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ACOG Committee Opinion: Postpartum Pain Management
Date Posted: 13/Jun/2018
Committee on Obstetric Practice 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 endorse this document. This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice, in collaboration with the American College of Nurse-Midwives liaison member Tekoa L. King, CNM, MPH; American Academy of Family Physicians liaison member Beth Choby, MD; and committee member Yasser Y. El-Sayed, MD.
 
Postpartum Pain Management
ABSTRACT: 
Pain and fatigue are the most common problems reported by women in the early postpartum period. Pain can interfere with a woman’sability to care for her self and her infant. Untreated pain is associated with a risk of greater opioid use, postpartum depression, and development of persistent pain. Nonpharmacologic and pharmacologic therapies are important components of postpartum pain management. Because 81% of women in the UnitedStates initiate breastfeeding during thepostpartum period, it is important to consider thedrugeffects of all prescribed medications on the mother–infant dyad. Multimodal analgesia uses drugs that have different mechanisms of action, which potentiates the analgesic effect. If opioids are included, a multimodal regimen used in a stepwise approach allows for administration of lower doses of opioids. Given interindividual variation in metabolism of opioids, as well as the risk of maternal and neonatal adverse effects in women who are ultra-rapid metabolizers of codeine, monitoring for excessive sedation and other adverse effects in infants is prudent for women who are prescribed opiates. Although the U.S. Food and Drug Administration recommendations underscore the need for anticipatory guidance regarding opioid effects in all patients, obstetrician–gynecologists and other obstetric care providers should ensure that the application of this guidance does not interfere with pain control or disrupt breastfeeding during the postpartum period. Women with opioid use disorder, women who have chronic pain, and women who are using other medications or substances that may increase sedation need additional support in managing postpartum pain.
 
Recommendations 
The American College of Obstetricians and Gynecologists makes the following recommendations:
c Pain can interfere with a woman’s ability to care for herself and her infant. Nonpharmacologic and pharmacologic therapies are important components of postpartum pain management. 
c Because of the variation in types and intensity of pain women experience during the early postpartum period, as well as the concern that 1 in 300 opioidnaive patients exposed to opioids after cesarean birth will become persistent users of opioids, a stepwise approach using a multimodal combination of agents can enable obstetrician–gynecologists and other obstetric care providers to effectively individualize pain management for women in the postpartum period. 
c For postoperative cesarean pain, standard oral and parenteral analgesic adjuvants include acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and opioids that are in combination formulations with either acetaminophen or an NSAID. 
c Parenteral or oral opioids should be reserved for treating breakthrough pain when analgesia from the combination of neuraxial opioids and nonopioid adjuncts becomes inadequate. 
c A shared decision-making approach to postpartum discharge opioid prescription can optimize pain control while reducing the number of unused opioid tablets.
c If a codeine-containing medication is the selected choice for postpartum pain management, medication risks and benefits, including patient education regarding newborn signs of toxicity, should be reviewed with the family. 
c Regardless of the medication selected, it is prudent to counsel women who are prescribed opioid analgesics about the risk of central nervous system depression in the woman and the breastfed infant. Duration of use of opiate prescriptions should be limited to the shortest reasonable course expected for treating acute pain.
 
Introduction 
Pain and fatigue are the most common problems reported by women in the early postpartum period. Pain can interfere with a woman’s ability to care for herself and her infant. Untreated pain is associated with a risk of greater opioid use, postpartum depression, and development of persistent pain 
 
(1). A stepwise approach using a multimodal combination of agents (ie, the use of two or more pain medications that have different mechanisms of action) can enable obstetrician–gynecologists and other obstetric care providers to effectively individualize pain management for women in the postpartum period. This is important because of the variation in types and intensity of pain women experience during the early postpartum period, as well as the concern that 1 in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users of opioids 
 
(2). Nonpharmacologic and pharmacologic therapies are important components of postpartum pain management. Because 81% of women in the United States initiate breastfeeding during the postpartum period, 
 
(3) it is important to consider the drug effects of all prescribed medications on the mother–infant dyad.
 
 
By American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc.

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