Page 45 Acute Pain Management

8. Local anaesthetic wound infiltration and abdominal nerve blocks reduce opioid
consumption following Caesarean section (N) (Level I [Cochrane Review]).
9. Continuous or one‐to‐one support by a midwife or trained layperson during labour
reduces analgesic use, operative delivery and dissatisfaction (U) (Level I).
10. There is no significant difference in any outcome between use of bupivacaine and
ropivacaine for epidural labour analgesia (U) (Level I).
11. Patient‐controlled epidural analgesia provides effective analgesia but optimal settings are
not clear (N) (Level I).
12. Single‐injection intrathecal opioids provide comparable early labour analgesia to epidural
local anaesthetics with increased pruritus (U) (Level I).
13. Systemic opioids in labour increase the need for neonatal resuscitation and worsen acid‐ SUMMARY
base status compared with regional analgesia (U) (Level I).
14. Nitrous oxide has some analgesic efficacy and is safe during labour (U) (Level I).
Pain management during lactation
 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).

Pain management in the puerperium
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).

 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).

The older patient
1. Experimental pain thresholds to a variety of noxious stimuli are altered in older people;
there is also a reduction in tolerance to pain (Q) (Level I).

2. PCA and epidural analgesia are more effective in older people than conventional opioid
regimens (U) (Level II).

Acute pain management: scientific evidence xlv