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Post-Caesarean Pain Management in Ghana: A Research Study
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PREPARED MANUSCRIPT FOR CUREUS ARTICLE ssessment of Postoperative Pain Management After Caesarean A Delivery: A Study in Ghana elody Asare, Ebenezer Owusu Darkwa¹,George Aryee¹,Raymond Essuman¹ , M Promise Ahiagbenyo², Denzel Tay³ .Anesthesia, Intensive Care and Pain Management,University of Ghana Medical 1 School, Accra, GHA2.Public Health, Korle-Bu TeachingHospital, Accra, GHA3. Obstetrics and Gynaecology, Korle-Bu Teaching Hospital, Accra, GHA Corresponding author:Ebenezer Owusu Darkwa,eoddarquah@yahoo.co.uk Abstract Background elivery by caesarean section (CS) is becoming more frequent and one of the most D common operative procedures performed worldwide. The optimal rate for CS births is indicated to be 5% to 10% of all births. In most developed countries, the rates range from 20% to 26% and in Ghana, 16%. Though a CS has associated predictable or expected benefits, the operation may be complicated by factors such as post-operative pain. Despite the recent advances in the management of post-cesarean pain management, there appears to be little improvement in our set up. Objective he aim of this study was to assess the management of postoperative pain in T women undergoing CS at Korle-Bu Teaching Hospital in Ghana (KBTH). Methods longitudinal study involving 60 women who had CS at KBTH was conducted with A the aid of a pre-tested, structured, self-administered questionnaire. Assessment of patients’ pain was done using the Verbal Descriptor Scale, VDS (no pain, mild, moderate, severe) at 0, 6, 12, 24 hours after surgery. Patients’ satisfaction with pain control was assessed at 24 hours after surgery and at discharge using a 2-point scale. Patients’ charts were reviewed for records of analgesics administered. The data was subjected to descriptive analysis. Categorical variables were presented in absolute and relative frequencies. The quantitative variables were summarized as means, standard deviation, medians and interquartile intervals. Chi-square test was used to determine patient satisfaction with analgesia. One Way Analysis of Variance ( ANOVA) was used to compare pain scores at the times 0, 6 hours, 12 hours, 24 hours and at discharge. Linear regression was used to determine the factors associated with pain scores. All p-values less or equal to 5% were considered statistically significant. Results ajority of the participants (63.3%) were aged between 30-39years and married M (90%). Sixty (60%) of the participants had an elective caesarean section. Majority of the participants (53.2%) had a history of previous abdominal surgery. About 83.3% of the caesarean sections were done under spinal anaesthesia. Intramuscular pethidine was the common opioid used for post-cesarean pain management in the patients. Other analgesics used for postoperative caesarean pain management included paracetamol and non-steroidal anti-inflammatory drugs (NSAIDS). Majority of the participants (90%) were satisfied with their post-caesarean pain management both at 24 hour postoperative period and at discharge. There was a low incidence of nausea and vomiting among the participants studied. Majority of the study participants (73.3-76.7%) started breastfeeding between 6-12 hour postoperative periods. Conclusion artial implementation of MMA - particularly underuse of analgesics and neuraxial P techniques- leads to inadequate pain management in the post cesarean patient and consequently affects early initiation of breastfeeding. Categories:Anaesthesia, Caesarean Surgery, postoperativepain management Keywords:analgesia, caesarean delivery, postoperativepain, breastfeeding Introduction regnancy and delivery are important stages in the life of a woman and when due, P women may deliver via spontaneous or induced vaginal delivery or via a Caesarean Section (CS)[1]. Many studies have shown that thereis a rise in the rate of caesarean deliveries in the last two decades[2].The estimated CS rate in Ghana as at 2017 was 16%[3]. There is however a vast rangeof regional varieties, with the highest rate estimated at 24.3% for the Greater Accra Region, and the lowest 7.2% for the Upper East Region[3] common symptom for which patients seek health care is pain, and patients A undergoing surgical procedures commonly wish to know the amount of pain they would experience after the surgery[4-5].Acute painshould be seen as the initiation phase of an extensive, persistent nociceptive and behavioral cascade, often stimulated by tissue injury[6]. Surgeries in general,especially in the first six (6) hours of the postoperative period, are associated with severe pain[7]. Two different ain sensations are associated with postoperative pain after CS; somatic pain from p the wound and the visceral pain from the uterine contractions[8]. ifferent mechanisms are involved in the transduction of these pains, with the D somatic pain being better localized and usually declines within one to two days, whereas the visceral pain is sensed as being more diffuse and lasts some days longer[8]. Furthermore, evidence suggests that theexperience of postcesarean pain may be associated with preoperative sleep quality and anxiety, both of which are usually worse postpartum than before delivery[8]. CS is often associated with moderate to severe pain for about forty-eight (48) A hours requiring effective perioperative pain management[9-11]. Uncontrolled acute pain after surgery leads to discomfort and suffering, as well undesirable consequences such as delayed healing, increased morbidity risk, a lengthened hospital admission and the risk of developing chronic pain syndrome[12]. Effective postoperative pain control promotes early ambulation, minimises hospital stay, promotes good patient outcome and care of the newborn, hence improving the overall quality of life of post-caesarean patients[7]. ethod of pain control is influenced by drug availability, institutional protocols, M individual preferences, available resources, and financial considerations[13⦎. Techniques previously deployed to achieve effective pain management after a CS showed inherent limitations[14]. Systemic analgesicsincluding parenteral opioids have extensively been used but do not achieve adequate pain relief and have associated opioid use dependence[15]. Regional anaesthetictechniques including neuraxial opioids seem to be relatively more effective but have a shorter half-life and hence, require additional analgesics[16]. The currentuse of multimodal analgesia (MMA) aims to combat limitations of the use of individual agents[17]. MMA employs the use of multiple analgesic agents with different mechanisms of actions at different locations in the nervous system and the combination of these agents at low doses results in a synergistic effect of controlling pain after a CS with minimized side effects [18]. MMA involves the use of non-steroidal anti-inflammatorydrugs (NSAIDs), local wound infiltration, neuraxial opioids/adjuvants, and use of truncal blocks⦍16]. ffective post caesarean pain management has become a major medical and E nursing challenge[4-5,19]. It is particularly challengingin low-income countries because patients expect the pain and hence do not make the effort to demand pain relief[20]. Also, there is a high patient-to-clinicalpersonnel ratio, which makes assessment and administration of pain relief medication inadequate and burdensome[20]. In Ghana, postoperative pain managementhas been a major issue in healthcare delivery, not excluding CS patients[21]. This has been blamed on lack of human and logistic resources[21]. aesarean delivery patients have more compelling reasons to achieve optimal C postoperative pain relief because of their unique challenges. These women want to e alert and energetic enough to care for, interact with and breastfeed their newborn b so as to create maternal and child bonds[22]. Itis therefore necessary to assess the severity and how mothers perceive their pain management after CS so as to inform health care professionals on the need to optimize pain management post-surgery. Materials And Methods Study and Site longitudinal study involving 60 women who had CS at Korle-Bu Teaching Hospital A (KBTH) was conducted with the aid of a pre-tested, structured, self-administered questionnaire. The study was conducted at the recovery ward of the Obstetric theatre and the main wards of the maternity block of KBTH. KBTH is the largest teaching hospital in Ghana and hence, has relatively more obstetric patients. The Obstetric and Gynaecological department has 275 beds for Obstetric cases and 97 beds for gynaecological cases. There are 2 labour wards attached to the 6 storey maternity block. There are 3 operating theatres located on the labour wards. These theatres are served by an eight-bed recovery ward. Inclusion and exclusion criteria ll patients above 15 years who underwent CS and gave their informed consent A were sampled for the study. Patients who were critically ill, mentally unstable or retarded, and those could not speak were excluded from the study. Sample size determination In a study determining the effectiveness of pain relief following CS, the authors found 95% of the patients to experience some degree of pain in the immediate postoperative period, whilst 80% reported having moderate to severe pain on postoperative day 1 [23]. Using a 90% power at aconfidence level of 95%, a sample size of 44 participants was estimated to be adequate taking into account a 10% attrition rate. Sixty (60) participants were recruited into this study. Data collection structured research questionnaire (Appendix I) was used to collect the data. The A questionnaire was divided into two main sections, addressing the demographics and the objectives of the study. The structured questionnaire was self-administered. Assessment of patients’ pain was done using the Verbal Descriptor Scale, VDS (no pain, mild, moderate, severe) at 0, 6, 12, 24 hours after surgery. Patients’ satisfaction with pain control was assessed at 24 hours after surgery and at discharge using a 2-point scale (yes/no). Patients’ charts were reviewed for records of analgesics administered. Data Analysis ata obtained was entered in Microsoft Excel 2010 version and validated for errors. D The data was then exported to the Statistical Package for Sciences (SPSS) version 21 for analysis. The data was subjected to descriptive analysis. Categorical variables were presented in absolute and relative frequencies. The quantitative variables were summarized as means, standard deviation, medians and interquartile intervals. Chi-square test was used to determine patient satisfaction with analgesia. ne Way analysis of variance (ANOVA) was used to compare pain scores at the O times 0, 6 hours, 12 hours, 24 hours and at discharge. Linear regression was used to determine the factors associated with pain scores. All p-values less or equal to 5% were considered statistically significant. Ethical consideration thical approval for the study was sought from the University of Ghana Medical E School (protocol ID: UGMS-CHDRC-052/2021). The interviews were carried out in a peaceful and private manner and voluntariness of participation was ensured. Written informed consent was sought from the participants before the start of study. Participants had the added option to opt out of the study without any implications. Results Demographic characteristics of patients Table 1: Demographic characteristics of patients Variable Number ercenta P ge (%) ge (years) A 20-29 30-39 40 and above 6 1 38 6 6.7 2 63.3 10.0 MI (Kg/m2) B 18.5-24.9 25-29.9 30-39.9 4 1 20 26 3.3 2 33.3 43.4 Educational status Secondary Tertiary 6 3 24 0.0 6 40.0 Marital status Single Married 6 54 0.0 1 90.0 Ethnicity kan A Ewe Ga-Adangbe Northerner 44 2 8 6 3.4 7 3.3 13.3 10.0 Parity <2 >2 4 2 36 0.0 4 60.0 Type of CS Elective Emergency 6 3 24 0.0 6 40.0 ASA Classification II III 52 8 6.7 8 13.3 istory of previous H Abdominal surgery Yes No 2 3 28 3.2 5 46.7 Table 2: Indication for CS Variable Number ercentage P (%) Indication of CS BOH in pregnancy 4 6.7 TL B CPD Fibroids in pregnancy Foetal distress Breech 4 4 4 12 2 .7 6 6.7 6.7 20.0 3.3 Placenta abruption 4 6.7 lacenta Praevia P Preeclampsia 4 6 .7 6 10.0 Previous CS 16 26.7 Table 3: Intraoperative Anaesthetic Technique Variable Number Percentage (%) Anaesthetic Technique GA Spinal 0 1 50 6.7 1 83.3 Wound infiltration Yes No 0 60 0.0 100.0 Table 4: Postoperative Pain Management at time 0, 6hrs, 12hrs and 24hrs ariable V Opioid IM Pethidine IV morphine IM Pethidine + IV Morphine No Opioids NSAID Diclofenac suppository No NSAID Paracetamol IV Paracetamol No Paracetamol Regional Block TAP Block No Block 0hrs; n (%) 6hrs; n (%) 12hrs; n (%) 24hrs; n (%) 8 (79.9) 4 2 (3.3) 2 (3.3) 8 (13.3) 4 (56.7) 3 2 (3.3) 0 (0.0) 24 (40.0) 0 (50.0) 3 2 (3.3) 0 (0.0) 28 (46.7) 2 (53.3) 3 2 (3.3) 0 (0.0) 26 (43.3) 2 (70.0) 4 18 (30.0) (3.3) 2 58 (96.7) 4 (23.3) 1 46 (76.7) 8 (63.3) 3 22 (36.7) 0 (83.3) 5 10 (16.7) 0 (83.3) 5 10 (16.7) 0 (66.7) 4 20 (33.3) 0 (66.7) 4 20 (33.3) (3.3) 2 58 (96.7) (0.0) 0 60(100.0) (0.0) 0 60 (100.0) (0.0) 0 60 (100.0) Table 5: Postoperative Nausea and Vomiting and time of breast feeding/ oral Sips ariable V Nausea Yes No n (%) 0hrs n (%) 6hrs n (%) 12hrs n (%) 24hrs 0 (16.7%) 1 50 (83.3%) (6.7%) 4 56 (93.3) (3.3%) 2 58 (96.7%) (0.0%) 0 60 (100.0%) omiting V Yes No 0 (16.7%) 1 50 (83.3%) (0.0%) 0 60 (100.0%) (0.0%) 0 (3.3%) 2 60 (100.0%) 58 (96.7%) Breastfeeding Yes No (6.7%) 4 56(93.3%) 4 (73.3%) 4 16 (26.7%) 6 (76.7%) 4 14 (23.3%) 6 (93.3%) 5 4 (6.7%) Oral Sips Yes No (0.0%) 0 60(100.0%) (10.0%) 6 54(90.0%) 0 (33.3%) 2 40 (66.7%) 0 (100.0%) 6 0 (0.0%) Antiemetic Treatment Promethazine Metoclopramide Granisetron None (6.7%) 4 4 (6.7%) 2 (3.3%) 50 (83.3%) (3.3%) 2 0 (0.0%) 0 (0.0%) 58 (96.7%) (0.0%) 0 0 (0.0%) 0 (0.0%) 60 (100.0%) (0.0%) 0 0 (0.0%) 2 (3.3%) 58 (96.7%) Table 6: Patients Satisfaction with Pain Management at 24 hours Post Surgery and at Discharge Variable Number ercentag P e (%) 4 5 6 0.0 9 10.0 4 5 6 0.0 9 10.0 ain management P satisfaction at 24 hrs atisfied S Not satisfied Pain management satisfaction at discharge Satisfied Not satisfied Discussion his study investigated the patterns and effectiveness of postoperative pain T management following Caesarean delivery at the Korle-Bu Teaching Hospital, with a particular focus on the application of Multi-Modal Analgesia (MMA). The findings generally support the efficacy of MMA, as proposed by[17], in enhancing postoperative pain control in Caesarean section patients. However, inconsistent pplication of this approach across different postoperative time points revealed gaps a in pain management that warrant attention. In the immediate postoperative period (time 0), a high proportion of patients received a combination of analgesics—parenteral opioids (76.7%), NSAIDs (70%), and paracetamol (83.3%)—consistent with MMA principles. This comprehensive analgesic regimen likely contributed to the majority of patients (53.3%) reporting only mild pain during a period typically associated with high pain intensity. However, a concerning subset of patients did not receive any form of analgesia: 13.3% received no opioids, 30% no NSAIDs, and 16.7% no paracetamol. These omissions may explain the 26.7% of patients who reported severe pain in the immediate postoperative phase. Furthermore, neuraxial techniques—such as spinal or epidural blocks, which are known to provide superior analgesia⦍16]—were rarely utilized, with only 3.3% of patients receiving such interventions. t six hours postoperatively, a notable reduction in the use of opioids (56.7%) and A NSAIDs (3.3%) was observed, while paracetamol administration remained stable (83.3%). This shift away from a balanced MMA regimen may have contributed to the highest proportion of patients reporting moderate pain at this time point. The reduction in analgesic administration appears to reflect systemic gaps, such as a lack of physician prescription or missed administration by nursing staff. The consequences of suboptimal pain control extended beyond patient comfort; 16.7% of patients had not initiated breastfeeding at this time, an outcome previously linked to poor pain control by[24-25] y 12 hours postoperatively, parenteral opioid use further decreased (50%), B paracetamol use slightly declined (66.7%), and NSAID administration increased to 23.3%. This partial restoration of a multimodal approach corresponded with an increase in the number of patients reporting mild pain (46.7%). At 24 hours, use of all three drug classes (opioids, NSAIDs, and paracetamol) increased to 63.3%, coinciding with the highest proportion of patients (56.7%) experiencing mild pain, indicating a positive correlation between adherence to MMA protocols and effective pain control. y discharge, 93.3% of patients reported experiencing mild or no pain. However, B despite the overall trend of declining pain intensity over time, full implementation of an ideal MMA strategy—including consistent use of pharmacological agents and regional techniques—was lacking. The minimal use of neuraxial analgesia, despite its proven benefits in Caesarean analgesia[16], underscoresa missed opportunity for optimizing pain outcomes. atient satisfaction correlated positively with the overall decline in pain severity, with P 90% reporting satisfaction with pain management. The remaining 10% cited delayed administration of medications and residual pain at discharge as reasons for issatisfaction, reflecting how logistical and systemic issues can impact patient d experience even when general trends are favorable. otably, certain patient characteristics appeared to predict pain outcomes. Higher N body mass index (BMI 30–39.9) was associated with increased pain severity, possibly due to altered pharmacokinetics or technical difficulties in drug administration. Patients who underwent general anesthesia (GA) reported more intense postoperative pain than those who received regional anesthesia. This is likely attributable to the emergency nature of many GA cases, often involving labor-related pain before surgery. Additionally, single women reported higher pain scores than married women, supporting the biopsychosocial model of pain, which incorporates emotional and social dimensions alongside physical sensation[26]. his study was limited by its small sample size (n = 60), primarily due to challenges T in patient follow-up, time constraints, and financial limitations. The relatively short study duration may also have influenced the generalizability of findings. Conclusion hile MMA principles were partially adopted in postoperative care at KBTH, W inconsistent application—particularly the underuse of NSAIDs, opioids at later time points, and neuraxial techniques—revealed opportunities for significant improvement. A standardized, multidisciplinary approach to postoperative pain management, incorporating both pharmacological and non-pharmacological strategies, is essential for optimizing maternal recovery and early functional outcomes such as breastfeeding. Future research with larger cohorts and longer follow-up is needed to evaluate the long-term implications of current pain management practices and to support evidence-based interventions. Additional Information Author Contributions ll authors have reviewed and agreed to be accountable for every detail of this final A work oncept and design:Melody Asare, Ebenezer Owusu Darkwa,George Aryee, C Raymond Essuman,Promise Ahiagbenyo, Denzel Tay cquisition, analysis, or interpretation of data:George Aryee, Raymond A Essuman rafting of the manuscript:Melody Asare, Ebenezer Owusu Darkwa,George D Aryee, Raymond Essuman,Promise Ahiagbenyo, DenzelTay ritical review of the manuscript for important intellectual content:Melody C Asare, Ebenezer Owusu Darkwa,George Aryee, RaymondEssuman,Promise Ahiagbenyo, Denzel Tay Supervision:Ebenezer Owusu Darkwa isclosures: D Human Subjects:participants of the study were informedof open-access publication and consent was sorted from all. Ethical approval was granted by the University of Ghana Medical School (protocol ID: UGMS-CHDRC-052/2021).Animal Subjects:no animal subjects nor tissue were employedin this study.Conflicts of Interest:In accordance with the ICMJE disclosureguidelines, the authors declare the following:Funding:No financial support was receivedfrom any organization for the conduct or submission of this work.FinancialRelationships:The authors report no financial relationships with any organizations that could be perceived as having an interest in the submitted work, either currently or within the past three years.Other Disclosures:The authors confirm thatthere are no additional relationships or activities that could be construed as potential conflicts of interest related to this study. References 1. Abebe, F. E., Gebeyehu, A. W., Kidane, A. N., & Eyassu, G. A. (2016). Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: A retrospective record review.Reproductive Health, 13(1), 6.10.1186/s12978-015-0114-8 2. World Health Organization. (2021, June 16).Caesareansection rates continue to rise, amid growing inequalities in access. https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-t o-rise-amid-growing-inequalities-in-access 3. Ghana Statistical Service (GSS), Ghana Health Service (GHS), & ICF. (2018). Ghana Maternal Health Survey 2017. Accra, Ghana: GSS,GHS, and ICF. Retrieved fromhttps://www.dhsprogram.com/pubs/pdf/FR340/FR340.pdf 4. Dihle, A., Helseth, S., Paul, S. M., & Miaskowski, C. (2006). The exploration of the establishment of cutpoints to categorize the severity of acute postoperative pain.The Clinical Journal of Pain,22(7), 617–624. 10.1097/01.ajp.0000210905.57546.c1 5. Schoenwald, A., & Clark, C. R. (2006). Acute pain in surgical patients. Contemporary Nurse, 22(1), 97–108.10.5172/conu.2006.22.1.97 6. Carr, D. B., & Goudas, L. C. (1999). Acute pain.TheLancet, 353(9169), 2051–2058.10.1016/S0140-6736(99)01311-2 7. Teng, Y. H., Hu, J. S., Tsai, S. K., Liew, C., & Lui, P. W. (2004). Efficacy and adverse effects of patient-controlled epidural or intravenous analgesia after major surgery. Chang Gung Medical Journal, 27(12),877–886. 8. Kehlet, H., Jensen, T. S., & Woolf, C. J. (2006). Persistent postsurgical pain: Risk factors and prevention. The Lancet, 367(9522),1618–1625. 10.1016/S0140-6736(06)68700-X 9. Bonnet, M. P., Mignon, A., Mazoit, J. X., Ozier, Y., & Marret, E. (2010). Analgesic effect and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review. European Journal of Pain, 14(9), 894–899.10.1016/j.ejpain.2010.03.003 10.Mitra, S., Khandelwal, P., & Sehgal, A. (2012). Diclofenac-tramadol vs diclofenac-acetaminophen combinations for pain relief after caesarean section. Acta Anaesthesiologica Scandinavica, 56(6),706–711. 10.1111/j.1399-6576.2011.02623.x 11.Apfelbaum, J. L., Chen, C., Mehta, S. S., & Gan, T. J. (2003). Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia,97(2), 534–540. 10.1213/01.ANE.0000068822.10113.9E 12.Vijayan, R. (2011). Managing acute pain in the developing world. IASP Pain Clinical Updates,XIX, 1–7. 13.Kuczkowski, K. M. (2004). Postoperative pain control in the parturient patient: New challenges (and their solutions). Journal of Clinical Anesthesia,16(1), 1–3.10.1016/j.jclinane.2003.07.002 14.Pickering, E., & Holdcroft, A. (2006). Pain relief after caesarean section. In M. Kinsella (Ed.),Raising the Standard:A Compendiumof Audit Recipes (2nd ed., pp. 168–169). London: Royal College of Anaesthetists. 15.Bateman, B. T., Franklin, J. M., Bykov, K., Avorn, J., Shrank, W. H., Brennan, T. A., et al. (2016). Persistent opioid use following cesarean delivery: Patterns and predictors among opioid-naive women. American Journal of Obstetrics and Gynecology,215(3), 353.e1–353.e18.10.1016/j.ajog.2016.03.016 16.Sutton, C. D., & Carvalho, B. (2017). Optimal pain management after cesarean delivery. Anesthesiology Clinics, 35(1), 107–124. 10.1016/j.anclin.2016.09.010 17.Chou, R., Gordon, D. B., de Leon-Casasola, O. A., Rosenberg, J. M., Bickler, S., Brennan, T., et al. (2016). Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain, 17(2),131–157. 10.1016/j.jpain.2015.12.008 18.American College of Obstetricians and Gynecologists. (2018). ACOG Committee Opinion No. 742: Postpartum pain management. Obstetrics & Gynecology,132(e35–e43).10.1097/AOG.0000000000002683 19.Ismail, S., Shahzad, K., & Shafiq, F. (2012). Observational study to assess the effectiveness of postoperative pain management of patients undergoing elective cesarean section. Journal of Anaesthesiology Clinical Pharmacology, 28(1), 36–40.10.4103/0970-9185.92432 20.Bagi, I. A., & Ahmed, M. E. (1993). Postoperative pain and analgesic prescription in Khartoum: Evaluation of current practice. East African Medical Journal,70(8), 502–505.https://pubmed.ncbi.nlm.nih.gov/8261971/ 21.Amponsah, G. T. (2014). Postoperative pain management in Ghana: Patients' experiences and nurses' perspectives.Ghana MedicalJournal,48(2), 92–97. 10.4314/gmj.v48i2.5 22.Takashi, S. (2023). The impact of cesarean section on breastfeeding and mother-infant bonding. Case Reports in Surgery and Invasive Procedures, 7(2), 139.10.35841/aacrsip-7.2.139 23.Kolawole, K., & Fawole, A. A. (2003). Postoperative pain management following caesarean section in University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria. West African Journal of Medicine,22(4), 305–309. 10.4314/wajm.v22i4.28052 24.Karlström, A., Engström-Olofsson, R., Norbergh, K.-G., Sjöling, M., & Hildingsson, I. (2007). Postoperative pain after cesarean birth affects breastfeeding and infant care. Journal of Obstetric, Gynecologic, & Neonatal Nursing,36(5), 430–440.10.1111/j.1552-6909.2007.00160.x 25.Kainu, J. P., Sarvela, J., Tiippana, E., Halmesmäki, E., & Korttila, K. T. (2010). Persistent pain after caesarean section and vaginal birth: A cohort study. International Journal of Obstetric Anesthesia,19(1), 4–9. 10.1016/j.ijoa.2009.03.009 26.International Association for the Study of Pain. (2014). IASP taxonomy. https://www.iasp-pain.org/resources/terminology/
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