Comparison between Placing Surgical Sponges on both Sides of Uterus and Reverse Trendelenburg Position of 30 Degree to Reduce the Incidence of Shoulder Pain after Cesarean Section with Spinal Anesthesia

Document Type : Original Article


1 Assistant Professor, Department of Obstetrics and Gynecology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.

2 Assistant Professor, Department of Anesthesiology, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.

3 Lecturer, Department of Biostatistics, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.

4 Assistant Professor, Department of Internal Medicine, School of Medicine, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.


Introduction: Shoulder pain is one of the most common complaints after cesarean section that sometimes may be serious and cause malfunction of mothers in breastfeeding and neonatal care. As one of the causes of shoulder pain is referred pain caused by diaphragm irritation due to existence of blood and amniotic fluid in the peritoneal cavity after surgery, we decided to investigate the comparison between placing surgical sponges on both sides of uterus and reverse trendelenburg position of 30 degree to reduce the incidence of shoulder pain after cesarean section with spinal anesthesia.
Methods: This three blind clinical trial was conducted on 201 women undergoing cesarean section in Niknafas hospital of Rafsanjan, Iran in 2011. Women were randomly divided into three groups. Surgeries were performed by two surgeons equally in each group. In group A, spinal anesthesia was performed and 2 surgical sponges with a radio opaque line impregnated with normal saline were placed on both sides of uterus and operation continued in supine position with no angle with horizon line. In group B, patients were operated in reverse trendelenburg position of 30 degree to horizon line without placing surgical sponges. In group C, cesarean was performed without any surgical sponges and in supine position. Severity of shoulder pain was assessed 24 hours after surgery in right, left or both shoulders in all patients. Data were analyzed using SPSS software (version 18) and one way ANOVA, chi-square, Post-hoc tests and t-test. P value less than 0.05 was considered significant.
Results: Mean of pain severity had no significant differences between the three sites of pain (p=0.728). No significant differences were observed in pain severity between the three groups (p=0.111) and between the operations were performed by the two surgeons (p=0.430).
Conclusion: According to no statistically significant difference between groups in pain severity, there might be another agent exclusive of blood and amniotic fluid that irritates diaphragm and cause shoulder pain.


  1. Dobbs FF, Kumar V, Alexander JI, Hull MG. Pain after laparoscopy related to posture and ring versus clip sterilization. Br J Obstet Gynaecol 1987 Mar;94(3):262-6.
  2. Joris J, Cigarini I, Legrand M, Jacquet N, De Groote D, Franchimont P, et al. Metabolic and respiratory changes after cholecystectomy performed via laparotomy or laparoscopy.Br J Anaesth1992 Oct;69(4):341-5.
  3. Alexander JI, Hull MG. Abdominal pain after laparoscopy: the value of a gas drain. Br J Obstet Gynaecol1978 Mar;94(3):267-9.
  4. Moore KL, Dalley AF, Agur AM. Clinically oriented anatomy. 6 th ed. Philadelphia:Lippincott Williams and Wilkins ;2010:472-3.
  5. Sabiston DC, Lyerly HK. Textbook of surgery: the biological basis of modern surgical practice. 15th ed. Philadelphia:W.B. Saunders;1997:389.
  6. Mille RD. Transfusion therapy. In: Miller RD. Anesthesia. 5th ed. Philadelphia:Churchill Livingstone;2000:1613-1662.
  7. Collins KM, Docherty PW, Plantevin OM. Postoperative morbidity following gynaecological outpatient laparoscopy. A reappraisal of the service.Anaesthesia 1984 Aug;39(8): 819-22.
  8. Edwards ND, Barclay K, Catling SJ, Martin DG, Morgan RH. Day case laparoscopy: a survey of postoperative pain and an assessment of the value of diclofenac. Anaesthesia 1991 Dec;46(12):1077-80.
  9. Joris J, Thirty E, Paris P, Weerts J, Lamy M. Pain after laparascopic cholecystectomy: charactristics and effect of intra peritoneal bupivacaine. Anesth Analg 1995;81(2):379-84.
  10. Zirak N, Soltani Gh, Pakravan Sh, Taherzadeh M, Mashayekhi Z.[Evaluation of the prevalence of shoulder pain after cesarean with general anesthesia] [Article in Persian]. Iran J Obstet Gynecol Infert 2010;14(3):8-12.