Postpartum pain is common and may interfere with a patient's self- and infant care. Untreated pain has been associated with postpartum depression, persistent pain, and higher use of opioids. This is a summary of a new American College of Obstetricians and Gynecologists (ACOG) Clinical Consensus guideline on pharmacologic pain management for acute perineal, uterine, and incisional pain in the postpartum period (ACOG, 2021).
General Principles for Care
Clinicians should use shared decision making with patients when determining their preferences for pain management. Engaging in shared decision making has been shown to decrease opioid use, improve patient satisfaction, and may mitigate opioid misuse and diversion (ACOG, 2021). As with other perinatal outcomes, there are known racial and ethnic disparities in assessment and treatment of pain. As clinician biases may contribute to these disparities, it is important for clinicians to examine their biases and understand how these may influence their care.
Vaginal Birth
A stepwise and multimodal approach for postpartum pain management is recommended after vaginal birth, modeled on approaches used for management of cancer pain. This involves first using nonopioid analgesics, followed by low potency opioids, and then higher potency opioids as needed. First-line oral agents include nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, ideally administered on a fixed schedule versus as needed (ACOG, 2021). Note that former guidance to avoid NSAIDs in patients with postpartum hypertension (ACOG, 2019) has not been substantiated (ACOG, 2021). When these first-line agents are ineffective, additional low-dose, low-potency, and short-acting oral opioids including codeine, hydrocodone, oxycodone, tramadol, or morphine may be used. Single-agent medications are recommended over the combination medications (NSAID-opioid or acetaminophen-opioid) that are commonly prescribed (ACOG, 2021).
Cesarean Birth
Strategies for postoperative pain management after cesarean birth include the same recommendations as for vaginal birth with a few additional considerations. Low-potency opioids may be introduced at the same time as NSAIDs and acetaminophen, reserving higher potency opioids for refractory or breakthrough pain (ACOG, 2021). A key goal is to reduce exposure to opioids while providing adequate pain control. Cesarean birth may allow for administration of spinal or epidural opioids that offer pain relief during the immediate postoperative period (ACOG, 2021).
Breastfeeding Considerations
Ibuprofen and acetaminophen are first-line medications recommended for postpartum patients intending to breastfeed (ACOG, 2021). Opioids have molecular and chemical properties that facilitate their transfer into breast milk. Patients receiving opioids should be counseled on the risk of central nervous system (CNS) depression for themselves and their infant(s) (ACOG, 2021). Opioid metabolism is complex and is subject to genetic variations in individuals; further emphasizing the importance of individualized and informed care. Codeine-containing medications may heighten the risk of CNS depression in neonates; thus, providers should review duration of therapy and neonatal signs of toxicity with breastfeeding individuals prescribed these medications (ACOG, 2021). Intravenous ketorolac may be used in the immediate postpartum period for breastfeeding individuals (ACOG, 2021).
Summary
A review of the full guideline is recommended as other agents, modalities, and strategies are discussed that are beyond the scope of this column (ACOG, 2021). These include, but are not limited to, use of preoperative intravenous acetaminophen, dexamethasone, split dosing of opioids, transversus abdominus plane (TAP) block, patient-controlled analgesia, and nonpharmacologic approaches (ACOG, 2021). Perinatal nurses can advocate for postpartum patients by being knowledgeable about contemporary pain management approaches, minimizing patient exposure to opioids, role modeling and supporting shared decision making, and self-reflecting on how personal and professional biases may affect delivery of equitable high-quality nursing care.
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