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Am Fam Physician. 2005;71(4):802

Pain management has been established as one of the benchmarks of quality health care. Quality hospital care now must include the assessment of pain relief. In addition, the patient’s perception of pain control has been established as a marker of quality. Pain is to be labeled the “fifth vital sign” in hospitals. In response to new requirements from the Joint Commission on Accreditation of Health Care Organizations, the authors’ hospital formed a quality improvement pain management committee. Yost and associates assessed pain management strategies after cesarean deliveries.

The study included patients at a large urban hospital who had cesarean deliveries. The patients were assigned to one of four pain management strategies that included (1) intramuscular meperidine, (2) patient-controlled analgesia (PCA) with intravenous meperidine, (3) intramuscular morphine sulfate, and (4) PCA morphine sulfate. Post-partum complications were recorded during the study.

Before discharge, a postpartum survey was administered to each patient by trained personnel. The survey was based on a national questionnaire that assessed patient satisfaction. In addition, patients were asked to complete a Visual Analog Scale (VAS) every four hours during the first 24 hours in the postpartum unit. The VAS is a 10-cm visual pain scale, with zero representing no pain and 10 representing the worse pain possible.

There were 1,256 women who participated in the study. In comparing the median dose of meperidine, those who received it via PCA received a significantly higher dose than those who received it intramuscularly. The opposite was true with morphine sulfate. Patients who received meperidine via PCA had significantly fewer times when they rated their pain as moderate or worse (4 cm or greater on the VAS) when compared with patients who received intramuscular meperidine. The two groups who received morphine had significantly fewer times when they rated their pain as moderate or worse when compared with the meperidine group, regardless of route. Subjective responses to pain management were no different among the four groups. Women who received morphine for pain control were more likely to continue breastfeeding and more likely to allow rooming-in of their infants when compared with the meperidine groups. There were no significant differences in postpartum complications between the four pain management strategies.

The authors conclude that pain management with morphine sulfate is superior to management with meperidine in women who have undergone cesarean delivery. They state that, in addition to better pain control, the morphine pain-control group also had a more positive outcome when comparing breastfeeding and infant rooming-in. The authors add that the improvement in pain control in two of the groups did not significantly improve those patients’ satisfaction with pain management strategies.

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