International Journal of Obstetric Anesthesia (2021) 45, 56–60

0959-289X/$ - see front matter Ó 2020 Elsevier Ltd. All rights reserved.
https://doi.org/10.1016/j.ijoa.2020.11.003

ORIGINAL ARTICLE
www.obstetanesthesia.com

A prospective observational study to investigate the relationship

between local anesthetic infiltration pain before spinal
anesthesia and acute and chronic postsurgical pain in women
undergoing elective cesarean delivery
S. Nimmaanrat,a W. Wongwiwattananon,a S. Siripreukpong,a V. Chongsuvivatwong,b
M.P. Jensenc
a
Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
b
Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
c
Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA, USA

ABSTRACT
Background: Cesarean delivery is one of the most common procedures performed worldwide. We conducted this prospective
cohort study to evaluate the association between local anesthetic infiltration (LAI) pain prior to spinal anesthesia and pain and
morphine consumption within 24 h after cesarean delivery (primary outcomes). A secondary objective was to assess the association
between LAI pain and pain at one month postoperatively.
Methods: Recruitment of 216 eligible women scheduled for elective cesarean delivery. Local infiltration before spinal anesthesia
was performed using a 24-gauge needle and 3 mL 2% plain lidocaine. All subjects received 2.2 mL 0.5% hyperbaric bupivacaine
with 200 mg morphine for spinal anesthesia. A 0–10 verbal numerical rating scale was used to assess LAI pain severity, and sub-
sequent pain at 24 h, 1, 3 and 12 months.
Results: We found a moderate correlation between LAI pain intensity and severity of acute pain at rest (rho=0.56, P <0.001) and
with movement (rho=0.58, P <0.001) and a weak correlation with morphine consumption (rho=0.17, P=0.01) within 24 h post-
operatively. We also found a positive correlation between LAI pain and the severity of persistent wound pain at rest (rho=0.30,
P <0.001) and with movement (rho=0.52, P <0.001) at 1 month. The incidence of wound pain at 1, 3 and 12 months postoper-
atively was 37.1%, 7.0% and 1.4%, respectively.
Conclusions: Pain from LAI prior to spinal anesthesia is significantly associated with subsequent postoperative pain both acutely
and at one month in women scheduled for elective cesarean delivery under spinal anesthesia.
Ó 2020 Elsevier Ltd. All rights reserved.

Keywords: Acute postoperative pain; Cesarean delivery; Chronic postsurgical pain; Infiltration pain

Introduction movement-related postoperative pain, pre-operative

Cesarean delivery (CD) is a very common operation.1
Women undergoing CD have rated pain during and fol-
lowing surgery as their greatest concern.2 The acute pain
following CD has the potential to contribute to chronic
postsurgical pain3 of at least 3–6 months’ duration.4
Risk factors for CD-related chronic postsurgical pain
include severe postoperative pain at rest,5 greater
Accepted November 2020
Correspondence to: S. Nimmaanrat, Department of Anesthesiology,
Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla
90110, Thailand.
E-mail address: snimmaanrat@yahoo.com.au
depression, and longer surgical time.3
Factors predicting acute postoperative pain severity
after CD include the response to local anesthetic infiltra-
tion (LAI) and a tool using three questions to examine
anxiety, anticipated pain, and expected analgesic
requirement.6 Orbach-Zinger et al. found that pain
severity during LAI for spinal anesthesia was correlated
with pain intensity at rest and movement during the first
24 h after CD.7 Here we sought to replicate and extend
these findings. Our primary aim was to investigate the
association between LAI pain severity, measured by
the 0–10 verbal numerical rating scale (VNRS), and
acute postoperative pain severity and morphine
S. Nimmaanrat et al.
consumption within 24 h of CD. A secondary aim was
to estimate the incidence and severity of longer-term
wound pain and assess the association of LAI pain with
these outcomes. We hypothesized that the severity of
LAI pain would be positively associated with pain sever-
ity and morphine consumption within 24 h of CD, and
also with wound pain severity at 1, 3 and 12 months
postoperatively.
Methods
This prospective cohort study was approved by the
Ethics Committee of the Faculty of Medicine,
Prince of Songkla University, Thailand (REC Number
59-091-08-1) on 23 May 2016 and registered with
Thai Clinical Trials Registry on 6 June 2016
(TCTR20160606002). All participants provided written
informed consent. Study recruitment was from 22 June
2016 until 22 November 2018.
Inclusion criteria included being 18 years of age or
older, being scheduled for elective CD with Pfannenstiel
skin incision under spinal anesthesia, and having an
American Society of Anesthesiologists (ASA) classifica-
tion II-III. Exclusion criteria included inability to com-
municate easily, having contraindications for spinal
anesthesia, being scheduled for general anesthesia or
converting to general anesthesia, not receiving 200 mg
of intrathecal morphine, having analgesics administered
intra-operatively, sustained postpartum complications
or wound-associated adverse consequences, allergy to
morphine, paracetamol or ibuprofen, being in labor
before the operation, co-existing pain conditions, con-
comitant analgesics and psychopathology, including
anxiety and depression, requiring medical treatment.
Intensity of pain in the surgical wound during rest
and with movement was assessed using the VNRS.8
The VNRS was administered by a shift ward nurse to
measure pain intensity within 24 h of the CD, and via
telephone (by one of the authors, WW) at 1, 3 and
12 months postoperatively.
Each participant was told that, just before the LAI
was performed, the anesthesiologist would inject a local
anesthetic into her back while using neutral wording ‘‘I
am going to give you a local anesthetic in your back” to
minimize the chances for either a placebo or nocebo
effect.9 Then 3 mL 2% plain lidocaine was administered
via a 24-gauge needle at either the L3-L4 or L4-L5 inter-
space. Immediately after withdrawal of the needle, the
participant was asked to rate the pain caused by the
LAI. Spinal anesthesia was then achieved using 2.2 mL
0.5% hyperbaric bupivacaine plus 200 mg morphine.
Following the CD, all participants received the standard
postoperative pain protocol consisting of oral paraceta-
mol 500 mg every 6 h and ibuprofen 400 mg three times
per day for three days. The oral analgesics were initiated
when liquid diet was allowed. Two to 5 mg of intra-
57
venous morphine was allowed every 2 h, as needed, for
breakthrough pain.
The sample size was calculated to detect as significant
a correlation coefficient of 0.20 between LAI pain and
acute postoperative pain, assuming an alpha of 0.05
and power of 0.80. Given these assumptions, 194 partic-
ipants were required. Assuming a 10% dropout rate, we
sought to enrol a total of 215 participants. We used
Spearman’s rank to test the hypothesis that LAI-
related pain would correlate with wound pain and mor-
phine consumption during the first 24 h after the CD,
and with wound pain at 1, 3 and 12 months after the
CD. The presence (VNRS  1) or absence of pain
(VNRS=0) at each of the follow-up assessment points
was also recorded. All analyses were performed using
Program R version 3.1.1 (Vienna, Austria).
Results
Participant flow is presented in Fig. 1. Of 237 patients
screened for eligibility, 235 were deemed eligible. Of
these, 19 ultimately became ineligible, leaving 216 indi-
viduals who provided a VNRS rating at the 24 h assess-
ment point. At 1, 3 and 12 months following the CD, we
were able to contact 213, 213 and 207 participants
respectively, via telephone, to obtain their pain ratings.
Table 1 presents the demographic data for the study
sample. Local anesthetic infiltration pain was signifi-
cantly correlated with pain at rest (rho=0.555,
P <0.001) and with pain on movement (rho=0.576,
P <0.001) during the 24-h recovery period (Fig. 2). In
addition, LAI pain was significantly associated with
morphine consumption within 24 h of CD (rho=0.17,
P=0.01). The median morphine consumption was
3 mg, with a range of 0–30 mg.
Seventy-nine out of 213 (37.1%), 15/213 (7.0%) and
3/207 (1.4%) participants reported wound pain at 1, 3
and 12 months postoperatively. Fig. 3 shows the inci-
dence of wound pain at all three follow-up times.
Because the number of patients with pain at 3 and
12 months was very small, the correlation coefficients
between LAI pain and pain at rest and with movement
were only calculated for the one-month follow-up
assessment, and these were statistically significant.
Discussion
This study found positive correlations between LAI pain
assessed prior to spinal anesthesia and the severity of
acute postoperative pain and morphine consumption
within 24 h of CD. There was also a significant correla-
tion between LAI pain and the presence and severity of
wound pain one month later.
The findings of a moderate association between LAI
pain severity and pain intensity at rest and with
movement during the 24-h recovery period are consis-
58 Local anesthetic infiltration pain and post-surgical pain

Fig. 1 CONSORT flow diagram of participants enrolled in the study

Our study also revealed a statistically significant but

Table 1 Demographic data of the study population
weak association between LAI pain and morphine con-
Characteristics n=216 sumption within the first 24 h postoperatively. Orbach-
Age (years) 32.3 ± 5 Zinger et al. found a significant association between
Body weight (kg) 69 (62.8, 79) LAI pain and post-cesarean delivery use of rescue anal-
Height (cm) 157 (153.8, 161) gesics. However, the participants in their study did not
BMI (kg/m2) 28 (25.5, 31.2) receive regular multimodal analgesia plus opioids for
ASA classification (n,%) breakthrough pain, and the investigators only assessed
II 196 (90.7)
the number of requests for three different oral analgesics
III 20 (9.3)
rather than measuring overall medication dosing.7 Our
Gravida (n,%)
1 24 (11.1) findings showed a positive association between LAI pain
2 113 (52.3) and the amount of analgesic requested in the first 24 h
3 53 (24.5) postoperatively in a sample of patients who received the
4 26 (12.1) institution’s standard postoperative pain relief protocol.
Previous CD (n,%) The incidence of persistent pain at 6–8 weeks after
Yes 176 (81.5) CD has been shown to vary from 10% to 42%.10–12 At
No 40 (18.5) 3, 6 and 12 months, the incidence of ongoing pain after
Health insurance scheme (n,%) CD is reported to be from 2% to 40%,3,5,13,14 4% to
UHC 43 (19.9) 27%3,5,12,14 and 0% to 22%,3,5,11,12,14–16 respectively. At
SSS 7 (3.2)
12 months, we found a very low incidence of chronic
CSMS 72 (33.3)
postsurgical pain which is similar to other studies.14,17
Out-of-pocket 91 (42.1)
Others 3 (1.4) A limitation of this study is that it was restricted to
women undergoing elective CD. Thus, the extent to
Data are presented as mean ± standard deviation (SD) or median
(interquartile range, IQR). VNRS: verbal numerical rating scale. BMI:
which the correlation of LAI pain with response in
body mass index. ASA: American Society of Anesthesiologists. CD: women undergoing intrapartum or emergency CD is
cesarean delivery. UHC: Universal Health Coverage. SSS: Social unknown. Additional research is needed to determine
Security Scheme. CSMS: Civil Service Medical Benefit Scheme. if LAI pain might also be a reliable indicator of acute
postoperative pain and chronic postsurgical pain in
response to intrapartum or unscheduled CD. On the
tent with those of Orbach-Zinger et al., who demon- other hand, to our knowledge, this is the first study that
strated that severe pain during LAI for spinal anesthesia evaluated the associations between LAI pain with the
is correlated with pain at rest and with movement in the presence and severity of pain one month after CD. By
first 24 h after CD (average rest pain rho=0.53, P identifying subjects at risk for pain that may become
<0.001; average movement pain rho=0.48, P persistent, it may be possible to provide more effective
<0.0001).7 Our results replicate these findings and sup- analgesia in both the short- and long-term following
port their reliability. CD. Finally, research to evaluate the potential benefit
S. Nimmaanrat et al. 59

Fig. 2 The correlation between local anesthetic infiltration pain intensity and pain at rest (A) or pain with movement (B) at 24 h
after cesarean delivery

Fig. 3 The incidence of wound pain at 1, 3 and 12 months after cesarean delivery, according to local anesthetic infiltration pain
intensity. NNN: no pain at 1, 3 and 12 months. YNN: pain present at 1 month, no pain at 3 and 12 months. YYN: pain present at
1 and 3 months, no pain at 12 months. YYY: pain present at 1, 3 and 12 months

of a personalized pain relief strategy, based on LAI Funding

pain, is warranted.
In conclusion, LAI pain is significantly correlated
with acute pain and pain at one month following elective
CD. Local anesthetic infiltration pain can be used as an
indicator of women who are at risk of requesting more
analgesia and experiencing more severe pain in the early
postoperative period.
Acknowledgements
The authors thank Maliwan Oofuvong, MD, PhD and
Jirawan Jayuphan for their assistance in statistical
analysis.
This work was solely supported by the Faculty of Med-
icine, Prince of Songkla University, Hatyai, Songkhla
90110, Thailand.
Declaration of interests
The authors declare no competing interests.
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