Best Practices in Management of Postpartum Pain

Integrative Review of Opioid Use and Protocol Adherence in Hospitals After Implementing Enhanced Recovery After Surgery Protocols for Cesarean Birth

OBJECTIVE

To evaluate the enhanced recovery after surgery (ERAS) protocols used and amount of opioids administered during hospitalization for cesarean birth after the ERAS protocols were implemented.

DATA SOURCES

A search was conducted in CINAHL Complete, Scopus, and PubMed for sources published in English between January 2018 and December 2023. Search terms were cesarean AND opioid∗ AND eras OR erac OR enhanced recovery.

STUDY SELECTION

Eligible studies were conducted in the United States, used key pain management components from the ERAS guidelines, and reported results for in-patient postsurgical opioid use.

DATA EXTRACTION

Data obtained were for post-ERAS implementation only and included authors, date, sample size, study location, participant inclusion and exclusion criteria, methods, interventions used (ERAS guideline components), and morphine milligram equivalents (MME) used during the hospital stay.

DATA SYNTHESIS

Weighted averages were calculated for results reported as means and percentages. Descriptive summaries were used for the remainder of the results.

RESULTS

Twenty-six studies were found, accounting for 19,961 individuals' post-ERAS experiences. Although 30% of participants experienced a scheduled cesarean birth, 70% experienced all types of cesarean births, including scheduled, urgent, or emergent. There was substantial heterogeneity of the data reported, especially for how opioid use was measured and analyzed and time frames for opioid use. In 11 studies that reported MME as means, the weighted average for in-patient opioid use was 54 MME per stay. In only 17 studies, researchers reported the number of women who experienced an opioid-free recovery, which averaged 40% of the women.

CONCLUSION

While implementation of key components of the ERAS protocol is associated with reduced opioid exposure for women experiencing scheduled and nonscheduled cesarean births, a benchmark for the amount of in-patient opioid use was not established. Still, this review offers evidence regarding best practices, lessons learned, and outcome analysis strategies. These findings can support perinatal teams who are considering implementing ERAS for cesarean birth, or those looking for further improvements.

Paracetamol versus ibuprofen for early postpartum pain control: a randomized controlled trial

INTRODUCTION

To evaluate the effectiveness of paracetamol and ibuprofen as non-opioid treatments for postpartum pain control after vaginal delivery.

MATERIALS AND METHODS

This randomized controlled study at a university-affiliated medical center involved parturient who received blindly oral tablets of either 1000 mg of paracetamol or 400 mg of ibuprofen, post-vaginal birth. Pain levels were assessed using a numeric rating scale (NRS) at four time points: before treatment, and 1, 4, and 6 h post-treatment (T0, T1, T4, and T6, respectively). We also compared the need for additional analgesia, breastfeeding initiation, mobilization, and urination following the delivery between the groups. To ensure statistical power, the study was designed to detect differences of one point on the NRS with at least 37 women per group.

RESULTS

A total of 107 women participated, including paracetamol (n = 52) and ibuprofen (n = 55) groups. Demographics and perinatal outcomes were similar across groups. No significant differences were found in the interval between delivery and request for pain control (8 ± 6-10.5 and 11 ± 6-16 h for the paracetamol and the ibuprofen, respectively, P = .13). Pain levels on the NRS were similar for both groups at all intervals. There were also no group differences in the time to the initiation of breastfeeding, mobilization, urination, or the need for additional analgesia.

CONCLUSION

Both, paracetamol and ibuprofen, can be considered equivalent and effective non-opioid alternatives for postpartum pain control. REGISTRY AT CLINICALTRIALS.GOV: (NCT04653506), https://register.

CLINICALTRIALS

gov/prs/beta/studies/S000AFOR00000066/recordSummary .

Impact of obstetric physiotherapy and transcutaneous electrical nerve stimulation (TENS) on pain management and gastrointestinal function following cesarean birth: A randomized controlled trial

INTRODUCTION

The study aimed to compare the impact of the physiotherapeutic method combined with TENS and physiotherapy alone on post-cesarean pain levels and the time required for intestinal peristalsis recovery. The study was conducted at the Specialist Hospital in Kraków, from January to March 2020.

METHODS

The study was designed as a parallel randomized controlled trial (RCT). Participants were randomly assigned to one of three groups: TENS (n=52), nTENS (n=50) and control group (n=34), based on block randomization of 6. The allocation sequence was provided using a computer-generated random list. The participants were 136 postpartum primiparous women after cesarean birth, aged ≥18 years, having a healthy newborn, with no contradictions to TENS. The TENS group received a physiotherapeutic procedure involving a 20-minute exercise program plus a 40-minute session of TENS. The nTENS group received physiotherapeutic procedure alone, and the control group was under the routine care of midwives. The pain was assessed using the Numerical Rating Scale (NRS) at 6, 7, 12 and 24 hours after cesarean birth and twice during verticalization.

RESULTS

TENS and nTENS groups had decreased pain intensity immediately after the intervention compared to the control group (p=0.002, p=0.027, respectively). During the first stage of the verticalization, the smallest increase in pain was observed in the TENS (p=0.044 compared to nTENS, p=0.000 compared to the control group). Within the increase in the pain score, the intestinal peristalsis recovery time was longer. In both groups undergoing physical therapy, a shortened recovery time of intestinal peristalsis was demonstrated (p=0.000).

CONCLUSIONS

The proposed physiotherapy program, combined with TENS and instruction, proved effective in relieving post-cesarean pain and accelerating the time to first defecation and should be considered part of the standard patient management program in maternity units.

The comparison of effectiveness of acupressure on Spleen 6 and Hugo points on the severity of postpartum pain: A randomized clinical trial

Background and aims

Postpartum pain poses a significant challenge for new mothers. Various nonpharmacological methods are employed to manage postpartum pain. This study aimed to compare the effectiveness of acupressure on Spleen 6 and Hugo points on the severity of postpartum pain.

Methods

In this parallel randomized trial study, 68 eligible primiparous women who had vaginal deliveries and experienced postpartum pain at Farabi Hospital in Malekan (a city in East Azarbaijan Province in Iran) were selected according to inclusion/exclusion criteria and then allocated to the Hugo (n = 34) and Spleen 6 (n = 34) acupressure groups using a randomized block design (six blocks). The data collection process took place from November 2022 to April 2023. The participants were blinded; however, the analysts and investigators were not blinded. Acupressure interventions were applied bilaterally for 20 min, consisting of 10 s of pressure followed by 2 s of rest. Pain intensity was assessed using a visual pain scale before, immediately after, and 1 h after the intervention. In total, 68 participants fulfilled the study. Data were analyzed using Statistical Package for the Social Sciences version 25 with chi-square, Mann-Whitney, and Friedman tests.

Results

Both groups exhibited a statistically significant reduction in postpartum pain intensity across all periods (p < 0.001). Although there was a significant difference in pain intensity between the groups before the intervention (p = 0.039), this distinction was not observed immediately and 1 h after the intervention (p ≥ 0.05). Both Hugo and Spleen's 6 acupressure interventions reduced postpartum pain intensity. No significant adverse events or side effects were observed.

Conclusion

Acupressure on Spleen 6 and Hugo points helped decrease the severity of postpartum pain in primiparous women who had vaginal deliveries. Healthcare providers are encouraged to consider acupressure for postpartum pain management.

The Use of Capacitive and Resistive Energy Transfer in Postpartum Pain Management in Women after Perineal Trauma

Perineal pain occurs in 97% of women with episiotomy or first- and second-degree perineal tears on the first day after delivery. The study aimed to assess the impact of capacitive and resistive energy transfer (TECAR) on perineal pain and discomfort in the first two postpartum days. The prospective randomized double-blind study was performed with the pain and discomfort assessment using the Visual Analogue Scale at baseline and after both TECAR interventions. Characteristics data, delivery information, and the number of painkillers taken were collected. The assumed significance level was α < 0.05. The study included 121 women with a mean age of 30.7 ± 4.2 years and a median BMI of 26.1 kg/m2 (24.1; 28.9). Pain reduction at rest, when walking, and discomfort reduction when walking were significantly higher in the TECAR group compared to the sham group (p < 0.05). After the first TECAR intervention, significant reduction in all measured parameters was observed in the study group (p < 0.03), whereas in the control group, it was observed in pain and discomfort while sitting (p < 0.04). The amount of ibuprofen taken on the second day was significantly reduced in the study group compared to the first day (p = 0.004). TECAR has been shown to provide more immediate and significant reduction in perineal pain and discomfort.

Effects of opioids administered via intravenous or epidural patient-controlled analgesia after caesarean section: A network meta-analysis of randomised controlled trials

Background

Post-caesarean section analgesia is important physiologically and psychologically for both mothers and infants. Patient-controlled analgesia is a well-established method of administering opioids for postoperative pain. However, to date, no study has systematically investigated the effects of opioids administered through intravenous patient-controlled analgesia (IVPCA) or patient-controlled epidural analgesia (PCEA) in parturients who have undergone caesarean section.

Methods

This systematic review and network meta-analysis aimed to evaluate the analgesic and adverse effects of opioids administered via IVPCA or PCEA in parturients who have undergone a caesarean section. PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched from inception through 02 10, 2022 for relevant records. Randomised controlled trials (RCTs) that compared opioids administered via IVPCA or PCEA and reported outcomes of interest were included. Studies were excluded if the solution for patient-controlled analgesia contained antiemetics and/or other analgesics in addition to opioids. The methodological quality of RCTs was assessed using the revised Cochrane Risk of Bias Tool. Summary data were extracted from each eligible study. The primary outcome was pain intensity, and the secondary outcomes were opioid-related adverse effects. Frequentist network meta-analyses were performed using a contrast-based random-effects model. This study is registered with PROSPERO, CRD42021254040.

Findings

Twenty-three studies with 2589 parturients were included. Compared with IVPCA morphine as a reference treatment, PCEA fentanyl had better analgesic effects at 4 h (mean difference [MD] in the visual analogue scale score, -0.75; 95% confidence interval [CI] [-1.16, -0.34]) and 8 h (MD, -0.93; 95% CI [-1.57, -0.28]) and yielded lower odds of developing nausea/vomiting (odds ratio [OR], 0.27; 95% CI [0.09, 0.80]) and sedation/drowsiness (OR, 0.22; 95% CI [0.11, 0.45]). However, PCEA fentanyl may be more likely to cause pruritus than IVPCA treatments.

Interpretation

Considering the analgesic efficacy; opioid-induced nausea, vomiting, and sedation; and the well-being of breastfed infants, PCEA fentanyl may be the treatment of choice for post-caesarean section analgesia.

Funding

The Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (TCRD-TPE-111-27).

Operationalizing Whole-Person Postpartum Care: Health Care Provider-Level Strategies

Postpartum mothers report feeling unsupported and unprepared by their health care providers to meet the challenges of the postpartum period. This gap perpetuates a cycle of disappointment with and disengagement from postpartum care services. The need to revamp postpartum care has been recognized at the population level but implementing changes at the health care provider level is challenging without practical guidance. The needs of new mothers are broad in scope and variable between individuals, requiring a whole-person care approach that is comprehensive yet nimble. Presented here are provider-level strategies to promote care that both elicits and is responsive to the unique care goals of this population.

Postpartum symptom clusters in birthing individuals: A systematic review

BACKGROUND

Birthing individuals experience various postpartum symptoms which have been associated with adverse health outcomes. Previous systematic reviews have focused on the examination of individual symptoms and their impact on health, which have limited our understanding of postpartum symptom clusters.

OBJECTIVE

To examine the compositions of symptom clusters, analytic methodologies and predictors of symptom clusters in birthing individuals up to 1 year postpartum.

DESIGN

Systematic review.

METHODS

This systematic review was reported following the PRISMA. Five databases were searched: PubMed, Embase, CINAHL Complete, PsycINFO and Scopus. Two reviewers performed title and abstract and full-text screening independently. Standard Quality Assessment Criteria were used to assess the articles' qualities. Key information was extracted into evidence table, which was checked for accuracy and completeness. A narrative synthesis was conducted.

RESULTS

A total of 30 articles were included. Studies were conducted in 16 countries, mostly in Europe (n = 9) and North America (n = 7). The majority were quantitative (n = 27) and cross-sectional (n = 27). Factor analysis was the most frequently used analytic methodology (n = 21). All three qualitative studies used grounded theory. Taking into consideration the variations among the studies, stress (n = 15, infant or partner-related and from other sources), depression (n = 12), somatic (n = 12) and anxiety clusters (n = 10) were most frequently identified. Symptom cluster predictors were examined in less than half of the included studies (n = 13). Among these, most were focused on how individual postpartum symptoms influence symptom clusters.

CONCLUSIONS

Stress, depression, somatic and anxiety clusters are the most frequently identified postpartum symptom clusters. Future studies should examine the consistency, stability and clinical meaningfulness of these four symptom clusters.

RELEVANCE TO CLINICAL PRACTICE

The identification and management of the four symptom clusters should be of particular interest to clinicians and researchers.

NO PATIENT OR PUBLIC CONTRIBUTION

This systematic review did not directly involve patient or public contribution to the manuscript.

Laparoscopic management of suspected postpartum uterine rupture: a novel approach

BACKGROUND

Exploratory laparotomy is considered the gold standard treatment for women with suspected uterine rupture. We aimed to investigate the feasibility and safety of laparoscopy as an alternative for laparotomy for the management of hemodynamically stable women with suspected postpartum uterine rupture.

STUDY DESIGN

We conducted a case series study including all women who were diagnosed with postpartum uterine rupture following vaginal delivery in a university-affiliated tertiary hospital, between November 2012 and July 2021. Until 2016, all women with suspected post-partum uterine rupture underwent laparotomy. Following 2016, a new tailored protocol based on laparoscopy for the management of postpartum uterine rupture in hemodynamically stable women was implemented. A comparison was made between women who underwent emergent laparoscopy to laparotomy.

RESULTS

During the study period 17 women were diagnosed with postpartum uterine rupture. From January 2012 to January 2016, four cases of uterine rupture were diagnosed, all of whom underwent laparotomy. Since 2016, thirteen cases of uterine rupture were diagnosed, of whom seven women (54%) underwent laparoscopy and 6 (46%) laparotomy. The median time interval from delivery to surgery was 70.5 min IQR (40-179) in the laparotomy group and 202 min IQR (70-485) in the laparoscopy group. The median operative time for laparoscopic surgery was 80 min (IQR 60-114) and 78 min (IQR 58-114) for the laparotomy group. Four women who underwent laparotomy (40%) and one who underwent laparoscopy (14.2%) were admitted to the intensive care unit following surgery. Blood products transfusion was required in six women who had laparotomy (60%) and one who had laparoscopy (14.2%). Median hospitalization period was 5 d IQR (4-5) in the laparotomy group as compared to 3 d IQR (3-4) in the laparoscopy group. There were no conversions to laparotomy in the laparoscopy group.

CONCLUSIONS

In hemodynamic stable women laparoscopic surgery for suspected postpartum uterine rupture is feasible and safe.

The Influence of Breastfeeding Educational Interventions on Breast Engorgement and Exclusive Breastfeeding: A Systematic Review and Meta-Analysis

BACKGROUND

Breast engorgement and breast pain are the most common reasons for the early cessation of exclusive breastfeeding by mothers.

RESEARCH AIMS

(1) To examine the influence of breastfeeding educational interventions on breast engorgement, breast pain, and exclusive breastfeeding; and (2) to identify effective components for implementing breastfeeding programs.

METHODS

Randomized controlled trials of breastfeeding educational interventions were searched using five English and five Chinese databases. Eligible studies were independently evaluated for methodological quality, and data were extracted by two investigators. In total, 22 trials were identified, and 3,681 participants were included. A random-effects model was used to pool the results, and a subgroup analysis and meta-regression analysis were conducted.

RESULTS

Breastfeeding education had a significant influence on reducing breast engorgement at postpartum 3 days (odds ratio [OR]: 0.27, 95% CI [0.15, 0.48] p < .001), 4 days (OR: 0.16, 95% CI [0.11, 0.22], p < .001), and 5-7 days (OR: 0.24, 95% CI [0.08, 0.74], p = .013) and breast pain (standardized mean difference: -1.33, 95% CI [-2.26, -0.40]) at postpartum 4-14 days. Participants who received interventions had higher odds of exclusive breastfeeding. Breastfeeding educational interventions provided through lecture combined with skills practical effectively reduced breast engorgement (OR: 0.21; 95% CI [0.15, 0.28]; p = .001) and improved exclusive breastfeeding at postpartum 1-6 weeks (OR: 2.16; 95% CI [1.65, 2.83]; p = .001).

CONCLUSIONS

Breastfeeding educational interventions have been effective in reducing breast engorgement, breast pain, and improved exclusive breastfeeding. A combination of knowledge and skill-based education has been beneficial for sustaining exclusive breastfeeding by mothers.

A randomized clinical trial on the effect of foot reflexology performed in the fourth stage of labor on uterine afterpain

Background

Uterine afterpains are among the most prevalent complaints after natural vaginal delivery. Non-pharmacological treatment modalities to relieve afterpains are an important care priority. This study was conducted to investigate the effect of foot reflexology in the fourth stage of labor on afterpains in multiparous women.

Methods

This single-blind, randomized, clinical trial recruited 80 eligible pregnant women presenting to Allameh Bohlool Hospital in Gonabad and 17-Shahrivar Hospital in Mashhad, Iran, in 2019. In the first and second hours postpartum, the reflexology group received 10 min of general massage and specific reflexology massage on each foot on the uterine, pituitary, and solar plexus points. The control group received 10 min of general massage, and then rotational massage on a neutral point on the lateral side of the heel. The pain was measured every hour up to 4 h postpartum using a visual analogue  scale. The collected data were analyzed in SPSS-16 software at a significance level of P < 0.05.

Results

The median of the afterpain score in the first hour (P = 0.05) and second hour (P = 0.274) postpartum did not differ significantly between the two groups, but this score was lower in the reflexology group at the third hour (P < 0.001) and fourth hour (P < 0.001) postpartum. The mean total afterpain score in the 4 h postpartum was significantly lower in the reflexology group (P < 0.001).

Conclusion

The results revealed that foot reflexology in the fourth stage of labor has positive effects on relief from uterine afterpain. Reflexology is therefore recommended as a measure to reduce postpartum uterine afterpains.

Peripartal pain perception and pain therapy: introduction and validation of a questionnaire as a quality instrument

BACKGROUND

Labor pain is difficult to measure. The aim of this proof-of-concept study is to implement and test a questionnaire assessing pain sensation during and after vaginal deliveries. Its key aspect is a highly standardized survey of patient-reported outcome (PRO) by staff not involved in routine care.

METHODS

Between January and November 2015 339 women were assessed 24-48 h after spontaneous or operative-vaginal delivery of a singleton. German language skills were a prerequisite to participate. The test-retest reliability was calculated in 38 women 24-36 and 48-72 h postpartum between July and October 2017. Primiparae after spontaneous delivery and multiparae with no history of operative deliveries were compared in a subgroup analysis.

RESULTS

Maximum labor pain and post-partum pain were reported a median of 9 [8-10] and 4 [3-6]. Higher ratings were associated with younger age, higher gestational ages, infant's biometrics, and the duration of laboring. Only regional analgesia tended to reduce pain perception (NRS 8 vs. 9). Higher-degree injuries were associated with less pain postpartum. The questionnaire proved to be reliable in most aspects (Cronbach's α > 0.6 for 19/21 questions) and showed an acceptable content and criterion validity (Cohen correlation >  ± 0.3, interrelation between items).

CONCLUSION

Labor is a very painful experience, irrespective of previous obstetric history. Ratings indicate inadequateness of treatment except for patients receiving preventive postoperative pain management. Systematic postpartum pain assessment, hence, is still a pending issue. Adjustments will be made concerning language skills and specific questions on effectiveness of analgesia otherwise good reliability and validity of the questionnaire were proven.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

A standardized post-cesarean analgesia regimen reduces postpartum opioid use

BACKGROUND

Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen.

OBJECTIVE

To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth.

STUDY DESIGN

A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 h postoperatively. Total dose at 12, 24, and 48 h were also compared.

RESULTS

Of 2340 women who underwent cesarean birth during the study period (1 July 2017 - 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (p < .001). The average cumulative MME use was higher in the pre-protocol period compared to post-protocol at all time periods: 12 h (57.3 ± 23.8 vs 48.6 ± 26.2 MME, p < .001), 24 h (98.1 ± 34.1 vs 82.1 ± 38.8 MME, p < .001), and 48 h (165.8 ± 58.3 vs 134.9 ± 66.2 MME, p < .001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p < .001).

CONCLUSION

Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.

Reduction of opioid utilization after vaginal delivery with an electronic health record intervention

BACKGROUND

The national epidemic of opioid misuse has focused its attention on postpartum analgesic usage. Adequate pain control achieved with nonopioid pain medications and conservative measures could reduce the number of opioid pain medications available for misuse and diversion. Interventions that decrease inpatient opioid use after delivery could reduce the potential for chronic dependence in postpartum women. Modification of preloaded electronic order sets to decrease opioid administration has successfully reduced opioid use following a major abdominal surgery, including cesarean delivery. However, interventions to reduce opioid use following vaginal delivery are not well described.

OBJECTIVE

We aimed to evaluate the effect of removing opioid medications from postpartum order sets on medication usage following vaginal delivery.

STUDY DESIGN

We performed a retrospective cohort study of women undergoing a singleton vaginal delivery at an academic tertiary care center. Our institution removed opioid medications from postpartum order sets in April 2018. We compared the following 2 delivery cohorts: the "preintervention" cohort (April 2016-March 2018) and the "postintervention" cohort (June 2018-July 2018). The primary outcome was postpartum opioid use. The secondary outcomes were nonopioid analgesic use and discharge with an opioid prescription. We compared the demographic and obstetrical data, self-reported pain scores, and postpartum analgesic usage between groups. We determined that a minimum of 138 patients would be needed in each group to identify a 20% decrease in opioid usage (α=.05; β=.2).

RESULTS

We analyzed 276 subjects: 138 in the preintervention group and 138 in the postintervention group. The postintervention group was older and more likely to have an operative vaginal delivery. Otherwise, groups had similar demographic and obstetrical characteristics. Postpartum opioid use decreased from 56% in the preintervention group to 16% in the postintervention group, a 71% reduction (P<.001). The incidence of severe pain score (>7) was similar between groups with a median occurrence of 1 (interquartile range, 0-4) for both (P=.7). The number of opioid discharge prescriptions among those receiving inpatient opioids was significantly lower in the postintervention group than in the preintervention group (18% vs 38%, respectively), a 53% decrease (P<.001).

CONCLUSION

Removal of opioids from the postpartum order set was associated with lower rates of opiate usage following vaginal delivery in a single center without changing the frequency of severe pain scores. This simple intervention has the potential to reduce opioid exposure.

Prevalence, characteristics, and impact of pain during the postpartum period

OBJECTIVE

To identify the prevalence of pain in puerperal women, describe the characteristics of pain and its impacts on the performance of daily life activities, and evaluate satisfaction with received analgesia.

METHOD

Cross-sectional study which included women who had given birth. These were evaluated within 72 hours postpartum in a public teaching hospital in São Paulo city. Obstetric and clinical data were evaluated, as well as presence and characteristics of pain and its impact on daily activities.

RESULTS

A total 128 women participated in this study. The prevalence of pain was 36.7% during the interview and 54.6% in the previous 24 hours. The main pain site was the abdominal region (64.7%) and pain intensity was moderate to 48.9% of women, with intermittent frequency in 58% of the cases. There was a significant association between presence of pain and type of delivery (cesarean; p=0.030). Not being able to provide care to the newborn, requiring going to a different unit, increased pain perception (p=0.038). A significant impact of pain on the capacity of walking, eating, sleeping, taking care of the baby, evacuating, breathing deeply, breastfeeding, and sitting was verified.

CONCLUSION

Pain was frequent during the postpartum period and significantly affected the mothers' activities, indicating a need for improving pain management in puerperium.

Associations between Maternal and Infant Illness and the Risk of Postpartum Depression in Rural China: A Cross-Sectional Observational Study

This study explored how maternal and infant illness correlated with the risk of postpartum depression in the Chinese Qinba Mountains region. In total, 131 villages comprising 435 families with infants (≤6 months old) were randomly sampled. We collected data on maternal and infant illnesses and maternal health knowledge level. The Depression, Anxiety, and Stress Scale-21 was used to measure the risk of postpartum depression. We used descriptive statistics and multivariate logistic regression for the analysis. Infant overall health status was a risk factor for postpartum depression (odds ratio (OR) = 1.90, 95% Confidence Interval (95% CI) = 1.10~3.28), whereas maternal overall health status was not correlated with postpartum depression (OR = 1.36, 95% CI = 0.55~3.39). For specific illnesses, infants experiencing over two common illnesses in the past two weeks (OR = 1.98, 95% CI = 1.13~3.45) and mothers experiencing over two common pains within two weeks after delivery (OR = 1.77, 95% CI = 1.02~3.08) were risk factors for postpartum depression, whereas infants with mild and severe stunted growth, maternal C-section, and postpartum body mass index (normal or overweight) were not correlated with it (all p > 0.050). Maternal health knowledge was an important moderator of maternal and infant illnesses on the risk of postpartum depression. In conclusion, maternal and infant illness were essential factors for the risk of postpartum depression in a poor rural region in western China, which may be mainly affected by the feeling of uncertainty of illness. Improved maternal and infant health and enhanced maternal health knowledge might alleviate the risk of postpartum depression.

The Price of Pre-adolescent Abuse: Effects of Sexual Abuse on Perinatal Depression and Anxiety

INTRODUCTION

Childhood abuse is a major public health concern and a risk factor for subsequent poor maternal mental health. This study of 176 racially diverse women explored the associations between the histories of childhood sexual abuse and depression and anxiety during pregnancy, at six weeks postpartum, and 12 weeks postpartum.

METHODS

Data on depressive and anxiety symptoms were gathered during pregnancy, at six weeks postpartum, and 12 weeks postpartum. Sociodemographic data were collected during pregnancy, while data on childhood sexual abuse were gathered during the 12-week postpartum period. Bivariate analyses and repeated mixed-effects linear regression with bootstrapping were used to assess the association between childhood sexual abuse and perinatal depressive and anxiety symptoms.

RESULTS

Childhood sexual abuse was significantly associated with depressive symptoms (β = 2.52, 95% CI 1.72, 3.32, p < .001) and anxiety symptoms (β = 4.44, 95% CI 3.70, 5.81, p < .001) over time, while controlling for demographic characteristics and lifetime major depression and anxiety. Depressive and anxiety symptoms decreased over the perinatal period and were highest during pregnancy. Black women were more likely to report higher depressive symptoms (β = 1.35, 95% CI 0.51, 2.19, p = .002) and anxiety symptoms (β = 3.29 95% CI 1.72, 4.87, p < .001) over time compared to White women.

DISCUSSION

The results highlight the importance of assessing the long-term effects of childhood sexual abuse on perinatal depressive and anxiety symptoms to help inform the development of interventions for women, particularly Black women.

Research Recommendations on the Effects of Postpartum Depression and Pain on Infant Care and Development

Postpartum depression is one of the most common complications of childbirth, and another is pain. A growing body of research shows that the severity and duration of postpartum pain can increase a woman's risk for postpartum depression. Postpartum depression and pain negatively affect maternal well-being, and postpartum depression has been associated with adverse outcomes in children. However, there is a dearth of information about the effects of postpartum depression and pain on infant care and development. The objectives of this commentary were to highlight the need to address this gap in the literature, offer a preliminary conceptual model to advance the field, and ignite new lines of inquiry to inform infant care and development.

Low-level laser therapy improves pain in postcesarean section: a randomized clinical trial

This study aimed to evaluate the effect of low-level laser therapy (LLLT) on immediate postpartum pain relief during cesarean section. A randomized, parallel controlled trial was carried out. In total, 88 women with immediate postpartum were divided into 4 groups: control group (n = 22), placebo group (n = 22), experimental group I (n = 22, dose of 4 J/cm²), and experimental group II (n = 22, dose of 2 J/cm²). The pain measured by Numeric Rating Scale (NRS), algometry, and Global Change Perception Scale (GCPS) was assessed at 12, 20-24, and 44-48 h postpartum. Two LLLT sessions were performed at 12 and 24 h postpartum. A significant interaction was observed between time versus group for NRS F (2.40) = 36.80, p < 0.001 and algometry F (1.70) = 27.18, p < 0.001. GCPS revealed a significant difference between the groups during second (p = 0.04) and third evaluation (p = 0.04). The NRS and algometry presented a large effect size for the experimental groups. LLLT is an efficient method to reduce pain and enhance the GCP in postcesarean section. No significant clinical differences were found between the laser doses.