Pain and discomfort are the most common complaints postpartum, after both vaginal and cesarean deliveries.
16 Uncontrolled pain can interfere with activities of daily living, including infant care, and is associated with greater opioid use, depression, and development of chronic pain.
17 Thus, pain control with both pharmacologic and nonpharmacologic strategies in a stepwise, multimodal approach is an important consideration in the postpartum period. Uterine contractions occur with oxytocin release after delivery and in association with nursing and may be worse in multiparous women.
17 Oral nonsteroidal anti-inflammatory drugs (NSAIDs) have better evidence supporting their use for effective pain management than opioids, and the course is usually self-limited to a week.
16,17 After vaginal delivery, perineal hygiene and care, with elevation of the foot of the bed, may help with pain and discomfort. Use of perineal ice packs has been shown in meta-analysis to improve pain in the first 72 hours after delivery but does not appear to change wound inflammation/edema or healing.
17,18 Scheduled pharmacologic treatment using NSAIDs alternating with acetaminophen appear to effective in decreasing perineal pain for the majority of women but can be supplemented in a stepwise fashion with opioids if insufficient, especially for women with significant lacerations.
17 To decrease the risk of acetaminophen toxicity, opioids should be given individually and not in a combination formulation with acetaminophen. After cesarean delivery, opioids given via neuraxial regional anesthesia provide the most effective pain control but must also be augmented with other forms of analgesia as the effects wear off over time. A similar stepwise approach should be taken with scheduled alternating NSAIDs and acetaminophen, reserving opioids for breakthrough pain as needed. A local anesthetic block injected between the internal oblique and transversus muscles may also benefit postcesarean pain.
17
There is wide variation in opioid prescribing patterns for discharge after delivery, and usually the amount does not correspond to level of pain reported or opioid requirements in the hospital.
19 The majority of women report being prescribed twice the number of opioids needed after delivery, and a minority dispose of leftover opioids appropriately.
19 Additionally, recent studies demonstrate that 1 in 300 opioid-naïve women will become persistent opioid users after postcesarean exposure (
Chapter 8).
17,19 As opioid-related overdose deaths have drastically increased and the incidence of opioid use disorder continues to rise in this country, prudent prescribing of opioids is imperative to decrease rates of misuse and diversion, while at the same time appropriately treating postpartum pain.
17 Shared decision-making with the patient to determine the amount of prescribed discharge opioids, which includes discussing average pain scores and average opioid requirements after cesarean delivery, appears to improve patient satisfaction with pain control and decrease leftover opioids.
19
Notably, about 4% to 5% of the population in the United States is “ultrafast metabolizers” of codeine and tramadol, resulting in high serum and breast milk levels of active metabolites.
17,20 Cases of breastfed infants exposed to maternal intake of codeine have been reported with oversedation, respiratory depression, and even death.
17,20 Thus, in 2017, the United States Food and Drug Administration issued a warning against codeine and tramadol in breastfeeding women.
20 However, oxycodone and hydrocodone are also metabolized by the same
enzyme, and cases of infant sedation in breastfeeding mothers have also been reported.
17 Due to the wide variation in metabolism of opioids, all women prescribed opioids should have counseling regarding the risk of maternal and infant oversedation and/or toxicity, and opioids should be used for the shortest necessary time.