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Postpartum Pain Management (2021)
About the Guideline
• The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric
Practice developed this practice guideline.
• This is an update of the 2018 ACOG committee opinion 742, Postpartum Pain Management.
• ACOG medical librarians searched Cochrane Library, Cochrane Collaboration Registry of
Controlled Trials, EMBASE, PubMed, and MEDLINE for human-only studies written in English.
• Search terms for implicit bias and racial and ethnic disparities in the assessment and treatment
of pain were incorporated into the literature review, and recommendations were drafted with
the intent to promote health equity and to reduce these disparities.
• All recommendation statements were presented and voted on at a meeting of the Committee
on Clinical Consensus. All statements either met or exceeded the 75% approval threshold
required for consensus.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline,
especially if you work in an acute care setting.
General Considerations
• Practitioners should be familiar with safe and effective pharmacologic and nonpharmacologic
therapies for postpartum pain management.
• Practitioners should practice shared decision-making with patients regarding their preferences
for pain management.
o This can improve patient satisfaction, decrease the amount of opioid prescribed, and
reduce opioid misuse and diversion.
• Practitioners should be aware of racial and ethnic inequities that exist in the assessment and
treatment of pain, and they should acknowledge the ways in which their own biases may
contribute to the care they provide.
• Practitioners should use a stepwise multimodal approach to effectively individualize postpartum
pain management.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first-line medications for the
management of postpartum pain in all patients, including patients with hypertensive disorders
of pregnancy.
Vaginal Birth
• Breast engorgement, uterine contractions, and perineal lacerations are the most common
sources of pain after a vaginal birth.
• A multimodal approach to analgesia—using a combination of an NSAID, acetaminophen, and an
opioid, if needed—may be a better approach to pain management than using an NSAID alone.
• Administration of an NSAID and acetaminophen on a set schedule is preferred over the use
of acetaminophen-opioid combinations. The scheduled delivery of medications may decrease
overall opioid use.
• Stronger opioids should be used only if absolutely needed for adequate pain control after a
reasonable trial of other pain control methods and combinations.
December 2023
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o Clinical evaluation is warranted if stronger opioids are required for opioid-naïve patients
after an uncomplicated birth.
• Adjunct pharmacologic or nonpharmacologic strategies for pain relief may include the following:
o Uterine cramping: heating pads to the abdomen and concomitant use of NSAIDs, which
have been shown to be more effective than acetaminophen.
o Perineal pain: topical anesthetics, topical agents, or oral analgesics. Ice packs or cold gel
packs may also be useful for reducing edema in the first 24 hours.
o Hemorrhoids: topical astringent, steroid, or anesthetic creams.
Cesarean Birth
• Neuraxial opioids provide the greatest post cesarean birth analgesia, but the effects diminish,
and additional analgesia is often required.
• Standard oral treatments may include acetaminophen, NSAIDs, opioids, and opioid combination
formulas.
• Preoperative IV administration of acetaminophen is safe for use around delivery time and can
provide postoperative opioid sparing effects.
• A single dose of dexamethasone in the preoperative period has been shown to
reduce nausea and vomiting in the first 24 hours; however, there is conflicting data related to
dexamethasone's effect on pain control.
• Parenteral and oral opioids should be utilized to treat breakthrough pain when nonopioid
adjuncts are inadequate.
o Parenteral opioid administration should be reserved for women with persistent pain or
for those who cannot tolerate oral medications.
• If continued administration of parenteral opioids is necessary, the use of patient-controlled
analgesia is preferred.
• Utilizing a transversus abdominis plane block may be beneficial for pain management.
Discharge Medication
• Studies have shown that the amount of opioid prescribed upon discharge often exceeds the
amount needed or consumed. This increases cost and safety concerns.
• Prescription of opioids should be for the shortest duration expected for treating acute pain.
• Pain control upon discharge is critical and should be individualized.
Breastfeeding Considerations
• Orally administered NSAIDs and acetaminophen are excreted into breastmilk in relatively low
concentrations; they are therefore considered first-line analgesics for patients with postpartum
pain who are providing breast milk to their infants.
• IV ketorolac may also be used for managing moderate pain in the immediate postpartum period
in patients who intend to provide breast milk to their infants.
• If opioids are prescribed, monitoring for excessive sedation and adverse effects in the newborn
is prudent.
• If opioid analgesics are prescribed, the mother should be advised of the risks of central nervous
system depression to herself and the breastfed newborn.
• If a codeine-containing medication is prescribed, the duration of therapy and neonatal signs of
toxicity should be reviewed with patients and their families.
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Discharge Considerations
• Practitioners should practice shared decision-making with patients regarding pain
management after hospital discharge, especially when incorporating pharmacologic
interventions that may include opioids.
o Consideration should be given to the patient's condition and preferences, risks, benefits,
and alternative pain management modalities.
• Opioids should be prescribed for the shortest duration reasonable to treat acute
pain at discharge.
o NSAIDs and acetaminophen should be used as liberally as appropriate to reduce opioid
requirements.
Reference
American College of Obstetricians and Gynecologists. (2021). Pharmacologic stepwise multimodal approach for postpartum
pain management, ACOG clinical consensus no. 1. Obstetrics and Gynecology, 138(3), 507–517. (Level VII)
