What management approach is recommended for a postpartum female patient with persistent pain following a cesarean section (C-section) with epidural anesthesia, severe enough to prevent lifting weights?

Management of Persistent Post-Cesarean Pain with Functional Impairment

This patient requires immediate escalation of multimodal analgesia with scheduled paracetamol and NSAIDs as foundational therapy, plus consideration of nerve injury evaluation given the severity of functional impairment. 1, 2

Immediate Pain Management Algorithm

First-Line Pharmacological Intervention

• Initiate scheduled (not PRN) paracetamol and NSAIDs immediately as basic analgesics, which form the cornerstone of post-cesarean pain management regardless of whether neuraxial opioids were used initially 1, 3
• Add gabapentin or pregabalin for neuropathic pain characteristics, particularly if the pain is burning, lancinating, or specifically exacerbated by movement—these features suggest nerve injury 1, 2
• Minimize opioid use while implementing individualized prescribing practices, as opioids should not be the primary strategy, especially given breastfeeding considerations 1, 2

Regional Analgesia Considerations

• Consider diagnostic and therapeutic ilioinguinal-iliohypogastric nerve blocks if pain is localized to the groin, inner thigh, or labia, as these nerves can be entrapped during fascial closure 2
• Implement continuous wound local anesthetic infusion or fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) if not already done and if neuraxial opioids were not administered 1, 3

Critical Diagnostic Evaluation

Rule Out Complications

• Never dismiss persistent pain as "normal" post-cesarean discomfort—this severity warrants investigation for specific pathology 2
• Document pain characteristics systematically: constant vs. intermittent, relationship to menstrual cycle, quality (sharp, burning, aching), radiation pattern, and specific aggravating factors 2
• Palpate the incision for focal tenderness, induration, or fluctuance to assess for deep tissue infection or abscess, which can present without systemic signs initially 2
• Obtain ultrasound evaluation if pain persists beyond 6 weeks or worsens to assess for cesarean scar defect (niche), hematoma, or endometrioma 2

Nerve Injury Assessment

• Suspect ilioinguinal-iliohypogastric nerve entrapment when pain is burning, lancinating, or specifically exacerbated by standing/movement and radiates to groin, inner thigh, or labia 2
• Use diagnostic nerve blocks to confirm nerve entrapment when suspected—these serve both diagnostic and therapeutic purposes 2

Non-Pharmacological Adjuncts

• Apply transcutaneous electrical nerve stimulation (TENS) as an analgesic adjunct, particularly useful for fascial adhesions and neuropathic pain 1, 2, 3
• Use abdominal binders for additional pain control and support 1, 3

Common Pitfalls to Avoid

• Do not rely on PRN analgesics alone—scheduled administration of paracetamol and NSAIDs is essential for adequate pain control 1
• Do not assume adequate analgesia was achieved initially—pain after cesarean section is often under-treated due to unfounded fears about maternal and neonatal side effects 1
• Do not delay evaluation for nerve injury—inability to lift weight suggests significant functional impairment that may represent nerve entrapment requiring specific intervention 2
• Avoid excessive opioid prescribing—develop stratified post-discharge opioid prescribing practices rather than defaulting to opioids for breakthrough pain 1

Expected Timeline and Follow-Up

• Pain intensity typically peaks in the first week and gradually improves over 6-12 weeks 2
• Chronic wound pain affects 15.4% at 3-6 months, decreasing to 11.5% at 6-11 months 2
• Escalate care if pain does not improve within 2 weeks of optimized multimodal therapy or if functional impairment persists 2