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Drug Comments
droperidol, haloperidol Avoid if possible, or contact one of the
pregnancy drug information centres; if used
monitor infant for sedation
Source: Information taken with permission from Australian Medicines Handbook 2009.
Key messages
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Prescribing medications during lactation requires consideration of possible transfer into
breast milk, uptake by the baby and potential adverse effects for the baby; it should follow
available prescribing guidelines (U).
Local anaesthetics, paracetamol and several non‐selective NSAIDs, in particular ibuprofen,
are considered to be safe in the lactating patient (U).
Morphine and fentanyl are considered safe in the lactating patient and are preferred over
pethidine (U).
11.1.4 Pain management in the puerperium
Pain during the puerperium is common and of multiple aetiologies, most often being perineal
or uterine cramping pain initially and breast pain from the fourth postpartum day. Women are
often inadequately warned and remain ill informed of the best available treatments for
postnatal pain. In the first 6 months postpartum, backache was reported by 44% of women
and perineal pain by 21%, and many indicated they would have liked more help or advice
(Brown & Lumley, 1998). Severe perineal and uterine pain limited mobility during maternal‐
infant bonding, and perineal trauma and pain was associated with delayed resumption of
sexual relations after birth (Williams et al, 2007 Level IV). Breast, especially nipple, pain may
result in abandonment of breastfeeding (Morland‐Schultz & Hill, 2005).
Perineal pain
A number of obstetric and surgical factors contribute to perineal pain following delivery. After
adjusting for parity, perineal trauma, and length of labour, women with instrumented versus
unassisted vaginal deliveries reported more perineal pain (Thompson et al, 2002 Level IV).
Restrictive use versus routine mediolateral episiotomy reduced the rate of episiotomy from
CHAPTER 11 but did not influence the incidence or degree of perineal pain (Carroli & Mignini, 2009 Level I). In
75% to 28% and reduced the risk of severe perineal trauma and the requirement for suturing,
comparison with interrupted suturing methods, continuous suturing (particularly of all layers
rather than skin only) was associated with reductions in pain and analgesic use (Kettle et al,
2007 Level I).
Non-pharmacological treatments
There is only limited evidence to support the effectiveness of local cooling treatments (ice
packs, cold gel pads, cold/iced baths) for relieving pain from perineal trauma sustained during
childbirth, and pulsed electromagnetic energy was more effective than ice packs (East et al,
2007 Level I). Although improvement in perineal pain has been reported with ultrasound, there
is insufficient evidence to fully evaluate efficacy (Hay‐Smith, 2000 Level I).
For women without prior vaginal delivery, antenatal perineal massage (from 35 weeks
gestation) reduced the incidence of perineal trauma requiring suturing (NNT 14; CI 9 to 35)
and the requirement for episiotomy (NNT 23; CI 13 to 111), but values for NNT were high.
394 Acute Pain Management: Scientific Evidence
