Recovery after Nulliparous Birth: A Detailed Analysis of Pain Analgesia and Recovery of Function

Abstract

Background: The majority of parturients in the United States first return for evaluation by their obstetric practitioner 6 weeks after delivery. As such, there is little granular data on the pain experience, analgesic requirements, and functional recovery during the postpartum period. This prospective observational study was performed to evaluate these factors to provide expectations for patients.

Methods: A total of 213 nulliparous women were enrolled and assessed daily until they completed 3 outcomes: (1) pain resolution; (2) opioid cessation; and (3) self-assessed functional recovery from delivery. The primary endpoint, pain- and opioid-free functional recovery, was the time required to reach all three of the endpoints. Pain burden was assessed as the area under the curve created by plotting the daily numerical pain rating scale against the days required to attain pain resolution. Times to attain study endpoints after cesarean delivery and vaginal delivery were compared using survival analysis.

Results: After vaginal delivery, days required for pain and opioid-free functional recovery (median [interquartile range (IQR)]) were 19 [11 to 26], for opioid cessation 0 [0 to 2], termination of all analgesic (including nonsteroidal antiinflammatories and acetaminophen) 11 [5 to 17], and pain resolution 14 [7 to 24]. Achievement of these endpoints after cesarean delivery required 27 [19 to 40], 9 [5 to 12], 16 [11 to 24], and 21 [14 to 27] days, respectively.

Conclusions: There is clinically significant variability between healthy nulliparous parturients in the pain experience, opioid use, and functional recovery after childbirth following vaginal and cesarean delivery. Recovery to predelivery function is similar after vaginal and cesarean delivery, and approximately half of the variance was explained by pain burden.

Conflict of interest statement

Conflict of Interest: No other conflicts of interest to report

Figures

Figure 1

Flow diagram for participant’s inclusion and data completion.

Figure 2. Pain trajectory after vaginal and cesarean delivery

1. Pain trajectory after vaginal delivery. Colored dotted lines represent pain reports from individual subjects, and the solid white line is a moving average constructed with Friedman’s supersmoother in R; “supersmu” (R statistical software package, version 3). The shaded area covers the range from the 5th to 95th percentile of the data. NRS=verbal numerical pain score from 0–10, with 0=no pain and 10=worse pain imaginable.

2. Pain trajectory after cesarean delivery. Colored dotted lines represent pain reports from individual subjects, and the solid white line is a moving average constructed with Friedman’s supersmoother in R; “supersmu” (R statistical software package, version 3). The shaded area covers the range from the 5th to 95th percentile of the data. NRS=verbal numerical pain score from 0–10, with 0=no pain and 10=worse pain imaginable.

3. Pain trajectory in completers and non-completers after vaginal delivery. The solid lines represent the pain score mean values for subjects retained in the study (black) and those who dropped out (red) before completing the composite primary outcome of “pain and opioid free functional recovery” after vaginal delivery. Shaded areas are 95% confidence intervals. The dashed green line demonstrates the timing of dropout. The overlap of confidence interval with the mean of the other curve demonstrate that the patients who dropped out of the study were not having a significantly different pain experience compared to those who were retained.

4. Pain trajectory in completers and non-completers after cesarean delivery. The solid lines represent the pain score mean values for subjects retained in the study (black) and those who dropped out (red) before completing the composite primary outcome of “pain and opioid free functional recovery” after cesarean delivery. Shaded areas are 95% confidence intervals. The dashed green line demonstrates the timing of dropout. The overlap of confidence interval with the mean of the other curve demonstrate that the patients who dropped out of the study were not having a significantly different pain experience compared to those who were retained.

Figure 3. Kaplan-Meier estimates of daily probability of obtaining study outcomes

1. Time to “pain and opioid free functional recovery” (primary outcome) after vaginal delivery (solid line) and cesarean delivery (dotted line). (P=0.004, log rank test).

2. Time to pain-free state after vaginal delivery (solid line) and cesarean delivery (dotted line). (P=0.045, log rank test).

3. Time to opioid cessation after vaginal delivery (solid line) and cesarean delivery (dotted line). (P<0.0001, log rank test).

4. Time to all analgesic cessation after vaginal delivery (solid line) and cesarean delivery (dotted line). (P=0.008, log rank test).