SUMMARY:  

ACOG has published a Committee Opinion on the management of postpartum pain, and the document has been endorsed by ABM, ACNM, AWHONN, SMFM, SOGC, and SOAP.  The recommendations focus on the use of a  “stepwise, multimodal combinations of agents (ie, the use of two or more pain medications that have different mechanisms of action)”

• Vaginal Birth
• Cesarean Section
• Breastfeeding
• FDA Warning Against Tramadol or Codeine
• Opioid Use Disorder

Vaginal Birth 

Medications

• NSAIDs may be superior to acetaminophen (evidence ‘not strong’)  
• Acetaminophen (given together with NSAID) is preferred next step if NSAID insufficient  
  • Maximum daily acetaminophen dose is 3g to 4g  
• Milder opioid if necessary  
  • Scheduled vs ‘as needed’ is preferable  
  • Some milder opioid formulations are combined with 325 mg acetaminophen 
• Stronger opioid analgesics (eg, intravenous morphine, hydromorphone, fentanyl) should be considered if  
  • Pain uncontrolled after above multimodal approach  
  • “Absolutely” needed for pain control  

Breast Conditions 

• Breast engorgement 
  • Cold packs  
  • Breastfeeding more often  
  • Antiinflammatory analgesics 
• Nipple pain  
  • Review proper latching  
  • No evidence as to benefit of topical ointments/lotions  
  • Breast milk + breast shield may be effective 
• Persistent breast pain 
  • Assess additional causes including maternal factors (e.g., mastitis/other infections and infant factors (e.g., ankyloglossia)  

Uterine Cramping

• More common in multips and associated with nursing  
  • Heating pads  
  • NSAIDs (work better than acetaminophen) 
  • Opioids benefit unclear  

Perineal Pain

• Consider 
  • Oral analgesics 
  • Topical anesthetics 
  • Nonpharmacologic agents such as cold packs 

Hemorrhoids

• Multiple agents, but studies have not confirmed effectiveness 
  • Astringents | Steroid | Anesthetic creams
  • Avoid overuse of steroid creams

Cesarean Section  

Medications

• Neuraxial opioids provide good pain relief  
• As effects wear off, additional pain medication may be required  
  • Acetaminophen 
  • NSAIDs 
  • Dexamethasone as a single preoperative dose  
  • Opioids 
  • Combination opioid formulations with acetaminophen or NSAID 
  • Local anesthesia
    • Wound infiltration
    • Transversus abdominis plane block
• Oral opioids preferred vs parenteral

Opioids

• Parenteral opioids if  
  • Cannot take oral medication or persistent pain 
  • Persistent pain  
    • Use patient-controlled if possible  
• Opioid risks and adverse events include  
  • Worsening constipation  
  • Significant drowsiness  

Note: Gabapentin  

• Not recommended due to lack of evidence  
• ACOG does state that gabapentin can be considered in addition to other medications if there is “a history of chronic pain or pain not relieved by standard treatment protocols”

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  
  • No specific number of pills and/or duration of treatment  

KEY POINTS:  

Breastfeeding 

NSAIDs 

• Oral NSAIDs found in low concentrations in breast milk 
• Ibuprofen first-line for postpartum pain
  • low concentrations found in breastmilk  

Ketorolac  

• ACOG states that ketorolac has a role in a multimodal treatment plan when indicated, particularly after cesarean  
• 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 and hydrocodone also may be a target for ‘ultra-rapid metabolizers’ 
  • Hydromorphone metabolism is not affected by these genetic polymorphisms 
• Morphine use should be limited as the drug appears in breast milk   
• ACOG recommends monitor infants of mothers who are prescribed opioids and are breastfeeding

FDA Warning Against Tramadol or Codeine  

• FDA does not recommend tramadol or codeine in nursing women (see ‘Related ObG Topics’, below)  
  • No evidence for tramadol, but similar to codeine with respect to metabolism pathways 
  • ACOG recommends that this recommendation should “not interfere with pain control or disrupt breastfeeding”  
  • Discuss risks/benefits with patients, provide patient education and counseling especially about non-opioid alternatives

Opioid Use Disorder 

• Provide additional support  
• Use validated screening tools 
  • 4 Ps, NIDA Quick Screen, and CRAFFT questionnaires at first prenatal visit  
  • Continue opioid agonist pharmacotherapy through pregnancy and postpartum 
  • Monitor for relapse and screen for depression in postpartum period

Learn More – Primary Sources:  

ACOG Committee Opinion 742: 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, 2016

Related ObG Topics:

FDA Restricts Codeine and Tramadol in Children and Breastfeeding Mothers – ACOG SMFM ABM Respond 

Screening for Perinatal Depression

Do Non-Opioids Work as Well as Opioids for Acute Extremity Pain?