Oral celecoxib versus oral diclofenac for post-perineal repair analgesia after spontaneous vaginal birth: A randomised trial

Acute pain management after vaginal delivery with perineal tears or episiotomy

BACKGROUND

A vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored.

OBJECTIVE

The aim of this systematic review was to evaluate the literature and to develop recommendations for pain management after a vaginal delivery with perineal trauma.

EVIDENCE REVIEW

MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and systematic reviews assessing pain after a vaginal delivery with perineal tears or episiotomy until March 2023. Cochrane Covidence quality assessment generic tool and the RoB Vis 2 tool were used to grade the quality of evidence.

FINDINGS

Overall, 79 studies (69 RCTs and 10 systematic reviews and meta-analyses) of good quality of evidence were included. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment. Epidural morphine (≤2 mg) is recommended among women with labor epidural analgesia and severe perineal tears, with adequate respiratory monitoring. Local anesthetic infiltration, topical local anesthetic, ointment application, and pudendal nerve block are not recommended due to insufficient or lack of evidence. Ice or chemical cold packs are recommended for postpartum pain first-line treatment due to their simplicity of use. Transcutaneous nerve stimulation and acupuncture are recommended as adjuvants. When a perineal suture is indicated, a continuous suture compared with an interrupted suture for the repair of episiotomy or second-degree perineal tears is recommended for the outcome of pain. For women with first-degree or second-degree perineal tears, no suturing or glue compared with suturing is recommended for the outcome of pain.

CONCLUSIONS

Postpartum pain management after a vaginal delivery with perineal trauma should include acetaminophen, NSAIDs, and ice or chemical cold packs. Epidural morphine should be reserved for severe perineal tears. A surgical repair technique should depend on perineal tear severity.

Cold compared with room temperature compress on the repaired primiparous perineum following injury at normal vaginal delivery: a randomized controlled trial

BACKGROUND

The perineum is typically injured at the first vaginal birth. The application of a cold compress to the perineal repair site can reduce pain; however, the effect usually dissipates after a couple of hours. Repeated applications may be needed for sustained analgesia. However, the medium-term effect of repeated applications of cold compress on the perineal repair site on the recovery of sexual function and perineal healing is not known.

OBJECTIVE

This study aimed to evaluate repeated applications of cold vs room temperature (placebo control) compress to the repaired primiparous perineum on pain upon movement.

STUDY DESIGN

A randomized controlled trial was conducted in a university hospital in Malaysia from May 2022 to February 2023. A total of 224 women with a repaired episiotomy or spontaneous second-degree tear sustained at normal delivery were randomized as follows: 113 to frozen gel pack and 111 to room temperature gel pack, as wound compress. The compress was applied to the perineal repair site at 3 timepoints: immediately after repair, and at 4 and 8 hours after delivery, for 20 minutes at each application. The primary outcomes were pain during movement at 12 and 24 hours after delivery, scored using the 0 to 10 numerical rating scale. The secondary outcomes include duration of hospital stay; analgesic consumption; recovery and functional metrics of reestablishing flatus, mobilization, and urination, breastfeeding; maternal satisfaction with the allocated compress; and after hospital discharge for up to 6 weeks after birth through telephone interview, analgesic consumption, perineal pain, resumption of vaginal sex, and women's perception of perineal wound healing.

RESULTS

The median (interquartile range) of pain at movement scores were 4 (4-5) vs 5 (4-5) (P=.018) at 12 hours and 2 (1-3) vs 2 (2-3) (P=.173) at 24 hours after birth for cold vs room temperature compress, respectively. Maternal satisfaction scores were 8 (7-9) vs 7 (6-8) (P=.119), oral analgesic for perineal pain while at the postnatal ward was taken by 94 of 113 (83.2%) vs 85 of 109 (78.0%) (relative risk, 1.07; 95% confidence interval, 0.94-1.21), and time to the first satisfactory breastfeeding episode was 11.6 (7.9-15.5) vs 13.0 (8.0-20.7) hours (P=.303) for cold vs room temperature compress, respectively. At 2 weeks telephone follow-up, analgesic intake and perineal pain were not different. At 6 weeks, analgesic intake, perineal pain, resumption of vaginal sex, exclusive breastfeeding, and maternal perception of perineal healing were not different.

CONCLUSION

Intermittent cold compress in the first 8 hours to the repaired perineum reduces pain at 12 hours but the effect attenuates by 24 hours. Maternal satisfaction with their allocated compress was not different. There was no suggestion of harm or benefit on the other secondary outcomes.

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 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. This is an update of a review first published in 2016.

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

For this update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (9 December 2019), OpenSIGLE and ProQuest Dissertations and Theses (28 February 2020), and reference lists of retrieved studies.

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. We excluded quasi-RCTs and cross-over trials. We included papers in abstract format only if they had sufficient information to determine that they met the review's prespecified inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two review authors (FW and VS) independently assessed all identified papers for inclusion and risks of bias, resolving any discrepancies through discussion. Two review authors independently conducted data extraction, including calculations of pain relief scores, and checked it for accuracy. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 35 studies examining 16 different NSAIDs and involving 5136 women (none were breastfeeding). Studies were published between 1967 and 2013. Risk of bias due to random sequence generation, allocation concealment and blinding of outcome assessors was generally unclearly to poorly reported, but participants and caregivers were blinded, and outcome data were generally complete. We downgraded the certainty of evidence due to risk of bias, suspected publication bias, and imprecision for small numbers of participants. NSAID versus placebo Compared to women who receive a placebo, more women who receive a single-dose NSAID may achieve adequate pain relief at four hours (risk ratio (RR) 1.91, 95% confidence interval (CI) 1.64 to 2.23; 10 studies, 1573 women; low-certainty evidence) and at six hours (RR 1.92, 95% CI 1.69 to 2.17; 17 studies, 2079 women; very low-certainty evidence), although we are less certain about the effects at six hours. At four hours after administration, women who receive a NSAID are probably less likely to need additional analgesia compared to women who receive placebo (RR 0.39, 95% CI 0.26 to 0.58; 4 studies, 486 women; moderate-certainty evidence) and may be less likely to need additional analgesia at six hours after initial administration, although the evidence was less certain at six hours (RR 0.32, 95% CI 0.26 to 0.40; 10 studies, 1012 women; very low-certainty evidence). One study reported that no adverse events were observed at four hours post-administration (90 women). There may be little or no difference in 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 women; low-certainty 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-headedness (1), nausea (1), backache (1), dizziness (1), epigastric pain (1), not specified (1)), although not all studies assessed adverse effects. Neonatal adverse effects were not assessed in any of the studies. NSAID versus paracetamol NSAIDs may lead to more women achieving adequate pain relief at four hours, compared with paracetamol (RR 1.54, 95% CI 1.07 to 2.22; 3 studies, 342 women; low-certainty evidence). We are uncertain if there is any difference in adequate pain relief between NSAIDs and paracetamol at six hours post-administration (RR 1.82, 95% CI 0.61 to 5.47; 2 studies, 99 women; very low-certainty evidence) or in the need for additional analgesia at four hours (RR 0.55, 95% CI 0.27 to 1.13; 1 study, 73 women; very low-certainty evidence). NSAIDs may reduce the risk of requiring additional analgesia at six hours compared with paracetamol (RR 0.28, 95% CI 0.12 to 0.67; 1 study, 59 women; low-certainty evidence). One study reported that no maternal adverse effects were observed at four hours post-administration (210 women). Six hours post-administration, we are uncertain if there is any difference between groups in the number of maternal adverse effects (RR 0.74, 95% CI 0.27 to 2.08; 3 studies, 300 women; very low-certainty evidence), 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 or doses did not demonstrate any differences in effectiveness for any primary outcome measures; however, few data were available on some NSAIDs. None of the included studies reported on any of this review's secondary outcomes.

AUTHORS' CONCLUSIONS

In women who are not breastfeeding and who sustained perineal trauma, NSAIDs (compared to placebo or paracetamol) may provide greater pain relief for acute postpartum perineal pain and fewer women need additional analgesia, but uncertainty remains, as the evidence is rated as low- or very low-certainty. The risk of bias was unclear for many studies, adverse effects were often not assessed and breastfeeding women were not included. While this review provides some indication of the likely effect, there is uncertainty in our conclusions. The main reasons for downgrading were the inclusion of studies at high risk of bias and inconsistency in the findings of individual studies. Future studies could examine NSAIDs' adverse effects, including neonatal effects and the compatibility of NSAIDs with breastfeeding, and could assess other secondary outcomes. Future research could consider women with and without perineal trauma, including perineal tears. High-quality studies could be conducted to further assess the efficacy of NSAIDs versus paracetamol and the efficacy of multimodal treatments.

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.

Oral tramadol versus oral celecoxib for analgesia after mediolateral episiotomy repair in obese primigravidae: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

A variety of pharmacological and non-pharmacological interventions have been investigated, with the goal of relieving pain after post-episiotomy repair. We aimed to compare the efficacy of tramadol versus celecoxib orally in reducing pain after mediolateral episiotomy repair in obese primigravidae undergoing spontaneous vaginal delivery.

METHODS

We conducted a randomized double-blinded trial in Cairo University hospital, Cairo, Egypt, from October 2018 to December 2019. We randomly assigned 200 women into two groups: group A (n = 100) received one tramadol tablet 100 mg orally whereas group B (n = 100) received one celecoxib tablet 200 mg orally. Our primary outcome was pain score using a 10-cm visual analog scale at different time intervals. Our secondary outcomes were the overall satisfaction score and drug side effects.

RESULTS

After mediolateral episiotomy repair, the pain scores at 1, 2, and 4 h were significantly lower in the tramadol group than in the celecoxib group (p < 0.001). However, there were no significantly differences in pain scores at 8 and 12 h between the two groups (p = 0.50 and 0.48 respectively). Women's satisfaction score was significantly higher in the tramadol group than in the celecoxib group (p < 0.001). Fewer participants in the tramadol group needed additional analgesics than in the celecoxib group; however, the difference was not significant (p = 0.17). Drug adverse effects were comparable in the two groups.

CONCLUSIONS

Primigravid women who received tramadol 100 mg orally after mediolateral episiotomy repair had lower pain scores and were more satisfied than women who received celecoxib 200 mg orally. Both drugs were well tolerated, with few side effects.

Clonidine as an Adjuvant to Lignocaine Infiltration for Prolongation of Analgesia after Episiotomy

Background:

Epidural labor analgesia has not been fully accepted despite many advantages. Many times, the pregnant females reach hospital without antenatal checkup, and at that time, “episiotomy infiltration” becomes an ideal method for vaginal delivery. One of the most important problems after episiotomy is the severe perineal pain on the 1^st day of postpartum period.

Objectives:

We compared the efficacy of clonidine 1 μg/kg as an adjuvant to 20 mg/ml lignocaine infiltration along the line of episiotomy incision for prolonging the duration and quality of analgesia with respect to various activities by single injection.

Methodology:

Majority of the patients, 94.2% in our study, had no idea about labor analgesia, and only 2.5% of all the patients expressed their interest to deliver without suffering from labor pains. One hundred and twenty pregnant female patients scheduled for full-term vaginal delivery were assigned into lignocaine and lignocaine-clonidine group according to infiltration they received. Pain scoring using visual analog scale and maternal satisfaction scale was monitored. At the end of the research project, the data were compiled and analyzed using appropriate statistical tests.

Results:

Duration of analgesia after episiotomy during sitting, walking, and squatting was 22.7 ± 1.32, 21.73 ± 1.47, and 19.875 ± 1.48 h in clonidine + lignocaine group and 6.06 ± 1.26, 5.33 ± 1.18, and 4.01 ± 1.28 h in lignocaine only group, respectively, which was highly statistically significant P < 0001.

Conclusions:

Clonidine when added to 2% lignocaine infiltration in episiotomy improves the quality and significantly enhances the duration of analgesia.

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.

Analgesic efficacy of celecoxib in patients after oral surgery: special reference to time to onset of analgesia and duration of analgesic effect

PURPOSE

Cyclooxygenase-2 inhibitor celecoxib is also used in the dental field for analgesia. However, there are few reports on the time to onset and duration of analgesia. We investigated the analgesic effect of celecoxib after oral surgery.

METHODS

A total of 138 patients undergoing unilateral mandibular third molar surgery under local anesthesia were enrolled. After surgery, the patients who felt pain and requested an analgesic were instructed to take celecoxib 400 mg and to record the time. Primary efficacy outcome measures were time to onset of analgesia. In addition, the conditions of pain at the time of taking celecoxib, at the onset time of analgesia, and 2 and 6 h after taking the drug were recorded. Pain assessments were evaluated using a 10-cm visual analog scale and four-point verbal rating score. These data were documented in the questionnaire forms handed to the patients and retrieved by post.

RESULTS

Effective responses without missing were returned from 103 patients. The median time to onset of the efficacy was 35 min. The pain scales at celecoxib administration was significantly higher compared with the time of onset of analgesia, 2 hours after administraton and 6 hours hours administration (P<0.05, respectively). The pain scales at the onset time of analgesia were significantly higher compared to that after 2 or 6 h of taking the drug (P<0.05, respectively). There were no statistically significant differences in the pain scales between 2 and 6 h after taking the drug (P>0.05).

CONCLUSION

The analgesic effect of celecoxib was exhibited quickly and sustained after oral surgery.

Comparison of indomethacin suppository and lidocaine cream on post-episiotomy pain: A randomized trial

BACKGROUND

One of the most important problems after episiotomy is perineal pain which is more severe on the first day of postpartum period. The aim of this study was to compare the analgesic effects of indomethacin suppository and lidocaine cream in the management of post-episiotomy pain.

MATERIALS AND METHODS

In a randomized, controlled trial, 60 primiparous women who had mediolateral episiotomy received 50 mg indomethacin suppository (n = 30) or 2% lidocaine cream (n = 30) in the postpartum period in Hajar Hospital in Shahrekord (Iran). The mean severity of post-episiotomy pain was assessed with the first complaint and at 6, 12, and 24 h after the delivery, and compared in the two groups. The visual analog scale (VAS) was used for pain recording and data were analyzed with independent-samples t-test, χ(2), and Fisher's exact tests, and significance was defined as P < 0.05.

RESULTS

With the first complaint of pain, the mean intensity of pain was 4.9 (1.9) in the indomethacin group and 4.9 (1.8) in the lidocaine group, and the difference was not significant (P = 0.25). Six hours after birth, it was 3.3 (1.3) in the indomethacin group and 3.2 (1.9) in the lidocaine group, and there was not a significant difference between the two groups (P = 0.90). No significant difference was found between the two groups at 12 h after birth [2.3 (1.7) vs 2.5 (1.7); P = 0.59]. Also, the difference was not significant at 24 h after birth [1.5 (1.3) vs 1.8 (1.3); P = 0.31].

CONCLUSIONS

It was concluded from the study that indomethacin suppository and lidocaine cream have similar efficacy on episiotomy pain relief on the first day of postpartum period.

Paracetamol vs dexketoprofen for perineal pain relief after episiotomy or perineal tear

A randomised controlled trial was conducted to investigate efficacy of paracetamol and dexketoprofen trometamol for perineal pain relief after perineal repair. Subjects were randomly assigned to receive two doses of either 50 mg of intravenous dexketoprofen trometamol via slow i.v. infusion (Group I, n = 49) or 1,000 mg of paracetamol via intravenous infusion (Group II, n = 46). The main outcome measure was a VAS (visual analogue scale) for pain recorded at 1 h (VAS 1). A total of 82 patients were included in the final analysis (Group I, n = 41; Group II, n = 41). There was no difference among groups in terms of pain scores at the beginning (VAS 0). The pain was decreased in 70% of the patients in Group I and in 62% of the patients in Group II (p = 0.502). Both paracetamol and dexketoprofen are effective in perineal pain relief after episiotomy or perineal tear repair.

A comparative study on the efficacy of Ibuprofen and celecoxib on the intensity of perineal pain following episiotomy: a randomized clinical trial

Background:

Pain is a worldwide problem that often originates from disease process, and diagnostic and treatment procedures such as surgical operations.

Objectives:

This trial was performed to compare the effectiveness of two analgesics for the management of perineal pain caused by episiotomy.

Materials and Methods:

A total of 170 nulliparous women who gave birth vaginally with episiotomy between March 2009 and November 2010 were randomly assigned to receive either ibuprofen or celecoxib which were given orally every 6 or 12 hours, respectively. Pain levels were measured before the intervention, and at 1, 2, 4, 8 and 12 hours after providing the first dose on a 10-cm visual analogue scale.

Results:

The results showed that the two groups had no significant differences regarding demographic characteristics, maternal, neonatal, and post-delivery factors, and mean premedication pain severity. Means of pain severity were different between the two groups as patients in the celecoxib group had lower means than the other group at 1,2,4,8 and 12 hours (4.01 ± 1.8 vs. 4.46 ± 1.9, 3.17 ± 1.9 vs. 3.79 ± 1.7, 2.89 ± 1.3 vs. 2.96 ± 1.5, 2.19 ± 1.8 vs. 2.55 ± 1.4, and 1.98 ± 1.1 vs. 2.45 ± 1.2, respectively) after administration of analgesics.

Conclusions:

Patients who received celecoxib had lower VAS in comparison with others. Although these differences were not significant, as celecoxib has longer half-life, fewer upper GI symptoms, and is better tolerated based on the previous studies, and this study is in favor of using it.

Nonsteroidal anti-inflammatory drugs during pregnancy and the initiation of lactation

Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are available as "over-the counter" medications in most countries, are widely used by both pregnant and lactating women. They are popular non-opioid analgesics for the treatment of pain after vaginal and operative delivery. In addition, NSAIDs are used for tocolysis in premature labor, and low-dose aspirin has a role in the prevention of preeclampsia and recurrent miscarriage in antiphospholipid syndrome. NSAIDs and aspirin may affect fertility and increase the risk of early pregnancy loss. In the second trimester their use is considered reasonably safe, but has been associated with fetal cryptorchism. In the third trimester, NSAIDs and aspirin are usually avoided because of significant fetal risks such as renal injury, oligohydramnios, constriction of the ductus arteriosus (with potential for persistent pulmonary hypertension in the newborn), necrotizing enterocolitis, and intracranial hemorrhage. Maternal administration or ingestion of most NSAIDs results in low infant exposure via breastmilk, such that both cyclooxygenase-1 and cyclooxygenase-2 inhibitors are generally considered safe, and preferable to aspirin, when breastfeeding.

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.

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 STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2009).

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 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.