New ACOG guidelines on postpartum pain management

The American College of Obstetricians and Gynecologists has released new recommendations on managing pain in women who've recently given birth. The recommendations are published in the journal Obstetrics & Gynecology.

Pain and fatigue are the most common problems faced by women in the early postpartum period. Pain can interfere with a woman’s ability to care for herself and her infant. Untreated pain is associated with postpartum depression,
a risk of greater opioid use, and development of persistent pain. Nonpharmacologic and pharmacologic therapies are important components of postpartum pain management.

Key Recommendations:

• To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs


• Anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to parenthood and well-woman care.


• For postoperative cesarean pain, standard oral and parenteral analgesic adjuvants include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and opioids that are in combination formulations with either acetaminophen or an NSAID.


• Prenatal discussions should include the woman’s reproductive life plans, including a desire for and timing of any future pregnancies. A woman’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.


• All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.


• The timing of the comprehensive postpartum visit should be individualized and woman-centered.


• The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being.


• Parenteral or oral opioids should be reserved for treating breakthrough pain when analgesia from the combination of neuraxial opioids and nonopioid adjuncts becomes inadequate.


• Women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.


• Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders, should be counseled regarding the importance of timely follow-up with their obstetrician-gynecologists or primary care providers for ongoing coordination of care.


• For a woman who has experienced a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician-gynecologist or other obstetric care providers.


• Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.


• Clinicians should use a stepwise approach with a combination of agents to individualize pain management for postpartum women.

A stepwise, multimodal approach emphasizing nonopioid analgesia as first-line therapy is safe and effective for vaginal deliveries and cesarean deliveries. Opioid medication is an adjunct for patients with uncontrolled pain despite adequate first-line therapy. A shared decision-making approach to postpartum discharge opioid prescription can optimize pain control while reducing the number of unused opioid tablets.