One thing I think antenatal classes cover well is pain relief options for labour. What is perhaps not so well covered is how to manage pain after birth.
Dr Danny Morland, Consultant Anaesthetist at the Royal Victoria Infirmary in Newcastle-upon-Tyne, has very kindly answered some of my questions about pain and pain management in the postpartum period.
Here is what we discussed.
Disclaimer: I come from a very anaesthetic school of thought and we provide acute pain relief (analgesia) and anaesthesia for delivery and for complications arising from these, for example repair of perineal trauma, manual removal of placenta etc. I don’t usually deal quite so much with pain post-delivery except in the acute postoperative phase.
1 – Would you be able to give us some insight about what is to be expected after birth?Pain after birth depends very much on the type of delivery that one has experienced. Pain after operative delivery (caesarean section or forceps, for example) will be worse than after uncomplicated vaginal birth. Sometimes the way baby was presented (for example occipito-posterior or ‘back to back’) can lead to a more painful delivery. Pain can also come from a variety of sources; a vaginal birth can give rise to more pain in the perineal, ‘saddle’, area than after caesarean section, which will entail pain in the lower abdomen and operative site. A ‘traumatic’ birth that involves tissue damage requiring surgery to repair will also be much more painful than an uncomplicated, non-traumatic birth. Pain is also by nature very subjective, meaning two women having apparently identical deliveries can have very different experiences of pain afterwards. Finally, severe pain after any delivery is not normal and medical attention should be sought.
2 – Are there general pain management principles that you think would be useful for new mums to know?
I am very much a fan of ‘whatever gets you through the night’. If it works for you, use it. There are non-drug methods that some find very useful, such as warm or cold packs to tender areas. Also, don’t feel bad about using medication in the acute period following delivery. People are worried about using medications for fear of becoming dependent, ‘putting things into their system’ or harming baby in some way. None of the drugs that we use in the postnatal period are known to be harmful to baby and you can’t become physically ‘addicted’ to simple analgesics (drugs that one could buy in the supermarket, paracetamol and ibuprofen for example). Even with weak opioids, such as dihydrocodiene, addiction occurs in very few susceptible individuals after weeks to months of use for chronic conditions, not acute postnatal pain.
3 – What happens when you are still in hospital? How is pain controlled then?
Again, a lot depends on the mode of delivery. Simple, uncomplicated deliveries can be managed with simple analgesics like paracetamol and ibuprofen, drugs you can buy in the supermarkets. The midwives may also be able to advise on non-drug methods such as warm/cold packs for womb pain. More complicated deliveries, such as those requiring obstetricians to deliver and/or the use of instruments may need something a bit stronger; opioids like dihydrocodeine or oral morphine can be useful here. Caesarean section will be the next level up. If you have a spinal anaesthetic for a caesarean section in this country you will almost certainly have diamorphine put into your spinal. This provides excellent postoperative pain relief with very few and mostly minor side effects (usually itch, at worst). For women who have to have a general anaesthetic, pain tends to be worse and they may well require intravenous morphine infusions, at least for the first 12-24hrs. Anaesthetists can also use local anaesthetic techniques in these cases, such as Transversus Abdominis Plane blocks (TAP blocks) or Quadratus Lumborum (QL) blocks. These are injections of local anaesthetic into the abdominal wall under ultrasound guidance in an attempt to numb the nerves supplying the area cut through for caesarean section.
4 – What happens if there is severe trauma? Could you give some examples?
If the woman underwent operative delivery, we would manage it as above. If the woman suffers trauma during the birth process, this can happen during vaginal delivery (spontaneous or assisted) or as a complication of caesarean section. Complications during caesarean section are managed there and then (e.g. extension of uterine incision, broad ligament tears) and the pain managed in the same way as standard caesarean section. Vaginal birth trauma is more complicated and will often require proper evaluation and repair under anaesthesia. These can be perineal tears (perineum is the area between the vagina and anus in a woman) and are graded according to extent; 1 and 2 are relatively easy to repair and usually done in the delivery room by a midwife. 3 and 4 are much more extensive and will require surgical repair in the theatre under anaesthesia. These can be very sore afterwards. If it were me I would like a spinal anaesthetic with diamorphine, then simple analgesics afterwards avoiding opioids if possible because of the risk of constipation. Trauma can also be sustained anywhere in the genital tract, such as vaginal or cervical tears. I would ask an obstetrician about these!
5 – What happens once women go home or if they gave birth at home? What would you recommend they do?
Home birth is not really in my area of expertise, sorry. Simple analgesics for mild-moderate pain, seek help if pain is severe, out of proportion to what is expected or an injury is suspected. If going home after birth in hospital then simple analgesics and short courses of weak opioids should suffice, along with any non-drug methods found to be useful. Severe pain should be a red flag as can mean a complication (infection, haematoma – these are blood collections which need draining – for example) and help should be sought.
6 – We know that constipation should be banished after birth. Can women still use opioid based drugs like cocodamol which have constipation as a side effect?
This is difficult as opioids are so good and are often all we have left after exhausting the simple options. First of all maximise your simple drugs; paracetamol 1g four times a day regularly and ibuprofen 400mg three times a day. Alternate these to spread the analgesic effect. After these one is looking at opioids unfortunately (beware, cocodamol contains paracetamol so beware of overdose, 4g/day of paracetamol is max). A pragmatic technique is to use a laxative concurrently, such as senna or movicol, to keep stools loose. Or live with the discomfort over constipation, which I suspect many people choose to do!
7 – Is it worth scoring your pain? If yes, what is the best way of doing that? (how regularly and for how long for example or would you have a link to a good resource?)
We do score pain in hospital in the acute period. I’m not sure it’s worth doing routinely, but if something isn’t right and you’re seeking help then a measure of severity can be useful. We often use a score of ten in hospital, where 0 is complete comfort, 1 is a little niggle and 10 the worst pain you can imagine. Generally speaking, 1-3 is minor, 4-6 moderate and 7-10 would be severe.
8 – Are there any pain red flags? Possibly calf or chest pain?
Severe pain, wherever it is located, is a red flag. If you score 7 to 10 on a scale of 10, you should seek medical attention.
Calf pain is unusual and should be treated as a red flag, particularly if the pain is on one side only. Other calf symptoms include redness, tenderness or feeling warm to the touch. Help should be sought fairly swiftly as these can be signs of Deep Vein Thrombosis (DVT). We know that some women are at higher risk than other of developing DVT, such as those undergoing caesarean section or assisted deliveries in the operating theatres. Some things can help protect against DVT, for example early mobilisation or compression stockings, but usually there will be an individualised plan according to the risk in the postnatal period, which may even include a period of injectable blood-thinners (heparin, for example) in those at very high risk.
Chest pain is never normal and in the perinatal period could be a sign of a blood clot in the chest vessels, or Pulmonary Embolus (PE). If the pain is moderate to severe, you need to be checked.
If you had epidural analgesia or a spinal block, there is around a 1% chance of developing a post dural puncture headache. The headache usually comes on within a day or two of the intervention. Call your midwife, GP or the hospital you delivered at if you feel unwell.
Mild back pain after childbirth has many causes and is quite common. Moderate to severe back pain or acute onset after delivery in women who have had a spinal or epidural for delivery can be a sign of an extremely rare complication; infection in the spine or epidural abscess. We would not usually be worried by back pain alone and would expect other signs such as fever and nerve signs such as new numbness, weakness or heaviness in legs. This needs immediate attention. Generally though, blood clots or an infection of the spinal cord are very rare complications and back pain is much more likely to be due to common, self-limiting causes following childbirth.
Some types of sepsis, such as endometritis, can present with lower abdominal pain. These will often be associated with other symptoms such as general unwellness, fever or discharge.
9 – When do you know you can stop pain medication?
When you are ready for it. You can take simple analgesia for as long as you feel you need. Paracetamol is very safe. Ibuprofen has some side effects and can cause gastric irritation. As described above, be mindful that cocodamol contains paracetamol.
Opioids can cause constipation and can make some feel ‘foggy’. They are not recommended for long-term use as they can cause dependence in some people. But as long as you are in pain, take analgesic drugs.
You will be given a limited supply after a caesarean section. If you need more see your GP. Dihydrocodeine for acute pain probably shouldn’t be used for longer than a month, to put a ballpark figure on it. If you are still in pain after 1 or 2 months, go and see your GP again
10 – Sometimes postpartum pain can become chronic. I’m thinking of nerve damage or something like coccyx pain. When is pain considered to be chronic and what can be done about it?
Pain is a spectrum and it is difficult to define when acute pain becomes chronic. Three months is a general criteria for chronic pain but some acute pain can resolve beyond that point. Chronic pain has different mechanisms to acute pain. The brain and nervous system keep reacting beyond the point when the initial tissue damage is no longer there. Generally, the brain picks up on pain signals via the spinal cord and is able to modify these signals via downward impulses. These modifications usually supress the pain nerves in the spinal cord. However, in chronic pain the nervous system becomes activated and instead of suppressing pain can actually ‘create’ or perceive pain when the impulses from the periphery are no longer there.
Coccyx pain can be seen as ongoing acute pain.
Although nerve damage can happen with any type of delivery, there is an increased risk with caesarean sections and instrumental deliveries. Medium to long-term caesarean section wound pain probably has a higher incidence than we think. The obstetrician cuts through the nerves to access the baby and most women will feel numbness around the scar. Some of these women will actually go on to develop chronic post-surgical pain. With a vaginal delivery (and particularly with instruments), nerve damage can occur because of a compression of the pelvic nerves due to the baby’s head coming down or when the baby is rotated with instruments.
The nature of nerve pain is often different to acute pain. Common descriptions of chronic, nerve pain include burning, heat or ‘electric shock’ sensations.
11- 10 to 15% of women develop postnatal depression. What are the links (if any) between pain and mental health conditions? Can antidepressants be used as part of pain management?
It is a two way process. If you are in pain, you are more likely to develop depression and pain will make depression worse. And if you are depressed, your pain might feel worse. With nerve pain, you can get long term changes in the structure of the brain that make you more susceptible to depression.
There are treatments for chronic pain based on antidepressants and drugs that act on nerves such as amitriptyline or anticonvulsant drugs such as gabapentin.
If you experience ongoing pain that is lasting beyond 3 months, see your GP. They might refer you to a pain clinic where a pain physician can make an assessment and advise on treatment.