Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period

Is mediolateral episiotomy angle associated with postpartum perineal pain in primiparous women?

OBJECTIVE:

Our aim is to elucidate the relationship between mediolateral episiotomy (MLE) angle and postpartum perineal pain.

METHODS:

This study was designed prospectively. Primiparous women with MLE in the postpartum period were included in the study and divided into three groups according to episiotomy angle ranges (Group 1: <40°, Group 2: 40°–60°, and Group 3: >60°). Postpartum perineal pain was quantified with the short-form McGill Pain questionnaire (SF-MPQ) consisting of the following three parts: Sensory-affective-verbal descriptions, visual pain scale (VPS), and present pain intensity scale (PPI). Postpartum perineal pain scores on days 1 and 7 were compared among the angle group.

RESULTS:

Overall, 86 eligible women were enrolled in this study. Seventy-three women (85%) scored the perineal pain between 0 and 3 on the VPS and 13 women (15%) rated the pain from 4 to 6 on the 1^st postpartum day. No significant differences were noted among the three groups regarding the total pain scores on SF-MPQ and on the each part of form at the 1^st postpartum day. At 7 days postpartum, total pain score was found significantly high in Group 1 [Med; IQR (min-max)=0; 4 (0–5)] compared with Group 2 [Med; IQR (min-max)=0; 0(0–5)]. The pain scores obtained from the sensory, affective, VPS, and PPI parts of the questionnaire were [Med; IQR (min-max)=0; 1 (0–2)], [Med; IQR (min-max)=0; 1 (0–1)], [Med; IQR (min-max)=0; 2 (0–2)], and [Med; IQR (min-max)=0; 0.25 (0–1)], respectively, in Group 1. For Group 2, pain scores obtained from the sensory, affective, and PPI were [Med; IQR (min-max)=0; 0(0-1)]; and VPS was [Med; IQR (min-max)=0; 0(0-2)]. No significant differences were observed between Groups 1 and 2 for each part of the questionnaire on day 7. Percentage of need for analgesics on day 7 was found significantly higher in Group 1 (42.9%) than Group 2 (31.2%)

CONCLUSION:

MLE at an angle <40° to the midline is associated with a higher score of perineal pain and an increase need for analgesics during the early postpartum days.

Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period

BACKGROUND

Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative vaginal births (ventouse or forceps-assisted births). This is an update of a review last published in 2013.

OBJECTIVES

To determine the efficacy of a single administration of paracetamol (acetaminophen) used in the relief of acute postpartum perineal pain.

SEARCH METHODS

For this update, we searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (9 December 2019), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-RCTs, comparing paracetamol to placebo. We excluded quasi-RCTs and cross-over trials. Data from abstracts would be included only if authors had confirmed in writing that the data to be included in the review had come from the final analysis and would not change.

DATA COLLECTION AND ANALYSIS

Two review authors assessed each study for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

This update identified no new trials so the results remain unchanged. However, by applying the GRADE assessment of the evidence, the interpretation of main results differed from previous version of this review. We identified 10 studies involving 2044 women, but all these studies involved either three or four groups, looking at differing drugs or doses. We have only included the 1301 women who were in the paracetamol versus placebo arms of the studies. Of these, five studies (482 women) assessed 500 mg to 650 mg and six studies (797 women) assessed 1000 mg of paracetamol. One study assessed 650 mg and 1000 mg compared with placebo and contributed to both comparisons. We used a random-effects meta-analysis because of the clinical variability among studies. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context. The certainty of the evidence for the two primary outcomes on which data were available was assessed as low, downgraded for overall unclear risk of bias and for heterogeneity (I² statistic 60% or greater). More women may experience pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89; 10 trials, 1279 women), and fewer women may need additional pain relief with paracetamol compared with placebo (average RR 0.34, 95% CI 0.21 to 0.55; 8 trials, 1132 women). However, the certainty of the evidence was low, downgraded for unclear overall risk of bias and substantial heterogeneity. One study used the higher dose of paracetamol (1000 mg) and reported maternal drug adverse effects. There may be little or no difference in the incidence of nausea (average RR 0.18, 95% CI 0.01 to 3.66; 1 trial, 232 women; low-certainty evidence), or sleepiness (average RR 0.89, 95% CI 0.18 to 4.30; 1 trial, 232 women; low-certainty evidence). No other maternal adverse events were reported. None of the studies assessed neonatal drug adverse effects.

AUTHORS' CONCLUSIONS

A single dose of paracetamol may improve perineal pain relief following vaginal birth, and may reduce the need for additional pain relief. Potential adverse effects for both women and neonates were not appropriately assessed. Any further trials should also address the gaps in evidence concerning maternal outcomes such as satisfaction with postnatal care, maternal functioning/well-being (emotional attachment, self-efficacy, competence, autonomy, confidence, self-care, coping skills) and neonatal drug adverse effects.

Women's experience of episiotomy: a qualitative study from China

OBJECTIVE

To describe women's experience of episiotomy in urban China.

DESIGN

This is a semistructured, indepth interview with women after episiotomy. We analysed transcriptions using thematic analysis in Chinese. Emerging themes were debated in English to finalise interpretation.

SETTING

Two community health centres and four hospitals in Shanghai, China.

PARTICIPANTS

Purposive sampling of 30 postpartum women who had experienced episiotomy; 25 were primiparous and 4 had deliveries by forceps. We interviewed health providers to complement the data.

RESULTS

We identified four main themes: (1) women's views of the procedure vary considerably; (2) pain interferes with daily life for weeks; (3) long-term anxiety is a consequence for some, described as a 'psychological shadow'; and (4) societal norms assume women will not complain.

CONCLUSION

Women receive little information in advance about episiotomy, yet the procedure has a wide range of physical and psychological consequences. This includes long-term anxiety about the damage done to them as women.

Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting

BACKGROUND

The female perineum becomes suffused and stretched during pregnancy, and further strain during vaginal childbirth contributes to approximately 85% of women experiencing some degree of trauma to the perineal region. Multiple factors play a role in the type and severity of trauma experienced, including parity, delivery method, and local practices. There is ongoing debate about best midwifery practice to reduce perineal trauma. Once perineal trauma has occurred, treatment also varies greatly, depending on its degree and severity, local practice and customs, and personal preference. In order to optimise wound-healing outcomes, it is important that wounds are assessed and managed in an appropriate and timely manner. A perineal wound may cause significant physical and/or psychological impact in the short or long term, however little evidence is available on this subject.Antenatal education serves to prepare women and their partners for pregnancy, delivery and the postpartum period. The delivery of this education varies widely in type, content, and nature. This review examined antenatal education which is specifically tailored towards perineal care and wound healing in the postnatal period via formal channels. Appropriate patient education positively impacts on wound-healing rates and compliance with wound care. Risk factors that contribute to the breakdown of wounds and poor healing rates may be addressed antenatally in order to optimise postnatal wound healing. It is important to assess whether or not antenatal wound-care education positively affects perineal healing, in order to empower women to incorporate best practice, evidence-based treatment with this important aspect of self-care in the immediate postnatal period.

OBJECTIVES

To evaluate the effects of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who have experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2017), ClinicalTrials.gov (8th September 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (8th September 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) which referred to all formal methods of antenatal education and addressed care of a potential perineal wound as a result of a tear or episiotomy, which was experienced by pregnant women who planned to give birth within a hospital setting.Trials using a cluster-RCT and a quasi-randomised design would have been eligible for inclusion in this review but none were identified. Cross-over trials were not eligible for inclusion in this review. Studies published in abstract form would have been eligible for inclusion in this review, but none were identified.We planned to consider all formal methods of antenatal education which addressed care of a perineal wound. We also planned to consider all contact points where there was an opportunity for formal education, including midwifery appointments, antenatal education classes, obstetrician appointments, general practitioner appointments and physiotherapist appointments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for their eligibility.

MAIN RESULTS

No studies met the inclusion criteria for this review. We excluded one study and one other study is ongoing.

AUTHORS' CONCLUSIONS

We set out to evaluate the RCT evidence pertaining to the impact of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both. However, no studies met the inclusion criteria. There is a lack of evidence concerning whether or not antenatal education relating to perineal wound healing in this cohort of women will change the outcome for these women in relation to wound healing, infection rate, re-attendance or re-admission to hospital, pain, health-related quality of life, maternal bonding, and negative emotional experiences. Further study is warranted in this area given the significant physical, psychological and economic impact of perineal wounds, and the large proportion of childbearing women who have experienced a postnatal wound. The benefits of any future research in this field would be maximised by incorporating women in a range of socio-economic groups, and with a range of healthcare options. This research could take both a qualitative and a quantitative approach and examine the outcomes identified in this review in order to assess fully the potential benefits of a tailored antenatal package, and to make recommendations for future practice. There is currently no evidence to inform practice in this regard.

Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period

BACKGROUND

Many women experience perineal pain after childbirth, especially after having sustained perineal trauma. Perineal pain-management strategies are thus an important part of postnatal care. Non-steroidal anti-inflammatory drugs (NSAIDs) are a commonly used type of medication in the management of postpartum pain and their effectiveness and safety should be assessed.

OBJECTIVES

To determine the effectiveness of a single dose of an oral NSAID for relief of acute perineal pain in the early postpartum period.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2016), OpenSIGLE, ProQuest Dissertations and Theses, the ISRCTN Registry and ClinicalTrials.gov (31 March 2016). We also reviewed reference lists of retrieved papers and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing a single dose of a NSAID versus a single dose of placebo, paracetamol or another NSAID for women with perineal pain in the early postpartum period. Quasi-RCTs and cross-over trials were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors (FW and VS) independently assessed all identified papers for inclusion and risk of bias. Any discrepancies were resolved through discussion and consensus. Data extraction, including calculations of pain relief scores, was also conducted independently by two review authors and checked for accuracy.

MAIN RESULTS

We included 28 studies that examined 13 different NSAIDs and involved 4181 women (none of whom were breastfeeding). Studies were published between 1967 and 2013, with the majority published in the 1980s. Of the 4181 women involved in the studies, 2642 received a NSAID and 1539 received placebo or paracetamol. Risk of bias was generally unclear due to poor reporting, but in most studies the participants and personnel were blinded, outcome data were complete and the outcomes that were specified in the methods section were reported.None of the included studies reported on any of this review's secondary outcomes: prolonged hospitalisation or re-hospitalisation due to perineal pain; breastfeeding (fully or mixed) at discharge; breastfeeding (fully or mixed) at six weeks; perineal pain at six weeks; maternal views; postpartum depression; instrumental measures of disability due to perineal pain. NSAID versus placeboCompared to women who received a placebo, more women who received a single dose NSAID achieved adequate pain relief at four hours (risk ratio (RR) 1.91, 95% confidence interval (CI) 1.64 to 2.23, 10 studies, 1573 participants (low-quality evidence)) and adequate pain relief at six hours (RR 1.92, 95% CI 1.69 to 2.17, 17 studies, 2079 participants (very low-quality evidence)). Women who received a NSAID were also less likely to need additional analgesia compared to women who received placebo at four hours (RR 0.39, 95% CI 0.26 to 0.58, four studies, 486 participants (low-quality evidence)) and at six hours after initial administration (RR 0.32, 95% CI 0.26 to 0.40, 10 studies, 1012 participants (low-quality evidence)). Fourteen maternal adverse effects were reported in the NSAID group (drowsiness (5), abdominal discomfort (2), weakness (1), dizziness (2), headache (2), moderate epigastralgia (1), not specified (1)) and eight in the placebo group (drowsiness (2), light headed (1), nausea (1), backache (1), dizziness (1), epigastric pain (1), not specified (1)), although not all studies assessed adverse effects. There was no difference in overall maternal adverse effects between NSAIDs and placebo at six hours post-administration (RR 1.38, 95% CI 0.71 to 2.70, 13 studies, 1388 participants (very low-quality evidence)). One small study (with two treatment arms) assessed maternal adverse effects at four hours post-administration, but there were no maternal adverse effects observed (one study, 90 participants (low-quality evidence)). Neonatal adverse effects were not assessed in any of the included studies. NSAID versus paracetamolNSAIDs versus paracetamol were also more effective for adequate pain relief at four hours (RR 1.54, 95% CI 1.07 to 2.22, three studies, 342 participants) but not at six hours post-administration. There was no difference in the need for additional analgesia between the two groups at four hours (RR 0.55, 95% CI 0.27 to 1.13, one study, 73 participants), but women in the NSAID group were less likely to need any additional analgesia at six hours (RR 0.28, 95% CI 0.12 to 0.67, one study, 59 participants). No maternal adverse effects were reported four hours after drug administration (one study). Six hours post-administration, there was no difference between the groups in the number of maternal adverse effects (RR 0.74, 95% CI 0.27 to 2.08, three studies, 300 participants), with one case of pruritis in the NSAID group and one case of sleepiness in the paracetamol group. Neonatal adverse effects were not assessed in any of the included studies.Comparisons of different NSAIDs and different doses of the same NSAID did not demonstrate any differences in their effectiveness on any of the primary outcome measures; however, few data were available on some NSAIDs.

AUTHORS' CONCLUSIONS

In women who are not breastfeeding and who sustained perineal trauma, NSAIDs (compared to placebo) provide greater pain relief for acute postpartum perineal pain and fewer women need additional analgesia when treated with a NSAID. However, the risk of bias was unclear for many of the included studies, adverse effects were often not assessed and breastfeeding women were not included in the studies. The overall quality of the evidence (GRADE) was low with the evidence for all outcomes rated as low or very low. The main reasons for downgrading were inclusion of studies with high risk of bias and inconsistency of findings of individual studies.NSAIDs also appear to be more effective in providing relief for perineal pain than paracetamol, but few studies were included in this analysis.Future studies should examine NSAIDs' adverse effects profile including neonatal adverse effects and the compatibility of NSAIDs with breastfeeding, and assess other important secondary outcomes of this review. Moreover, studies mostly included women who had episiotomies. Future research should consider women with and without perineal trauma, including perineal tears. High-quality studies should be conducted to further assess the efficacy of NSAIDs versus paracetamol and the efficacy of multimodal treatments.

Intravenous paracetamol versus intramuscular pethidine in relief of labour pain in primigravid women

BACKGROUND

Intramuscular pethidine is one of most common opioids used for labour analgesia. There are a number of concerns in the literature regarding the use of pethidine. The aim of this study is to compare analgesic efficacy of paracetamol with pethidine for labour pain in normal vaginal delivery.

MATERIALS AND METHODS

In this single-blinded, randomised control trial, 80 primigravid singleton women with full-term pregnancy candidate for normal vaginal delivery, were entered the trial and divided in to pethidine (A) and paracetamol (B) groups. At the time of admission, age and body mass index of mother and gestational age based on last day of period were recorded. In both groups, intravenous promethazine and hyoscine were administered to each patient at the first stage of delivery. From beginning of active phase of delivery, patients in group A received 50 mg intramuscular pethidine injection. At the same time patients in group B, received an intravenous solution infusion containing 1000 mg paracetamol and 300 cc of normal saline. After child birth, average labour pain was assessed using Visual Analogue Scale (VAS) by direct questioning from patient in both groups.

RESULTS

After patients' selection, 19 individual omitted during study due to exclusion criteria and finally 30 patients in paracetamol group and 31 patients in pethidine group remained to enter the trial. There was no significant difference in age and BMI of mothers between both groups (P > 0.05). Maternal age and labour duration in paracetamol group had no meaningful difference with maternal age and labour duration of patients in pethidine group (P > 0.05). The average VAS pain score was significantly lower in paracetamol comparing to that of pethidine group (8.366 out of 10, 9.612 out of 10, respectively, P < 0.001).

CONCLUSION

It is concluded that intravenous paracetamol is more effective than intramuscular pethidine to relief labour pain in normal vaginal delivery.

Effect of ear acupressure on acute postpartum perineal pain: a randomised controlled study

AIMS AND OBJECTIVES

To explore the effect of ear acupressure in relieving perineal pain in women during the first 48 hours after delivery.

BACKGROUND

Perineal pain is a common problem during postpartum, and different treatment modalities have been used for relief. Ear acupressure has been reported to have possible benefit on relieving acute postpartum perineal pain.

DESIGN

This study was designed as a prospective, randomised controlled trial.

METHODS

Chinese women with a singleton vertex foetus at the gestation of 37 weeks or above were recruited. One hundred and twenty six and 130 women were randomised into the intervention and control groups, respectively. Women in the intervention group received application of tapes and seeds on four designated acupressure points on both ears, while women in the control group received tapes on four irrelevant points. Both groups were instructed to stimulate the points in a similar fashion. Pain perception was assessed by the Verbal Descriptive Pain Scale and the Visual Analogue Scale, and the consumption of analgesics was also reviewed.

RESULTS

No significant difference in perineal pain perception between the groups was observed in Verbal Descriptive Pain Scale. Although the mean Visual Analogue Scale and the accumulative mean consumption of paracetamol were generally lower in the intervention group, statistical significance was not reached.

CONCLUSIONS

There is no evidence so far to conclude that ear acupressure can effectively relieve perineal pain based on the statistical results. Further research is suggested to explore whether the effectiveness of pain relief is affected by the frequency and duration of acupressure point stimulation.

RELEVANCE TO CLINICAL PRACTICE

Training of midwives to perform this intervention is easy to achieve, but further evidence is required to prove its effectiveness.

The modern pharmacology of paracetamol: therapeutic actions, mechanism of action, metabolism, toxicity and recent pharmacological findings

Paracetamol is used worldwide for its analgesic and antipyretic actions. It has a spectrum of action similar to that of NSAIDs and resembles particularly the COX-2 selective inhibitors. Paracetamol is, on average, a weaker analgesic than NSAIDs or COX-2 selective inhibitors but is often preferred because of its better tolerance. Despite the similarities to NSAIDs, the mode of action of paracetamol has been uncertain, but it is now generally accepted that it inhibits COX-1 and COX-2 through metabolism by the peroxidase function of these isoenzymes. This results in inhibition of phenoxyl radical formation from a critical tyrosine residue essential for the cyclooxygenase activity of COX-1 and COX-2 and prostaglandin (PG) synthesis. Paracetamol shows selectivity for inhibition of the synthesis of PGs and related factors when low levels of arachidonic acid and peroxides are available but conversely, it has little activity at substantial levels of arachidonic acid and peroxides. The result is that paracetamol does not suppress the severe inflammation of rheumatoid arthritis and acute gout but does inhibit the lesser inflammation resulting from extraction of teeth and is also active in a variety of inflammatory tests in experimental animals. Paracetamol often appears to have COX-2 selectivity. The apparent COX-2 selectivity of action of paracetamol is shown by its poor anti-platelet activity and good gastrointestinal tolerance. Unlike both non-selective NSAIDs and selective COX-2 inhibitors, paracetamol inhibits other peroxidase enzymes including myeloperoxidase. Inhibition of myeloperoxidase involves paracetamol oxidation and concomitant decreased formation of halogenating oxidants (e.g. hypochlorous acid, hypobromous acid) that may be associated with multiple inflammatory pathologies including atherosclerosis and rheumatic diseases. Paracetamol may, therefore, slow the development of these diseases. Paracetamol, NSAIDs and selective COX-2 inhibitors all have central and peripheral effects. As is the case with the NSAIDs, including the selective COX-2 inhibitors, the analgesic effects of paracetamol are reduced by inhibitors of many endogenous neurotransmitter systems including serotonergic, opioid and cannabinoid systems. There is considerable debate about the hepatotoxicity of therapeutic doses of paracetamol. Much of the toxicity may result from overuse of combinations of paracetamol with opioids which are widely used, particularly in USA.

Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period

BACKGROUND

Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative births (ventouse or forceps assisted births).

OBJECTIVES

To determine the efficacy of a single administration of paracetamol (acetaminophen) systemic drugs used in the relief of acute postpartum perineal pain

SEARCH METHODS

We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 6 November 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing paracetamol (acetaminophen) in a single dose compared with placebo for women with early postpartum perineal pain. We excluded quasi-RCTs and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors assessed each paper for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores.

MAIN RESULTS

We did not identify any new trials from the updated search so the results remain unchanged as follows.We have included 10 studies describing two dosages of paracetamol. Of these, five studies (526 women) assessed 500 mg to 650 mg and six studies (841 women) assessed 1000 mg of paracetamol. We chose to use random-effects meta-analyses because of the heterogeneity in dosage used. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context.More women experienced pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89, 10 studies, 1279 women). In addition, there were significantly fewer women having additional pain relief with paracetamol compared with placebo (RR 0.34, 95% CI 0.21 to 0.55, eight studies, 1132 women). Both the 500 mg to 650 mg and 1000 mg doses were effective in providing more pain relief than placebo.Maternal and neonatal potential adverse drug effects were not assessed in any of the included studies. Indeed few secondary outcomes were assessed.

AUTHORS' CONCLUSIONS

More women experienced pain relief, and fewer had additional pain relief, with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of studies was unclear.

Local cooling for relieving pain from perineal trauma sustained during childbirth

BACKGROUND

Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments.

OBJECTIVES

To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012), CINAHL (1982 to 10 January 2012), the Australian New Zealand Clinical Trials Register (10 January 2012) and contacted experts in the field.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials for inclusion, assessed trial quality and extracted data. A sub-set of data were double checked for accuracy. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials.

MAIN RESULTS

Ten published RCTs were included (involving 1825 women). Comparisons were local cooling treatments (ice packs, cold gel pads (with or without compression) or cold/iced baths) with no treatment, gel pads with compression, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam (Epifoam), oral paracetamol or warm baths. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61; 95% confidence interval (CI) 0.41 to 0.91; one study, n = 208). Women preferred the utility of the gel pads compared with ice packs or no treatment (RR 0.82; 95% CI 0.73, 0.92). Differences detected in a composite of perineal oedema and bruising and overall wound healing were noted in one small study, favouring cold gel pads (n = 37) over ice (n = 35, mean difference (MD) 0.63 on a scale of 0 to 15; 95% CI 0.20 to 1.06) or no treatment (n = 39, MD -2.10; 95% CI -3.80 to -0.40) three to 14 days after giving birth. Women reported more pain (RR 5.60; 95% CI 2.35 to 13.33; one study, 100 women) and used more additional analgesia (RR 4.00; 95% CI 1.44 to 11.13; one study, 100 women) following the application of ice packs compared with PET.

AUTHORS' CONCLUSIONS

There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.

A qualitative study exploring women's personal experiences of their perineum after childbirth: expectations, reality and returning to normality

OBJECTIVE

to explore the feelings, perceptions and experiences of women in relation to their perineum following childbirth in the early postnatal period.

DESIGN

a qualitative study using grounded theory. Data were collected using diaries and interviews and analysed using constant comparative method.

SETTING

hospital and community setting in the South of England.

PARTICIPANTS

women (n=11) aged 20-42 years who had a vaginal birth.

FINDINGS

one core category, 'Striving for normality' and five major categories emerged: (1) 'preparing for the unknown', (2) 'experiencing the unexpected', (3) 'adjusting to reality', (4) 'getting back to normal' and (5) 'recovery of self'. 'Striving for normality' was where women wanted to be able to do normal things and feel like their normal selves soon after the birth of their baby. Much of what the women described doing during the early postnatal period was related to achieving this goal.

KEY CONCLUSIONS

the initial impact of childbirth on the perineum and surrounding area meant that in the first few postnatal days women largely concentrated on managing the effects of this. The impact however, went beyond the immediacy of coping with bodily functions extending into other daily activities in terms of managing and completing them. Examples of daily living activities in this context include bathing, eating, walking as well as completing household chores. Returning to normal following childbirth is significant for women and successfully achieving daily living activities is part of this process. However, women in this study seemed unprepared for the reality of this experience.

IMPLICATIONS FOR PRACTICE

women may be poorly prepared for the impact that perineal pain and discomfort can have on their lives especially related to successfully completing daily living activities in the early postnatal period. Consideration should be given to finding different ways of communicating the impact to women such as in the early postnatal period, rather than during pregnancy. The underpinning philosophy of care for the postnatal period should encapsulate a holistic approach, where physical symptoms of perineal pain and discomfort experienced by women are not tackled in isolation from any psychosocial impact this may also have.

Analgesia for relief of pain due to uterine cramping/involution after birth

BACKGROUND

Women may experience differing types of pain and discomfort following birth, including cramping after birth pains associated with uterine involution.

OBJECTIVES

To assess the effectiveness and safety of analgesia for relief of after birth pains following vaginal birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2010) and the reference lists of trials and review articles.

SELECTION CRITERIA

All identified published and unpublished randomised controlled trials comparing two different types of analgesia or analgesia with placebo or analgesia with no treatment, for the relief of after birth pains following vaginal birth. Types of analgesia included pharmacological and non-pharmacological.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data independently.

MAIN RESULTS

We have included 18 studies (involving 1498 women) in this review. However, only nine of the included studies (with 750 women) reported 24 comparisons of analgesia with other analgesia or placebo and had data that could be included in our meta-analyses. The majority of studies investigated pharmacological analgesics and these were grouped into classes for this review. Non-steroidal anti-inflammatory drugs (NSAIDs) were significantly better than placebo at relieving pain from uterine involution as assessed by their summed pain intensity differences (SPID) (mean difference (MD) 4.34; 95% confidence interval (CI) 2.87 to 5.82; three studies, 204 women) and summed pain relief scores (MD 5.94; 95% CI 3.83 to 8.01; three studies, 204 women). NSAIDS were compared with opioids in one small study of 23 women reporting SPID and summed pain relief and found no difference. A larger study of 127 women found NSAIDs to be significantly better than opioids at reducing pain intensity six hours following study intervention (MD -0.70; 95% CI -1.04 to -0.35). Opioids were compared with placebo in three studies that could be included in meta-analyses; one small study of 23 women reporting SPID and summed pain relief and found no difference. One study of 95 women found no difference in pain intensity six hours following the study intervention. A third study of 108 women found significantly more women in the placebo group reported no pain relief than women in the opioid group (risk ratio 0.10; 95% CI 0.04 to 0.23). Aspirin was significantly better than paracetamol when pain intensity score was assessed six hours after study intervention (MD 0.85; 95% CI 0.29 to 1.41; one study 48 women) at relieving pain from uterine involution. Paracetamol was not better than placebo when pain intensity was assessed six hours after the study intervention in one study of 48 women.

AUTHORS' CONCLUSIONS

Non-steroidal anti-inflammatory drugs (NSAID) including aspirin were better than placebo at relieving pain from uterine cramping/involution following vaginal birth. NSAIDs were better than paracetamol and paracetamol was not better than placebo, though numbers of participants for these comparisons were small. Data for opioids compared with NSAIDs and opioids compared with placebo were conflicting, with some measures showing similar effect and others indicating NSAIDs were better than opioids and opioids were not better than placebo. There were insufficient data to make conclusions regarding the effectiveness of opioids at relieving pain from uterine cramping/involution.The median year of publication of included studies was 1981; therefore more research is needed to assess the effectiveness of current pharmacological and non-pharmacological analgesia at relieving pain from uterine cramping/involution following vaginal birth.