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Managing Pain in the Postpartum Period: Recommendations Using the Multimodal Approach

SUMMARY:

ACOG has published a Clinical Consensus document on the management of postpartum pain. The recommendations focus on the use of “a stepwise multimodal approach using a combination of agents with different mechanisms of action to effectively individualize pain management in the postpartum period.” In general, the first step is nonopioid analgesics, “followed by opioids of lower and then higher potency as needed.”

Vaginal Birth
Cesarean Section
Breastfeeding

Vaginal Birth

Medications

First step: NSAIDs and acetaminophen on a set schedule
If NSAIDS and acetaminophen insufficient
- Add low-dose, low-potency, and short-acting oral opioid (e.g., codeine, hydrocodone, oxycodone, tramadol, and morphine)
- Combination acetaminophen-opioid or NSAID-opioid pills are not recommended
If NSAID/Acetaminophen plus low-dose opioid insufficient
- Stronger opioids are available (e.g., hydromorphone and fentanyl)
- Unusual to require these potent opioid medications following vaginal delivery and further investigation for ancillary cause of pain is warranted (e.g., vaginal hematoma)

Cesarean Section

Medications

Perioperative Pain Control

Neuraxial opioids (eg., intrathecal morphine) provide good pain relief
- Effective only within a day of surgery
Most patients will respond well to a combination of neuraxial opioids and nonopioid medication (e.g., NSAIDS)
Patient controlled analgesia for patients who receive neuraxial opioids
- Associated with “improved analgesic efficacy and is associated with increased patient satisfaction”
Additional perioperative medication options
- IV Acetaminophen
- Dexamethasone as a single preoperative dose
  - May decrease nausea and vomiting | Data on pain control unclear
- Local anesthesia: Transversus abdominis plane (TAP) block
  - Inject into plane between internal oblique and transversus abdominis
  - Not superior to neuraxial opioids but may reduce pain within 12 hours and lower need for opioids in patients who did not receive neuraxial opioids

Beyond Immediate Postop Period: Use Stepwise Multimodal Analgesia

Combination of NSAIDs, acetaminophen, and opioids similar to vaginal delivery
- First-tier: NSAIDS and acetaminophen on fixed schedule
- Follow with low-dose, low-potency, and short-acting opioids if needed
- Reserve stronger opioids for refractory/breakthrough pain

Discharge Medications and Opioids

Legitimate concern that opioids are over-prescribed, however women should be discharged with appropriate pain control
ACOG recommends Individualized therapy, with shared decision making
Recommendations are similar to inpatient with respect to avoidance of acetaminophen–opioid or NSAID–opioid combination pills
Liberal use of acetaminophen and NSAIDS can reduce opioid use
- should be used when appropriate even in setting of hypertensive disorders of pregnancy

Breastfeeding

NSAIDs and Acetaminophen

Oral NSAIDs and acetaminophen are found in low concentrations in breast milk
- “Both are acceptable and preferred choices for postpartum pain management”
Ibuprofen concentration in breast milk decreases with longer duration of breastfeeding
- low concentrations found in breastmilk

Ketorolac

ACOG states that “ketorolac is acceptable for use in the immediate postpartum period”
Drug label cautions use during breastfeeding
- Concentrations in breast milk are low in the first few days postpartum

Opioids

Transfer from mother to breast milk
Some individuals may be ‘ultra-rapid metabolizers’ of opioids due to genetic changes (called polymorphisms)
- Cytochrome P450 2D6 (encoded by the CYP2D6 gene) is the enzyme that breaks down codeine and tramadol | Minor changes in DNA sequence can significantly alter drug metabolism
- ‘Ultra-rapid’ genotype results in potent metabolites that are stronger than initial drug
- If more potent metabolites do transfer to the infant, excessive newborn sedation or even death can occur
Oxycodone may also be an issue due to partial metabolism by CYP2D6
Monitor infants of mothers who are prescribed opioids and are breastfeeding
The CDC has a section on opioids and pregnancy in the current ‘Clinical Practice Guideline for Prescribing Opioids for Pain’ | Recommendations include

When making decisions about whether to initiate opioid therapy for pain during pregnancy, clinicians and patients together should carefully weigh benefits and risks. For pregnant persons already receiving opioids, clinicians should access appropriate expertise if tapering is being considered because of possible risks to the pregnant patient and the fetus if the patient goes into withdrawal
For pregnant persons with opioid use disorder, medication for opioid use disorder (buprenorphine or methadone) is the recommended therapy and should be offered as early as possible in pregnancy to prevent harms to both the patient and the fetus

FDA Warning Against Tramadol or Codeine

FDA does not recommend tramadol or codeine in nursing women (see ‘Learn More – Primary Sources’, below)
- No evidence for tramadol, but similar to codeine with respect to metabolism pathways

Learn More – Primary Sources:

ACOG Clinical Consensus 1: Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management

ACOG Committee Opinion 711: Opioid Use and Opioid Use Disorder in Pregnancy

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2022

FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women

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Managing Pain in the Postpartum Period: Recommendations Using the Multimodal Approach