THE PREVALENCE AND THE ASSOCIATED PREDISPOSING

FACTORS FOR ONGOING POST-SURGICAL PAIN

FOLLOWING CAESEAREAN DELIVERY IN KENYATTA
NATIONAL HOSPITAL

DR. LESLEY GESARE MAKAMARA

H58/6967/2017

A DISSERTATION SUBMITTED IN PART-FULFILMENT OF THE

REQUIREMENTS FOR THE DEGREE OF MASTER OF MEDICINE IN
ANAESTHESIA OF THE UNIVERSITY OF NAIROBI.

©2023
PRINCIPAL INVESTIGATOR

Dr Lesley Gesare Makamara

MBChB (University of Nairobi)

SUPERVISORS
Dr Caroline Mwangi
MBChB, Mmed Anaesthesia (University of Nairobi)
Lecturer,
Department of Anaesthesia,
University of Nairobi

Dr Charles Kabetu
MBChB, Mmed Anaesthesia (University of Nairobi)
Adjunct Professor,
Jomo Kenyatta University of Agriculture and Technology
Regional Medical Officer,
Operation Smile Inc

Dr Timothy Mwiti
MBChB, Mmed Anaesthesia (University of Nairobi)
Lecturer,
Department of Anaesthesia,
University of Nairobi

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DECLARATION

I hereby declare that this dissertation is my original work. It has not been submitted before, either
in whole or in part, to this institution or any other institution elsewhere for academic
qualification. All material cited in this report that are not my own have been duly acknowledged.
Dr. Lesley Gesare Makamara

Sign__________________ Date: 17th July 2023

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SUPERVISORS’ APPROVAL

The undersigned certify that they have read and recommended this dissertation as the partial
fulfilment for the award of the degree of Masters of Medicine in Anaesthesiology of the
University of Nairobi to the Kenyatta National Hospital and University of Nairobi Ethics and
Research Committee (ERC).

Dr Caroline Mwangi, Lecturer, Department of Anaesthesia University of Nairobi, MBCHB,

MMED ANAESTHESIA, Cardiac Anaesthesiologist.

Signature………………………………………………… Date: ……… July 2023

Dr Charles Kabetu, Anaesthesiologist, Adjunct Professor JKUAT, MBCHB, MMED

ANAESTHESIA.

Signature……………………………………………….... Date: ………. July 2023

Dr Timothy Mwiti, Lecturer, Department of Anaesthesia University of Nairobi, MBCHB,

MMED ANAESTHESIA, Pain specialist.

Signature…………………………………………… Date: ………… July 2023

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DEPARTMENTAL APPROVAL

This Dissertation has been reviewed by the department of anaesthesia and approved for
submission for ethical review.

………………………………. Date…… July 2023…………………….

Chairman, Department of Anaesthesia

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LIST OF ABBREVIATIONS

ACOG The American College of Obstetricians and Gynaecologists

ASA American Society of Anaesthesiologists

BMI Body Mass Index

CS Caesarean Section

GA General Anaesthesia

KNH Kenyatta National Hospital

NSAIDS Non-Steroidal Anti-Inflammatory

NRS Numerical Rating Scale

TENS Transcutaneous Electrical Nerve Stimulation

PPP Persistent Post-surgical Pain

WHO World Health Organization

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DEFINITION OF KEY TERMS

Analgesia-Absence of pain in response to a stimulation which would normally be painful.

Analgesic - A drug that causes pain relief.

Central sensitization- Increased responsiveness of nociceptive neurons in the central nervous

system to their normal or subthreshold afferent input.

Hyperalgesia- A condition whereby an individual develops increased sensitivity to a painful

stimulus with an extreme pain response due to nerve damage.

Neuropathic pain- This is pain that results from nerve injury or damage. The nerve in question,
transfer noxious stimuli from the peripheral sites to the spinal cord and
central nervous system. It is characterized by pain that is burning in nature
and often sensitive to touch.

On-going postoperative pain. This is pain that is present following surgery. It is neither acute
nor chronic in nature. Furthermore, there is no duration attached
to this pain.

Paraesthesia- An abnormal sensation experienced as the result of pressure on or damage to

peripheral nerves. It is characterized as tingling or prickling sensations sometimes
described as pins and needles.

Parturient- A woman in labour who is about to give birth.

Peripheral sensitization- Increased responsiveness and reduced threshold of nociceptive

neurons in the periphery to the stimulation of their receptive fields.

Persistent Post-surgical Pain- Pain that persists for a period longer than 3 months after surgical
healing. It is chronic in nature with no other causative agent.

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TABLE OF CONTENTS

DECLARATION..........................................................................................................................iii

SUPERVISORS’ APPROVAL....................................................................................................iv

DEPARTMENTAL APPROVAL................................................................................................v

LIST OF ABBREVIATIONS......................................................................................................vi

DEFINITION OF KEY TERMS...............................................................................................vii

TABLE OF CONTENTS...........................................................................................................viii

LIST OF FIGURES.......................................................................................................................2

LIST OF TABLES.........................................................................................................................2

ACKNOWLEDGEMENTS..........................................................................................................3

ABSTRACT....................................................................................................................................4

CHAPTER 1: INTRODUCTION...............................................................................................5

CHAPTER 2: LITERATURE REVIEW....................................................................................6

2.1Post surgical pain..................................................................................................................6

2.1.1 Definition of pain...........................................................................................................6

2.1.2 Post-surgical pain..........................................................................................................6
2.2 Epidemiology of post-surgical pain....................................................................................6

2.3 Pathophysiology of persistent post-surgical pain..............................................................7

2.4 Predisposing Factors for Developing Post-Surgical Pain.................................................7

2.5 Caesarean delivery.............................................................................................................10

2.6 Complications of a caesarean delivery.............................................................................10

2.7 Pharmacological management of post caesarean delivery pain....................................11

2.8 Non pharmacological management of post caesarean delivery pain............................12

2.9 Validated Assessment Tools..............................................................................................12

2.10: Research Question, Study Justification............................................................................14

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 2.10.1 Research Question.........................................................................................................14

2.10.2 Study Justification.........................................................................................................14

2.10.3 STUDY OBJECTIVES....................................................................................................15

2.10.3.1 Broad Objectives........................................................................................................15

2.10.3.2 Specific Objectives.....................................................................................................15

CHAPTER 3: METHODOLOGY.............................................................................................16

3.1 Study Site............................................................................................................................16

3.2 Study Design.......................................................................................................................16

3.3 Study Population................................................................................................................16

3.4 Eligibility Criteria..............................................................................................................17

3.4.1The Inclusion Criteria..................................................................................................17

3.4.2 The Exclusion Criteria................................................................................................17
3.5 Sample Size Calculation....................................................................................................17

3.6 Sampling Procedure...........................................................................................................18

3.7 Study Procedure.................................................................................................................18

3.8 Data Processing......................................................................................................................19

3.8.1 Data Collection................................................................................................................20

3.8.2 Data Management...........................................................................................................20

3.8.3 Data Analysis...................................................................................................................20

3.9 Ethical Considerations.......................................................................................................21

3.10 Quality Control Assurance..............................................................................................22

3.11 Study Findings and Dissemination.................................................................................22

CHAPTER FOUR: RESULTS...................................................................................................23

The Prevalence of Ongoing Post Surgical Pain at 2 Months Post CS at KNH...................25

The Patient Factors Associated with Ongoing Post Surgical Pain at 2 Months Post CS at
KNH...........................................................................................................................................27

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 The Anaesthetic Factors Associated with Ongoing Post Surgical Pain at 2 Months Post
CS at KNH................................................................................................................................28

The Surgical Factors Associated with Ongoing Post Surgical Pain at 2 Months Post CS at
KNH...........................................................................................................................................29

Post-Operative Factors Associated with Ongoing Post Surgical Pain at 2 Months Post CS
at KNH......................................................................................................................................30

SECONDARY FINDINGS.........................................................................................................31

CHAPTER 5: DISCUSSION......................................................................................................32

CONCLUSION............................................................................................................................35

RECOMMENDATIONS............................................................................................................35

STUDY LIMITATION...............................................................................................................35

REFERENCES............................................................................................................................36

APPENDICES..............................................................................................................................45

Appendix One: Consent Form (English)...............................................................................45

Appendix Two: Fomu Ya Ridhara (Kiswahili).....................................................................49

Appendix Three: Pain Measurement Tools...........................................................................52

Appendix Four: Eligibility Criteria........................................................................................54

Appendix Five: Questionnaire................................................................................................57

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LIST OF FIGURES

FIGURE PAGES
Figure 3.1 Study flow chart…………………………………………………………………….19
Figure 4.1. Study participant flow chart………………………………………………………..23

Figure 4.2: Prevalence of pain at 2 months post-caesarean section………………………...….25

Figure 4.3: Pain intensity at 2 months post CS…………………………………………..…….26

LIST OF TABLES

TABLE PAGES
Table 4.1: Characteristics of maternity patients………………………………………….………23

Table 4.2: The indications for Caesarean Section………………………………………………..24

Table 4.3: The patient factors associated with surgical pain at 2 months…………………….….27

Table 4.4: Anaesthetic factors associated with surgical pain at 2 months………………...……..28

Table 4.5: Surgical factors associated with surgical pain at 2 months…………………………..29

Table 4.6: Post-operative factors associated with surgical pain at 2 months……………………30

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ACKNOWLEDGEMENTS

I want to acknowledge my beloved parents who have given me the motivation and the support to

pursue a medical career and still encourage me to this day. To my siblings, Gillian, Clive, Ian

and Angel for moral support throughout my academic journey.

I wish to thank the Kenyatta National Hospital and the University of Nairobi Ethics and

Research Committee for allowing me to carry out this study. I sincerely thank my three

immediate supervisors Dr C. Mwangi, Dr Kabetu and Dr Mwiti for their continued support and

encouragement since the start of this project.

I express my gratitude to the consultant anaesthesiologists; Dr. Olang, Dr. Chokwe, Dr.

Chikophe, Dr Gikore, Dr Gwaro and Dr Gatheru for invaluable input and support throughout the

research work. I also want to thank my research assistants, statistician and fellow residents for

their time and patience. Finally, I appreciate the support given by KNH-UON anaesthesia

departments in my data collection.

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ABSTRACT

Background: Caesarean section is one of the most performed surgeries. Many women complain
of post-partum pain following caesarean delivery. The aim of this study was to find out the
prevalence and associated factors leading to on-going pain following caesarean deliveries at
Kenyatta National Hospital.
Broad Objective: To determine the prevalence and the associated factors of on-going post-
surgical pain 2 months after emergency caesarean section at Kenyatta National Hospital
Methods: This was a prospective, longitudinal observational study involving 139 caesarean
delivery patients at Kenyatta National Hospital in a period of 1-2 months. The participants were
followed up every two weeks for a period of 2 months via telephone.
Data management: Data were collected using investigator directed questionnaire and recorded
using an electronic data capture, Redcap then imported to Stata version 16 for analysis. A total
number of 12 variables were collected in the study. The demographic variables included; age,
marital status, educational status, employment status, number of previous scars, pre-operative
pain, pre-operative usage of analgesia and post-operative pain. The independent variables
included; caesarean section indication, variability of intra-operative and post-operative analgesia
and the surgical factors such as type of surgery and layers repaired. The pain intensity levels
were assessed using mode and median. Patient, anaesthetic and surgical factors were assessed
with independent T-test for continuous data and chi-square test for categorical data. The
statistically significant factors were subjected to a multivariate analysis with the use of logistic
regression. Risk ratio as well as 95% confidence interval were calculated and reported where
appropriate. All statistical tests with the p-value < 0.05. were considered significant in the study.
Results: Out of the 139 participants, 33 patients reported ongoing post-surgical pain at the end of
2 months translating to a pain prevalence of 24% with 12.9% being mild pain, 6.5% moderate
pain and 4.3% severe pain. No patient, anaesthetic and surgical factors in this study were
associated with ongoing post-surgical pain at 2 months following caesarean section. The
secondary findings included neonatal loss (10) and wound infections (9).

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Conclusion: The ongoing pain at 2 months following caesarean deliveries at Kenyatta National
Hospital was 24%. Patient, surgical, and anaesthetic factors were not associated with ongoing
post-surgical pain at 2 months following caesarean delivery at KNH.

CHAPTER 1: INTRODUCTION

Tissue trauma following surgery may lead to both short term and long-term adverse effects. One
of the adverse outcomes of surgery is pain. Pain should be considered as the 5 th vital sign. It is
important to assess pain just like blood pressure, temperature, respiratory rate and oxygen
saturation in the post-operative phase. The effect of surgery on the body is significantly reduced
in surgical patients when pain is adequately managed (1,2).

Caesarean section is one of the commonly performed surgeries. The World Health Organization
(WHO) considers the ideal caesarean section rate to be 10-15%, both in developed and
developing countries. Globally, caesarean section rates are on the rise (3). The Kenya national
caesarean section rate is 14.4% while that of Kenyatta National Hospital (KNH) is 33%, as of
2014 (4).
In 2018, the American College of Obstetricians and Gynaecologists (ACOG) recognized that
caesarean delivery is a strong predictor for developing persistent post-surgical pain which leads
to maternal post-partum depression, difficulty in latching and bonding with the new-born (5). A
patient after caesarean delivery is expected to make a full recovery. Pain following caesarean
section may be more common than what is presumed (6).

The aim of this study was to find out the prevalence and associated factors for ongoing post-
surgical pain at 2 months following caesarean section at Kenyatta National Hospital, Nairobi
Kenya. Caesarean section is one of the commonly performed surgeries whereby one of the
primary outcomes is pain following the caesarean delivery.

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CHAPTER 2: LITERATURE REVIEW

2.1Post surgical pain

2.1.1 Definition of pain
The International Association for the Study of Pain (IASP) describes pain an unpleasant sensory
and emotional experience associated with, or resembling that associated with, actual or potential
tissue damage. Pain is a subjective experience and it is what the person says it is. Pain is
influenced by biological, psychological and social factors. According to the Declaration of
Montreal, it is the right of a person in pain to acknowledgement and treatment of his/her
identified pain (7).

2.1.2 Post-surgical pain

Pain is a known consequence of surgery. Acute pain should last shorter than a week following
surgery and it is easily treated. Chronic post-surgical pain may present as a continuum of acute
pain or develops after an asymptomatic period (8–10).

2.2 Epidemiology of post-surgical pain

The incidence of severe persistent post-surgical pain ranges between 2-61% of all surgeries. A
systematic review revealed that 80% of patients reported to have had pain within the first 14 days
after hospital discharge. 70% of these patients characterized their pain as being moderate to
severe. 10-40% of the patients progressed to persistent post-surgical pain (11). Additionally,
prevalence of post mastectomy pain syndrome is 61% at 1 month and 48% at 3 months (12).
Children do experience persistent post-surgical pain with a prevalence of 20% at 12months
following surgery (13).

Gan et al looked at 300 patients undergoing various types of surgeries. Preoperative evaluation
revealed that 80% of patients feared post-operative pain and this fear of pain led to perioperative
anxiety. Of these 300 patients, 86% had acute post-surgical pain, with 75% of the patients
complaining of moderate to severe acute post-surgical pain (14).

An Australian study by Liu et al found incidence of persistent post-surgical pain among

parturient women to be 15% at 2 months and 4 % at 1 year post caesarean section (15). The

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incidence of persistent post-surgical pain among Chinese women was 18.3% at 3 months, 11.3%
at 6 months and 6.8% at 1 year (16) . Furthermore, a study on Danish women found the
incidence of post caesarean section pain to be 18.6%, 12.3% at 3 and 6 months respectively (17).

2.3 Pathophysiology of persistent post-surgical pain

Pain is initiated by peripheral nociceptor stimulation via various receptors and or ion channels.
Pain processes include transduction, transmission, modulation and perception. For transduction
to occur, noxious stimuli from heat, cold, mechanical or chemical agents activate the nociceptors
at the peripheral sites. This leads to the release of inflammatory mediators and a generation of an
action potential. Transmission involves propagation of the generated action potential also known
as the nociceptive signal from the peripheral site of injury to the central nervous system. In
modulation, there is alteration of a painful impulse as its propagated along its nociceptive
pathway. Through this process, the mechanism of clinical analgesia is understood. Pain
perception is the interpretation of this biological process, governed by past experiences and
expectations (18–20).

Prolonged tissue inflammation results in chronic pain. This is due to peripheral sensitization
which is a sequalae of repetitive or prolonged tissue inflammation. This leads to changes in the
action potential duration and velocity of conduction. With repetitive insult to an injured nerve, an
action potential is easily generated. Clinically this will manifest as hyperalgesia, neuropathic
pain and paraesthesia. Central sensitization results in both short-term and long-term changes to
the nervous system. There is re-organization of cells at the level of the dorsal horn, such that
cross-depolarization occurs between neighbouring cells. This lowers the action potential
threshold by increasing membrane conductance (21).

2.4 Predisposing Factors for Developing Post-Surgical Pain.

The predisposing factors for the development of post-surgical pain can be classified in numerous
ways. One classification system is preoperative, intraoperative and postoperative factors. The
other classification system is modifiable and non-modifiable factors and lastly as patient,
surgical and anaesthetic factors (22)(23). Preoperative factors include continuous pre-operative
pain for more than a month, pre-operative analgesia consumption, younger age, gender, body

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mass index (BMI), genetics, psychological and socio-economic factors. The intraoperative
factors are; duration of the surgery, repeat surgeries, nerve injury, type of anaesthesia given and
American Society of Anaesthesiologists (ASA) classification. Postoperative factors include the
duration in which a patient is in severe pain within the first 24 hours and post-operative analgesia
(24).
American Society of Anaesthesiologists (ASA) is a baseline physical status classification used
by anaesthesiologists in determining the peri-operative risk to a surgical patient. ASA
classification entails ASA class 1 to ASA class 6. ASA class 1, a normal healthy patient
scheduled for surgery. Class 2, a patient with mild systemic disease or a known alcoholic or
smoker, an obese patient and a pregnant woman. Class 3, is a patient with severe systemic
disease while class 4 is a patient with severe systemic disease that is a constant threat to life.
ASA class 5, a patient is one who is moribund and will not survive without surgical intervention.
Lastly, class 6 is a braindead patient scheduled for organ harvesting (25). ASA classification has
been used to predict persistent post-surgical pain and classification of 3 and above is associated
with above average pain following surgery (14). However, Hoofwijk et al. found that ASA
classification had no bearing on persistent post-surgical pain (15).

Pain in the pre-operative period has a threefold risk of predicting persistent post-surgical pain
(26). It is thought that older people have reduced peripheral nociceptive function and therefore
experience less pain. With every increasing year, there is a 5% decrease in the probability of
developing persistent post-surgical pain (27).

Psychological factors that predispose to persistent post-surgical pain are negative emotions.
These include depression, anxiety, psychological vulnerability and pain catastrophizing (27,28).
Apart from developing persistent post-surgical pain, psychological disorders such as anxiety and
depression increase opioid consumption. The usage of opioids has also been linked to persistent
post-surgical pain. This is because the use of opioids may lead to hyperalgesia thus increasing
the consumption of opioids, leading to a vicious cycle. Moreover, anxiety and or depression
increases post-operative pain necessitating the use of opioids (27,28). Depression and anxiety in
the pre-operative phase leads to the experience of severe post-operative pain and vice versa (29).

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Studies have also revealed that parturient women from deprived socio-economic status have
higher rates of post-surgical pain (30). There are multiple factors associated with this; lack of a
good social support system and barriers that inhibit proper health seeking behaviours (31).

There are modifiable factors that can be altered to the benefit of the patient to either decrease or
eliminate post-surgical pain. Duration of surgery is key. Surgery that lasts for more than 3 hours
attributes to severe pain scores while surgery lasting less than 1 hour is associated with mild pain
scores (28). Nerve injury has been speculated to attribute to 50% of chronic post- surgical pain
following any surgery (23). Nerve injury leads to sensitization, wound hyperalgesia and
persistent post-surgical pain (22). In the presence of nerve injury, one may present with features
of sensory dysfunction such as hyperalgesia without pain (32).

The duration that an individual experiences severe post-operative pain in the 1 st 24 hours is a
strong predictor for developing persistent post-surgical pain (33). Severe acute pain within the
first 24 hours following caesarean delivery and maternal depression lead to persistent post-
surgical pain (16). Within the first 24 hours, spinal anaesthesia has been shown to be more
beneficial than general anaesthesia to the new mother. This is because the new mother is able to
mobilize early and attend to her neonate due to lower pain scores following spinal anaesthesia.
(34). Currently, the use of general anaesthesia for caesarean section is on the decline because
spinal anaesthesia has less adverse outcomes (34–37). Some authors have found that parturient
women who had undergone General Anaesthesia were more likely to develop persistent post-
surgical pain (38). In contrast, others studies found that there was no significant difference of
developing post-surgical pain in parturient women who underwent General Anaesthesia verses
Spinal Anaesthesia (17).

A Chinese study highlighted that the major risk factor for developing persistent post-surgical
pain following caesarean delivery is a previous caesarean section. The patients who had previous
caesarean delivery had higher post-operative analgesic intake and higher associated
psychological disorders. This group of patients displayed psychological vulnerability, depression
and pain catastrophizing more than the patients who had not undergone a previous caesarean
delivery. In this cohort anxiety had no connection with persistent post-surgical pain and the
usage of analgesia in the immediate post-operative phase (39). In a Brazilian study, the incidence

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of persistent post-surgical pain at 3 months following caesarean section was 25.5%. The
identified risk factors were pre-surgical anxiety, smoking and severe acute post-surgical pain
(40).

2.5 Caesarean delivery

This is a major abdominal surgical procedure, carried out by a team consisting of the surgeon,
surgeon’s assistant, the anaesthesia provider, anaesthesia technician and the nursing team.
Delivery of the foetus involves both a laparotomy and hysterotomy. Surgical technique will
differ with the surgeons. The abdominal incision chosen is dependent on the indication for the
caesarean section and the surgeon’s preference. The technique of repairing the laparotomy is
dependent on the surgeon’s preference. Caesarean section is an aseptic technique with
prophylactic antibiotics given before surgical incision. The mode of anaesthesia is dependent on
the patient status and indication of the caesarean section. Once the patient is anaesthetized, the
skin is cleaned and draped. The skin incision is then made and the rectus abdominis muscle
separated. The peritoneum is opened and the uterine incision is made. The amniotic membrane is
then ruptured, followed by delivery of the foetus followed by the placenta. The uterine cavity is
cleaned then exteriorized to facilitate repair in 2 layers. Once uterus has contracted and
haemostasis is achieved the closure of the abdomen begins in layers. Layers closed include the
peritoneum fascia, the rectus muscle, subcutaneous tissues and skin. Of note, not all surgeons
close all the 4 layers (41).

The different surgical incision includes Joel-Cohen, vertical and the Pfannenstiel-Kerr incisions.
Most surgeons prefer is the Pfannenstiel-Kerr incision due to cosmesis. The Joel-Cohen incision
is faster, with less blood loss, less post-operative surgical site infection and less post-operative
pain in relation to the Pfannenstiel-Kerr incision. The vertical or midline incision is considered
for preterm labour, dense adhesions and placental malposition. Apart from poor cosmesis, this
incision has a higher rate of incisional hernia and the greatest risk of post-operative pain (42–44).

2.6 Complications of a caesarean delivery

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Complications following caesarean delivery can be short term, long term and those that occur
due to repeated caesarean sections. The short-term complications are maternal mortality and
acute maternal morbidity. Acute maternal morbidity refers to acute pain, fatigue, haemorrhage
that may require hysterectomy or blood transfusion, puerperal infection and thromboembolism.
Long-term complications are chronic pain, menstrual disorders, urinary and faecal incontinence,
sexual dysfunction and subfertility. Pelvic adhesions, small bowel obstruction, abnormal
placentation and increased risk of hysterectomy increases with increasing caesarean sections. A
high maternal body mass index (BMI) increases the risk of complications during caesarean
sections (45–47).

Pain is an adverse effect following caesarean delivery. Post-surgical pain may present at the
surgical site, back and any other body part. In a study done by Rothaug et al., 59.9% of
parturients presented with surgical site pain, 10.8% presented with pain in other body parts while
29.3% presented with pain in both (48). In a Chinese study, 3 months post-caesarean delivery
56.3% mothers reported surgical scar pain while 36.4% reported backpain (39). Definition of
back pain includes both upper and lower back while pelvic pain and residual birth pain is defined
as any other pain that is related to the outcome of the pregnancy (49). Weibel et al found that the
incidence of chronic back pain following caesarean section was 29.8%, 38.5% and 17.5% at 3-
6months, 6-12 months and beyond 12 months. Additionally, the reported incidence of chronic
pelvic pain was at 5.5%, 11% and 9.9% at 3-6months, 6-12 months and beyond 12 months
respectively. While the incidence of residual pain was at 19.4% at 3-6 months and 22.1% beyond
12 months (49).

Ortner et al. looked at parturient women in the United States of America undergoing elective
caesarean delivery under spinal anaesthesia with a previous caesarean scar. Of these women,
41% presented with previous caesarean scar pain prior to the elective caesarean delivery. Acute
post-surgical pain and pre-operative hyperalgesia was a strong correlation for developing
persistent post-surgical pain that was neuropathic in nature (50).

2.7 Pharmacological management of post caesarean delivery pain

For adequate pain control, the WHO recommends a multimodal approach in a stepwise ladder
fashion (51). This includes systemic analgesia, neuraxial routes, peripheral nerve blocks and

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wound infiltration with local anaesthetics (52). Systemic agents are opioids, non-steroidal anti-
inflammatory drugs (NSAIDS), para-aminophenols, ketamine and gabapentinoids.
Acetaminophen, an example of a para-aminophenols reduces the opioid requirement, with
reduced milk transfer to the new-born and good safety maternal profile. Combined formulations
with NSAIDS has additive effects which also reduce the opioid requirement (53,54). NSAIDS
have a good safety profile with low transfer to breastmilk and can be given intravenously, orally
and per rectal. Rectally administered diclofenac offers good analgesia and reduces opioid
consumption in post-partum women (55). Analgesia with opioids can be administered either by
the health care giver or controlled by the patients. ASA encourages the use of neuraxial opioids.
Opioids have an added disadvantage of breast milk transfer and may result to sudden infant
death(56). Oral gabapentinoids administered in the pre-operative phase, decreases acute post
operative pain but easily transfers to milk leading to neonatal sedation. Sub-anaesthetic doses of
ketamine given intra-operatively decreases post-operative pain and opioid consumption (5,57).

2.8 Non pharmacological management of post caesarean delivery pain

Non pharmacological techniques are employed to manage pain following caesarean section to
reduce the opioid consumption and enhance recovery after surgery (ERAS). Techniques used
include surgical, electrical, mechanical and relaxation techniques. The following surgical
techniques have been shown to decrease pain scores for the 1 st 48 hours following caesarean
delivery. These surgical techniques include the use of a Joel-Cohen incision, blunt fascial
opening, extraperitoneal section, closure of the uterus in situ instead of exteriorization of the
uterus and non-closure of peritoneum. Application of laser irradiation to the surgical site at the
end of the surgery reduces pain scores for the 1st 24 hours following caesarean delivery (58).
Transcutaneous Electrical Nerve Stimulation (TENS) is an electrical technique whereby the
electrodes are placed just above the surgical site. TENS following caesarean delivery reduces
analgesic consumption therefore sparing the usage of opioids analgesics. However, there is lack
of consensus regarding the amount and duration of frequency used (59). Mechanically, the usage
of abdominal binders has been shown to reduce post-operative pain, early and longer
mobilization and decreases maternal distress following caesarean delivery. Abdominal binders
work by applying pressure over the entire abdomen thus reducing pain at the surgical site (60).
The Benson relaxation technique can be employed to reduce post caesarean delivery pain via

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anxiety reduction and reduced tension. For this method to work, it requires prior training on how
to breath and to focus on calming thoughts regularly and rhythmically (61).

2.9 Validated Assessment Tools

Tools for measuring pain can either be unidimensional or multidimensional. The unidimensional
tools include visual analogue scale (VAS), numerical rating scale (NRS), verbal descriptor scale
(VDS) and face pain scale –revised (FPS-R). The Numerical Rating scale is a tool used to assess
the intensity of pain. It is simple, easy to comprehend and commonly used to assess pain
clinically and in research. The visual analogue scale (VAS) is similar to the numerical rating
scale (NRS) only that the patient in this case marks on a non-graduated 10 cm line where the
pain lies. In the verbal descriptor scale (VDS) the patient is asked to describe the amount pain
from a chosen list of describers for example, no pain, mild, moderate, severe and excruciating
pain (21).

Douleur neuropathique 4 (DN4) is a simple screening tool that has high validity, high sensitivity,
high specificity and high reliability for assessing neuropathic pain. This tool has 10 items, 7 of
which relate to the quality of pain while the remaining 3 are based on patient assessment. The
DN4 tool is divided into 2 segments, the 1st segment entails the interview of the patient and the
2nd segment entails the examination of the patient. With each item the response is either yes or
no. A response of yes is equated to 1 point while a score of no equates to zero. A total score of
more than 4 is indicative of neuropathic pain. In the 1 st segment the patient is asked the
characteristics of that is pain that is, is it burning in nature, is it painful cold and does the patient
experience electric shocks. Each item is given a score of either yes or no. In the next step, the
patient is asked symptoms that are associated with the pain such as; tingling sensations, pins and
needles, numbness and itching. On the clinical assessment; is there hypoesthesia to touch,
hypoalgesia to pinprick and finally is pain caused or increased by brushing over the area (62–64).

A pain diary or a pain journal is a detailed record of an individual’s pain experience. This gives
useful information to both the healthcare provider and the patient. This tool can be modified to
collect certain variables regarding pain and is often employed to patients suffering from chronic
states such as cancer. A pain diary can be tailored to include variables such as the date and time

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of pain, pain intensity scores, pain sites, any analgesics taken and non-pharmacological
techniques used to alleviate the pain (65,66).

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2.10: Research Question, Study Justification

2.10.1 Research Question

What is the prevalence and the associated factors for ongoing post-surgical pain in parturients 2
months after undergoing emergency caesarean delivery at the Kenyatta National Hospital?

2.10.2 Study Justification

On-going post-surgical pain following caesarean section has devastating effects both to the
mother and the neonate. Pain following caesarean delivery is often under-reported and therefore
not given the appropriate medical attention. When pain is undertreated in the acute phase it leads
to reduced quality of life, impaired sleep, impaired physical function and a higher economic
burden.
Undertreated pain leads to the development of ongoing post-surgical pain. A life-saving
intervention such as a caesarean delivery should not lead to a life of pain and or disability. There
is paucity of data in our local setting regarding prevalence of ongoing pain following caesarean
delivery despite caesarean delivery rates increasing. When pain is anticipated, certain measures
can be utilized to either curb or treat this adverse effect of surgery. Awareness with the
appropriate management will lead to better patient care and satisfaction. This research has the
capability to enhance protocols and policies for better maternal care.

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2.10.3 STUDY OBJECTIVES

2.10.3.1 Broad Objectives

To determine the prevalence and the associated factors leading to on-going post-surgical pain, 2
months following caesarean delivery at Kenyatta National Hospital

2.10.3.2 Specific Objectives

1) To determine the prevalence of ongoing post-surgical pain at 2 months post emergency

caesarean Section at the Kenyatta National Hospital
2) To determine the patient factors that are associated with ongoing post-surgical pain at 2
months following emergency caesarean section at the Kenyatta National Hospital.
3) To determine the anaesthetic factors that are associated with ongoing post-surgical pain at
2 months following emergency caesarean section at the Kenyatta National Hospital.
4) To determine the surgical factors that are associated with ongoing post-surgical pain at 2
months following emergency caesarean section at the Kenyatta National Hospital.

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CHAPTER 3: METHODOLOGY

3.1 Study Site

This study was conducted at the Kenyatta National Hospital (KNH) obstetric unit. Kenyatta
National Hospital (KNH) obstetric unit serves patients primarily from Nairobi County and its
environs. The environs include, Kiambu County, Machakos County and Kajiado County. KNH
is the national referral hospital, therefore referral from all over Kenya are anticipated.
The study site was the labour ward, maternity theatres and the post-natal wards. KNH has one
labour ward and 2 maternity theatres. The 2 maternity theatres run concurrently continuously.
There are 3 post-natal wards in Kenyatta National Hospital. Each ward admits patients from the
maternity theatre in a cyclical manner. Each post-natal ward can admit 30 post caesarean
delivery mothers at a time.
Kenyatta National Hospital handles approximately 400 patients for caesarean delivery monthly.
In the month of February 2022, 380 caesarean deliveries were done, 430 in January 2022, 414 in
December 2021 and 408 November 2021. In the absence of any complications to the new
mother, patients following caesarean delivery are discharged on day 3 following the surgery.

3.2 Study Design

This was a prospective longitudinal observational study with consecutive sampling for patients
undergoing emergency caesarean delivery.

3.3 Study Population

The participants of this study were adult parturients following caesarean delivery at the Kenyatta
National Hospital. The participants were recruited in labour ward followed to maternity theatre
and post-natal wards. Informed consent was sought and those who fit with the inclusion criteria
were recruited to participate in this study.

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3.4 Eligibility Criteria

3.4.1The Inclusion Criteria

 Adult (18 years and above) participant scheduled to undergo emergency caesarean
delivery who consented to participate in the study
 The adult parturient should have an active mobile telephone number and device
registered to her by a Kenyan mobile service provider.
 The adult parturient should reside in an area with good mobile telephone coverage
 Patients who gave informed consent.
.

3.4.2 The Exclusion Criteria

 Parturient under the age of 18 years scheduled to undergo emergency caesarean.

This is because a Kenyan identity card is issued after one has attained the age of
18 years, and it is required for the registration of a mobile telephone number.

3.5 Sample Size Calculation

Sample size calculation was based on Cochran formula. This allows for the calculation of an
ideal sample size given a desired level of precision, desired confidence level and the estimated
proportion of the attribute present in the population.

Equation: Cochran Formula

Z 2 pq
n= 2
E
n = Desired sample size
Z = Value from standard normal distribution corresponding to desired confidence level (Z=1.96
for 95% CI)
p = Expected true proportion (Incidence % - from prior studies, will use incidence of 10%)

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q=1− p
E = Desired precision (0.05)
Substitution of the values in the sample size formula:
1.96 2 x 0.1(1−0.1)
n= 2
=139
0.05
The calculated sample size was139 participants.

3.6 Sampling Procedure

Consecutive sampling was used to select and enrol participants undergoing caesarean delivery
until desired sample size was achieved.

3.7 Study Procedure

Recruitment to this study started in the labour ward of Kenyatta National Hospital over the
course of 1-2 months until the desired sample size was achieved. The participants were identified
via the theatre list available in the labour ward. Once the principal investigator got informed of
the patient consent to participate in the study, she proceeded to capture; bio data, patient factors
and introduced the pain journal to the respondent at this point. This process took about 5
minutes. Once in maternity theatre, the principal investigator and research assistants observed
and recorded surgical and anaesthetic factors without interfering with the care of the study
participant. Following surgery, the participants were discharged to the post-natal wards. The
discharge from maternity theatre to post-natal wards took about an hour. Upon reaching the post-
natal wards the principal investigator and research assistants assessed their pain score of the
study participants post operatively and re-introduced the pain journal. The pain journal contained
the principal investigator’s number to enable the study participant reach the principal investigator
easily in case of pain. The participant received a phone-call 2 weeks from the date of the
caesarean delivery as a follow up of their post-operative pain according to the DN4 tool and the
pain journal. There after the participants were followed up after every 2 weeks for a period of 2
months. Participants who reported moderate to severe pain scores were referred to the nearest
facility for pain management. The participants rights, comfort and care were a priority
throughout this study.

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 STUDY FLOW CHART

Over 18-year-old parturient scheduled for caesarean delivery

Excluded: No phone /
No Network
Consented Decline Consent

PRE_OPERATIVE PHASE (LABOUR WARD)

Patient Factors- Age, Pre-op pain (+/- use of analgesic), level of education, employment and marital status
INTRA-OPERATIVE PHASE (MARTENITY THEATRE)
Surgical Factors- Type of surgeon, Type of incision, Type of surgical repair, Duration of surgery
Anaesthesia Factors-ASA classification, GA vs SA, all medications used by the anaesthesia team shall be
recorded, peripheral nerve blocks, wound infiltration shall be recorded as additional analgesia

POST-OPERARTIVE PHASE
PAIN- Intensity, site and character shall be assessed 8 hourly using the numerical rating scale
PAIN- analgesia plan shall be recorded and rescue analgesia recorded

AFTER DISCHARGE
Telephone interview, every 2 weeks until 2nd month post-operative
Utilization of the pain diary
Pain-Presence, Intensity, Character, Sites

Figure 3.1 Study flow chart

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3.8 Data Processing

3.8.1 Data Collection

An interviewer guided questionnaire was used to collect data from the participants. The data
obtained were quantitative. Data were collected using Redcap, an electronic data capture method.
There were six research assistants who participated in the study. The team of research assistants
included 4 clinical officers and 2 medical students. Two research assistants were based in
maternity theatre to record the surgical and anaesthetic factors. The rest of the research
assistance recorded the patients pain scores 8 hourly in the post-natal wards as they introduced
the pain journal to the participants follow up with telephone interviews. The questionnaires were
crossed checked for any missing entries to ensure completion of all questionnaires.

3.8.2 Data Management

Redcap, electronic data collection forms were developed and validated before starting the study
via a pilot study. The data was kept under a password protected encrypted electronic data
collection tool whose access was limited to the principal researcher and research assistants.
Data were checked for accuracy, consistency and completeness at all time by the principal
investigator. Data back-ups were stored in encrypted, password protected cloud-based storage for
remote access as well as a storage drive that was under lock and key. The key was stored by the
principal investigator.

3.8.3 Data Analysis

The data were downloaded from Redcap, then later exported to the Statistical Package for the
Social Sciences (SPSS) software version 23 for analysis. Demographic and clinical
characteristics were analysed and presented as frequencies and proportions for categorical data,
and as means with standard deviations or as median with interquartile range for continuous data.

The prevalence of on-going post-surgical pain at 2 months post caesarean section was calculated
as a proportion of those experiencing pain at 2 months over the total sample size and presented
as a percentage. The patient factors associated with ongoing post-surgical pain at 2 months

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following caesarean delivery were analysed with chi-square for categorical data and independent
t -test for continuous data. The anaesthetic factors associated with ongoing post-surgical pain at 2
months following caesarean delivery were analysed with chi-square for categorical data. The
surgical factors associated with ongoing post-surgical pain at 2 months following caesarean
delivery were analysed with chi-square for categorical data. The factors found to be statistically
significant were subjected to a multivariate analysis with the use of logistic regression. Risk ratio
as well as 95% confidence interval were calculated and reported where appropriate. All statistical
tests were considered significant where the p-value < 0.05. In addition to the study objectives
some secondary findings were relevant in this study.

3.9 Ethical Considerations

Approval was sought from the KNH/University of Nairobi Institutional research and ethics
committee and KNH administration before study commencement. The participants were given a
detailed explanation about the risks and benefits in a language they could comprehend and speak.
The participants were duly informed regarding the study procedure and informed consent
obtained with the knowledge that refusal/discontinuation to participate in the study will not result
in any variation in care accorded to the patient. Study subjects who declined consent or if
consent is withdrawn during the course of the study were allowed to do so without any
victimization or change in the level of care accorded to them. All data were stored with
confidentiality as the supreme concern. Trained research assistants conducted the study under
supervision of the principal investigator. There was no financial burden or benefits to the
participants who consented to participate in the study. The nature of the study caused minimal
psychological and physical harm to the participants.
The COVID 19 protocols and regulations were maintained throughout the period of the study to
ensure the interviewers and participants wellbeing. The interviewers had already been vaccinated
against COVID 19. Should an interviewer start experiencing symptoms related to COVID19,
they were to be excluded from the interviewing phase of this study to prevent transmission to the
participants. Interviewers interviewed the participants while observing COVID 19 protocols such
as open windows, observing safe distance and correct wearing of facemasks among others.
Participants who exhibited signs and symptoms of COVID 19 infection were to be referred to the

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Ministry of Health for further diagnosis and possibly isolation where necessary. The participants
that tested positive for COVID19 and satisfy the inclusion and exclusion criteria were not
excluded in this study. Participants who exhibited signs and symptoms of COVID 19 infection
were referred to the Ministry of Health for further diagnosis and possibly isolation where
necessary. Asymptomatic participants were guided on practices aimed to prevent and control the
spread of COVID19 as per the ministry of health guidelines.

3.10 Quality Control Assurance

The principal investigator completed an online certificate course on International Council on

Harmonisation (ICH) Good Clinical Practice E6 R2, and thereafter trained the research
assistants. The research assistants received training to enable them to be conversant with this
study and the data collection tools.
A standardized electronic data collection tool, redcap was used to gather the desired information.
The collection tool had a user-friendly interface for ease of use. The language used was simple
and precise. The research assistants were trained on ethical considerations and proper use of the
data collection tool to minimize errors.
The sample size achieved was a fair representation that allowed generalization of results at
KNH. The identifiable data, that is the phone numbers and names obtained during the period of
this study were used, processed and protected as per the Kenya Personal Data Protection Act.
With the help of Kenyatta National Hospital and University of Nairobi ethics committee as the
data controllers as per the Kenya Personal Data Protection Act.
Those participants who got lost during follow-up, their available data was analysed and
presented.

3.11 Study Findings and Dissemination

The results of the study were presented to the members of the department of anaesthesia of the
University of Nairobi and Kenyatta National Hospital and Kenyatta National Hospital
administration.

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CHAPTER FOUR: RESULTS
The study was carried out as shown below;

Figure 4.1. Study participant flow chart

All the 139 women who were recruited for this study participated to its completion (100%
response) and their results were analyzed.

Table 4.1: Characteristics of maternity patients

Characteristic N=139(%)
Age(year) 27(23.0-33.0)
BMI (Body mass index) 25(22.4-28.7)
Marital status Married 107(77)
Separated 2(1.4)
Single 30(22)
Employment status Formal 42(30)
Informal 12(8.6)
None 30(22)
Education status None 3(2.2)
Primary 20(14)
Secondary 69(50)
Tertiary 47(34)

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The lowest age was 18 years and the highest 41 years. A Shapiro-Wilk test indicated that the ages
and BMI were not normally distributed with a p value of 0.0004782 and 0.028. The minimum
BMI (body mass index) was 17.1 while the maximum was 39.5.

Table 4.2: The indications for Caesarean Section

Indication N (%)
Failed induction of labour 6(4.3)
Cephalopelvic disproportion 9(6.5)
Placental disease 9(6.5) Placental
Fetal malposition 12(8.6) disease
PET (pre-eclampsia) 12(8.6) included
Others Post dates 1(0.7) cord
Fetal macrosomia 1(0.7) prolapse,
Obstructed labour 2(1.4) placenta
Genital warts 2(1.4) previa,
Multiple gestation 3(2.1) placental
Bad obstetric history 3(2.1) abruptio.
Total 12(8.6) While all
Poor progress 13(9.4) those
Previous scar 26(99) who
Fetal distress 40(29) were
indicated for multiple gestation had twin pregnancy. Fetal malposition included breech
presentation, face presentation, compound presentation and oblique lie.

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The Prevalence of Ongoing Post Surgical Pain at 2 Months Post CS at KNH

PREVALENCE OF PAIN AT 2 MONTHS

80 76

70

60
Percentage of participants

50

40 Percentage

30
24
20

10

0
Pain No pain

Pain Status

Figure 4.2: Prevalence of pain at 2 months post CS

The patients that presented with pain at 2 months post-caesarean section were 33(24%) whereby
4 patients had back pains, 22 patients had surgical site pains while 7 patients experienced both
surgical site and back pain. The analgesics of choice were tramadol, diclofenac and paracetamol.

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 PAIN INTENSITY AT 2 MONTHS
14

12
Percentage of patients

10

0
Mild pain Moderate pain Severe pain

PAIN INTENSITY

Figure 4.3: Pain intensity at 2 months post CS

Most of the patients with mild pain opted not to take any analgesics, those who took analgesics
used paracetamol and were on pro re nata (PRN) basis. Majority of the patients with moderate
pain were on single analgesics on regular dosing intervals. While the patients with severe pain
opted for 2 types of analgesic and regular dosing.

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The Patient Factors Associated with Ongoing Post Surgical Pain at 2 Months Post CS at
KNH

Table 4.3: The patient factors associated with surgical pain at 2 months
Characteristic OVERALL [NO] [YES] p-value2
N (%) =139 N (%) = N (%) =
115 24
Presence of pre-operative pain 69 (50) 55 (48) 8 (33) 0.079
Use of pre- No use 63 (45) 55 (48) 8 (33) 0.2
operative Use 6 (4.3) 6 (5.2) 0 (0)
analgesia Not applicable 70 (50) 54 (47) 16 (67)
Age (years) 27.0 (23.0, 33.0) 27.0 27.5 0.7
(23.0, (24.8,
33.0) 33.3)
Body Mass Index 25.7 (22,4, 28.7) 25.7 25.7 0.6
(22.4, (23.0,
28.4) 30.6)
Parity Multiparous 96 (69) 79 (69) 17 (71) 0.8
Nulliparous 43 (31) 36 (31) 7 (29)
Previous scar 0 80 (58) 66 (57) 14 (58) 0.3
1 37 (27) 28 (24) 9 (38)
2 18 (13) 17 (15) 1 (4.2)
3 4 (2.9) 4 (3.5) 0 (0)
Married 107 (77) 89 (77) 18 (75)
Marital Status Separated 2 (1.4) 2 (1.7) 0 (0) 0.9
Single 30 (22) 24 (21) 6 (25)
Employment 54 (39) 47 (41) 7 (29%) 0.3
None 3 (2.2) 2 (1.7) 1 (4.2)
Education Primary 20 (14) 15 (13) 5 (21)
Secondary 69 (50) 58 (50) 11 (46) 0.5
Tertiary 47 (34) 40 (35) 7 (29)

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The W Mann-Whitney “U” test analyzed the non-parametric numerical data (age, previous scar
and BMI). The results showed no association with the development of ongoing post-surgical pain
at 2 months.

The categorical data, that is use pre-operative analgesia, parity, marital status, employment status
and educational status were subjected to t- test. The Pearson correlation analysis indicated there
was poor correlation with all the categorical data which were not statistically significant.

The anaesthetic Factors Associated with Ongoing Post Surgical Pain at 2 Months Post CS
at KNH

Table 4.4: Anaesthetic factors associated with surgical pain at 2 months

Anaesthetic Overal [NO] [YES] p-
Characteristic l N (%) N = 331 value
N (%) = 1061 2

= 139
Wound 5 (3.6 5 (4.3) 0 (0)
Regional infiltration 0.7
technique TAP block 1 (0.7) 1 (0.9) 0 (0)
None 133(94) 109(95) 24(100)
Type of General 8 (5.8) 7 (6.1) 1 (4.2)
anaesthesi anaesthesi >0.9
a a
Spinal 131 108 23 (96)
anaesthesi (94) (94)
a

All the patients that received spinal anaesthesia were given bupivacaine 7.5mg and fentanyl
25mcg intrathecally. Pain management intra-operatively was standardized. This means, patients
were given paracetamol, an opioid (tramadol/low dose morphine) and a NSAID (dexketoprofen
or diclofenac). Of the patients who received general anaesthesia, 2 opted for general anaesthesia

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due to persistent low back pain following spinal anaesthesia from a previous CS and the rest was
medically indicated.

The anaesthetic factors were subjected to t- test. The Pearson’s correlation analysis showed a
poor correlation of pain with all anaesthetic factors therefore, there was no statistical
significance.

The surgical factors associated with ongoing post-surgical pain at 2 months post CS at
KNH.

Table 4.5: Surgical factors associated with surgical pain at 2 months

Surgical factor characteristic Overall [NO] N [YES] N p-value2
N (%) = 139 (%) = (%) = 331
1061
Joel Cohen 6(4.3) 5 (4.3) 1 (4.2)
Type of Incision Midline 7 (5.0) 7 (6.1) 0 (0) 0.7
Pfannenstiel Kerr 126 (91) 103 (93) 23 (96)
Four 7 (5) 5 (4.3) 2 (8.3) 0.7
Layers of Layers 7 (5) 6 (5.2) 1 (4.2)
abdominal Three 46 (33) 37 (32) 9 (38)
closure Two 79 (57) 67 (58) 12 (50)
Surgical < 30 minutes 2 (1.4) 2 (1.7) 0 (0) >0.9
duration 30-60 minutes 89 (64) 73 (63) 16 (67)
>60 minutes 48 (35) 40 (35) 8 (33)

All the participants were operated on by obstetrics and gynaecology resident doctors
(postgraduate doctors in training). Most surgeons preferred Pfannenstiel Kerr incision on patients
who had no previous operations (fresh abdomen), with only 2 patients subjected to Joel Cohen
incisions on a fresh abdomen. The surgeons used vicryl 2.0 suture for skin closure with an
exception of 7 patients were closed with vicryl 3.0, rapid 2.0 and rapid 3.0 respectively.

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The surgical factors were subjected to t- test. The Pearson’s correlation analysis showed a poor
correlation with all surgical factors showing no statistical significance.

Post-operative factors associated with ongoing post-surgical pain at 2 months post CS at

KNH

Table 4.6: Post-operative factors associated with surgical pain at 2 months

Post-operative OVERALL [NO] N = 1061 [YES] N = 331 p-value2
factor
characteristic
0 post- 0 130(94) 106(92) 24(100)
operative 1 1(0.7) 1(0.9) 0(0)
hour pain 2 5(3.6) 5(4.3) 0(0)
severity 3 1(0.7) 1(0.9) 0(0) 0.8
4 1(0.7) 1(0.9) 0(0)
5 1(0.7) 1(0.9) 0(0)
8th post-operative 2.00(0.00,5.00) 2.00(0.00,5.00) 1.00(0.00,4.00) 0.5
hour pain
severity
16th post- 0 67(48) 54(47) 13(54)
operative 1 12(8.6) 10(8.7) 2(8.3)
hour pain 2 14(10) 9(7.8) 5(21)
severity 3 21(15) 19(17) 2(8.3)
4 12(8.6) 11(9.6) 1(4.2) 0.4
5 6(4.3) 6(5.2) 0(0)
6 2(1.4) 2(1.7) 0(0)
7 3(2.2) 3(2.6) 0(0)
8 2(1.4) 1(0.9) 1(4.2)
24th post- 0 70(50) 57(50) 13(54)
operative 1 42(30) 34(30) 8(33)
hour pain 2 18(13) 16(14) 2(8.3)
severity 3 4(2.9) 3(2.6) 1(4.2) >0.9
4 1(0.7) 1(0.9) 0(0)
6 1(0.7) 1(0.9) 0(0)
7 2(1.4) 2(1.7) 0(0)
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 8 1(0.7) 1(0.9) 0(0)

All post-operative drugs were prescribed by the obstetrics and gynaecology resident surgeons.
Most patients were given either intramuscular or subcutaneous morphine in the 1st 24 hours
following the surgery then followed by tramadol in the subsequent days. Majority of the patients
were given intravenous paracetamol on day 1 following surgery then followed by oral
paracetamol on subsequent days. All patients were given an NSAID post-operatively. No rescue
analgesia was requested or given in the 1st 24 hours following surgery.

A Shapiro wilk test indicated that hour 0, hour 8, hour 16 and hour 24 were not normally
distributed. The W Mann-Whitney showed that there is no association between hour 0, hour 8,
hour 16 and hour 24 to developing pain at the end of 2 months following caesarean section.

SECONDARY FINDINGS

a) Wound Infections

Out of the 139 participants 9 of them presented with wound infections. They did present with
surgical site pain at week 2 and week 6 post-caesarean delivery. By week 6 and week 8, all the 9
patients reported no pain. All participants with wound infections were encouraged to seek
medical care

b) Neonatal Deaths

Out of the 139 participants, 3 months had fresh still births. Out of the 136 remaining participants
23 newborns were admitted to the neonatal intensive care unit with 7 mortalities reported. All
participants went through psychotherapy and those who needed were given antidepressants by
the psychiatrists.

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CHAPTER 5: DISCUSSION

We defined ongoing post-surgical pain; as pain that persists by 2 months (8 weeks) following the
caesarean delivery with a numerical rating scale of anything above 0. Werner et al distinctively
described persistent post-surgical pain as pain that lasts at least 2 months following surgical
intervention and that all other causes of pain should be excluded (8). In the context of pain, IASP
defines pain as a personal experience influenced by varying degrees by biological, psychological
and social factors and a person’s pain experience should be respected (7, 9).

In this study of 139 parturient women aged more than 18 years who underwent caesarean
delivery, we reported a prevalence of 24% of ongoing post-surgical pain 2 months following
caesarean delivery. We found out that most women reported mild pain at the end of 2 months at
12.9% while those reporting moderate and severe pain scores were 6.5% and 4.3% respectively.
The common pain sites were the surgical site N=22, back N=4 and both surgical site and back
N=7. A review of studies on the prevalence and severity of pain following caesarean section
from several parts of the world; Brazil, China, Australia, Germany and Denmark revealed that
most patients experienced mild to moderate pain in terms of severity with very few cases
presenting with severe pain over a period of 2-3 months. The pain prevalence was between 9.2%
to 25% following caesarean delivery with most patients complaining of mild pain at the surgical
site, which is in line with this study (15, 16, 17, 38, 39, 40, 49).

The patient factor variables that were considered in this study included age, BMI, presence of
pre-operative pain with usage of analgesia, educational status, marital status and employment
status, parity and previous scar status. All patient factors were found to be statistically not
significant with p- values greater than 0.05. A Ghanian study (67) found out that age, level of
education, employments status was statistically insignificant with p- value of 0.559, 0.953 and
0.641 respectively which is similar to my study findings. Similarly, a Chinese study had similar
findings (16). Probably there were other patient factors such as psychological factors, menstrual
pain, lack of insurance that may have contributed to ongoing post-surgical pain that were not
captured in the study (4,23,30,31,37).

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The anaesthetic factors that were considered were between general or spinal anaesthesia, and
additional regional technique that is wound infiltration with a local anaesthetic and the
administration of a peripheral nerve block. The use of general anaesthesia for caesarean delivery
is on the decline as only 5% of my study participants underwent general anaesthesia which is line
with other reported studies from other parts of the world, (34-37). In our population spinal
anaesthesia was standard as our patients were given 7.5mg of isobaric bupivacaine and 25mcg of
fentanyl intrathecally. Ortner et al study participants were given standardized spinal anaesthesia
meaning, all patients were given 12mg of hyperbaric bupivacaine, 25mcg of fentanyl, 100 mcg
of preservative free morphine in the intrathecal space (50). Eisenach et al had a lower prevalence
of post-surgical pain at 8 weeks following caesarean section of 9.2% which could be attributed to
the use of intra-thecal clonidine (38). All anaesthetic factors in my study were found to be
statistically not significant with p-values greater than 0.05, similar to findings from other studies
(17, 39, 69, 70).

The surgical factors considered were the cadre of surgeon, the surgical duration, the type of
incision, the number of abdominal wall closure and the type of suture used for surgical skin
closure. All surgical factors were found not to be statistically significant with p-values greater
than 0.05. A Brazilian study found out from a sample size of 620 women, that previous caesarean
section and the duration of surgery, were not statistically significant (40). A study done in 2021
from Sierra Leone found the variables previous scar, emergency verses elective surgery and
incision type had no bearing to the development of chronic post-surgical pain (70). In my study
all the participants were operated by surgical residents, Daly et al found out that there was no
difference to being operated with consultants’ verses residents to the development of persistent
post-surgical pain after caesarean delivery (31).

Post-operative factors that were of interest in this study were acute post-surgical pain within the
1st 24 hours that is; hour “0’’, hour “8”, hour “16” and hour “24” and post-operative analgesia. In
my study acute post-operative pain didn’t lead to the development of ongoing post-surgical pain
at 2 months following caesarean delivery which is similar to (40). The post-operative analgesic
management was standardized for the participants which is similar to (50). The participants were
followed up every 2 weeks following surgery. Remarkably, pain at week 4 and week 6 post-
caesarean section were statistically significant with p-values of 0.002 and <0.001 respectively.

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The study results imply that there could be other factors not taken into consideration that had
statistical significance in association with on-going pot surgical pain at 2 months post CS. A
follow-up study with a larger sample size may be more powered for this study as most similar
studies from other parts of the world had larger sample sizes (15, 16, 17, 38, 39, 40, 49). In our
population, that is the urban Kenyan women maybe unique to other women from other parts for
the world due to; lower anaesthetic requirements (50), use of skin closure with stables in other
populations (71), the need to restart physical activities early without a confinement period (72,
73) and availability of social capital that understate mental issues (74). In some population,
smoking is modifiable factor that’s leads to the development of persistent post-surgical pain
following caesarean delivery (40). Tobacco usage during pregnancy has a low prevalence in the
African region (75).

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CONCLUSION
Prevalence of ongoing post-surgical pain at 2 months following caesarean section was found to
be 24% where by most patients presented with mild pain at the surgical site.

There were no patient, anaesthetic and surgical factors that attributed to ongoing post-surgical
pain at 2 months following caesarean section.

RECOMMENDATIONS
1. Another study to investigate the causation of acute pain post caesarean section.
2. A study with a larger sample size to assess the development of persistence post-surgical
pain following caesarean delivery.
3. Another study to be done to compare general anaesthesia and spinal anaesthesia
undergoing caesarean section to developing ongoing post-surgical pain.
4. Another study to assess other factors such as psychological factors (anxiety, depression,
catastrophizing pain) that predispose to the development of persistent post-surgical pain
while using validated tools in pregnancy for parturient undergoing caesarean section. As
in this study didn’t focus on the psychological factors.
5. Another study to assess other variables to developing persistent post-surgical pain
following caesarean delivery such as the presence of menstrual pain, gestational age at
the time of the caesarean section, availability of health insurance, usage of alcohol or
cigarettes. Other authors have found the above factors to be statistically significant in
their population.

STUDY LIMITATION
1. Limited generalizability of findings
 Only cadre of surgeons was involved in this study

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 2. Inability to compare groups;

 General anaesthesia vs spinal anaesthesia

 Elective verses emergency caesarean section

3. Inability to establish causal-effect relationships

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APPENDICES

Appendix One: Consent Form (English)

THE PREVALENCE AND THE ASSOCIATED PREDISPOSING FACTORS FOR

ONGOING POSTSURGICAL PAIN FOLLOWING CAESAREAN DELIVERY IN
KENYATTA NATIONAL HOSPITAL
Principal Investigator: DR. Lesley Gesare Makamara
Supervisors: DR Caroline Mwangi
DR Charles Kabetu
DR Timothy Mwiti
Introduction
I would like to let you know about a study that will be carried out by the researcher mentioned
above. This is a consent form; whose purpose is to give as much information as possible to
enable you to make an informed decision to either participate or to decline to participate in this
study. Any questions that may arise regarding this study, you as the volunteer is encouraged to
ask freely. Any clarity needed on any matter or issue pertaining to this study will be clarified to
you, the volunteer’s satisfaction. Therefore, we as the researchers, encourage you as the
volunteer to ask everything including the possible risks and benefits that come with getting
involved in this study. As this is a pertinent right to you as the volunteer. When all questions are
answered to your contentment, the choice is yours to either agree or to decline to participate in
this study. This process means once you have understood everything, you as the volunteer will
be able to make an informed consent. Meaning, you as the volunteer have the liberty to agree or
to decline to participate. Should you agree to participate in this study, your name, telephone
number and signature will be needed to sign on in this form as proof of informed consent. There
are some principles that you as the volunteer is required to know:
i) Your decision to participate is entirely voluntary
ii) You may withdraw from the study at any time without necessarily giving a reason for
your withdrawal
iii) Refusal to participate in the research will not affect the services you are entitled to in this
health facility or other facilities.

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May I continue? YES [ ] NO [ ]
This study has approval by The Kenyatta National Hospital-University of Nairobi Ethics and
Kenyatta National Hospital Administration
Research Committee protocol No. __________________
Purpose of the study/aim
To determine the prevalence and the associated predisposing factors leading to ongoing post-
surgical pain, 2 months following emergency caesarean section at Kenyatta National Hospital
Study procedure
I am Dr Gesare. I will be carrying out a study to find out how common pain is following
caesarean delivery. If you agree to participate, I will follow you from labor ward to maternity
theatre to the postnatal wards. I will record your biodata, surgical and anaesthetic procedure. In
labour ward I will introduce to you a pain journal. This is a diary where you can record your pain
as it comes along. Once you are in the post-natal ward, I will record your pain scores for the 1 st
24hours following your surgery. I will also show you how to fill the pain journal. Upon
discharge I will call you every 2 weeks for a period of 2 months. Should you feel pain before I
get in touch with you, the pain journal has my number. Feel free to call regarding pain, I will be
able to assist you. Should you decide not to participate in this study, your care will not be
compromised in any way. Do you have any questions or clarifications? I would love to answer
your questions.
Role of the participant
Your role in this study as a participant will be to answer the data collection tool. This requires
giving your phone number and to rate pain. You will be taught on how to use and fill the pain
diary at home and to give the information required on the telephone. Other pertinent information
will be taken from the participant’s medical records.
Participation and Risks to participation
Your participation should you choose to enrol in the study is purely on a voluntary basis. You
will be interviewed by the researchers listed above relating to the pain following caesarean
section. There will be information that the researcher will obtain from your medical records. The
researcher will interview you while in hospital and upon discharge via telephone regarding pain.
Should you report pain you will be referred to a centre nearest to you for medical assistance. No
form of remuneration will be offered or given to you. Note that withdrawal from participation in

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this study, at any point will not affect your quality of care in anyway. Your participation will not
add to any risk to your care.
.

Confidentiality and Data sharing

Throughout the collection of data your anonymity will be maintained. Names and any other
patient identifiers will be withheld and therefore not appear in any of the research
documentation. Instead, you will be assigned a unique number for the purposes of analysing the
data.
The results from this study are intended to be shared with other experts in formal platforms
particularly the KNH institution and possibly different health journal for publication as well. If
any clarifications are needed regarding your participation or the study itself the consenting
personnel will address them. Should you need to contact me, my contact details are attached at
the end of this form.
If you agree to participate after explanation has been done and you understand information
regarding the study kindly indicate with a signature at the attached consent form.

Contacts
Principle investigator: Dr. Lesley Gesare Makamara
Tel: 0705895355
Supervisors contacts: Dr Caroline Mwangi
MBChB, MMed Anaesthesia, Senior Lecturer, Anaesthesia UoN
Tel: 0721546600
Dr Charles E Kabetu
MBChB, MMed Anaesthesia, Senior Consultant at JKUAT
Tel: 0722 512205
Dr Timothy Mwiti,
MBChB, MMed Anaesthesia, Senior lecturer, Anaesthesia UoN
Tel: 0721366294

The secretary: KNH/UON Ethics and Review committee Tel:2726300 Ext:44102

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Consent Form
I…………………………………………… hereby give written consent for the participation in
the prospective study assessing THE PREVALENCE AND THE ASSOCIATED FACTORS
FOR ONGOING POST-SURGICAL PAIN FOLLOWING CAESEAREAN DELIVERY IN
KENYATTA NATIONAL HOSPITAL. I have understood the information regarding the study. I
have had my questions addressed. I have the right to withdraw at any point
Signed………………………………………………. Date………………………………….
Investigator’s Declaration: I have explained to the patient about the study. I have addressed all
their questions and concerns to the best of my knowledge.

Signed……………………………………………. Date…………………………

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Appendix Two: Fomu Ya Ridhara (Kiswahili)

WATAFITI
Mchunguzi mkuu: Dk Lesley Gesare Makamara
Wasimamizi: Dk Caroline Mwangi
Dk Charles Kabetu
Dk Timothy Mwiti

Utangulizi
Ningependa kukujulisha juu ya utafiti ambao utafanywa na mtafiti aliotajwa hapo juu. Hii ni
fomu ya idhini; ambaye kusudi lake ni kutoa habari nyingi iwezekanavyo kuwezesha mtu
kufanya uamuzi sahihi wa kushiriki au kukataa kushiriki katika utafiti huu. Maswali yoyote
yanayoweza kujitokeza kuhusu utafiti huu, wewe kama mtu wa kujitolea unahimizwa kuuliza
kwa uhuru. Ufafanuzi wowote unaohitajika juu ya jambo lolote au suala linalohusu utafiti huu
utafafanuliwa kwako, kuridhika kwa kujitolea. Kwa hivyo, mimi kama mtafiti, ninakutia moyo
kama kujitolea kuuliza kila kitu pamoja na hatari na faida zinazokuja na kushiriki katika utafiti
huu. Kwa kuwa hii ni haki inayofaa kwako kama kujitolea. Maswali yote yanapojibiwa kwa
kuridhika kwako, chaguo ni lako kukubali au kukataa kushiriki katika utafiti huu. Utaratibu huu
unamaanisha ukishaelewa kila kitu, wewe kama mtu wa kujitolea utaweza kutoa idhini ya habari.
Maana yake, wewe kama kujitolea una uhuru wa kukubali au kukataa kushiriki. Ukikubali
kushiriki katika utafiti huu, jina lako, nambari yako ya simu na saini zitahitajika, kutia saini
kwenye fomu hii kama uthibitisho wa idhini ya habari. Huu ukiwa utafiti wa matibabu, kuna
kanuni kadhaa ambazo wewe kama kujitolea unahitajika kujua:
i) Uamuzi wako wa kushiriki ni wa hiari kabisa
ii) Unaweza kujiondoa kwenye utafiti wakati wowote bila kutoa sababu ya kujitoa kwako
iii) Kukataa kushiriki katika utafiti hakutaathiri huduma unazostahiki katika kituo hiki cha afya
au vituo vingine. Tutakupa nakala ya fomu hii kwa kumbukumbu zako.
Naweza kuendelea? NDIO [ ] LA [ ]
Utafiti huu umeidhinishwa na Itifaki ya Kamati ya Maadili na Utafiti ya Hospitali ya Kitaifa ya
Kenyatta-Chuo Kikuu cha Nairobi Na. __________________
Kusudi la utafiti / lengo

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Kuamua matukio na sababu zinazopelekea kusababisha maumivu ya baada ya upasuaji, miezi 3
baada ya kujifungua kwa upasuaji katika Hospitali ya Kitaifa ya Kenyatta
Ushiriki na Hatari za kushiriki
Ushiriki wako ikiwa utachagua kujiandikisha katika utafiti ni kwa hiari. Utahojiwa na msaidizi
wa utafiti unaohusiana na maumivu kufuatia sehemu ya upasuaji. Kutakuwa na habari ambayo
mtafiti atapata kutoka kwa rekodi za matibabu za kujitolea. Mtafiti atahoji kujitolea wakati yuko
hospitalini na baada ya kutolewa mahojiano yataendelea kupitia simu. Kisha kujitolea atahojiwa
juu ya uwepo wa maumivu, tovuti ya maumivu na mwishowe kuelezea maumivu. Ikiwa kujitolea
ataripoti maumivu watapelekwa kwenye kituo kilicho karibu na kujitolea kwa msaada wa
matibabu. Hakuna aina ya malipo inayotolewa au kutolewa kwa kujitolea. Ikiwa wewe kama
kujitolea unahisi kuwa hutaki tena kushiriki katika utafiti huu, inaruhusiwa. Kumbuka kuwa
kujiondoa au kushiriki katika utafiti huu hakuathiri ubora wa huduma yako kwa vyovyote vile.
Mara tu unapochagua kushiriki katika utafiti huu, huna kujitolea kuongezewa au maelewano kwa
afya yako na utunzaji wako na hautapata gharama ya ziada.
Usiri na ushiriki wa Takwimu
Wakati wote wa ukusanyaji wa data kutokujulikana kwako kutahifadhiwa. Majina na
vitambulisho vingine vyovyote vya mgonjwa vitahifadhiwa na kwa hivyo havitaonekana kwenye
hati yoyote ya utafiti. Badala yake, kila mshiriki wa utafiti atapewa nambari ya kipekee kwa
madhumuni ya kuchambua data.
Matokeo ya utafiti huu kwa hivyo yamekusudiwa kugawanywa na wataalam wengine katika
majukwaa rasmi haswa taasisi ya KNH na labda jarida tofauti la afya kwa kuchapishwa pia.
Ikiwa ufafanuzi wowote unahitajika kuhusu ushiriki wako au utafiti wenyewe wafanyikazi
wanaokubali watawashughulikia. Ikiwa unahitaji kuwasiliana nami, maelezo yangu ya
mawasiliano yameambatanishwa mwishoni mwa fomu hii.
Ikiwa unakubali kushiriki baada ya maelezo kutolewa na unaelewa habari kuhusu utafiti huo
onyesha kwa saini kwenye fomu ya idhini iliyoambatanishwa.

Mawasiliano
Mchunguzi mkuu: Dk Lesley Gesare Makamara
Simu: 0705895355
Mawasiliano ya wasimamizi: Dk Caroline Mwangi

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 MBChB, Mmed Anaesthesia, Mhadhiri Mwandamizi Anaesthesia UoN
Simu:0721546600
Dk Charles E Kabetu
MBChB, Mmed Anaesthesia, Mshauri Mwandamizi wa JKUAT
Simu: 0722 512205
Dk Timothy Mwiti,
MBChB, Mmed Anaesthesia, Mhadhiri Mwandamizi, Anaesthesia UoN
Simu: 0721366294

Katibu: Kamati ya Maadili na Mapitio ya KNH / UON Simu: 2726300 Ext: 44102

Fomu ya Idhini
Mimi
………………………………………………………………………………………………………
………………………………………………………………………………………………………
…………………………………………………………………………………… (TAMTHILIA)
Nimeelewa habari kuhusu utafiti. Nimejibiwa maswali yangu. Nina haki ya kujiondoa wakati
wowote

Imesainiwa ………………………………………………….
Tarehe………………………………….

Azimio la Mchunguzi: Nimeelezea mgonjwa kuhusu utafiti. Nimeshughulikia maswali yao yote
na wasiwasi kwa kadiri ya ufahamu wangu.

Imesainiwa ………………………………………………. Tarehe…………………………

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Appendix Three: Pain Measurement Tools

NUMERICAL RATING SCALE

The NRS tool a patient is able to quantify the intensity of pain on a scale. Zero means no pain
while 10 means the worst pain. This a simple and easily reproducible tool and it is used to
measure the intensity of pain.

0 1 2 3 4 5 6 7 8 9
10

Interpretation:
0 means there is no pain
1, 2 and 3 means that the patient is in pain but the pain is mild
4,5 and 6 means that the patient is in pain and the pain is moderate
7, 8, 9 and 10 means that the patient is in pain and the pain is severe
DOULEUR NEUROPATHIQUE 4
This is a tool that analyses neuropathic pain and consists of 10 items. Each item gives a score of
1 when answered in the affirmative. A score that is equal to or greater than 4 is indicative of
neuropathic pain.

1st QUESTION: Does the pain have one or more of the following characteristics?
Burning ………………………………………………………(YES)(NO)
Painful cold…………………………………………………(YES)(NO)
Electric shocks…………………………………………….(YES)(NO)
2nd QUESTION: Is the pain associated with one or more of the following symptoms?
Tingling……………………………………………………….(YES)(NO)
Pins and needles…………………………………………(YES)(NO)
3rd QUESTION- Is the pain located in an area where the physical examination may reveal one
Numbness………………………………………………….(YES)(NO)
or more of the following characteristics
Itching……………………………………………………….(YES)(NO)
Hypoesthesia to touch…………………………(YES)(NO)
Hypoesthesia to pinprick……………………….(YES(NO)
4th QUESTION- In the painful area, can the pain be caused or increased by:
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Brushing?....................................................(YES)(NO)
Interpretation:
For each score of (YES) is awarded 1 point
For each score of (NO) is awarded 0 point
A total score of 4 points out of 10 gives the diagnosis of neuropathic pain
PAIN DIARY
This is a tool that will be used by the participants to record their pain scores, pain sites, and pain
management measures taken. This record will be filled by date and time. This will be useful as
the participants will note struggle to remember the past events.
Date Pain Pain Site Analgesics Non drug Pain score
Time score Techniques After
Surgical Back Both Opioids NSAIDS Paracetamol
(NRS 1- Site to relieve intervention
10) pain

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Appendix Four: Eligibility Criteria

All the participants enrolled in this study, must meet all the inclusion criteria and should fail to
meet any of the exclusion criteria.

Study name: The incidence and associated factors of persistent

post-surgical pain following caesarean delivery.
Institutional review board (IRB) protocol:

Date:

Principal investigator:

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SUBJECT NUMBER:
INCLUSION YES N LOCATION OF NOTES
CRITERIA O SUPPORTING
“Must be yes” DOCUMENTS
1.Adult (18 years and above) parturient scheduled to undergo
caesarean delivery who consents to participate in the study

2.The adult parturient should have an active mobile telephone

number and device registered to her by a Kenyan mobile service
provider.

3.The adult parturient should reside in an area with good mobile

telephone coverage.

EXCLUSION CRITERIA YES N LOCATION OF NOTES

“Must be no” O SUPPORTING
DOCUMENTS
1.Parturient under the age of 18 years scheduled to undergo
caesarean. This is because a Kenyan identity card is issued after
one has attained the age of 18 years, and it is required for the
registration of a mobile telephone number.

2.Adult parturient without an active mobile telephone number

and device registered to her by a Kenyan mobile service provider
3.Adult parturient who resides in an area with poor or no mobile
telephone coverage.
4. Adult parturients who decline to be included in the study.

This subject is:

Eligible for this study Ineligible for this study

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Signature: Date:
Printed Name:

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Appendix Five: Questionnaire
THE PREVALENCE AND THE ASSOCIATED PREDISPOSING
FACTORS FOR ONGOING POST SURGICAL PAIN FOLLOWING
CAESEAREAN DELIVERY IN KENYATTA NATIONAL
HOSPITAL
BIODATA
Patient Code:…………………………………………
Age(years)………………… WEIGHT(KG) ……………… HEIGHT(cm)
……………………………
Patient phone no……………………. Next of kin phone no…………………………………..
Indication of caesarean section
□ Fetal Distress □ Fetal malposition □ Multiple gestation □ Poor progress □ Failed Induction
□ Placental issues □ CPD □ Other………………….
A previous caesarean scar
□ Yes □ No
If YES, How many previous caesarean scars……………………………………………………
PATIENT FACTORS
Marital Status
□ Married □ Single □ divorced □ widowed □ separated
Level of education
□ None □ Primary level □ Secondary Level □ Tertiary Level □ Doctorate level
Employment
□ Yes □ No
If YES, □ formal □ Informal
Presence of pre-op pain
□ Yes □ No
If YES, duration prior to labour □ <month □ >month
If YES to pre-op pain, usage of analgesics □ Yes □ No
If YES, which ones and dosages…………………………………………………………….
History of Pre-op anxiety □ Yes □ No

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History of Pre-op depression □ Yes □ No
SURGICAL FACTORS
Operating surgeon □ Medical Officer □ Resident □ Consultant □ combined
Type of incision □ Mid-line □ Pfannenstiel-Kerr □ Joel- Cohen
The type of repair……………………………………………………………………………….
Duration of surgery □ <30minutes □ 30-60 minutes □ >60 minutes
ANESTHETIC FACTORS
Type of anaesthesia □ General Anaesthesia □ Spinal Anaesthesia
If General Anaesthesia, drugs used and
dosages……………………………………………………………
………………………………………………………………………………………………………
……
If Spinal Anaesthesia, drugs used and
dosages……………………………………………………………………………………………
………………
Additional analgesia □ Nerve block □ Wound infiltration □ None
If YES to nerve block, which nerve block……………………………………..
1st POST-OP DAY ASSESSMENT
Presence of pain □ Yes □ No
For how long patient has been in pain □ <60min □ >60 min
If YES to pain, location of pain □ surgical site □ lower back □ both □ other,
specify……….
Intensity of pain using Numerical Verbal rating scale (No Pain) (Mild) (Moderate) (Severe)

HOUR ZERO- End of surgery

Scoring of pain
TIME PAIN SCORE (tick appropriate box) (none) (mild)
O 1 2 3 4 5 6 7 8 9 10 (moderate)(severe)

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 HOUR 0
HOUR 8
HOUR
16
HOUR
24
Characteristic and description of Pain □ Dull □ Sharp
□ Localized □ Generalized
if localized where……………………………………..
□ Radiating □ not radiating
if radiating where……………………………………
Character of the pain
□ stubbing □ cutting □ stinging □ burning □ boring □ splitting □ colicky
□ crushing □ throbbing □ itching □ numbness □ tingling □ pins and needles
Location of the pain
□ Surgical site □ Back □ Both
Analgesic plan as per treatment sheet
Treatment sheet written by □ Surgeon □ Anaesthetist
DRUG DOSAGES FREQUENCY DURATION ADVERSE
EFFECTS

Rescue analgesia: any top up of analgesia requested within the 1 st 24 hours? If yes proceed to the
next table
DRUG DOSAGE ROUTE

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TELEPHONE INTERVIEW:
Then patients shall be interviewed via phone call every 4 weeks (monthly), assessed if presence
of pain, pain intensity, pain site and characteristic of pain.
Is the patient in pain, □ Yes □ No
If yes
1. Pain intensity □ mild pain □ moderate pain □ severe pain
2. Pain site □ surgical site □ lower back □ both surgical site and lower back
□ other
If other
specify……………………………………………………………………………………………
3. Character of pain fill the DN4 questionnaire
Interpterion: Yes translates to a score of 1 and No translates to a score of 0.
A score ≥4 out of 10 translates to neuropathic pain

MONTH 1 MONTH 2
YES NO YES NO
1st QUESTION: Does the pain have one or more of the
following characteristics?
Burning
Painful cold
Electric shocks

2nd QUESTION: Is the pain associated with one or more of

the following symptoms?

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 Tingling
Pins and needles
Numbness Itching

3rd QUESTION- Is the pain located in an area where the

physical examination may reveal one or more of the
following characteristics
Hypoesthesia to touch
Hypoesthesia to pinprick

4th QUESTION- In the painful area, can the pain be

caused or increased by:
Brushing?

CONCLUSION (Presence of neuropathic pain

(yes)(no)

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