Obstetrics Pain Management

There are many ways to manage pain after having a baby. Your clinician will discuss with you the different recommended options based on the kind of birth and pain you are experiencing and answer any questions you have. Together, you and your clinician can choose what options are best for you. Your clinician will talk to you about your beliefs, wishes, and values related to pain management and how the following may influence your pain plan:

• What kind of birth you had: Cesarean births may have more pain
• Medications and substances you take: Such as tobacco, alcohol, other drugs 
• Opioid use: Including history of opioid use disorder and chronic pain
• Mental health conditions or negative experiences: Like trauma and stress that can make pain more difficult to manage

The goal of pain management is for you to do daily activities like eating, sleeping, breathing deeply, and walking for yourself and to take care of your infant.

Some Types of Pain are NOT normal. If you see these signs, call your clinician:

• Pain that is severe, rating 10/10 
• Pain prevents you from sleeping 
• Pain does not get better with medication 
• Fever 
• Foul-smelling vaginal discharge 
• Redness or drainage at your incision 
• Heavy vaginal bleeding (soaking through >1 pad/hour) 
• Headaches

Documenting your pain management preferences and sharing them with your clinician can help you work together to develop a plan that’s right for you. Below are several options for pain management after childbirth that can be incorporated into your plan.

Non-Opioid Medications

Use non-opioid medications, like acetaminophen and ibuprofen, for as long as you are having pain. These medications can help lessen your pain and are usually well-tolerated with few side effects. You can take these medications together at the same time OR staggered at different times. Choose one!

Together

Patients may choose to take medications together at the same time because of busy schedules. 

Staggered 

Patients may choose a staggered schedule if pain is more severe.

Non-Medication Options

There are many techniques to reduce pain that do not require medications. Choose options you would like to try:

• Abdominal binder 
• Heat/Ice 
• Mindful breathing 
• Mindfulness
• Acupuncture/Acupressure (where available)
• Topical spray or cream directly on the area like benzocaine, for vaginal pain
• Aromatherapy 
• Deep breathing 
• Music 
• Visualization

Opioid Medications

Sometimes an opioid medication may be needed for a short time to manage pain. Most patients who have a vaginal birth do NOT need an opioid medication. Even 60% of patients after cesarean birth reported not needing an opioid when using other options to manage pain. If an opioid medication is needed, your clinician will work with you to find the right opioid prescription size. Opioids are prescription pain medications that may be offered by your prescriber after birth.

• Use opioids only for severe pain that is not controlled with acetaminophen and ibuprofen. 
• Stop using or use fewer opioids as your pain gets better. 
• Do not use opioids at the same time as other medications or substances that can cause sleepiness like alcohol, anti-anxiety medications like Xanax or Valium, muscle relaxers like Flexeril, or sleep aids like Ambien.

Know the Risks
Anyone who uses an opioid, even for just a short time, is at risk for dependence, tolerance, misuse, addiction, and overdose. Opioids can cause slowed breathing and lead to overdose death. 

Discuss the following signs and symptoms of an overdose with your family and friends: 

• Cannot be awakened or speak 
• Vomiting or making gurgling noises 
• Limp body that may seem lifeless 
• Fingernails/lips turned blue/purple 
• Very pale or clammy to the touch

Opioids are also associated with several side effects. Contact your clinician if you notice any side effects. 

Ask Your Clinician about Naloxone 

Naloxone is a medication that temporarily reverses the dangerous effects of an opioid overdose. Talk to your clinician about a prescription for naloxone. Learn more about Naloxone here. 

Safe Storage and Disposal

Protect your family and friends by safely storing medications and disposing when done. Learn more about Safe Storage and Disposal here.

Small amounts of opioids over short periods of time are safe and do not pose risks to babies, but some opioids (codeine, tramadol) are not recommended when breastfeeding.

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

Talk to your prescriber if you are breastfeeding about the best option for you. Call your pediatrician if your baby seems sleepier than normal, cannot suck as well or is constipated.

There are many ways to manage pain after having a baby. Discuss the different recommended options with your patient depending on the kind of birth they choose to have and the pain they are experiencing afterwards. Together, you and your patient can develop a plan that works best for them.

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 proportion of patients who receive an opioid prescription and the prescription size, even when accounting for patient factors.³

Opioid prescribing for acute pain is excessive and risky 

• EXCESSIVE: Only 25-50% of prescribed opioids are consumed after cesarean delivery in cohort studies^{4, 5}
• 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 use⁶

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

• 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^{7, 8}
• Patients from historically marginalized groups have faced inequities in postpartum pain management (e.g., receiving fewer pain assessments and opioid medication for the same pain scores when compared to White patients).^{9, 10}

Clinical Practice Guidelines for acute pain after surgery successfully reduce opioid prescribing without compromising patient-reported pain scores or patient satisfaction²

• 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

The COMFORT clinical practice guideline (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.

“…it seemed almost like they just gave me what they give to everyone and then let me go home, and then the next person would come in and give birth and they’d get the same thing and then go home… It wasn’t asking pointed questions to get to the best to answers for me because I’m obviously different than everybody else that day that was giving birth… Everybody’s different.” (Patient)

“…this would really standardize postpartum pain management, which desperately needs to be standardized in the United States. I think this would improve satisfaction with postpartum pain control, because it sets an expectation and forces the conversation if it isn’t already happening. And I think it would reduce the amount of opioids that are prescribed, reduce the amount of extra opioids in everyone’s medical cabinets, and hopefully reduce the number of patients that have to see me for opioid use disorder as well.” (Clinician)

“…you do need the standardization in terms of, ‘here are the main things that you need to do for everybody regardless.’ But then also before you just check off a box, you have to consider the human that you’re treating. And are there any patient factors that would change how you check that box?” (Clinician)

Interviews with 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:

• “My concerns were not taken seriously… you’re not believed.” (Patient)
• “I didn’t get the desired attention that I needed. I had so many questions, and I was going through pain. So I needed relief, and I needed to know why I was feeling that way.” (Patient)

Individuals 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:

• “I can see that certain people are believed a little bit more about their pain […] I’ve seen this in the Black population , […] in the Hispanic population […] in the Asian population, the East Asian population too.” (Clinician)
• “…we all have bias… we all were raised in this racist, sexist, homophobic system” (Clinician)
• “ Am I going to be treated differently because of my background or because I’m not American enough?” (Patient)
• “I feel like they had reason to look down on me, because of my financial and social status.” (Patient)
• “I told her I hadn’t had any medicine in the last 24 hours, and I was literally being ignored… this is how, especially with Black women, this is how we die after childbirth or during labors, is [sic] because no one’s listening.” (Patient)

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.

Key Considerations

1. Provide comprehensive, clinician-initiated anticipatory guidance, prior to the birth hospitalization if possible, and in the patient’s primary language: This may help set expectations for postpartum pain, help patients feel more comfortable with pain management options, reduce anxiety, and promote patients’ ability to participate in shared decision making. 
2. Include support people, if desired by a patient, in conversations about pain management: This may help clinicians and families to better function as a team and help support people advocate for birthing individuals. 
3. Utilize non-judgmental, respectful language, acknowledge patients’ lived expertise, and adapt educational content to each patient’s informational needs. This may help patients feel seen, cared for, and well-positioned to participate in shared decision-making. 

Patient-Centeredness & Health Equity

“…I didn’t know what to expect… I feel like if I had a conversation with my provider about these things, of what to expect and have a solid plan, I feel like I would’ve been more at ease and comfortable with how things would possibly turn out.” (Patient)

SET CLEAR EXPECTATIONS FOR PAIN EXPERIENCE: 

DISCUSS EFFECTIVE MEDICATIONS FOR PAIN MANAGEMENT:

Key Considerations

Clinicians should consider assessing for barriers to non-opioid medications, and providing resources and strategies to overcome them such as: 

Patient-Centeredness and Health Equity

“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)

Ibuprofen is the NSAID most studied in pregnancy. Other NSAIDs may be appropriate if preferred by the patient or provider for dosing intervals or other considerations.

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.2

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. 

Inpatient: Simultaneous dosing may be easier to incorporate on busy floors or with high patient to nurse staffing ratios. 

Discharge: Patients may choose this dosing to reduce burden or facilitate sleep.

Why choose this schedule?

There is limited evidence in non-obstetric patients to support staggering medications.

Inpatient: Patients with more breakthrough pain may benefit from staggered dosing. 

Discharge: Patients with poorer pain control may consider this approach.

*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) 

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.

NSAID Safety Considerations and Side Effects
Allergy	-Hypersensitivity to NSAIDs or aspirin
Cardiovascular	-Diseases that impair activity (hemophilia, thrombocytopenia with platelets -Taking warfarin -Congestive Heart Failure
Gastrointestinal	-Short-term use (<=7 days) is safe for most patients -Long term use risk is low (<2%) -History of peptic ulcers, gastrointestinal bleeds, or Helicobacter pylori infections, consider celecoxib (Celebrex) and/or use of a concomitant proton pump inhibitor (PPI, e.g. OTC omeprazole) -History of bariatric surgery
Renal	-Acute kidney injury from NSAID use can occur in those with risk factors including pre-existing kidney impairment, or CKD with high cumulative doses (e.g. ibuprofen 700 mg/day) -Use with caution in patients with CKD
Acetaminophen Safety Considerations and Side Effects
Allergy	-Hypersensitivity to acetaminophin
Gastrointestinal	-Hepatic dysfunction or sever liver disease of cirrhosis

Since acetaminophen and most NSAIDs 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 NSAIDs 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 Considerations

1. Clinicians should be aware of barriers to non-pharmacologic strategies, and provide resources and strategies to overcome them such as:
   1. Cost:
      1. 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).
   2. Time:
      1. 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).
2.  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.

Patient-Centeredness and Health Equity

“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)

“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)

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.

*Recommended for cesarean birth patients only

Key Considerations

1. 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. 
2. 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. 
3. 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.

Patient-Centeredness and Health Equity 

“…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)

Key Considerations for Routine Postpartum Patients:

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 conversation with the patient to determine the best 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. Type of birth
2. Additional procedures 

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

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.

For patients at risk of inadequate pain management (e.g., cannot recieve NSAIDs/Acetaminophen): Consider prescribing closer to the upper range.
For patients at risk of adverse effects of opioid medications (e.g., use of sedating medications, non-opioid SUD): Consider prescribing closer to the lower ranger

Key Considerations

Counseling about peripartum pain management should include a discussion of the safety and efficacy of regional analgesia: Eliciting patients’ concerns about regional analgesia can promote shared knowledge and trust. 

Patient-Centeredness and Health Equity

“So I have patients who come in telling me, oh, the epidural’s going to give me chronic back pain, and so they don’t want it. And that’s just a matter of, I think misunderstanding and a lot of work we have to do on patient education. Not only misunderstanding, but also mistrust of the healthcare system because they’ve probably been mistreated in the past.” (Clinician)

CESAREAN BIRTH 

Patient Controlled Analgesia with IV medications may be appropriate for patients who do not have adequate pain control with routine measures after cesarean birth or cannot receive routine pain control.

Transversus Abdominis Plane (TAP) Block, Ketamine infusion, surgical site infiltration with local anesthetic and perioperative gabapentin has uncertain benefit for patients who do not have adequate pain control with routine measures or cannot receive routine pain control after cesarean birth.

Considerations for practice: 

• Ensure hospital is following the Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean
• Patients who require general anesthesia or cannot receive long acting medications may have different pain management needs. Consult with anesthesia and/or acute pain service for management and recommendations. 
• Patient Controlled Analgesia with IV medications should NOT be used as a first-line strategy.

Vaginal Birth

Surgical site infiltration with local anesthetic has uncertain benefits for patients who do not have adequate pain control with routine measures after vaginal birth.

Transversus Abdominis Plane (TAP) Block and Ketamine infusion are inappropriate, and long-acting regional analgesia, Patient Controlled Analgesia with IV medications, and perioperative gabapentin are likely inappropriate for patients who do not have adequate pain control with routine measures after vaginal birth.

Considerations for practice: 

• Not for use in patients who have a vaginal birth.

Key Considerations

1. Clinicians should receive education on how biases and social stigma may influence clinical counseling and decision-making related to pain management and work towards dismantling their effects:  Patients with OUD and complex pain experience significant biases that negatively affect their care, including being labeled as “drug seeking” when requesting assistance with pain management or having their pain undertreated. 
2. Standardized protocols for patients with complex pain:  Universal approaches may reduce stigma and inequities in pain management by ensuring patients with OUD and complex pain have access to the same evidence-based strategies as other patients. 
3. Tailor pain management plans to individuals’ unique needs: For patients with complex pain, include clear points of tailoring within standardized protocols  to best address differences in pain management needs, risks of opioid exposure, and preferences. 
4. Shared decision making – with decisions driven by patients – is the ideal way to develop pain management plans for patients with complex pain: This may reduce stigma and improve the patient experience by demonstrating respect and promoting individual self-efficacy for patients who have been marginalized by the health system.

Patient-Centeredness and Health Equity

“So I think also with being an addict, a lot of times hospitals think you’re drug seeking when you’re telling them you’re in pain and you need something for it. For example, during my pregnancy, my epidural came out and they didn’t believe me. Then finally hours checking, they realized my epidural came out… I felt like I was being treated like I wasn’t being taken seriously, and they just thought that I was trying to get drugs even though I had been clean ever since my pregnancy. So that was kind of my experience with it.” (Patient)

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