Chronic pain after cesarean delivery: what do we know today? A narrative review

Childbirth is a major event in life, associated with both physical and psychological changes which may affect women's quality of life. Cesarean delivery (CD) is among the most frequent surgical procedures performed worldwide. Because of the high CD volume and patients' vulnerability (young age and female sex), for chronic postsurgical pain (CPSP), the societal impact of chronic pain after CD requires attention. According to the literature, the incidence of CPSP after CD is highly variable but reasonable evidence suggests a low incidence at six months (3-4%) and later (0.6-0.8%). The recent definition of CPSP in the ICD-11 coding system may not necessarily apply to the specific context of childbirth and CPSP after CD, suggesting that some modifications could be implemented. Interestingly, the incidence of chronic pain after CD is lower than that observed after gynecologic procedures performed in the similar body area. Consequently, since the risk factors do not really differ from those reported for other procedures, the existence of protective factors related to hormonal modulations secondary to pregnancy and lactation have been suggested. Such observations, in preclinical models, also question the pathophysiology of chronic pain after childbirth. Because severe acute postpartum pain is a striking risk factor of CPSP after CD, the preventive effect of different analgesic treatments, mainly regional analgesia techniques, has been evaluated but the results remain disappointing. In conclusion, many questions remain regarding the incidence, pathophysiology and potential prevention of CPSP after CD, and these questions warrant further research.