Analgesia Post Emergency Caesarean Section and Educational Intervention in The Developing World

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Analgesia Post Emergency CaesareanSection and
Educational Intervention inThe Developing World

• Dr Michelle Gerstman
• Anaesthesia Registrar
• Alfred Hospital Melbourne

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Hospital Nacional Guido Valdares (HNGV)
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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, 20204-120
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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
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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.

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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.

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Analgesic Prescribing

• Obstetricians prescribe post op analgesia in
  Timor
• Midwives transcribe and administer
• Analgesics available
• Any combination
• Opioid analgesia is not prescribed

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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

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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

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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

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Results

• 54 patients were included in the pre-education
  audit
• 54/54 on day 1
• 52/54 on day 2
• 63 in the post-education audit
• 63/63 on day 1
• 55/63 on day 2

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Post op analgesia
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Analgesia
Pre Education Pre Education Post 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
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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
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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

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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

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Discussion

• Different Anaesthesia Registrar
• Audit, not RCT
• Small number of patients had midline incision
  rather than Pfannenstiel incision

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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?

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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

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