Evaluation of the Practice and Adequacy of Current Pain Management Following Caesarean Delivery in Patients at Kenyatta National Hospital Between March & May 2019 a Descriptive Cohort Study

Abstract

Introduction: The global increase in caesarean deliveries is associated with a rise in the burden of postoperative pain which is ranked highest among undesirable clinical outcomes. Acute post operative pain remains under-treated. Adequate pain control in post CS patients has many benefits including early mobilisation averting the risk of thromboembolism and prompt recovery that enables the mothers to breastfeed, bond and generally take care of the newborn. There is a paucity of local data on incidence of acute postoperative pain and adequacy of pain management in patients undergoing CS. Objectives Broad objective: To determine the practice and adequacy of current pain management following caesarean delivery in patients at Kenyatta National Hospital between March and May 2019. Specific objectives: To describe the type(s) of analgesics prescribed by the attending physicians and their dosing schedule; to determine the proportion of analgesics administered to post caesarean delivery patients; to evaluate level of pain control & physical function limitation and to establish patients’ satisfaction with post cesarean delivery pain management. Methodology: Approval to carry out a descriptive cohort study at the labor and postnatal wards of Kenyatta National Hospital was granted by the KNH-UoN ethics & research committee. 246 post CS patients who gave informed consent were enrolled following recruitment through consecutive sampling. Independent variables were postoperative analgesics and patients’ sociodemographic & reproductive/ surgical characteristics. Dependent variables were pain levels 24, 48 & 72 hours postoperatively, limitation of function and patients’ satisfaction. Data was collected using a structured questionnaire. Review of records (daily birth register and patients’ files) was done. Adequacy of pain management was inferred from Visual Analogue Scale scores where a cut off pain score of 40mm on a scale of 0-100 was used. Data on limitation of function was obtained on a ten-point likert scale whereas data on satisfaction was obtained on a twopoint scale. Data analysis was performed using SPSS version 23.0. Descriptive and inferential statistics were computed. Mean was used to summarise continuous variables like age. Categorical variables were analysed using frequencies. Data on pain scores were used to create binary variables where <40mm was coded as mild pain and >40mm as moderate-severe pain. Primary and secondary independent variables were analysed against outcome variables using multivariate analysis. Chi square test was used to determine relationship between post CS pain and independent variables, as well as satisfacxi tion status and pain scores. T-tests were used to compare limitation of function and pain scores. Tables and graphs/charts were used to present these statistics. Results: Intermittent IM administration of post CS analgesics was the commonest mode of treatment. Morphine was the commonest opioid prescribed (97.9%). Diclofenac was the commonest coanalgesic prescribed (94.3%). Acetaminophen was prescribed by 91.2%. Multimodal analgesia prescription was practised by 84% of doctors.14.8% of Morphine prescription orders were adhered to whereas 74% of prescribed Diclofenac was administered accordingly. 100% of paracetamol prescription orders were adhered to. Of the QID/TID morphine prescription orders, 100% were administered at an OD frequency. Majority (51.2%) of the morphine prescription orders were at 8-hourly intervals, followed by QID at 10.1%, BID at 9.3%, PRN at 4% and OD at 3.6%. Tramadol was given in combination with Morphine in 28.5% of the patients and as monotherapy in 4%. Incidence of post CS pain was 95.9%. Moderate-severe pain levels were reported in 85.7% of patients while 14.3% reported mild pain levels 24 hours post operatively. On day 3 post operatively 83.7% reported mild pain levels while 16.3% reported moderate-severe pain levels. Associations between age, parity, type of CS, type of anaesthesia and 24-hour pain scores were not significant. >60% reported physical function limitation scores corresponding to insignificant interference. 85% of the patients were satisfied with post CS pain management. Conclusion: The current practice of post-cesarean delivery pain management at Kenyatta National Hospital is not standardised. Actual administration of post CS pain medications does not match the prescription orders. Orders on less labor-intensive routes of administration were adhered to more. Based on the 2012 RCoA Audit Recipes recommendations, post CS pain management is inadequate despite the percentage of patients satisfied. Recommendations: Standardization of post CS pain management through SOPs, sensitisation of healthcare..........................