Page 444 Acute Pain Management
P. 444
loss and the incidence of postpartum haemorrhage compared with no uterotonic drugs
(Liabsuetrakul et al, 2007 Level I).
Paracetamol and nsNSAIDs had similar efficacy for reducing uterine cramping pain and were
modestly effective compared with placebo (Skovlund et al, 1991a Level II; Skovlund et al, 1991b
Level II; Huang et al, 2002 Level II; Hsu et al, 2003 Level II).
High‐intensity TENS was more effective than low‐intensity TENS for postpartum uterine pain,
but also produced more local discomfort (Olsen et al, 2007 Level III‐2).
Key messages
1. Routine episiotomy does not reduce perineal pain (U) (Level I).
2. Paracetamol and non‐selective NSAIDs are effective in treating perineal pain after
childbirth (U) (Level I).
3. Paracetamol and non‐selective NSAIDs are equally but only modestly effective in treating
uterine pain (U) (Level II).
4. Topical agents may improve nipple pain, but no one treatment is superior (N) (Level I).
5. There is only limited evidence to support the effectiveness of local cooling treatments in
treatment of perineal pain after childbirth (Q) (Level I).
6. Topical local anaesthetic preparations are not effective for perineal pain after childbirth
(N) (Level I).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Pain after childbirth requires appropriate treatment as it coincides with new emotional,
physical and learning demands and may trigger postnatal depression (U).
Management of breast and nipple pain should target the cause (U).
11.2 THE OLDER PATIENT
The need to manage acute pain in the older patient is becoming more common as the
population ages. Advances in anaesthetic and surgical techniques mean that increasingly older
patients, including patients over 100 years old (Konttinen & Rosenberg, 2006), are undergoing
CHAPTER 11 more major surgery (Kojima & Narita, 2006). Medical conditions that are more common in older
people may also lead to acute pain; these include acute exacerbations of arthritis,
osteoporotic fractures of the spine, cancer and pain from other acute medical conditions
including ischaemic heart disease, herpes zoster and peripheral vascular disease.
Factors that can combine to make effective control of acute pain in the older person more
difficult than in younger patients include: a higher incidence of coexistent diseases and
concurrent medications, which increases the risk of drug‐drug and disease‐drug interactions;
age‐related changes in physiology, pharmacodynamics and pharmacokinetics; altered
responses to pain; and difficulties with assessment of pain, including problems related to
cognitive impairment.
396 Acute Pain Management: Scientific Evidence
