European Journal of Cardiovascular Medicine

Postoperative pain following caesarean delivery under spinal anaesthesia remains a significant clinical problem, despite advances in analgesic techniques. Caesarean section is among the most frequently performed major surgeries worldwide, and optimizing postoperative pain control is critical for enhancing maternal recovery, facilitating early mobilization, improving breastfeeding, and reducing the risk of chronic pain. Yet many patients continue to report moderate or severe pain in the first 24 hours [1,2].

In the context of resource-limited settings, analgesic regimens are often restricted to basic doses of systemic analgesics (e.g., intravenous paracetamol or nonsteroidal anti-inflammatory drugs) without routine use of intrathecal opioids or regional abdominal blocks. Consequently, pain outcomes in such populations may be worse, underscoring the need to characterize local predictors and pain trajectories.

Given this background, we designed a cross-sectional observational study to quantify the intensity of postoperative pain in women undergoing caesarean section under spinal anaesthesia and to evaluate a comprehensive set of demographic, psychological, surgical, and analgesic factors associated with pain. Identification of such predictors can guide individualized analgesic planning and inform interventions to reduce the burden of post-caesarean pain in similar settings.

Study design and setting The current study is a cross-sectional observational research aimed at the maternity and obstetric wards of [Name of Hospital] in 3-months. The institutional ethics committee approved the study and all the participants gave written informed consent. Study population and sampling The variables included women aged 18 years or older whose physical status was ASA I or II, who were scheduled to undergo a caesarean section using spinal anaesthesia (elective or emergency). Women who were critically ill, had a known psychiatric disease, refused the spinal anaesthesia or had contraindications (e.g., spinal deformity, coagulopathy, infection at puncture site) were not included. The sample size was estimated using the formula n=(Z 1/222S2)/d2n=(Z 1/2 2(Z 1/2) 2S2)/d2n=(Z 1/2)2/d2n=(Z 1/2)/d2n=(Z 1/2)/d2=1.96/0.7d=1.96/0.7=1.96. We registered 60 women to provide the possibility of dropouts. Data collection Demographic (age, height, weight, BMI, education level), obstetric (parity, previous surgeries) and a simple preoperative anxiety score (e.g. 010) were noted preoperatively (in the course of admission or in labour). A Numeric Rating Scale (NRS 010) was used to record baseline pain score (if any). Records of surgical variables such as indication to caesarean section, number of individuals in the operating theatre, duration of the operation (in minutes), type of skin incision (e.g. Pfannenstiel), and length of incision (in cm), were taken. At L3L4 level, the spinal anaesthesia was done in the standard technique. The standardization of analgesia was done postoperatively, with the default analgesic as intravenous paracetamol 1 g SOS (on demand); the use of other analgesics (e.g. NSAIDs, tramadol) and the rate of analgesic use were noted. Notes The intensity of pain was measured at 30 minutes of analgesic administration (first dose) and at 12 hours postoperative using NRS (0 = no pain, 1–3 = mild, 46 = moderate, 710 = severe). At 12 hours, satisfaction with pain control (Yes/No) was measured. Data management and statistical analysis The data was coded and put into spreadsheet, Microsoft Excel, and then exported to SPSS version 21.0 to analyse them. Descriptive statistics: frequencies and percentages of categorical variables; mean ± SD or median (IQR) of continuous variables depending on distribution. Shapiro wilk test was used to check the normality. In the case of continuous predictor variables, Pearson correlation (parametric data) or spearman rank correlation (non-parametric) was used to determine association with intensity of postoperative pain (at 12 hours). Chi-square test or Fisher exact test was applied when the predictors comprised of categorical variables (e.g. previous surgery, type of incision, satisfaction). Any p-value below 0.05 was taken to be statistically significant. Confounders can also be adjusted with the help of multivariate linear regression. Tables and figures were also made to demonstrate the demographic distribution, trends in the score of pain, and factors associations.

Overview of participant characteristics and pain trajectory

Sixty women were enrolled, all of whom completed the study without major protocol deviations. The mean age was 29.8 ± 4.2 years (range 21 to 38). Mean height was 160.5 ± 5.7 cm, mean weight 69.8 ± 8.4 kg, and mean BMI 27.1 ± 3.8 kg/m². Thirty-four (56.7 %) had reached at least secondary education, while 26 (43.3 %) had primary or no formal schooling. Regarding obstetric history, 38 (63.3 %) were primiparous, and 22 (36.7 %) had prior uterine surgery (including prior caesarean in 18). The mean preoperative anxiety score was 4.5 ± 2.2 (scale 0–10). The mean baseline pain score (if present) was 4.2 ± 1.5.

Operatively, the mean surgical duration was 65.3 ± 12.8 minutes; mean incision length was 11.2 ± 1.6 cm. The number of persons in the operating room ranged from 4 to 8 (median 5). Analgesic regimen: all participants were given IV paracetamol 1 gm as first-line analgesic; 28 (46.7 %) also received an NSAID (diclofenac 75mg) during the 12-hour period. The average number of analgesic doses given was 2.1 ± 0.9 in the first 12 hours.

Figure 1 shows the mean pain intensity at baseline, 30 minutes post-analgesic, and 12 hours post-analgesic. The pain decreased modestly at 30 minutes but increased again by 12 hours.

FIGURE 1. MEAN NRS PAIN TRAJECTORY OVER TIME

Table 1. Demographic and surgical characteristics (n = 60)

Next, Table 2 presents the distribution of pain intensity categories (none, mild, moderate, severe) at 12 hours.

Table 2. Pain intensity categories at 12 hours (n = 60)

Thus, 45 women (75.0 %) reported at least moderate pain (NRS ≥ 4) at 12 hours.

Table 3 shows the correlation analyses between continuous predictor variables and 12-hour pain score.

Table 3. Correlation of continuous variables with 12h pain (NRS)

Significant positive associations were found with BMI, surgical duration, incision length, and preoperative anxiety.

Table 4 shows categorical associations (e.g. prior surgery, additional NSAID use, satisfaction) with moderate-to-severe pain (NRS ≥ 4) at 12 hours.

Table 4. Associations of categorical predictors with moderate/severe pain (NRS ≥ 4)

Finally, Figure 2 displays a scatterplot of surgical duration (x-axis) versus 12h pain score (y-axis), illustrating a positive trend.

FIGURE 2. SCATTERPLOT OF SURGICAL DURATION VERSUS 12-HOUR NRS PAIN

In this cross-sectional observational study of 60 women undergoing caesarean delivery under spinal anaesthesia, we found that a substantial majority (75 %) experienced moderate to severe pain (NRS ≥ 4) at 12 hours postoperatively. While the analgesic regimen temporarily alleviated pain at 30 minutes, pain intensity increased by 12 hours, indicating a likely waning effect of analgesics or inadequate multimodal coverage. Among studied variables, higher BMI, longer operative duration, greater incision length, increased preoperative anxiety, and prior abdominal surgery were significant predictors of more severe postoperative pain.

Reported incidence of moderate to severe postoperative pain after caesarean ranges widely, with meta-analyses estimating up to 58 % prevalence in resource-limited settings [3]. In some observational cohorts, rates reach 70–85 % depending on the analgesic regimen and patient population [4,5]. The heterogeneity is likely due to differences in analgesia protocols, surgical technique, patient demographics, and pain assessment methods.

Our finding that three-quarters of patients report moderate or worse pain at 12 hours aligns with other reports from low- and middle-income settings, where resource constraints limit access to advanced analgesic modalities [4,5]. A pooled analysis indicated that acute postoperative pain after caesarean may affect up to 58 % of women [3]. Differences in prevalence across studies could reflect variations in analgesia protocols, incorporation of intrathecal adjuvants, or definitions of “moderate to severe” pain.

Multiple factors have been proposed as predictors of postoperative pain intensity in caesarean patients.

Demographic and anthropometric variables such as younger age, higher body mass index (BMI), and lower

education have been implicated [6]. Psychological factors, particularly preoperative anxiety, have shown consistent associations with increased postoperative pain in obstetric and non-obstetric surgeries [7]. Surgical and anaesthesia-related factors, including duration of surgery, incision length, number of persons in the operating room (which can reflect procedural complexity), prior abdominal surgeries, type of spinal needle or insertion attempts, and analgesic strategy (type, dose, frequency) also influence pain response [8,9].

The use of neuraxial anaesthesia itself introduces potential modifiable factors: the addition of intrathecal adjuvants (such as fentanyl or morphine) or use of multimodal analgesia is associated with reduced pain scores and analgesic consumption [10]. As noted in a recent review, optimal neuraxial anaesthesia planning must consider the interplay of patient, surgical, and aesthetic factors to mitigate post-caesarean pain [11].

The positive correlation between BMI and pain intensity is consistent with other surgical pain literature: adipose tissue can influence pharmacokinetics of analgesics, increase technical difficulty, and possibly generate greater tissue stress. Similarly, the association with surgical duration and incision length supports the notion that prolonged operative trauma and larger wounds lead to increased nociceptive input and inflammatory sensitization. Some prior studies in caesarean populations have similarly implicated longer surgical times and larger incision size as pain predictors [8].

Preoperative anxiety emerged as a significant predictor, echoing a substantial body of literature linking psychological distress to heightened pain perception, increased analgesic requirement, and lower pain thresholds in both obstetric and general surgery settings [7]. This underscores the importance of preoperative counselling, anxiety mitigation (e.g. cognitive behavioural techniques, anxiolytics), and possibly stratifying analgesia based on psychological risk.

Prior abdominal surgery (including repeat caesarean) was associated in our data with a higher proportion of moderate-severe pain. This is plausible, as scar tissue and previous surgical trauma may contribute to sensitization (hyperalgesia) and altered nociceptive processing; indeed a recent prospective cohort study found that repeated caesarean section patients had higher postoperative pain compared to primary caesarean patients (relative risk ~1.36 for incisional pain). The difference in time to first analgesic request was also shorter in repeated CS groups in that study — which might reflect lower pain threshold or higher baseline sensitization.

Interestingly, analgesic augmentation (use of NSAIDs) did not show a statistically significant reduction in moderate-severe pain in our dataset, though the direction was favourable (78.6 % vs. 71.9 %). This might reflect underpowering to detect modest effects or suboptimal dosing/timing of NSAID therapy.

Our results have several clinical implications. First, a one-size-fits-all analgesic regimen (paracetamol SOS only) may not adequately cover postoperative pain trajectories, especially beyond the early postoperative window. Multimodal analgesia (e.g. scheduled NSAIDs, use of intrathecal opioids, regional abdominal blocks like TAP or quadratus lumborum blocks) may better sustain analgesia. Indeed, observational studies suggest combining intrathecal morphine/fentanyl with systemic analgesics yields superior control at 6 and 24 hours compared to regimens without intrathecal opioids [9]. Second, preoperative identification of high-risk women (e.g. BMI > threshold, high anxiety scores, prior surgery) can facilitate individualized analgesic planning, closer monitoring, or scheduled rescue doses. Third, intraoperative strategies to minimize surgery duration and limit incision extension where feasible could yield analgesic benefit.

However, our study has limitations. The cross-sectional design and modest sample size limit the ability to infer causality or explore subtle associations. Confounding variables (e.g. intraoperative analgesic adjuncts, anaesthesia technique nuances) might not be fully controlled. We also did not perform multivariate regression due to limited power, though the univariate associations are biologically plausible. Additionally, the absence of longer-term follow-up precludes assessment of persistent pain transition risks. Our analgesic regimen was relatively basic; results might differ in settings using advanced multimodal analgesia. Finally, the study reflects a single centre experience and may not generalize widely. Future studies should involve larger, multicentre cohorts, use standardized multimodal analgesia, and include multivariate adjustment to refine predictive models.

In conclusion, our findings reinforce that a substantial burden of postoperative pain persists despite spinal anaesthesia and highlight modifiable predictors (BMI, surgical duration, incision length, anxiety) that should guide analgesic tailoring. Incorporating both psychological and procedural strategies into perioperative planning is essential to optimize post-caesarean pain outcomes in resource-limited settings.

In this study, the majority of women undergoing caesarean section under spinal anaesthesia experienced moderate to severe pain at 12 hours postoperatively. Key risk factors associated with higher pain intensity included higher BMI, prolonged surgery duration, greater incision length, elevated preoperative anxiety, and prior abdominal surgery. These findings underscore the need for personalized multimodal analgesic planning and preoperative anxiety management to reduce post-caesarean pain burden. Implementation of stratified analgesic protocols and adjunct regional techniques may improve maternal comfort and recovery.

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