatient visit, nociceptive words included cramping 25 (83%), tender 22 (73%), sore 21 (70%), and sharp 19 (63%). Neuropathic words included aching 21 (70%) and itchy 17 (57%). By 6 weeks, tender 18 (60%) and sore 15 (50%) (nociceptive pain) and aching 14 (47%) (neuropathic pain) continued to be chosen; annoying 16 (53%) (other descriptor) was another frequent choice.

Discussion We were able to achieve the primary and secondary aims of this research by fully describing postpartum pain after cesarean delivery in terms of all four pain dimensions (sensory, affective, cognitive, and behavioral) and by pain type (nociceptive and neuropathic). To our knowledge, this is the first study in which pain has been measured with a comprehensive instrument and the complete findings have been reported. There are few studies to compare with our postpartum pain dimension findings, and no studies to compare with postpartum pain type. Thus, for comparison, the dimensions and types of postpartum pain after cesarean delivery will be compared to other pain examples.

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was 3 (Karlstrom et al., 2007). However, in another sample of women, mean pain intensity was 2.5 out of 10 in the first 24 hours after cesarean delivery (Woods et al., 2012), more similar to the intensity reported by our participants. Quality and pattern are also aspects of the sensory dimension of pain. Regarding pain quality for our participants, median PRI-Total scores were 22 between 24 and 48 hours postcesarean delivery, much higher than the median PRI-Total scores of 11 in the same timeframe postvaginal delivery reported by Kindberg et al. (2008). This comparison supports Schindl et al.’s (2003) previous findings that the postpartum period following cesarean delivery is more painful than vaginal delivery. In comparison to patients after abdominal surgery reporting PRI-Totals ranging from 2.5 to 9.6 over the 3 days postsurgery (Katz et al., 1994), our participants reported higher PRI-Total scores, identifying more descriptors in the sensory, affective, and cognitive dimensions. For the affective dimension, no previous investigators reported postpartum PRI-Affective scores. However, for a sample of laboring patients, mean PRI-Affective scores were reported as 1.2 (Wilkie, Savedra, Holzemer, Tesler, & Paul, 1990), the same score reported by our participants while inpatients. For the cognitive dimension, participants expected the pain they experienced and were satisfied with their pain level at the inpatient and 6-week visits. At the inpatient visit, only 17% of participants reported pain worse than expected. These findings are consistent with Karlstrom et al.’s (2007) findings; 11 (18%) participants reported more pain than expected in the 2 days following a cesarean delivery and most women were satisfied with their pain level.

Location and intensity are aspects of the sensory dimension of pain. Participants reported pain as primarily occurring in the abdomen, an expected location with the cesarean procedure and similar to Declercq et al.’s (2008) report that 85.5% of primiparous and up to 97.3% of multiparous participants reported pain at the cesarean incision site. In this study, pain intensity decreased over time from the inpatient to the 6-week visits. For this sample of women, the inpatient postpartum pain report was mild, contrasting with other samples where the median VAS pain score was 6 out of 10 on the first day after cesarean delivery, although, by the second day, the median pain score

In regard to the behavioral dimension of pain, investigators reported that postpartum pain after cesarean delivery negatively affected 62% of participants’ ability to care for their infant and 33% of participants’ ability to breastfeed (Karlstrom et al., 2007); 30% of participants reported these same negative effects in a follow-up study (Karlstrom et al., 2010). Although our participants did not explicitly report difficulty with infant care and breast feeding, they did report difficulty with positioning and movement early in recovery; these activity challenges could affect the ability to provide infant care or position for successful breastfeeding. Another behavior—lifting, including lifting the

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infant—was identified as painful at 6 weeks by participants in this study. Similarly, at 2 months, 22% of postcesarean delivery participants reported pain interfered with routine activities (Declercq et al., 2008). And, at 6 to 10 months after delivery, participants reported heavy lifting, heavy work, and standing bent over a sink as the most limited activities (Nilsson-Wikmar, Pilo, Pahlback, & Harms-Ringdahl, 2003). Difficulty with lifting and household work may make the care giving tasks of motherhood a struggle; responding to a newborn can be a challenge, at best. This issue is multiplied for multiparous mothers whose toddlers also need attention. Taken together, these findings show that pain after cesarean delivery can affect mothers’ activities and could make newborn care a challenge. Participants frequently identified sleep and rest as one of the most important behaviors to help relieve pain. And yet women experiencing a cesarean delivery have been shown to sleep less than women who delivered vaginally (Lee & Lee, 2007). Sleep is an example of a simple management strategy that may be effective for managing pain; however, with a newborn, sleep may not be feasible. If at all possible, health care providers and family members should find ways to support new mothers and offer them opportunities to rest. To our knowledge, this is the first report of nociceptive and neuropathic descriptors for postpartum pain after cesarean delivery. During a cesarean delivery, somatosensory non-neural and neural tissue is damaged (Loeser, 2012); our participants selected descriptors indicative of both types of pain. The most common nociceptive word selected by our participants at the first visit was cramping; as compared to cramping for 64 (100%) participants after a laparoscopic tubal ligation (DeSantana, Sluka, & Lauretti, 2009) and tender for 22 (52%) participants after abdominal surgery (Katz et al., 1994). Our participants selected numerous neuropathic descriptors, most commonly aching. No neuropathic words were reported in previous studies. Future research is needed to determine if neuropathic pain descriptors are selected after the neural and non-neural tissues have fully healed and if so to determine the epidemiology of residual neuropathic pain after cesarean section.

Limitations Limitations of this study include sample size, sample composition, and timing. This sample was

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Nurses’ ability to differentiate pain type can have implications for treatment tailored to the pain experience.

small, and mostly multiparous, White, older, and educated. Thus, results from this study cannot be generalized to the pain experiences of all women delivering by cesarean (including first-time cesareans). The timing of the data collection at 6 weeks may also be a limitation. Participants often indicated that they were experiencing little pain at this visit and were asked to retrospectively recall the pain they felt throughout the entire 6-week period. At both visits, the interview was conducted prior to the questionnaire to minimize the possibility of PAINReportIt descriptors being introduced to participants’ interviews. Thus, without randomization we do not know the order effect on data collection. In spite of these limitations, this work is novel and the findings are informative, especially as an important first step in comprehensively describing postpartum pain. This study needs to be replicated with a larger sample, with more frequent measurement between the inpatient and 6week visits, and with vaginal deliveries and nonscheduled cesarean deliveries. Together, these studies would provide a broad picture of the experience of postpartum pain.

Implications for Nursing Practice and Research The most important finding for nursing practice was that postpartum pain after cesarean delivery is multidimensional and has been described with words indicative of nociceptive and neuropathic pain. Just because women report mild pain intensity does not mean another dimension of pain may not affect their lives. A new mother with a pain score of 2 of 10 (sensory dimension) may still find it difficult to get out of bed or to reposition herself to care for her new infant (behavioral dimension). Although nurses may have an expectation for a woman’s pain trajectory and recovery after giving birth, a woman’s experience is individualized and complex; nurses should be aware of this fact and complete a thorough and comprehensive pain assessment. The PAINReportIt is a viable option for practice. Completion time for the instrument was 13.2 minutes for this sample, but has been reported in as little as 10 minutes (Ngamkham, Holden, & Wilkie, 2011). After an initial orientation to the program, patients could make use of the portable pentablet format

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A Comprehensive Description of Postpartum Pain after Cesarean Delivery

of the PAINReportIt and may not require any additional nursing assistance to complete the assessment tool. The information collected from postpartum mothers using PAINReportIt regarding their pain experience is valuable. Nurses’ ability to differentiate pain type can have implications for treatment tailored to the pain experience while inpatient and after discharge. Nurses have the ability to recognize pain at the earliest stages, treat it, and educate patients about appropriate management as they recover from a cesarean delivery. For example, supporting sleep and rest for new mothers is a simple management strategy that can be helpful to deal with pain.

cesarean deliveries: Results of a national survey. Birth, 35(1), 16–24. doi:10.1111/j.1523-536X.2007.00207.x DeSantana, J. M., Sluka, K. A., & Lauretti, G. R. (2009). High and low frequency TENS reduce postoperative pain intensity after laparoscopic tubal ligation: A randomized controlled trial. Clinical Journal of Pain, 25(1), 12–19. doi:10.1097/AJP.0b013e31817d1070 Dodd, J. M., Hedayati, H., Pearce, E., Hotham, N., & Crowther, C. A. (2004). Rectal analgesia for the relief of perineal pain after childbirth: A randomised controlled trial of diclofenac suppositories. British Journal of Obstetrics and Gynaecology, 111(10), 1059– 1064. doi:10.1111/j.1471-0528.2004.00156.x Dubuisson, D., & Melzack, R. (1976). Classification of clinical pain descriptions by multiple group discriminant analysis. Experimental Neurology, 51(2), 480–487. doi:10.1016/0014–4886(76) 90271–5 East, N., Dube, J., & Perreault, E. L. (2007). Postpartum pain relief: a randomized comparison of self-administered medication and

For research, the fact that postpartum pain after cesarean delivery is multidimensional and complex has implications. Future research is necessary to further understand the experience of postpartum pain after all deliveries and the effect this pain may have on mothers and infants. With a better understanding of the pain experience, new management strategies can be developed specifically targeted to the type of pain and the dimensions experienced.

standard administration. Journal of Obstetrics and Gynaecology Canada, 29(12), 975–981. Eisenach, J. C., Pan, P. H., Smiley, R., Lavand’homme, P., Landau, R., & Houle, T. T. (2008). Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain, 140(1), 87–94. doi:10.1016/j.pain.2008.07.011 Giddings, L. S., & Grant, B. M. (2006). Mixed methods research for the novice researcher. Contemporary Nurse, 23(1), 3–11. doi:10.5555/conu.2006.23.1.3 Goodman, S. R., Drachenberg, A. M., Johnson, S. A., Negron, M. A., Kim-Lo, S. H., & Smiley, R. M. (2005). Decreased postpartum use of oral pain medication after a single dose of epidural morphine. Regional Anesthesia and Pain Medicine, 30(2), 134–139. doi:10.1016/j.rapm.2004.11.010

Conclusion

Graham, C., Bond, S. S., Gerkovich, M. M., & Cook, M. R. (1980).

Participants in this study reported rich descriptions of their postpartum pain after cesarean delivery in the sensory, affective, cognitive, and behavioral dimensions at the inpatient and 6-week visits. In addition, these participants also reported nociceptive and neuropathic qualities at both visits. Pain improved over time in all aspects measured but was still present at the end of 6 weeks, the traditional postpartum period.

Use of the McGill pain questionnaire in the assessment of cancer pain: Replicability and consistency. Pain, 8(3), 377–387. doi:10.1016/0304-3959(80)90081-0 Gustafsson, J., & Nilsson-Wikmar, L. (2008). Influence of specific muscle training on pain, activity limitation and kinesiophobia in women with back pain post-partum–a ‘single-subject research design’. Physiotherapy Research International, 13(1), 18–30. doi:10.1002/pri.379 Huang, H. Y., Wilkie, D. J., Zong, S. P., Berry, D., Hairabedian, D., Judge, M. K., . . . Chabal, C. (2003). Developing a computerized data collection and decision support system for cancer pain management. Computers, Informatics, Nursing, 21(4), 206–217. doi:10.1097/00024665-200307000-00011

REFERENCES

Kainu, J. P., Sarvela, J., Tiippana, E., Halmesmaki, E., & Korttila, K. T.

Ahles, T. A., Blanchard, E. B., & Ruckdeschel, J. C. (1983). The multidi-

(2010). Persistent pain after caesarean section and vaginal birth:

mensional nature of cancer-related pain. Pain, 17(3), 277–288.

A cohort study. International Journal of Obstetric Anesthesia, 19(1), 4–9. doi:10.1016/j.ijoa.2009.03.013

doi:10.1016/0304–3959(83)90100–8 Andrews, V., Thakar, R., Sultan, A. H., & Jones, P. W. (2008).

Karacam, Z., & Eroglu, K. (2003). Effects of episiotomy on bonding and

Evaluation of postpartum perineal pain and dyspareunia–

mothers’ health. Journal of Advanced Nursing, 43(4), 384–394.

A

prospective

study.

European

Journal

of

Obstetrics,

Gynecology, and Reproductive Biology, 137(2), 152–156. doi:10.1016/j.ejogrb.2007.06.005

& Hildingsson, I. (2007). Postoperative pain after cesarean

Bonica, J. J. (1991). Introduction: Semantic, epidemiologic, and edu-

birth affects breastfeeding and infant care. Journal of Ob-

cational issues. In K. L. Casey (Ed.), Pain and central nervous

stetric, Gynecologic, and Neonatal Nursing, 36(5), 430–440.

system disease: The central pain syndromes (pp. 13–30). New York, NY: Raven Press.

doi:10.1111/j.1552-6909.2007.00160.x Karlstrom, A., Engstrom-Olofsson, R., Nystedt, A., Sjoling, M., & Hild-

Borg-Stein, J., & Dugan, S. A. (2007). Musculoskeletal disorders of

ingsson, I. (2010). Women’s postoperative experiences before

pregnancy, delivery and postpartum. Physical Medicine and

and after the introduction of spinal opioids in anaesthesia for

Rehabilitation Clinic of North America, 18(3), 459–476, ix.

caesarean section. Journal of Clinical Nursing, 19(9–10), 1326–

doi:10.1016/j.pmr.2007.05.005

740

doi:10.1046/j.1365-2648.2003.02727.x Karlstrom, A., Engstrom-Olofsson, R., Norbergh, K. G., Sjoling, M.,

1334. doi:10.1111/j.1365-2702.2010.03213.x

Declercq, E., Cunningham, D. K., Johnson, C., & Sakala, C. (2008).

Katz, J., Clairoux, M., Kavanagh, B. P., Roger, S., Nierenberg, H., Reda-

Mothers’ reports of postpartum pain associated with vaginal and

han, C., . . . Sandler, A. N. (1994). Pre-emptive lumbar epidural

JOGNN, 43, 729-741; 2014. DOI: 10.1111/1552-6909.12483

http://jognn.awhonn.org

RESEARCH

Chin, E. G., Vincent, C., and Wilkie, D.

anaesthesia reduces postoperative pain and patient-controlled

Sayyah Melli, M., Rashidi, M. R., Delazar, A., Madarek, E., Kargar Ma-

morphine consumption after lower abdominal surgery. Pain,

her, M. H., Ghasemzadeh, A., . . . Tahmasebi, Z. (2007). Effect

59(3), 395–403. doi:10.1016/0304-3959(94)90026-4

of peppermint water on prevention of nipple cracks in lactating

Kindberg, S., Stehouwer, M., Hvidman, L., & Henriksen, T. B. (2008).

primiparous women: A randomized controlled trial. International

Postpartum perineal repair performed by midwives: A ran-

Breastfeeding Journal, 2, 7. doi:10.1186/1746-4358-2-7

domised trial comparing two suture techniques leaving the skin

Schindl, M., Birner, P., Reingrabner, M., Joura, E., Husslein, P.,

unsutured. British Journal of Obstetrics and Gynecology, 115(4),

& Langer, M. (2003). Elective cesarean section vs. spon-

472–479. doi:10.1111/j.1471-0528.2007.01637.x

taneous delivery: A comparative study of birth experience.

Klepac, R. K., Dowling, J., & Hauge, G. (1981). Sensitivity of the McGill Pain Questionnaire to intensity and quality of laboratory pain. Pain, 10(2), 199–207. doi:10.1016/0304-3959(81) 90195–0

Acta Obstetricia Gynecologica Scandinavica, 82(9), 834–840. doi:10.1034/j.1600–0412.2003.00194.x Turk, D. C., Rudy, T. E., & Salovey, P. (1985). The McGill Pain Questionnaire reconsidered: Confirming the factor structure and examin-

Lansakara, N., Brown, S. J., & Gartland, D. (2010). Birth outcomes, postpartum health and primary care contacts of immigrant moth-

ing appropriate uses. Pain, 21(4), 385–397. doi:10.1016/03043959(85)90167-8

ers in an Australian nulliparous pregnancy cohort study. Mater-

Wilkie, D. J. (2001). TNEEL (Toolkit for Nurturing Excellence at End of

nal Child Health Journal, 14(5), 807–816. doi:10.1007/s10995-

Life) (Version 1.0). Chicago, IL: University of Illinois at Chicago

009-0514-x

College of Nursing.

Lee, S. Y., & Lee, K. A. (2007). Early postpartum sleep and fatigue for

Wilkie, D. J., Huang, H. Y., Reilly, N., & Cain, K. C. (2001). Nociceptive

mothers after cesarean delivery compared with vaginal delivery:

and neuropathic pain in patients with lung cancer: A comparison

an exploratory study. Journal of Perinatal and Neonatal Nursing,

of pain quality descriptors. Journal of Pain and Symptom Man-

21(2), 109–113. doi:10.1097/01.JPN.0000270627.73993.b0 Loeser, J. D. (2012, May 22). IASP taxonomy. Retrieved from

agement, 22(5), 899–910. doi:10.1016/S0885-3924(01)00351-7 Wilkie, D. J., Judge, M. K., Berry, D. L., Dell, J., Zong, S., & Gilespie, R.

http://www.iasp-pain.org/Content/NavigationMenu/

(2003). Usability of a computerized PAINReportIt in the general

GeneralResourceLinks/PainDefinitions/default.htm

public with pain and people with cancer pain. Journal of Pain

Martin, J. A., Hamilton, B. E., Osterman, M. H. S., Curtin, S. C., & Mathews, T. J. (2013). Births: final data for 2012 national vital statistics report (Vol. 62). Hyattsville, MD: National Center for Health Statistics. Melzack,

R.

(1975).

properties

and

Symptom Management, 25(3), 213–224. doi:10.1016/S08853924(02)00638-3 Wilkie, D. J., Molokie, R., Boyd-Seal, D., Suarez, M. L., Kim, Y. O., Zong, S., . . . Wang, Z. J. (2010). Patient-reported outcomes:

The

McGill

scoring

Pain

methods.

Questionnaire: Pain,

1(3),

Major

Descriptors of nociceptive and neuropathic pain and barriers to

277–299.

effective pain management in adult outpatients with sickle cell

doi:http://dx.doi.org/10.1016/0304-3959(75)90044-5

disease. Journal of the National Medical Association, 102(1),

Melzack, R. (1983). The McGill Pain Questionnaire. In R. Melzack (Ed.), Pain measurement and assessment (pp. 41–47). New York, NY: Raven Press.

18–27. Wilkie, D. J., Savedra, M. C., Holzemer, W. L., Tesler, M. D., & Paul, S. M. (1990). Use of the McGill Pain Questionnaire to mea-

Melzack, R. (2005). The McGill Pain Questionnaire: From description to measurement. Anesthesiology, 103(1), 199–202.

sure pain: A meta-analysis. Nursing Research, 39(1), 36–41. doi:10.1097/00006199-199001000-00008

Melzack, R., & Torgerson, W. S. (1971). On the language of pain. Anes-

Woods, A. B., Crist, B., Kowalewski, S., Carroll, J., Warren, J., & Robert-

thesiology, 34(1), 50–59. doi:10.1097/00000542-197101000-

son, J. (2012). A cross-sectional analysis of the effect of patient-

00017

controlled epidural analgesia versus patient controlled analge-

Ngamkham, S., Holden, J. E., & Wilkie, D. J. (2011). Differences

sia on postcesarean pain and breastfeeding. Journal of Ob-

in pain location, intensity, and quality by pain pattern in

stetric, Gynecologic, and Neonatal Nursing, 41(3), 339–346.

outpatients with cancer. Cancer Nursing, 34(3), 228–237.

doi:10.1111/j.1552–6909.2012.01370.x

doi:10.1097/CC.0b013e3181faab63 Nilsson-Wikmar, L., Pilo, C., Pahlback, M., & Harms-Ringdahl, K. (2003). Perceived pain and self-estimated activity limitations in women with back pain post-partum. Physiotherapy Research International, 8(1), 23–35. doi:10.1002/pri.269 Portenoy, R. K. (1989). Mechanisms of clinical pain. Observations and

Supporting Information Additional supporting information may be found in the online version of this article at the publisher’s web-site:

speculations. Neurologic Clinics, 7(2), 205–230. Sandelowski, M. (1995). Sample size in qualitative research. Research

in

Nursing

and

Health,

18(2),

179–183.

doi:10.1002/nur.4770180211 Sandelowski, M. (2000). Combining qualitative and quantitative sampling, data collection, and analysis techniques in mixed-method studies. Research in Nursing and Health, 23(3), 246–255. doi:10.1002/1098–240X(200006)23:33.0.CO;2-H

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Figure 2. Frequency of neuropathic descriptors selected by 30 participants from the PAINReportIt. Figure 3. Frequency of nociceptive descriptors selected by 30 participants from the PAINReportIt. Figure 4. Frequency of Other Descriptors selected by 30 participants from the PAINReportIt.

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