An individualised approach to postpartum pain management that may include non-opioids, opioids, and non-pharmacologic approaches is appropriate for women following childbirth, according to new guidance released by the American College of Obstetricians and Gynecologists (ACOG).
Evidence shows that women experience pain in variable ways during the early postpartum period. As such, providers should engage in a shared decision-making approach to pain management instead of relying on a predefined number of tablets or duration. If used, opioids should only be prescribed for the shortest reasonable course expected for treating pain.
In addition to non-pharmacologic treatments, the new Committee Opinion, released early online ahead of the print July issue of Obstetrics and Gynecology, recommends a stepwise, multi-modal course of treatment that would first employ non-opioid therapies such as acetaminophen or NSAIDs. If needed, a milder opioid can be added, with stronger opioids only added for women with inadequate pain control. This tiered approach helps treat pain by matching drug effectiveness to pain severity and relies heavily on shared decision-making between provider and patient. This approach can also optimise pain control while reducing the number of unused opioid tablets.
“There is individual variation in pain experience, as well as differences in how women metabolise medication,” said Yasser El-Sayed, MD, Stanford University Medical Center, Stanford, California. “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. It is also critical to counsel the mother on the side effects of any drug prescribed, particularly if the mother is breastfeeding.”
Both nonopioid and opioid medications can be transferred to breast milk, although generally in low concentrations. Some opioids excreted into breast milk contain properties that, in certain women, can result in excessive sedation or depressed respiration in infants, even with typical dosing. For this reason, it is imperative that all breastfeeding women receive accurate information about the risk and benefits of a drug and signs of toxicity in the newborn or mother.
Upon patient discharge, ob-gyns should be familiar with applicable prescription drug monitoring programs, and be aware that standard order sets may provide more pills than an individual needs. Mothers with opioid use disorder, who have chronic pain, or women who are using other medications or substances that may increase sedation need additional support in managing pain.
“With the heightened awareness around opioid use disorder, it is understandable that there is a desire to evaluate discharge medications,” said Dr. El-Sayed. “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.”