Page 443 Acute Pain Management

Effects on acute postpartum pain have not been reported, but a reduction in the incidence of
pain at 3 months postpartum was reported in women who used antenatal massage and had
previously given birth vaginally (Beckmann & Garrett, 2006 Level I).
Pharmacological treatments
Paracetamol is moderately effective for perineal pain during the first 24 hours after birth.
nsNSAID suppositories reduced perineal pain in the first 24 hours postpartum (Hedayati et al,
2003 Level I). Both oral celecoxib and diclofenac reduced perineal pain, with slight advantages
of celecoxib for pain scores at rest and incidence of gastrointestinal symptoms (Lim et al, 2008
Level II).
Topical local anaesthetics (lignocaine, cinchocaine, pramoxine plus hydrocortisone
preparations) and placebo did not improve pain relief in the 24 hours postpartum. One trial
reported a reduction in supplemental analgesic requirements with epifoam (1% hydro‐
cortisone and 1% pramoxine in mucoadhesive base). The use of systemic analgesics was not
standardised across studies and may be a confounding factor (Hedayati et al, 2005 Level I).
Following mediolateral episiotomy repair under epidural analgesia, a pudendal block with
ropivacaine improved pain scores and reduced the proportion of women requiring additional
analgesia (Aissaoui et al, 2008 Level II).
Breast pain
Painful breasts are a common reason for ceasing breastfeeding (Morland‐Schultz & Hill, 2005).
Management is firstly directed toward remedying the cause, whether this is infant‐related
(incorrect attachment, sucking, oral abnormalities); lactation‐related (breast engorgement,
blocked ducts or forceful milk ejection); nipple trauma; dermatological or infective problems
(Candida or mastitis); or other causes (Amir, 2003).
Nipple pain is experienced by 30% to 90% of women and tends to peak around the third day
postpartum (Morland‐Schultz & Hill, 2005). Topical agents (such as lanolin, wet compresses,
hydrogel dressings, collagenase or dexpanthenol ointment) produce mild improvements in
nipple pain, but no one agent was shown to be superior. Education in relation to proper
breastfeeding technique is important for decreasing the incidence of nipple pain (Morland‐
Schultz & Hill, 2005 Level I).
Mastitis defined by at least two breast symptoms (pain, redness or lump) and at least one of
fever or flu‐like symptoms occurs in 17% to 33% of breastfeeding women, with most episodes
occurring in the first 4 weeks (Amir et al, 2007 Level IV; Jahanfar et al, 2009 Level I). Infective
mastitis is most commonly from Staphylococcus aureus, and non‐infective mastitis is equally
common. Currently, there is insufficient evidence to confirm efficacy for antibiotics in relieving
symptoms, but only two trials met the inclusion criteria for analysis (Jahanfar et al, 2009 Level I).
Symptomatic therapies for breast engorgement have been inadequately investigated, but CHAPTER 11
cabbage leaves and cabbage extract cream were no more effective than placebo (Snowden et
al, 2001 Level I). Similarly, ultrasound was not effective and observed benefits may be due to
the effect of radiant heat or massage (Snowden et al, 2001 Level I).
Uterine pain
Uterine pain or ‘after pains’ often worsen with increasing parity, are experienced by most
multiparous women, and result from the release of oxytocin from the posterior pituitary gland
especially in response to breastfeeding. Lower abdominal pain may be mild to severe,
accompanied by back pain and is described as throbbing, cramping and aching. Ergot alkaloids
during the third stage of labour increased the requirement for analgesia for pain after birth
due to persistent uterine contraction (RR 2.53; CI 1.34 to 4.78), but also decreased mean blood

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