Nurse practitioner led pain management the day after caesarean section: A randomised controlled trial and follow-up study

Abstract

BackgroundPain on the day after caesarean section is often treated with controlled-release oxycodone to supplement the decline in analgesia from intrathecal opioids. Evidence suggests that caesarean birth is a biopsychosocial experience where a comprehensive approach is needed that promotes control and participation in pain management. ObjectivesThis study compared immediate-release oxycodone integrated with supportive educational strategies to controlled-release oxycodone. A follow-up phase aimed to explore pain over three months. DesignThis study was a two-group parallel randomised controlled trial. SettingA metropolitan hospital in Australia with a birthing suite, operating rooms, and a postnatal unit. ParticipantsEnglish-speaking women scheduled for elective caesarean section were mailed trial information. Exclusion criteria included contraindications to intrathecal analgesia, herpes simplex infection, a history of chronic pain, opioid tolerance, or substance abuse. A total of 131 participants were recruited and randomised out of 298 eligible participants. MethodsGroup allocation was undertaken using sequentially numbered opaque sealed envelopes. The nurse practitioner intervention commenced on the day after surgery with immediate-release oxycodone alongside supportive strategies. The control group received scheduled doses of controlled-release oxycodone. All participants could request additional oxycodone or tramadol. Primary outcomes were pain intensity and secondary outcomes included patient global impression of change, pain interference, opioid consumption, and maternal perception of control. A follow-up phase evaluated pain outcomes over three months. ResultsThe final sample size was 122, with 61 participants in each group. Pain intensity scores were analysed by linear mixed regression models. There were no statistical differences over 24h between the control and intervention groups at rest (p=0.40, 95% CI – 4.8mm, 11.9mm) or on sitting or moving (p=0.561, 95% CI –15.2mm, 8.3mm). Patient global impression of change was significant over three hours (p=0.014, OR=2.5, 95% CI 1.2, 5.3). The intervention group reported less pain interference while consuming less oxycodone (p<0.05). There was no difference between groups in terms of perceived control over pain management (p=0.273, 95% CI –16.2mm, 4.6mm). The follow-up analysis graded 5.9% of participants as experiencing severe pain interference. Chronic pain following caesarean was associated with postnatal depression (p<0.001). ConclusionsThe research showed that a nurse practitioner intervention can improve pain management following caesarean section. The results underscore the influence of biological, psychological, and social factors on acute pain. Hence, this study reinforces the need for a biopsychosocial approach to acute pain management following caesarean delivery.