What is the best management approach for a 38-year-old obese post-cesarean section (post-LSCS) patient on day 2 with a history of cough, occasional sputum production, and severe abdominal pain on coughing, without desaturation, tachypnoea, or tachycardia?

Management of Post-Cesarean Cough with Severe Abdominal Pain

This patient requires aggressive multimodal analgesia optimization with scheduled NSAIDs and acetaminophen, incentive spirometry with splinting techniques, and close monitoring for wound complications—the severe pain on coughing is primarily musculoskeletal from the surgical incision and requires better pain control rather than respiratory intervention given the absence of desaturation, tachypnea, or tachycardia. 1

Immediate Pain Management Optimization

The priority is addressing inadequate analgesia, which is common and often undertreated in post-cesarean patients 1:

• Ensure scheduled (not PRN) NSAIDs and acetaminophen as basic analgesics, as these are the foundation of multimodal analgesia after cesarean section 1, 2
• Reassess opioid dosing if already prescribed, though minimize opioid use when possible through multimodal approaches 1, 2
• Consider additional regional analgesia such as transversus abdominis plane (TAP) block or quadratus lumborum block if pain remains uncontrolled, as these provide effective opioid-sparing analgesia 1, 3

The severe pain on coughing is expected post-cesarean but indicates suboptimal pain control, which delays recovery and impairs maternal-infant bonding 1, 4

Respiratory Support and Cough Management

Despite stable vital signs, this obese patient requires proactive pulmonary care 1:

• Teach and enforce splinting technique: Have patient hold a pillow firmly against the incision when coughing to reduce pain and enable effective cough 1
• Incentive spirometry: Regular use (every 1-2 hours while awake) to prevent atelectasis, which is increased risk in obese post-surgical patients 1
• Early aggressive mobilization: Critical for obese patients to prevent pulmonary complications and VTE 1

The pre-existing cough with occasional sputum suggests either upper airway cough syndrome or post-infectious cough 1, 5:

• First-generation antihistamine/decongestant combination for presumed upper airway cough syndrome if cough preceded surgery 1, 5
• Inhaled ipratropium can be considered if cough is post-infectious in nature 1
• Avoid central antitussives (codeine, dextromethorphan) initially as they suppress necessary cough clearance and add opioid burden 1

Obesity-Specific Considerations

This patient's obesity significantly increases her risk profile 1, 6:

• Enhanced VTE prophylaxis: Ensure weight-adjusted thromboprophylaxis dosing, as obesity and post-cesarean state are both major VTE risk factors 1, 6
• Wound surveillance: Obese patients have significantly increased risk of wound infection and dehiscence; examine incision daily for signs of infection or separation 1, 6
• Adequate staffing for mobilization: Multiple staff members may be needed to safely mobilize this patient 1

Red Flags Requiring Escalation

Monitor closely for complications that would change management:

• Wound dehiscence: Severe pain on coughing could indicate fascial separation; examine incision for gaps, drainage, or bulging 6
• Pulmonary embolism: Though currently stable, maintain high suspicion given obesity and post-surgical state; escalate if tachycardia, tachypnea, or desaturation develop 1
• Pneumonia: If fever, productive purulent sputum, or respiratory compromise develops, obtain chest radiograph 7
• Atelectasis: Common in obese post-surgical patients; if oxygen saturation declines, consider chest imaging 1

Common Pitfalls to Avoid

• Don't undertreat pain due to unfounded fears about analgesics in postpartum period—inadequate analgesia leads to worse outcomes including chronic pain 1, 4
• Don't rely on PRN medications alone—scheduled multimodal analgesia is essential for post-cesarean pain 1, 2
• Don't delay mobilization—early ambulation is critical in obese patients to prevent VTE and pulmonary complications 1
• Don't ignore the pre-existing cough—treat the underlying cause while managing surgical pain 1, 5