Obstetrics Pain Management

To date, recommendations for pain management after childbirth have largely been limited to cesarean birth (CB), leaving a gap for the two-thirds of patients who undergo vaginal birth (VB). Recommendations have not adapted to the variety of additional procedures patients may undergo at the time of childbirth, like repair of advanced laceration, tubal ligation, or procedures to control hemorrhage. Nor have guidelines specified how to adapt care for those with complex pain management needs. Additionally, current pain management may sometimes fail to center patients’ needs and preferences and miss opportunities to promote equitable, exceptional experiences for all patients.  

EVIDENCE SHOWS:

Opioid prescribing after childbirth remains high and widely variable

• In Michigan, there is wide variation across hospitals in opioid prescribing after vaginal and cesarean birth, including the proportion of patients who receive an opioid prescription and the prescription size
• These differences exist even when accounting for patient factors, suggesting unwarranted variation

Opioid prescribing for acute pain is excessive and risky 

• Excessive: Only 20% of prescribed opioids are consumed after cesarean delivery in cohort studies
• Risky: Up to one in 75 pregnant individuals who receive an opioid at childbirth, and one in 25 who receive an opioid for acute pain in pregnancy, develop new persistent opioid use

Significant disparities in pain management practices exist, resulting in suboptimal pain control for patients marginalized by racism, social determinants of health, language barriers, and substance use.

• In the U.S., individuals who are Black, young, living in poverty, or affected by substance use disorder, are more likely to experience disrespectful maternity care–including paternalism, neglect of reproductive autonomy, and other dehumanizing treatment.
• Patients from historically marginalized groups have faced inequities in postpartum pain management such as receiving fewer pain assessments and receiving less opioid medication for the same pain scores when compared to White patients.

Clinical Practice Guidelines for acute pain after surgery successfully reduce opioid prescribing without compromising patient-reported pain scores or patient satisfaction³

• From an interrupted time series analysis of opioid prescription size, opioid consumption, and satisfaction among adults undergoing surgery in Michigan before and after release of postoperative opioid prescribing guidelines

For all of these reasons, the FDA provided funding to develop a standardized Clinical Practice Guideline (CPG) for pain management after childbirth that:

• Promote excellent pain control 
• Reduce harmful opioid prescribing
• Promote more equitable, patient-centered care

To accomplish this goal, we used a rigorous, inclusive process to develop a new CPG. 

Promoting Standardized Evidence-Based Practices and Personalized Decisions

The COMFORT CPG is designed to promote care standardization (i.e., all patients receive the same pain management choices supported by evidence) and personalization (i.e., patients and clinicians select from evidence-based options to create tailored care plans responsive to individual patient needs, preferences, and values). Offering everyone the same choices supported by evidence and deciding on the best options through partnership between clinicians and patients, may help promote better clinical outcomes, better experiences of care, reduced risk of opioid harms, and more equitable outcomes for all. 

Standardized Care	Opportunity for Tailoring
Preparation for and education about postpartum pain and management options. For patients receiving opioid medication, information on the risks and benefits of opioid prescribing (including sedation, overdose, and persistent use), the effects on lactation, and safe disposal.	Assessment of individual factors (e.g., medical and social risks, preferences) that may affect pain management counseling and decision-making.
Scheduled non-opioid medications, (e.g. NSAID, acetaminophen), among those without contraindications.	Selecting simultaneous vs. staggered dosing.
Non-pharmacologic strategies (e.g., abdominal binder, heat/ice therapy).	Selecting which strategies to use, if any.
Opioid medication, if needed, prescribed within COMFORT CPG-concordant ranges.	Electing whether to receive an opioid prescription, and if so, how many tablets within the recommended opioid prescribing range.

Road Map for Postpartum Pain Management: 

IMAGE TO COME

Our interviews with 51 patients and providers about acute pain management for peripartum patients documented experiences of unmet information needs, dismissive care, unresponsiveness to patient concerns and preferences, and failures to offer compassionate, respectful, humanistic care: 

Interviewees often noted the effects of racism, classism, and other biases and social stigma on care delivery, with overlapping systems of inequity creating exponential disadvantage for some individuals navigating peripartum pain management in the healthcare system:

Taking Action to Promote Patient-Centeredness and Equity 

These findings suggest an urgent need for clinicians to rectify current care disparities. We can take action by: 

• Engaging in self-reflection and education about how biases and social stigma may influence clinical counseling and decision-making related to pain management
• Striving to build trusting, collaborative alliances with patients by offering non-judgmental, compassionate, respectful care that is responsive to patient’s lived experiences, preferences, and values
• Offering universal anticipatory guidance about postpartum pain and standardized, evidence-based pain management may promote more equitable care and a better patient experience.
• Personalizing pain management plans, using shared decision-making, to anchor individual patient needs, preferences, and values at the center of care decisions

Throughout this document, we have incorporated Key Patient-Centeredness and Health Equity Considerations to highlight important considerations for improving outcomes and the experience of care for all.

To establish a tailored postpartum pain management plan, first assess for individual factors that may influence how we treat pain. These factors include patient preference, mental health conditions, birth type, history of trauma and other health conditions like substance use and ability to receive non-opioid medications. 

It is important to reassess factors, like mental health, history of trauma, and patient preferences throughout the pregnancy: through relationship and trust building, patients may gain greater comfort sharing these factors with their care team and these individual factors can evolve over time. 

Key Considerations for Patient-Centeredness & Health Equity:

“I would’ve felt so much more, I guess unique, for lack of a better word. I wouldn’t have felt so like an assembly line, you’re giving birth, you’re getting one thing, and you’re moving along. You know what I mean? It would feel more like someone was taking the time to ask actually how I’m feeling, give me options and then let me make the decision that’s best for myself.” (Patient)

• Tailoring care to patients’ individual needs helps them feel heard, included, respected, and cared for: patients welcomed the COMFORT CPG’s call for tailoring, and described how, if executed well, it could improve their care experience.
• Using validated screening tools when appropriate is an important way to reduce clinician biases and promote equity. Tools should be universally administered to identify all individuals with factors that may influence pain management and avoid further stigmatizing historically marginalized individuals.

Why? 

There is a moderate to high level of evidence to support scheduled Acetaminophen (Tylenol®) and ibuprofen (Motrin®) after both vaginal and cesarean birth for effective pain management and reduced opioid requirements.3 

What about lactation? 

Acetaminophen and ibuprofen are both safe during breastfeeding. They are found in low concentrations in breast milk and are the first choice for pain management for lactating parents.

Why choose this schedule?

• Simultaneous dosing may be easier to administer
• Impatient: Simultaneous dosing may be easier to incorporate on busy floors or with high patient to nurse staffing ratios
• Discharge: Patients may choose this dosing schedule to reduce burden or facilitate sleep

*Schedules above are based on every 8 hour dosing. Dosing medications every 6 hours may also be appropriate (e.g., acetaminophen 650 mg q6 and ibuprofen 600mg q6 together or staggered)

Why choose this schedule?

• There us limited evidence in non-obstetric patients to support staggering medications
• Impatient: Patients with more breakthrough pain may benefit from staggered dosing
• Discharge: Patients with poorer pain control may consider this approach

Cesarean Birth Considerations

• For the first 24 hours postpartum, the first 3 doses of oral NSAID, can be replaced with 3 doses of Toradol 15 mg IV every 8 hours

Since acetaminophen and ibuprofen are available over the counter and don’t require a prescription, patients and support persons often do not receive instructions on how to use them after surgery. Following packaging instructions may result in underdosing. Additionally, some patients may not be able to pay out of pocket for medications. Universally prescribing acetaminophen and ibuprofen can ensure: 1) patients know the right dosing; 2) non-opioid medications are used first-line; and 3) all patients have access to these medications.   

Key Patient-Centeredness and Health Equity Considerations: 

“But telling me like, ‘Oh, well you could go buy Tylenol and Advil,’ and if I don’t have that 10 bucks to buy it, then I’m going to just sit there and suffer in pain.” (Patient) 

“My pain management was really staying on top of that scheduled medicine. I was setting alarms. I had notebooks of when I took the last dose of even the over-the-counter medicines, [to avoid] playing catch up to pain…” (Patient)

• Clinicians should consider assessing for barriers to non-opioid medications, and providing resources and strategies to overcome them such as: 
  • Cost: Provide prescriptions for acetaminophen and ibuprofen to reduce out of pocket costs as these may be covered by insurance or consult social work to determine additional support options
  • Competing Demands: Provide strategies to increase adherence to using non-opioid medications such as encouraging setting alarms, timing medication with other routine activities (e.g., diaper change, infant feeds)

Why: 

While evidence for many non-pharmacologic strategies is limited, these interventions are low risk with potential for benefit. In combination with other opioid-sparing strategies, non-pharmacologic interventions can potentially improve a patient’s pain experience.

Key Patient-Centeredness and Health Equity Consideration: 

“If you’re a single mom, like I’m a single mom now, there is no time for mindfulness…. So, while those are wonderful things, they’re not realistic things for people whose situations are not a two-parent household, whose situations don’t allow for them to have five minutes for themselves without a person and/or someone needing them.” (Patient)

• Clinicians should be aware of barriers to non-pharmacologic strategies, and provide resources and strategies to overcome them such as: 
  • Cost: Consider providing patients with a COMFORT bundle (e.g., package including abdominal binder, reusable heating pad); provide low-cost resources for non-pharmacologic approaches (e.g., free meditation app, do it yourself aromatherapy). 
  • Time: Consider assessing a patient’s ability and desire to engage in non-pharmacologic strategies. Where possible, suggest how interventions can be incorporated in daily activities (e.g., deep breathing while feeding baby). 

“You want to be pretty sensitive in how you’re presenting it, because someone in pain is very likely to be hypervigilant to, ‘I’m in horrible pain, and all you’re telling me to do is smell this lavender oil. Why aren’t you treating my pain?’ And then the relationship is soured.” (Clinician)

Clinicians should present non-pharmacological strategies as supplemental to routine postpartum pain management to avoid minimizing patients’ pain: Use caution and appropriate timing when offering non-pharmacological strategies. Consider emphasizing that these strategies may accompany first-line treatments used to manage pain, but should not replace them.

*Recommended for cesarean birth patients only

Key Considerations for Routine Postpartum Patients

Details

• Due to improved efficacy of PO agents, providers should consider the use of oral analgesics, even when patients are written for a NPO diet.

Clinician Tool: Discharge Opioid Prescribing Recommendations 

When an opioid is needed, use the COMFORT Panel prescribing ranges as the foundation for a shared decision-making patient conversation to determine the appropriate prescription size. Starting from a standardized approach and then allowing for individualization helps to promote both equity and patient-centeredness. 

• Determine the opioid prescribing range based on:

1. 1. 1. Type of birth
      2. Additional procedures 
      3. Individual risk factors

• Determine the right prescription size: With the patient, determine the best prescription size within the appropriate range. 

1. 1. Assess/reassess for individual risk factors 
   2. Consider Patient Preferences and other non-opioid strategies
   3. Pain Management at Time Discharge: 
      1. Pain Scores in 24 hours prior to discharge*
      2. Medication Use in 24 hours prior to discharge*
      3. Timing of Discharge

*Clinicians should be aware of inequities in how pain is assessed and treated. 

Key Patient-Centeredness and Health Equity Considerations: 

“…if the conclusion and what I got was the same, I still would’ve had that feeling of a) being heard, and b) being included in my own care… it doesn’t really matter what the ultimate outcome is… it’s more valuable to me, even above pain management, to feel like I’m in control of my health decisions.” (Patient)

• Standardizing opioid prescribing ranges for specific procedures and conditions can improve health equity: Utilizing the COMFORT prescribing ranges may help ensure that all patients have access to appropriate opioid prescription options. 
• Shared decision making – with decisions driven by patients – is the ideal way to select the final opioid prescription size: Aligning opioid prescribing with a patient’s wishes and lived realities may promote trust, autonomy, and a better patient experience of care. 

Anticipated activity upon discharge and risk of opioid abuse/misuse may affect postpartum pain needs: Clinicians should be cautious when incorporating these factors into decisions about opioid prescribing given the known biases in determining how these factors might affect postpartum pain needs.

Case Example

You are preparing to discharge a patient on POD 2 who had a cesarean birth. On further screening and assessment, you realize that this patient meets criteria for tobacco use disorder. The patient has been tolerating acetaminophen and ibuprofen using the simultaneous schedule during hospitalization. In review of hospital opioid consumption, the patient has only received one dose in the last 24 hours. The patient reports using a heating pad as needed and thinks it might help some. 

Prescribing: 

1. Determine the prescribing range: Using the type of birth and additional procedures and any individual risk factors, you determine the appropriate range for the prescription size which you enter into the chart.
2. Elicit and clarify the patient’s preferences and values:  Inquire about their concerns and priorities for postpartum pain management. This patient reports concerns about “getting addicted” because her sister developed opioid use disorder after a knee surgery. She is also really worried about being in pain since she has to climb a flight of stairs to get to her bedroom and the nursery.
3. Determine the right prescription size: With the patient, determine the best prescription size within the appropriate range. Consider the patient’s preferences and markers of the patient’s pain management needs (e.g., pain level, pain medication use) and the day of discharge (i.e., potentially increased pain medication needs with earlier discharge.
4. The patient and her clinician decide a prescription of 5 tabs of 5mg oxycodone, in addition to acetaminophen and ibuprofen, will be best for her pain.

Patients who receive long-acting regional analgesia following routine cesarean birth do not benefit from additional inpatient pain management strategies like TAP block, surgical site infiltration with local anesthetic, or IV PCA.

Patients who cannot receive long-acting regional analgesia following cesarean birth, have complex pain management needs (e.g., patients with OUD, chronic pain), or have poorly controlled pain after birth may benefit from additional inpatient pain management strategies.

Clinicians should use a principles based approach to managing pain in patients with complex pain.  Where possible, clinicians should offer patients COMFORT with some additions and specific considerations.

1. SR paper
2. Rimsza, R. R., Perez, W. M., Shyken, J., & Vricella, L. K. (2021). Reduction of opioid utilization after vaginal delivery with an electronic health record intervention. American journal of obstetrics & gynecology MFM, 3(5), 100402. https://doi.org/10.1016/j.ajogmf.2021.100402
3. Blitz, M. J., Rochelson, B., Prasannan, L., Stoffels, G. J., Pappas, K., Palleschi, G. T., & Marchbein, H. (2022). Scheduled versus as-needed postpartum analgesia and oxycodone utilization. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 35(6), 1054–1062. https://doi.org/10.1080/14767058.2020.1742318
4. Vu, J. V., Howard, R. A., Gunaseelan, V., Brummett, C. M., Waljee, J. F., & Englesbe, M. J. (2019). Statewide Implementation of Postoperative Opioid Prescribing Guidelines. The New England journal of medicine, 381(7), 680–682. https://doi.org/10.1056/NEJMc1905045