Management of Persistent Pain After Cesarean Section

Persistent postoperative pain after a cesarean section occurs frequently and impairs maternal quality of life. A multimodal  analgesic approach in the pre-, intra- and postoperative phases offers an effective strategy to reduce this burden. 

Persistent pain after cesarean section: 
an underrecognized complication  

Cesarean section is the most frequently performed surgical procedure worldwide — and it is also among the most painful.¹ More than half of women (53.9 %) undergoing the procedure reported severe pain, and the majority (82.2 %) reported at least moderate pain, with direct consequences for mood, mobility, sleep, and breathing.² It may further delay recovery and impair mother-child bonding and breastfeeding.³ Inadequate postoperative pain relief may lead to hyperalgesia and persistent postoperative pain.^{3, 4}

For a substantial number of mothers, the pain does not end with discharge. Chronic post-surgical pain (CPSP) — defined as pain continuing beyond three months after surgery — affects approximately 16.7 % of women at three to six months following a cesarean delivery, with around 9 % still experiencing pain at twelve months and beyond⁵ - a persistent issue that remains largely under-recognized.

Risk factors for CPSP arise across the full perioperative period,⁶ but severe acute postoperative pain is the most important modifiable one, with affected women carrying almost three times the risk of progression to chronic pain compared to those with well-controlled pain.^4,7 Effective pain management is therefore not merely a comfort measure — it is a preventive intervention.

Consequences of persistent pain: 
beyond the surgical scar

For a mother recovering from a cesarean section, persistent pain shapes every aspect of the postpartum period — the ability to move, to sleep, to work, and most importantly, to care for a newborn. The negative impact on quality of life is greatest when neuropathic symptoms are present.⁴ Chronic pelvic pain occurs in more than 40% of women with CPSP, with implications for intimate relationships and long-term wellbeing that can persist for years postpartum.⁴ 

Many women with CPSP after a cesarean section receive no analgesic treatment at all — often due to concerns about medication safety during breastfeeding.^{2, 4} Yet undertreated acute pain carries consequences beyond persistent pain alone: severe acute postoperative pain is independently associated with an increased risk of postpartum depression (PPD), and hyperalgesia triggered by uncontrolled pain may amplify this risk.^{8, 9, 10} The risk factor profile for both CPSP and PPD substantially overlaps — preoperative anxiety, depression, and a heightened psychological response to pain all increase the risk of chronification, creating a cycle that adequate perioperative pain management can interrupt.^{3, 5, 7}

Multimodal pain relief:
A structured approach to prevention

Preventing acute pain from becoming persistent requires addressing all phases of care — before, during, and after the surgery. The 2026 PROSPECT guidelines for an elective cesarean section provide an evidence-based framework for achieving this, recommending a combination of analgesic techniques to manage pain safely and effectively.³

Neuraxial analgesia — including spinal, epidural, and combined spinal-epidural (CSE) techniques — is the foundation of pain management in cesarean section, offering reliable and effective pain control that can be adapted to the clinical situation and the needs of the patient.³ Where appropriate, adding an intrathecal opioid extends postoperative pain relief within this framework.

When long acting neuraxial opioids are not used, fascial plane and abdominal wall blocks are effective alternatives.³ Where regional techniques are not available, wound infiltration with local anesthetic is a practical option. Alongside these techniques, scheduled systemic non-opioid analgesia supports pain control, reducing pain intensity and the need for opioids,³ reducing opioid-related side effects.

The message is clear: a single technique is not sufficient. It is the combination — neuraxial analgesia, regional blocks where indicated and scheduled non-opioid analgesia — that best protects against both acute pain and its progression to chronic pain. Making this approach standard practice means better outcomes for mothers and their newborns.