New Guidance on Managing Postpartum Pain

Megan Brooks

May 21, 2018

Women experience pain in different ways in the early postpartum period, and pain management should be considered on a case-by-case basis, a new Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG) advises.

"There is individual variation in pain experience, as well as differences in how women metabolize medication," Yasser El-Sayed, MD, vice chair of ACOG's Committee on Obstetric Practice, said in a news release. "Knowing that pain can interfere with a woman's ability to care for herself and her infant, it's important that ob-gyns talk with their patients about the level of pain they're experiencing and create a tailored plan that works for them," said El-Sayed.

"It is also critical to counsel the mother on the side effects of any drug prescribed, particularly if the mother is breastfeeding," he added.

Stepwise Approach Best

In addition to nonpharmacologic approaches to manage postpartum pain, ACOG recommends a stepwise approach to drug therapy, starting with nonopioid agents, such as acetaminophen or nonsteriodal anti-inflammatory drugs (NSAIDs).  If needed, a milder opioid can be added, with stronger opioids added only in women who do not achieve adequate pain control, they advise.

This tiered approach helps manage pain by matching drug effectiveness to pain severity and relies heavily on shared decision-making between provider and patient. This approach can also optimize pain control while reducing the number of unused opioid tablets, ACOG says.

If a codeine-containing medication is used for postpartum pain, the risks and benefits should be reviewed with the family and the family should be educated regarding newborn signs of toxicity, ACOG advises.

"Regardless of the medication selected, it is prudent to counsel women who are prescribed opioid analgesics about the risk of central nervous system depression in the woman and the breastfed infant. Duration of use of opiate prescriptions should be limited to the shortest reasonable course expected for treating acute pain," ACOG recommends.

ACOG also recommends that obstetricians and gynecologists be familiar with prescription drug monitoring programs and be aware that standard order sets may provide more pills than a woman with postpartum pain needs.

New mothers with an opioid use disorder who have chronic pain, or those who are using other medications or substances that may increase sedation, need additional support in managing pain, they point out.

El-Sayed noted that with increased awareness around opioid use disorder, "it is understandable that there is a desire to evaluate discharge medications. However, this should not interfere with appropriate pain management. Providers can ensure that women can get the appropriate relief they need so that they are better able to care for themselves and their infants while also prescribing responsibly," he said.

The ACOG Committee Opinion 742, "Postpartum Pain Management," was released May 17 and appears in the July issue of Obstetrics & Gynaecology.

Obstet Gynecol. 2018;132:e1-e7. Abstract

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