New Guidance on Pregnancy Pain Relief

Peter Russell

December 13, 2018

Appropriate management of pain during and after pregnancy is essential to minimise the risk of adverse outcomes to mother and baby, but the type and timing of pain relief is important, a new review said.

A team of leading doctors carried out the review for the Royal College of Obstetricians and Gynaecologists (RCOG) following concerns over the use of codeine during breastfeeding.

The scientific impact paper, Antenatal and Postnatal Analgesia , supported the use of appropriate pain relief options, as advised by NHS guidance.

Avoiding Foetal Harm

It recommended that, where possible, all drugs should be avoided during the first trimester because the embryo is most vulnerable to teratogenic effects between 4 to 10 weeks gestation. However, it acknowledged that some would need to be continued to prevent maternal harm.

It found that paracetamol "remains the analgesic of choice" in pregnant and breastfeeding women because of its excellent safety record, although it noted limited associations between the use of paracetamol and adverse outcomes including an increased incidence of childhood asthma, behavioural problems, and a delay in gross motor and communication development in children with long‐term antenatal exposure.


The review said that nonsteroidal anti-inflammatory drugs (NSAIDS) – such as ibuprofen – should be avoided unless clinically indicated, such as for a severe migraine, within the first trimester and should not be taken after 30 weeks of gestation due to increased risk to the baby. 

The reviewing doctors recommended the lowest effective dose for the shortest time because of some evidence that the use of NSAIDS might increase the risk of first-trimester miscarriage.

However, NSAIDS were safe to use during breastfeeding, they said, as the quantity of drug that passed into milk was very small.


The guidelines said that opioid analgesics, such as codeine, tramadol, dihydrocodeine (DHC), and morphine should be avoided wherever possible and only administered by a health professional.

However, it highlighted the important difference between codeine and DHC during breastfeeding and emphasised that DHC was safer to take during breastfeeding, whereas codeine should be avoided, because of increased concerns regarding toxicity. 

Dr Dina Bisson, a consultant obstetrician who led the review, said: "It is absolutely essential that pain is managed appropriately during pregnancy and breastfeeding. Many women may develop headaches, lower back pain and pelvic pain during pregnancy and breastfeeding, while others may have chronic conditions, where pain management is necessary.

"If pain is not adequately managed, this can have a negative impact on a woman's physical and mental wellbeing.

"Women should be encouraged to try non-medical treatments, such as adequate rest, hot and cold compresses, massage, physiotherapy, and exercise. But if pain relief drugs are required, it is important that doctors and midwives are able to advise on appropriate medication and hopefully this review will be helpful."

Influenza Concerns

The RCOG said it was concerned by reports that fewer pregnant women were having a flu vaccine this year. Public Health England said this week that only around 40% of pregnant women have had the vaccine so far this season.

Dr Pat O'Brien, a consultant obstetrician and spokesperson for the RCOG, said: "Flu can occasionally be serious for pregnant women as it increases risk of complications, such as bronchitis, a chest infection that can develop into pneumonia.

"The best way to avoid getting this is to have the flu vaccination. Women who are pregnant should be reassured that current evidence shows the flu vaccine is safe to use."

Bisson DL, Newell SD, Laxton C, on behalf of the Royal College of Obstetricians and Gynaecologists. Antenatal and Postnatal Analgesia. Scientific Impact Paper No. 59. BJOG 2018;


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