Fig. 12.1
Long-term potential consequences of a caesarean section for the upcoming life of a woman
12.2 Long-Term Health Problems: Except Local Pain—After Caesarean Section
Childbirth is a major event in life, associated with both physical and psychological changes which may affect the woman’s quality of life. The awareness on long-term maternal, physical, and emotional health problems after childbirth is increasing, with some recent study including a 5-year follow-up [3]. The global perception of her health status as well as the overall perceived health-related quality of life by the women herself is interesting. Childbirth is generally an expression of good health and thereby, self-rated health in women after childbirth is higher than in a population sample of women of same age [4]. Nevertheless, the mode of delivery seems to affect the health-related quality of life up to 5 years after birth of the first child because women who have undergone an emergency caesarean section or a caesarean section due to medical indication are more likely to report health concerns than women who had vaginal delivery, instrumental vaginal delivery, or caesarean section on request [3].
The most common problems at 8 weeks and later after childbirth are reported in Table 12.1. Two large prospective cohort studies published in 2002 [5] and 2012 [6] confirm the high prevalence of health problems which persist or recur after childbirth by either vaginal route or caesarean section. Tiredness is by far the most common physical symptom after childbirth [4]. However, women who had a caesarean section are more likely to report major fatigue (adjusted OR: 1.4; 95% CI: 1.06–1.83) and to suffer back pain at 6 and 12 months postpartum than women who had a vaginal delivery. Fatigue is often associated with sleeping problems which are very frequent in the early postpartum period but may persist [4, 5]. Furthermore, the presence of pain also interferes with sleep as sleep disturbances are frequently reported in questionnaires assessing the quality of life in patients with chronic pain. Between 10 and 25% of women with chronic pain at 6 months and later after childbirth mention associated sleeping problems [4, 5, 7–9], unrelated to the mode of delivery.
Table 12.1.
Prevalence of the most common health problems (except local pain) reported as significant problems after childbirth
2 months (%) | 6 months (%) | 12–24 months (%) | |
|---|---|---|---|
Physical exhaustion | 50–66 | 45–50 | 58–60 |
Low back pain | 51–53 | 43–47 | 42–44 |
Urinary incontinence | 21–27 | 11–12 | 20–23 |
Bowel problems | 35–37 | 17–21 | 9–11 |
Painful intercourse | 36–56 | – | 8–9 |
Breast problems | 14–18 | 6–9 | 4–6 |
Headaches, migraine | 18–22 | 16–19 | 23–25 |
Depressive symptoms | 10–13 | 7–10 | 10–12 |
Others: colds, illnesses… | 19–23 | 16–19 | 36–39 |
Besides, whether caesarean section causes less urinary incontinence, it seems to induce more bowel problems, i.e., constipation [5, 10]. The risk of intra-abdominal adhesions and hence intestinal obstruction is higher in women with a history of caesarean section (OR 2.1; 95% CI: 1.8–2.4) by comparison with women who had vaginal birth [11]. Having a caesarean section is often thought to avoid trauma to the genital tract and to protect postpartum sexual function. However, over 6 weeks after childbirth, sexual function does not seem to be affected by the mode of delivery [12].
Postpartum depression is a specific mental disorder, with 13–15% of women experiencing a major depressive episode during the first postpartum year [13]. Accordingly, the prevalence of self-reported postpartum depressive symptoms range from 12 to 20% and mood lability is common after childbirth. Suicide in mothers with postpartum depression accounts for 17% of late-pregnancy-related death [14]. Beyond the distress of the mother, postpartum depression and maternal mental health in general affect the child’s health outcomes in terms of cognitive, behavioral problems and risk of subsequent depression at adolescence [15]. Regarding depressive symptoms, assessed by a questionnaire used in the general population, a prospective Chinese study found a higher prevalence at 3 months (46% vs. 38%) but not later after caesarean delivery [12]. In contrast, a few prospective studies using the same specific questionnaire and scoring, i.e., the Edinburgh Postnatal Depression Scale (EPDS) [7, 10], report an incidence of 10.5% postpartum depression at either 2 months and 2 years after delivery, whatever the mode of delivery [7, 10, 16]. Both studies confirm the previous results of a large prospective population cohort study (N = 14,663) which already found no different risk among elective caesarean section, emergency caesarean section, and spontaneous vaginal delivery [13]. Finally, several studies on the quality of life after delivery also mention mood alterations caused by the presence of persistent pain (prevalence of 10–25% in women who underwent a caesarean section) [7, 9, 17].
At 2 years postpartum, maternal outcomes (i.e., fatigue, back pain, incontinence, sexual problem, menstrual problem, depression) after planned caesarean section are similar to planned vaginal birth as found in a prospective study on breech presentation at term [10]. For other physical health problems, the pattern of morbidity does not differ between caesarean section and spontaneous vaginal birth. Breast problems are very common, such as sore nipples and mastitis, but resolve with time. Interestingly, breast problems are also experienced by women who did not breastfeed at all [6]. In contrast to breast problems which decrease with time, the frequency of colds and coughs increases with time and they are more frequent in multiparas [4, 6].
12.3 Chronic Postsurgical Pain After Caesarean Section
Chronic pain is recognized as pain that persists past normal healing time and hence lacks the acute warning function of physiological nociception. Moderate to severe pain that persists at least 3 months (by definition, Chronic Post-Surgical Pain, CPSP) is frequent after surgery and may concern up to 6–10% of the patients [18, 19]. Depending the type of surgery, CPSP often involves a neuropathic component (average 30% of the cases, range 6–54%). In this case, pain is usually more severe and affects the quality of life more adversely. CPSP has become a health priority and will be included in the new version of the International Classification of Diseases (ICD-11) [18] because adequate pain treatment is a human right and also because CPSP represents a complex biopsychosocial problem. Further, the prevention of CPSP is currently a challenge for the clinicians as an indicator of the quality of healthcare [20]. Chronic pain related to caesarean section has received little attention until the first study was published in 2004 [21]. According to the definition of CPSP, chronic pain after caesarean section should persist at least 3 months after delivery and should not be present before or during pregnancy (Table 12.2).
Table 12.2.
Type and incidence (*) of chronic postsurgical pain after caesarean section compared with hysterectomy for a benign condition
Caesarean section | |
|---|---|
Scar pain | |
With predominant neuropathic pain | 4–5% (2% severe pain) |
50–60% at 6 months; 26% at 12 months | |
Visceral pain | |
Deep intra-abdominal pain | 5.4–7.6% |
Chronic pelvic pain | 2.9% at 6 months; 1.3% at 18 months |
Hysterectomy | |
Scar pain | |
With predominant neuropathic pain | 16–25% at 4 months; 8–10% at 1 year and later |
33% at 6 months and later | |
Visceral pain | |
Deep intra-abdominal pain | 15.3% |
Chronic pelvic pain | 16.7% |
The first studies on the topic were retrospective ones with inherent bias and have reported on global CPSP without distinction between parietal scar pain and deeper abdominal or pelvic pain. According to these studies (N = 220–1573), the prevalence of CPSP at 6 months and later was 12–18%. The prevalence of disabling pain with a negative impact on the mother’s quality of life and on the mother-child relationship was consistently 4–7% [8, 21–24]. Reported incidence of CPSP after caesarean section did not really change over time from 2004 [21] until 2016 [22]. In contrast, the relative risk of developing chronic pain after caesarean delivery compared with spontaneous vaginal delivery differed from one study to another [8, 22], probably because most of the retrospective studies did not characterize chronic pain, i.e., parietal abdominal pain versus deep intra-abdominal pain versus pelvic pain.
Because of the increasing interest on the topic, prospective studies emerged, focusing on new pain related to the procedure and excluding preexisting pain. In these studies, the incidence of CPSP at 6 months and later ranges from less than 1% [7, 17] to 4–9% [25, 26] (mainly pain of moderate intensity with only 2.1% of women complaining of severe pain [26]). Two studies have reported a very low incidence of CPSP after caesarean section, 1.8–3% at 6 months and 0.3–0.6% at 1 year [7, 17] but possible bias may exist. One study [7] only followed up at 6 months and later patients who reported pain at 2 months while it is now evident that CPSP may develop later after surgery [19]. The other study mostly included Brazilian women who underwent planned caesarean section at their own request [17]. By comparison, the incidence of CPSP after gynecologic surgery (i.e., hysterectomy for benign causes) decreases from 16–25% at 4 months post-surgery [27] to 8–10% at 1 year [26, 28] and to 7% at 2 years post-surgery [29]. The majority of theses studies report 4–6% moderate pain and only 1–2% severe pain [26, 28, 29].
12.3.1 Scar Pain and Neuropathic Pain Component in Chronic Pain After Caesarean Section
As scar pain predominates, being the major complaint in more than 83% of the women with CPSP after caesarean section [7, 17], some studies have focused on scar pain and/or have distinguisched scar pain from deep intra-abdominal and pelvic pain. The prevalence of scar pain remains constant over years and ranges from 4 to 5% with less than 2% severe pain [6, 10, 25]. Recent arguments are in favor of a predominant neuropathic origin as the presence of CPSP and the presence of sensory abnormalities in the area of surgery are commonly associated despite wide ranges for normal variability in sensory function [30]. A Pfannenstiel incision is commonly used for caesarean delivery; its advantages include a low incidence of incisional hernia and an aesthetic scar. However, the risk of ilio-inguinal and ilio-hypogastric nerve entrapment related to the technique is real. Among the 32% of women who had undergone obstetric or gynecologic procedures with a Pfannenstiel incision and suffered CPSP at incision site at 2 years after surgery (including 7% with severe pain), neuropathic descriptors were used by 50% of them, and pain was located at lateral ends of the incisional scar in 70% of the patients [29]. Few studies have used adequate screening tools to characterize scar pain after caesarean section. In one study, when pain quality was assessed using the Short-Form McGill Pain Questionnaire Revised (SF-MPQ2), chronic pain was qualified as predominantly neuropathic, respectively, in 56%, 50%, and 26% of the patients at 3, 6, and 12 months after surgery [17, 31]. In another study, the prospective epidemiologic French study “EDONIS” aimed to assess the prevalence and possible neuropathic character of postsurgical pain using the Douleur Neuropathic 4 (DN4) questionnaire, the 6-months cumulative incidence of CPSP after caesarean section was approximately 20% with an established neuropathic origin in 61% of the cases [32]. It is interesting to note that the reported pain intensity was generally low (pain score > 3/10 in only 2% of the patients). The low intensity of neuropathic pain diagnosed after caesarean delivery is intriguing. According to the EDONIS results [32] and findings from other studies [26], neuropathic characteristics are generally associated with severe CPSP (average pain score of 5–6 on a scale from 0 to 10) and functional impairement. By comparison, the prevalence of neuropathic characteristics in chronic pain after abdominal hysterectomy is less, around 33% [33, 34]. The variability in the incidence of the neuropathic origin of CPSP relates not only on the different modalities of assessment but also on the fact that chronic pain intensity and characteristics fluctuate considerably over time [30, 32].
12.3.2 Visceral Pain Component in Chronic Pain After Caesarean Section
Studies on sex-gender differences demonstrate that females have a higher incidence of severe pain, which is more anatomically diffuse and longer lasting pain than males [35] with the prevalence of visceral pain being more frequent. The abdomen (47%) and the perineal region (38%) are often mentioned as locations for CPSP by patients attending pain clinics [36]. In the classification of chronic pain for ICD-11, chronic visceral pain represents persistent or recurrent pain that originates from the internal organs including abdominal and pelvic cavities [18]. Pain is perceived in the somatic tissues of the body wall (skin, muscles), in the areas that receive the same sensory innervation as the internal organ at the origin of the symptom (referred to as visceral pain). By consequence, visceral pain related to caesarean section should be perceived as diffuse abdominal wall pain, not localized at the surgical scar, and in some cases felt as a deep intra-abdominal pain. Few studies about CPSP after delivery have assessed deep abdominal pain. Three prospective studies however report a very low incidence at 6 months and later because the incidence of CPSP itself was already very low [7, 10, 17]. Also, because of the low incidence of CPSP and thereby abdominal pain, it is difficult to determine if caesarean section carries a higher risk than vaginal delivery but it does not seem to be the case [10]. At 2 years after a planned caesarean section for breech delivery, intra-abdominal pain was mentioned by 5.4% of the women versus 4.3% of the women who had planned vaginal birth. By comparison, 15.3% of the women undergoing gynecological surgery for a non-painful condition will develop chronic intra-abdominal pain (prevalence around 3.6% in general female population) [37].
Among the various “chronic visceral pain conditions,” chronic pelvic pain (CPP) is a common problem in women of reproductive age with a prevalence rate of 15–25% [38]. The definition proposed by the American College of Obstetricians and Gynecologists includes noncyclic pelvic pain of at least 6 months duration that localizes to anatomical pelvis, anterior abdominal wall at or below umbilicus, lumbosacral back, or buttocks, sufficient to cause functional disability or to lead to medical care [39]. CPP is a multifactorial disease, difficult to treat. A retrospective case-control study including patients (mean age of 34 years; range 19–52 years) who underwent a laparoscopy for CPP found a significantly higher incidence of caesarean section history (67% of the cases) [40]. The risk factor associated with previous caesarean section was almost 4 times greater (OR 3.7; 95% CI: 1.7–7.7). Possible causes for CPP after caesarean section include adhesions, inflammation, and abnormal healing of bladder, round ligaments, and adjacent structures. Myofascial pain and neuroma may also be involved. While a relationship between caesarean section and CPP is easy to understand, CPP prevalence has been rarely assessed in most of the studies about CPSP after delivery. Furthermore, most of these studies did not exclude women with preexisting pelvic pain; hence, the true incidence of CPP, i.e., new onset of pelvic pain secondary to caesarean section was not evaluated. Two retrospective studies mention an incidence of 9% new onset CPP at 1 year after delivery [41, 42]. Both studies report an important impact on the daily quality of life, upon a wide range of sexual and nonsexual activities. The median duration of CPP was 24 months (IQR 6–51 months). A few prospective studies looking into physical health problems and pain after delivery mention an incidence of 5–7.6% CPP between 6 months and 2 years after delivery, with no difference regarding the mode of delivery [6, 10]. A recent longitudinal population study dedicated to assess the new onset of pelvic pain after delivery (N = 20,248) found a global incidence of 4.5% at 6 months and 1.7% at 18 months [43]. Both planned and emergency caesarean section was associated with a reduced risk of CPP (2.9% at 6 months and 1.3% at 18 months) by comparison with vaginal delivery. In patients with CPP, mean pelvic pain score was low, did not change over time and did not differ according to the mode of delivery. No information about the duration of pain was available. These results may support those of a recent retrospective study (N = 495) which also found a protective effect of caesarean section over spontaneous vaginal delivery regarding chronic pain at 2 years (odd ratio 0.13; 95% CI: 0.01–0.63) [22].
12.4 Caesarean Section as a Risk for Chronic Pain After Later Obstetric or Gynecologic Surgery
Although a history of caesarean delivery does not preclude further vaginal delivery, it is often a cause of resection. The initial publication related to CPSP after caesarean section [21] did not report previous caesarean section or previous abdominal surgery as a cause of CPSP, a finding supported by later publications, either retrospective ones [8] and prospective ones [25]. Nevertheless, the report from Loos [29] about the Pfannenstiel incision as a source of chronic pain (N = 866, including >90% caesarean sections) mentioned repeated surgeries as an independent risk factor (OR 2.92; 95% CI: 1.44–5.93) whereas the length of the scar was not. In this study, around 50% of the patients presented with characteristics of neuropathic pain in their chronic pain description and the presence of numbness also significantly predicted CPSP (OR 3.01; 95% CI: 2.05–4.4). Modifications of skin sensitivity surrounding the scar of a previous caesarean section was also reported by others [44] who found the presence of scar hyperalgesia in 41% of women scheduled for a repeat procedure at 55 ± 33 months after their first caesarean section. The presence of scar hyperalgesia was correlated with higher acute postoperative pain and with the presence of increased central sensitization processing assessed by mechanical temporal summation [44]. Thereby, it is not excluded that nerve lesion during repeat section might lead to CPSP in some patients with a predisposed background as demonstrated by Martinez and colleagues in a different surgical model [45].
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