COMPARISON OF POSTOPERATIVE PAIN SEVERITY AND ANALGESIC CONSUMPTION WITHIN 24 HOURS BETWEEN PRIMARY AND REPEAT CESAREAN SECTIONS UNDER SPINAL ANESTHESIA: A PROSPECTIVE COHORT STUDY

This prospective cohort study conducted in Ethiopia found that women undergoing repeat cesarean sections under spinal anesthesia experience significantly higher postoperative pain severity and require greater analgesic consumption within the first 24 hours compared to those having primary cesarean sections.

The Gist

The "Second Time Around" Pain Study: A Simple Breakdown

Imagine you are moving into a new house. The first time you move in, the floors are clean, the walls are fresh, and everything is straightforward. You might get a little sore from carrying boxes, but it's manageable.

Now, imagine you have to move into that same house again, but this time, the previous tenants left behind some heavy furniture stuck to the floor, some nails in the walls, and the layout has changed. Moving in the second time is going to be much harder, messier, and likely more painful for your back and arms.

This study is essentially about that "second move," but instead of a house, it's about a Cesarean section (C-section) surgery. The researchers wanted to know: Is the pain and recovery harder for women having a second (or third) C-section compared to their very first one?

Here is the story of what they found, told in plain English.

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1. The Setup: Two Groups of Moms

The researchers looked at 203 women at a big hospital in Ethiopia (Tikur Anbessa Specialized Hospital). They split them into two teams:

• Team First-Timers: Women having their very first C-section.
• Team Repeaters: Women having their second or third C-section.

They watched them closely for 24 hours after surgery, asking them to rate their pain on a scale of 0 to 10 (like a video game health bar) and tracking how much pain medicine they needed.

2. The Big Discovery: The "Second Move" Hurts More

The results were clear and surprising to some, but logical to others. Team Repeaters had a much harder time.

• The Pain Score: When the "First-Timers" were resting, their pain was like a dull throb (a score of 3 or 4). But the "Repeaters" felt like they were carrying a heavy backpack (a score of 5 or higher).
• The "Cough Test": This is the real kicker. When the moms tried to cough, laugh, or move (which is like jumping on a trampoline after a move), the pain spiked.
  • First-Timers: About 2 out of 3 felt moderate-to-severe pain.
  • Repeaters: Almost all of them (9 out of 10) felt moderate-to-severe pain.
• The Medicine Bill: Because the pain was worse, the "Repeaters" had to take significantly more painkillers. Think of it like this: If the First-Timers needed one cup of coffee to stay awake, the Repeaters needed two and a half cups.

3. Why Does This Happen? (The "Scar City" Analogy)

You might wonder, "If it's the same surgery, why is it worse the second time?"

The study explains that the body is like a construction site.

• First C-Section: The surgeons cut through fresh, clean tissue. It's like cutting through a new sheet of paper.
• Repeat C-Section: The body has healed from the first surgery, but it leaves behind scar tissue. Think of scar tissue like dried glue or sticky tape that has formed inside the belly.
  • When surgeons go back in, they have to peel back this "sticky tape" (adhesions) and navigate around old scars.
  • This causes more internal trauma, more inflammation, and more "visceral" pain (the deep, gurgling kind of pain inside your organs), not just the cut on the skin.

4. The "Pain Type" Difference

The study also noticed a difference in what hurt:

• First-Timers: Mostly felt pain right at the cut on their skin (like a paper cut).
• Repeaters: Felt a mix of the skin cut plus deep internal pain. It was like having a paper cut and a bruise on your ribs at the same time.

5. What Does This Mean for Doctors and Patients?

The most important takeaway is that one size does not fit all.

Currently, many hospitals have a "standard pain plan" for everyone. This study says that's like giving everyone the same size shoe. It doesn't work!

• For First-Timers: The standard pain plan is usually fine.
• For Repeaters: They need a "VIP Pain Plan." They need more medicine, earlier medicine, and a plan that accounts for the fact that their "construction site" is messier than the first time.

The Bottom Line

Having a second or third C-section is not just a "repeat" of the first one; it's a different, more challenging experience for the body. The pain is sharper, lasts longer, and requires more help to manage.

The Recommendation: Doctors need to look at a woman's history. If she has had a C-section before, they should treat her pain more aggressively from the very start, just in case her body is dealing with that "sticky tape" of scar tissue.

Note: This study was a "preprint," meaning it's new research that hasn't been fully checked by other scientists yet, but the findings are very clear and point toward a need for better, more personalized care.

Technical Summary

1. Problem Statement

Cesarean sections (CS) are among the most common surgical procedures globally, frequently resulting in moderate to severe postoperative pain that hinders recovery and maternal-infant bonding. While the general prevalence of post-CS pain is well-documented, there is a significant gap in literature regarding the comparative differences in pain intensity and analgesic requirements between primary (first-time) and repeat (subsequent) cesarean sections.

Existing literature presents conflicting findings: some studies suggest repeat CS patients experience higher pain due to adhesions and surgical complexity, while others indicate lower pain scores or opioid consumption in repeat cases. Furthermore, in the Ethiopian context, postoperative pain management is often suboptimal due to a lack of provider awareness regarding these specific differences. This study addresses the need to quantify these disparities to facilitate individualized pain management strategies.

2. Methodology

• Study Design: A prospective cohort study conducted at Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia.
• Study Period: January 1 to March 30, 2025.
• Participants:
  • Total Sample: 203 women (102 Primary CS, 101 Repeat CS).
  • Inclusion Criteria: Women aged 18–40, ASA physical status II or III, undergoing elective or emergency CS under spinal anesthesia.
  • Exclusion Criteria: Chronic pain disorders, hearing impairment, failure of spinal anesthesia, general/epidural anesthesia, life-threatening complications requiring immediate intervention, multiple pregnancies, IUFD, or three or more previous scars.
• Sampling: Systematic random sampling was employed to select eligible patients from the daily surgical schedule.
• Intervention & Anesthesia: All procedures utilized spinal anesthesia with 0.5% Bupivacaine (L3–L4 interspace). Target sensory block was T5–T6.
• Data Collection:
  • Pain Assessment: Measured using the Numerical Rating Scale (NRS) (0–10) at 1, 6, 12, and 24 hours postoperatively. Assessments were conducted both at rest and during movement (coughing).
  • Analgesic Consumption: Total consumption of tramadol (IV) and diclofenac (IM/suppository) within the first 24 hours was recorded and converted to milligram equivalents.
  • Variables: Socio-demographics, obstetric history, intraoperative factors (duration, incision type), and pain characteristics (incisional vs. visceral).
• Statistical Analysis: Data were analyzed using SPSS v27. Continuous variables were compared using independent t-tests (normal distribution) or Mann–Whitney U tests (non-normal). Categorical variables were analyzed using Chi-square tests. A p-value < 0.05 was considered statistically significant.

3. Key Contributions

• Contextual Evidence: Provides the first prospective data from a major Ethiopian teaching hospital comparing primary vs. repeat CS pain profiles, addressing a regional knowledge gap.
• Differentiation of Pain Types: Distinguishes between incisional pain (predominant in primary CS) and mixed incisional/visceral pain (predominant in repeat CS), linking the latter to adhesions and internal scarring.
• Quantification of Burden: Establishes a clear correlation between the number of previous surgeries and increased analgesic requirements, challenging the notion that repeat procedures are less painful due to patient familiarity.

4. Key Results

• Demographics: The repeat CS group was significantly older (mean 30.86 vs. 26.89 years, p < 0.001) and had higher parity. No significant differences were found in BMI, education, or marital status.
• Intraoperative Factors: The duration of surgery was significantly longer in the repeat group (51.7 ± 5.4 min) compared to the primary group (41.7 ± 4.1 min, p < 0.001), likely due to adhesions.
• Pain Severity (NRS):
  • At 6 Hours: The repeat group reported significantly higher pain scores (Median NRS 7, IQR 7–8) compared to the primary group (Median NRS 5, IQR 4–7; p < 0.001).
  • Movement (Coughing): At 6 hours, 92.1% of the repeat group experienced moderate-to-severe pain vs. 66.7% in the primary group (p < 0.001).
  • At Rest: Moderate-to-severe pain at 6 hours was reported by 74.3% of the repeat group vs. 52.9% of the primary group (p = 0.002).
• Analgesic Consumption:
  • The repeat group consumed significantly more analgesics in the first 24 hours (243.3 ± 98.4 mg) compared to the primary group (146.3 ± 82.5 mg; p < 0.001).
• Pain Character:
  • Primary CS: Predominantly incisional pain (77.5%).
  • Repeat CS: Predominantly a combination of incisional and visceral pain (78.2%), attributed to increased internal manipulation and scarring.
• Risk Assessment: The Relative Risk (RR) of experiencing moderate-to-severe pain during movement for repeat CS patients was 3.03 (95% CI: 1.6–5.7) compared to primary CS patients.

5. Significance and Implications

• Clinical Practice: The findings strongly support the need for individualized, intensified pain management protocols for women undergoing repeat cesarean sections. Standardized protocols based on primary CS outcomes are insufficient for this high-risk group.
• Preoperative Counseling: Clinicians should counsel patients with prior CS about the higher likelihood of visceral pain and increased analgesic needs, managing expectations regarding recovery.
• Policy Recommendations: Anesthesia and surgical teams should proactively consider surgical history and scarring when planning postoperative analgesia (e.g., multimodal approaches, earlier intervention, or higher dosing thresholds) to prevent inadequate pain control.
• Future Research: The study highlights the need for multicenter trials and longer-term follow-up (beyond 24 hours) to assess the impact of these acute pain differences on chronic postoperative pain and long-term recovery.

Conclusion: Repeat cesarean sections are associated with significantly higher early postoperative pain severity and increased analgesic consumption compared to primary sections, driven by factors such as adhesions, visceral pain, and longer operative times. Tailored pain management strategies are essential for optimizing outcomes in this population.