Analgesia Post Emergency Caesarean
Section and Educational Intervention in
The Developing World
Dr Michelle Gerstman
Anaesthesia Registrar
Alfred Hospital Melbourne
Hospital Nacional Guido
Valdares (HNGV)
Introduction
• Caesarean sections amongst the most common
surgical procedures performed in the world
• Pain relief is a basic human right
• Acute pain often poorly managed in developing
world
• High morbidity associated with pain
• Small improvements can potentially have a large
positive impact
• Simple easy to follow education regarding obstetric
postoperative analgesia has wide application
WHO: Mother Baby Package: implementing safe motherhood in countries (practical guide).
Bosenber, A, Paediatric anaesthesia in developing countries, Current opinion in Anaesthesiology, 2007, 20:204-120
Current Evidence
• Minimal in the developing world
• Extensive evidence regarding multimodal
analgesia in the developed world
Australian and New Zealand College of Anaesthetists and Faculty of Pain
Medicine. Acute Pain Management: Scientific Evidence. 3rd Edition 2010
Hypothesis
• Simple education regarding postoperative
multimodal analgesia can result in
significantly improved pain scores after
Emergency Surgery for Caesarean
Section in a Developing World setting with
limited resources.
Study
• Prospective audit
• Analgesia prescribing patterns and pain
intensity after Emergency Cesarean
Section for a 48 hour period in two groups.
• BEFORE and AFTER simple education
regarding multimodal analgesia for
prescribers.
Analgesic Prescribing
• Obstetricians prescribe post op
analgesia in Timor
• Midwives transcribe and administer
• Analgesics available
• Any combination
• Opioid analgesia is not prescribed
Methods
• Emergency CS
– Pre education - 16 October - 1 December 2009
– Education
– Post education - 10 May 2010 - 21 June 2010
• Anaesthesia Registrar/Consultant
• Nurse anaesthetists acted as an interpreters
Methods: Education
• Obstetricians and midwives
• Presentation and discussion of pre-education
audit data
• Agreement that analgesia provision was
inadequate
• A multimodal analgesia protocol of regular
tramadol, paracetamol and ibuprofen was
agreed upon
Audit data: Primary Measures
•
•
•
Analgesia prescribed by the surgical team in
surgical notes
Actual analgesia transcribed by midwives to
drug chart and given on day 1 and day 2 post
operatively
Pain scores at rest and with movement on day
1 and day 2 post surgery
• verbal description of pain (5 categories)
from no pain to severe pain then
converted to numerical value 1-5
Results
• 54 patients were
included in the preeducation audit
– 54/54 on day 1
– 52/54 on day 2
• 63 in the posteducation audit
– 63/63 on day 1
– 55/63 on day 2
Post op analgesia
100%
90%
80%
70%
Nil
60%
3 agents
2 agents
50%
Single agent
40%
30%
20%
10%
0%
Day 1 Pre
Day 2 Pre
Day 1 Post
Day 2 Post
Analgesia
Pre Education
Post Education
Day 1
Day 2
Day 1
Day 2
Tramadol alone
62%
12%
32%
11%
Paracetamol alone
9%
35%
0%
0%
Ibuprofen alone
2%
31%
5%
0%
Tramadol/Paracetamol
19%
6%
0%
0%
Tramadol/ Ibuprofen
4%
0%
0%
0%
Ibuprofen /Paracetamol
0%
4%
3%
74%
Tramadol/ Ibuprofen /
Paracetamol
0%
0%
57%
11%
Nil
4%
12%
0%
2%
Mean Pain scores
Pre Education
Post Education
P value
Day 1 Rest
2.7 ± 0.9
2.0 ± 0.8
0.0003
Day 1 Movement
3.7 ± 0.8
3.3 ± 0.8
0.0036
Day 2 Rest
2.1 ± 0.8
1.8 ± 0.9
0.0908
Day 2 Movement
3.0 ± 0.8
3.0 ± 0.7
0.8858
Conclusion
•
Large increase in the use of multimodal
analgesia after educational intervention
•
Significant improvement of early postoperative
pain relief
•
Successful education and implementation of
knowledge after one education session
Discussion
• Less marked improvement with late pain relief
– Impact of tramadol?
– Rapid mobilization of patients with less use of
pre-emptive analgesia?
– Loss to follow up?
• Language/cultural issues
• Challenges with staff changeover
• Stoic patients vs. developed world
Discussion
• Different Anaesthesia Registrar
• Audit, not RCT
• Small number of patients had midline
incision rather than Pfannenstiel incision
Future
• Further education
sessions
• Retention of information repeat audit 1 year after
post education audit
• Written pain protocol
displayed in Obstetric
ward and OR
• Potential application to
other surgical specialties
• Potential for opioid?
Acknowledgements
• Dr Eric Vreede – Head Department of
Anaesthesia HNGV, Team Leader RACS
• Dr Alex Konstantatos – Analysis
• Dr Jane Chia – Audit 1
• HNGV Nurse Anaesthetists - Translation
services