Post C-Section Pain and Initiation of Breastfeeding: Changing Practice through Process
- Identify the relationship of post C-Section pain, analgesic modalities, and breastfeeding initiation.
- Apply the evidence based practice process in resolving the clinical problem of post-C-Section pain and delayed breastfeeding initiation.
- Critique the associated outcomes of practice change.
- Identify the relationship of post C-Section pain, analgesic modalities, and breastfeeding initiation.
- Apply the evidence based practice process in resolving the clinical problem of post-C-Section pain and delayed breastfeeding initiation.
Design: retrospective descriptive comparative correlational design
Patients/Participants: All singleton C-Section deliveries during 2007 at community based hospital in Northeast U.S. Final sample = 621.
Methods: After IRB approval, an interdisciplinary team of RNs, lactation consultants, and physicians conducted a retrospective electronic chart review. Descriptive and inferential statistics were performed. Chi-square correlation was conducted to identify the relationship of post C-section pain, analgesic modality, and breastfeeding initiation; and logistic regression was conducted to identify significant predictors of breastfeeding success in the first 24 hours post C-Section.
Implementation Strategies: Interdisciplinary research team meetings were conducted; interrater reliability for chart review was performed demonstrating acceptable reliability (K > .85).
Results:
The final sample of 621 singleton C-Section deliveries consisted of primarily term, multigravid women having a primary C-Section. Overall, nearly 60% (n = 370) had documented maternal and/or fetal complications, with the most common maternal complication being arrest of labor (32.7%) and the most common fetal complication being non-reassuring fetal heart tracing (19.3%). The average birth weight in grams was 3434.2 grams with average APGAR scores at one and five minutes showing appropriate adjustment to extra-uterine life. More than one-half the total sample breastfed, with an average time of 4.2 hours to initiation of breastfeeding.
The majority of patients (87.1%) had PCEA for post C-Section pain management. Women with PCEA had significantly less moderate to severe pain in the first 24 hours compared to women with PCA (14% vs. 28.6% respectively, x2 = 8.1, p= .004). Women with PCEA required significantly less analgesic adjuvant doses (3.4 vs 4.4, t = -2.01 (689), p = .038) during the first 24 hours postpartum. Severity of pain was significantly correlated with frequency of breastfeeding sessions. Women with higher pain scores had fewer breastfeeding sessions (r = -.128, p = .023). There were no statistically significant differences for time to initial breastfeeding for PCEA vs PCA. Method of post C-Section analgesia was a significant predictor of adequacy of pain management within the first 24 hours postpartum (aOR = 2.2; 95% CI = 1.1, 4.5; p = .03). Additionally, maternal pain (mild pain aOR = 2.5; 95% CI = 1.1, 5.4; p = .024), breastfeeding within 2 hours of birth (aOR = 5.3; 95% CI = 2.9, 9.8; p = .000) and having a term infant (aOR = 3.9; 95% CI = 1.7, 9; p = .001) were significant predictors of successful breastfeeding within 24 hours postpartum.
Conclusion/Implications for nursing practice:
Findings from this study indicated that the best modality for pain relief post cesarean section was PCEA. Over ¼ of women with PCA analgesia report moderate to severe pain in the first 24 hours post-op, even with significantly greater analgesic adjuvant dosing. Additionally, women with poorer pain management are less likely to breastfeed six or more times within the first 24 hours. This potentially could impact duration of breastfeeding and breastfeeding success. Results were presented to key stake holders with recommendations for practice changes in anesthesia (all appropriate patients will receive PCEA), and nursing (to develop an innovative strategy to decrease the time for first breastfeeding to 120 minutes). Nursing staff received the conclusions and implications for practice changes. A formal re-education program on the standards regarding timeliness of 1st breastfeeding event was conducted and staff resources were allocated at the time of the C/S delivery to assist with initiation of breastfeeding in PACU. Lactation Consultants audit concurrently to monitor compliance with standards. Findings on adherence to standards will be presented.
Keywords: c-section, breastfeeding initiation, pain management, PCEA, PCA
