Washington, DC—An individualized approach to postpartum pain management that may include nonopioids, 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) today.
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 pre-defined 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, “Postpartum Pain Management,” ACOG recommends a stepwise, multi-modal course of treatment that would first employ nonopioid 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 optimize pain control while reducing the number of unused opioid tablets.
“There is individual variation in pain experience, as well as differences in how women metabolize medication,” said Yasser El-Sayed, M.D., vice chair of the Committee on Obstetric Practice. “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 breastmilk, 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 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.”
Committee Opinion #742, “Postpartum Pain Management,” is endorsed by The Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the Association of Women’s Health, Obstetric and Neonatal Nurses, the Society for Maternal–Fetal Medicine, the Society for Obstetric Anesthesia and Perinatology and the Society of Obstetricians and Gynaecologists of Canada. It will be published in the July edition of the journal Obstetrics and Gynecology.
The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, ACOG strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. www.acog.org