Treating Pain after C-section — Highlights from ACOG’s Guidelines
Postpartum pain after cesarean delivery is not just an unpleasant experience for women, but a strong predictor for developing chronic pain later, according to the American College of Obstetricians and Gynecologists (ACOG).1
According to a 2018 study in Anesthesia & Analgesia, women who have had C-sections, which constitute more than 32% of all live births every year, 2 are at triple the risk of adverse effects such as postpartum depression and difficulty with breastfeeding and infant care. Of the nearly 1.3 million C-sections performed, approximately 1 in 5 women are also likely to have “severe acute postoperative pain.”2
Thus, researchers suggest that it is important to manage postoperative pain with adequate analgesia in women who have cesarean delivery. ACOG has published new recommendations for the management of postpartum pain in women who have had C-sections.1
A multimodal approach
Since the pain that is associated with a C-section is “complex”,2 and can vary in both intensity and type,1 providers should avoid a “one-size-fits all” approach in favor of a “multimodal, stepwise” combination of medications and therapies to manage postpartum pain “emphasizing nonopioid analgesia as first-line therapy.”1
The ACOG guidelines take into consideration that 1 in 300 patients prescribed opioids may become “persistent users”,1 thus recommending that providers reserve parental and oral opioids for breakthrough pain when other medication options are inadequate.1
They suggest following a threestep approach derived by the World Health Organization (WHO): Step one is to use non-opioid analgesics such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs). Step two is to add mild opioids such as codeine, hydrocodone, oxycodone or tramadol. Step three would be to move up to the strongest opioids such as parenteral morphine, hydromorphone, and fentanyl.
ACOG suggests that some women may want to consider local anesthetics delivered by wound infiltration or transversus abdominus plane (TAP) block after C-section. The medication is delivered by a blunt-tip needle between the internal oblique and transversus abdominus muscles, and aims to block pain in the peripheral nerves that innervate the lower abdomen.
Considerations for breastfeeding women
Obstetric care providers should discuss the risks and benefits of analgesic options with breastfeeding women.1 Opioid analgesics can depress the central nervous system in both mother and infant, so families should be made aware of the risks and taught to look for signs in their infants if they choose this route while breastfeeding.
A 2013 study in Anesthesiology3 found that asking three simple preoperative screening questions about anxiety, anticipated pain and analgesic needs helped providers predict which women were likely to have a higher pain sensitivity,1 and yielded a “validated model” for predicting pain comparable to a more general pain threshold test known as quantitative sensory testing.
In general, shared decision-making is the recommended approach not only for helping women achieve the best and safest analgesic pain, but also to reduce the waste of unused opioid tablets.1
ACOG cites recent studies that show that opioids are often overprescribed after C-section, resulting in wasted or unused medications. Though they emphasize the importance of not under-medicating pain, they recommend that shared decision-making and practitioner awareness that standard order sets may contain more pills than the individual patient needs, can also “optimize pain control while reducing the number of unused opioid tablets.”1
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion on Postpartum Management. Vol. 132. No.1, July, 2018.
- Gamez, Brock, H. S; Habib, Ashraf, S., MBBCh, MSc, MHSc, FRCA. Anesthesia & Analgesia: Predicting Severity of Acute Pain After Cesarean Delivery: A Narrative Review. May 2018-vol. 126, Issue 5. P 1606-1614. Doi: 10.1213/ANE.0000000000002658.
- Pan, Peter H. M.S.E.E., M.D. Anesthesiology. 2013 May: 118(5): 1170-1179. Predicting Acute Pain after Cesarean Delivery Using Three Simple Questions. Doi: 10.1097/ALN.0b013e31828e156f.