pain assessment in CS women

1. Introduction
Child birth is one of emotional experience for woman and her family. Mother needs to
bond with new baby as early as possible and initiate early breast feeding, which helps to contract
the uterus and accelerates the process of uterine involution in the postpartum period. Delivery by
cesarean section is becoming more frequent and is one of the most common major operative
procedures performed worldwide. 1
Caesarean section has been a part of human culture since ancient times. It has been used
effectively throughout the 20th century and among the major abdominal surgeries, it is the most
common, oldest worldwide surgery performed in obstetrics. Some problems like longer duration
of hospital stay, post-operative pain, delayed ambulation, increased period required to return to
normal meals, breast engorgement, problems in relation to bladder and bowel, lactation failure
and less maternal newborn bonding .2
Post-operative pain is common problem after cesarean deliveries. Acute pain at the time
of child birth was found to be a risk factor for development of postpartum depression and post
traumatic stress disorder.3
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented
pain management standards in 2001 that recognized patients’ rights to appropriate assessment
and management of pain. The World Health Organization (WHO) reported in 2003 that pain is
the leading cause of death and disease burden worldwide. Acute pain is still a major factor that
annoys both patients and hospital staff. Having a baby is considered a pleasant event, but it can
be annoying if the mother is in pain during childbirth4.

2. In Europe, a trial of labor after caesarean section (TOLAC) has been standard practice,
driven in part because of obstetric concerns about the maternal mortality and morbidity
associated with CS. It is only since the 1950’s that papers reporting on TOLAC emerged from
the United States. With advances in clinical practice, CS became safer and rates started to
increase. As CS rates increased the National Institute of Health (NIH) held a Consensus
Development conference in 1980. Subsequently, a policy encouraging TOLAC was adopted, and
the overall vaginal birth after caesarean section (VBAC) rate reached 28% in the United States
by 1996 with an associated decrease in the overall CS rate .5
Pain:
The word “pain” is from the Latin “poena”, which means “punishment”. Labour pain has always
been considered a normal phenomenon, though a unique pain experience, because it is intense
and expected6.
Pain has long been recognized as a highly personal and subjective phenomenon unique to the
individual. The most common recognized definition of pain is that of the International
Association for the Study of Pain (1979):'an unpleasant sensory and emotional experience
associated with actual or potential damage or described in terms of such damage'. Many factors
are known to affect the experience of pain, including gender, age, culture, previous experiences,
the meaning the pain has to the individual experiencing it.
Pain Intensity: Can be broadly categorized as: mild, moderate and severe. It is common to use a
numeric scale to rate pain intensity where 0 = no pain and 10 is the worst pain imaginable:
 Mild: <4/10
 Moderate: 5/10 to 6/10
 Severe: >7/10

3. Time course: Pain duration
 Acute pain: pain of less than 3 to 6 months duration
 Chronic pain: pain lasting for more than 3-6 months, or persisting beyond the course of
an acute disease, or after tissue healing is complete.
 Acute-on-chronic pain: acute pain flare superimposed on underlying chronic pain
Assess Pain Intensity
Use a numeric pain rating scale in most clinical settings. The most common is an 11 point scale
where 0 = no pain and 10 =worst pain imaginable. Since this is an ordinal scale, a score of 8/10
is not twice as severe as a score of 4/10. Many use a 0 to 5 faces scale for children.
 Important: Pain is a subjective experience (the experience is unique for each individual
person) with a different meaning to each person. The pain rating reflects a patient's
interpretation of what that pain means for him/her at that moment and it is a combination
of the patient's physical discomfort and emotional interpretation. Changes in pain
intensity are valuable when measured for single individuals (for example, before and
after a treatment), but they should not be used to compare pain between different
individuals. One person's 4/10 might be another's 10/10.
 Nonverbal patients, such as those in coma or with dementia or other cognitive
impairments, must be assessed for pain by observational means, such as body language,
movement, autonomic arousal, and nonverbal pain behavior. Similar approaches should

4. be used when assessing pain in young children or infants. Consult someone with
expertise in pain assessment if you are unsure whether a patient is experiencing pain. 8
Pain assessment scales
Achieving effective pain management requires careful assessment and regular review of the
patient’s experience of pain. As pain is a subjective symptom, pain assessment tools are usually
based on the patient’s own perception of his or her pain and its severity.
Many different pain scales are available, including those for infants, children, adults and patients
with difficulties communicating. Below is a selection of pain scales that may prove useful to you
and your patients.
Numeric Rating Scale
Like the VAS, the numeric rating scale (NRS) is a unidimensional measure of pain intensity. It is
a segmented numeric version of the VAS. Patients rate their pain on a simple scale marked from
0 to 10, where 0 is ‘no pain’ and 10 is ‘worst pain imaginable’, either verbally or by placing a
mark along a line.

5. Numeric Rating Scale
Wong-Baker FACES Pain Rating Scale
The Wong-Baker FACES® Pain Rating Scale combines pictures and numbers to allow pain to
be rated by the user. The faces range from a smiling face to a sad, crying face. A numerical
rating is assigned to each face, of which there are 6 total. The Wong-Baker FACES® Pain
Rating Scale is a self-assessment tool, so the patient must be able to understand the tool and be
able to indicate which face most closely depicts the pain experience. The scale is used for people
aged 3 and older. This is not the tool to use for unresponsive patients.
Pain Quality Assessment Scale (PQAS)
Pain Quality Assessment Scale (PQAS) is a 20-item instrument developed to quantify the quality
and intensity of pain associated with all types and categories of pain problems, including both
nociceptive and neuropathic pain. The specific items added assess tender, numb, electrical,
tingling, radiating, throbbing, aching, shooting, cramping and heavy pain qualities.9

6. Many women describe it as the most severe pain they have experienced .Pain during this
circumstance is an important signal indicating that labour has started and the perception of pain
increases as labour progresses.
The major determinant of labour pain is parity, prim parous women having more pain than
multiparous women. One of the most important tasks for a midwife, except providing obstetric
care, is to support women during pregnancy and childbirth. It has been demonstrated that
empathetic and physical support during labour has many benefits, including shorter labour and
less medication. It also reduces anxiety and helps mothers to cope with labour pain and thus
improves the childbirth experience. The literature describes different methods to assess labour
pain.
Pain is a multidimensional, subjective phenomenon, so a person’s self-report is the most valid
way of assessing pain if the person is able to communicate .11
Objectives
The study conducted to assess the Pain, health related quality of life and medication adherence in
women after cesarean section by the following objectives
 To assess and characterize the post cesarean section Pain, aiming to reach a humanized
care during the post-partum.
 To measure and characterize the post cesarean section Pain and verify its relationship
with daily activity limitations.

7. To assess the patient’s readiness to adhere, provide advice on how to do it, and follow up the
patient at every contact.
Pain Quality Assessment Scale Scores
By using the Pain Quality Assessment Scale the following scores were obtained as; in the
overall 153 women’s the assessing parameters includes the Intensity with the total score as
738.0 and the mean as 824;Sharpness with the total score as 300.1 and the mean as 1.962;
Hotness showed by patients with the total score of 245.8 and the mean as 1.607; Dullness with
the score as 364.9 and the mean as 2.385;Freezing with the score as 85.98 and the mean as
0.562; sensitivity towards pain showed by the sample score as 352.34 and the mean as 2.300;
Tenderness among population had the total score as 582.32 and the mean as 3.803; Itching had
the less score as 99.12 and the mean as 0.647; Shooting with the score as 287.23 and the mean
as 1.871;Numbness with the score as 415.21 and the mean as 2.712; Sparking or Lightning with
the score as 118.22 and the score as 118.22 with the score as 0.771; Pricking or Tingling with the
score as 296.34 and the mean as 1.934; Squeezing or cramping with the score as 211.2 and the
mean as 1.379; Radiating with the score as least as 23.02 and the mean as 0.150; Pounding with
the score as 291.32 and the mean as 1.901; aching with the score as 548.21 and the mean as
3.581; Heaviness with the score as 207.01 and the mean as 1.352; Unpleasant sensation with the
score as 823.3 and the mean as 5.37; Deep pain with the score as 490.2 and the mean as 3.202;
Surface pain with the score as 306.32 and the mean as 2.0; Stability of pain with the score as
369.23 and the mean as 2.414.

8. Table: 6 Distributions of PQAS-Pain Scores among Study Subjects
S.No Description Total score Mean
1. Intensity 738.0 4.824
2. Sharpness 300.1 1.962
3. Hotness 245.8 1.607
4. Dullness 364.9 2.385
5. Freezing 85.98 0.562
6. Sensitivity(raw skin) 352.34 2.300
7. Tenderness(bruise) 582.32 3.803
8. Itching 99.12 0.647
9. Shooting 287.23 1.871
10. Numbness 415.21 2.712
11. Sparking/lightning 118.22 0.771
12. Pricking/tingling 296.34 1.934
13. Squeezing/cramping 211.2 1.379
14. Radiating 23.02 0.150
15 Pounding 291.32 1.901
16. Aching 548.21 3.581
17. Heaviness 207.01 1.352

9. 18. Unpleasant sensation 823.3 5.37
19.(a) 1.Deep pain 490.2 3.202
(b) 2.Surface pain 306.32 2.0
20. Stability of pain 369.23 2.414
Graph 6: Distribution of PQAS-Pain Scores among Study Subjects
0
100
200
300
400
500
600
700
800
900
Pain Quality AssessmentScale data
Total score Mean

10. Discussion
153 women with the post Cesarean section were participated in this study belongs to
hospitals of local Obstetrics and Gynecology department.
Socio-demographics include the age, occupation, education, BMI, number of children, number of
deliveries.
Normal Body mass Index was mostly found because the weight of the person may also related
with the type of pain and most of the parous women in this study were primipara women at rest,
sitting down, standing and walking. From this study there is no difference in the pain intensity
between the primipara and multipara women.
Pain assessment was carried out by using three scales numerical, visual and quality
assessment scale. Numeric scale was simple to apply and participants showed a good
understanding acceptance of it. From this scale scores maximum frequency had the moderate
pain at about 77 participants out of 153. Less percentage of mild pain in the cesarean women.
Wong –Baker pain rating scale shows the major percentage as 55% having the type as little more
hurts, by this scale the decision purely by the participant based. Quality of pain assessment by
PQAS includes the unpleasant sensation towards the pain had noticed by most of the
participants, after that the intensity had the major mean value between the surface and deep pain
surface pain was more pain when compared to deeper one. There was less indication of freezing,
radiating, itching and lightening effect of pain.
Quality of pain is a broad term; HRQoL encompasses several domains of life directly
affected by changes in health. In this study HRQoL was measured by SF-12 method. This
method is used in order taking information from patient was simple and easy to ask in order to
provide a generic measure of health. SF-12 creates a health profile that enables comparison of

11. interruption of daily activities related to physical health and emotional problems. From this study
participants have the effect on more physical health and less emotional problem interference and
most of the women were feeling like lack of energy to do normal work and down hearted, also
some of the participants like about 3 of 153 said reduced peace of mind and pain interference
with the normal activities, related to general health most of the patients said feeling good about
their health but not very good.
Poor adherence is directly linked to patient behavior; there is no definitive data that had
defined a non-adherent personality or revealed a relationship between adherence and the ability
to follow self-care or life style recommendations. Medication adherence had not been correlated
to demographics variables such as age, gender or race. Major cause for adherence is lower
education and the income variables. In our study medium adherence in the patient was noticed.
Summary &Conclusion
From this study we state that age had less interference with pain, educated women with
or without occupation experienced more pain than uneducated and women engaged with
informal employment. Even though there is no difference between the primipara and multipara
women about their expression of pain, a little severe pain has been observed in primipara
compared to multipara. On an average most of the participants experience the moderate pain and
very few have severe and mild pains. Having more pain also most of the women told that they
hurt little more not as a whole lot.
From this study pain interferes mostly with physical health rather than emotional
problems, women expose to less physical activity because of pain, so they should be suggested
with some simple body movements like walking and little exercise with precautions and thus to

12. avoid unpleasant pain intensity. In this study adherence to prescription was moderate; adherence
to medication had a lead role after any surgery. For the fastest recovery from pain we must
improve the communication between the health care professionals and the patients.
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16. Annexures 4
PAIN QUALITY ASSESSMENT SCALE (PQAS