Evaluation of perineal wound healing and pain outcomes after low-angle mediolateral episiotomy in women undergoing vaginal childbirth: A systematic review and meta-analysis

The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis aimed to evaluate the impact of low-angle mediolateral episiotomy on perineal wound healing and pain outcomes in women undergoing vaginal childbirth. Adhering to PRISMA guidelines, a systematic review was conducted using the PICO framework. Studies were selected based on predefined inclusion and exclusion criteria, focusing on randomised controlled trials (RCTs) involving low-angle mediolateral episiotomies. Comprehensive literature searches were performed across major electronic databases including PubMed, Embase, Web of Science and Cochrane Library. Data extraction and quality assessments were meticulously carried out by independent reviewers, employing the Cochrane Collaboration's risk of bias tool. A total of 1246 articles were initially identified, with 8 articles meeting the strict inclusion criteria for the final analysis. The meta-analysis revealed significant heterogeneity among studies regarding postoperative pain (p < 0.0001, I2 = 77.5%), and employed a random-effects model. Results showed that low-angle episiotomies significantly reduced postoperative pain (OR = 0.27, 95% CI: 0.17-0.42, p < 0.001), and increased first-degree healing rates (OR = 2.95, 95% CI: 2.20-3.96, p < 0.001) compared to traditional angles. Sensitivity analyses confirmed the stability of these findings, and no significant publication bias was detected. The analysis suggests that low-angle episiotomies can potentially reduce postoperative perineal pain and enhance wound healing. However, the limited number and varying quality of the included studies warrant cautious interpretation of these results. Further well-designed studies are needed to corroborate these findings and guide clinical practice.

Postpartum pain and the risk of postpartum depression: A meta-analysis of observational studies

OBJECTIVE

This meta-analysis of observational studies aimed to derive a more precise estimation of the relationship between postpartum pain and postpartum depression (PPD).

METHODS

A systematic literature search was completed in the following databases from inception to September 26, 2022: PubMed, Embase, and Web of Science. Quality evaluation of each study was achieved through Newcastle-Ottawa scale (NOS) assessment. Heterogeneity across studies was evaluated by Cochran's Q test and I2 test. Pooled estimates of odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were analyzed using fixed-effects model or random-effects model, according to heterogeneity. Subgroup analysis, sensitivity analysis, and Egger's test were also performed.

RESULTS

From the identified 1884 articles, a total of 8 studies involving 3973 participants were included in the final meta-analysis. Seven of the 8 studies were evaluated as high-quality, with NOS scores ≥7. A significant heterogeneity was observed (I2  = 66.5%, p = 0.004) among eight studies. Therefore, the performed random-effect model suggested a significant association between postpartum pain and PPD risk (OR 1.29, 95% CI 1.10-1.52, p = 0.002). However, the subgroup analyses did not define the source of heterogeneity. Moreover, the sensitivity analysis showed the stability of the pooled results, but the significant publication bias was identified (p = 0.009). The trim and fill method was performed and resulted in an OR of 1.14 (95% CI 0.95-1.37, p = 0.162).

CONCLUSIONS

This meta-analysis found a potential association between postpartum pain and PPD. Further researches are needed to provide more robust evidences.

The analgesic effect of transversalis fascia plane block after caesarean section under spinal anaesthesia with intrathecal morphine: a randomised controlled trial

We aimed to test whether bilateral injection of bupivacaine 0.25% in the transversalis fascia plane reduced 24 h opioid dose after singleton caesarean section, under spinal anaesthesia with intrathecal morphine, compared with saline 0.9% injectate. We allocated randomly 52 women to bilateral injection of 20 ml saline 0.9% on arrival in the post-anaesthesia care unit and 54 women to bilateral injection of 20 ml bupivacaine 0.25% (with adrenaline 2.5 μg.ml-1 ). Mean (SD) cumulative morphine equivalent opioid dose 24 h after saline injection was 32.3 (28.3) mg and 18.7 (20.2) mg after bupivacaine injection, a mean (95%CI) difference of 13.7 (4.1-23.2) mg (p = 0.006). Median (IQR [range]) time to first postoperative opioid dose was 3.0 (1.5-10.3 [0.0-57.4]) h after saline 0.9% and 8.2 (2.7-29.6 [0.2-55.4]) h after bupivacaine 0.25% (p = 0.054). Transversalis fascia plane with bupivacaine 0.25% with adrenaline reduced postoperative pain at rest during 48 h (0-10-point scale) by a mean (95%CI) of 0.9 (0.2-1.6) points (p = 0.013) and on movement by 1.2 (0.4-2.1) points (p = 0.004). We conclude that transversalis fascia plane bupivacaine 0.25% with adrenaline reduces pain and opioid dose after caesarean section compared with saline 0.9%.

Antepartum depressive symptoms are associated with significant postpartum opioid use

BACKGROUND

Antepartum depression is common, and outside of childbirth preoperative anxiety and depression have been associated with heightened postoperative pain. In light of the national opioid epidemic, the relationship between antepartum depressive symptoms and postpartum opioid use is particularly relevant.

OBJECTIVE

This study evaluated the association between antepartum depressive symptoms and significant postpartum opioid use during birth hospitalization.

STUDY DESIGN

This retrospective cohort study at an urban academic medical center from 2017 to 2019 included patients who received prenatal care at the medical center and linked pharmacy and billing data with electronic medical records. The exposure was antepartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale ≥10 during the antepartum period. The outcome was significant opioid use, defined as: (1) any opioid use following vaginal birth and (2) the top quartile of total opioid use following cesarean delivery. Postpartum opioid use was quantified using standard conversions for opioids dispensed on postpartum days 1 to 4 to calculate morphine milligram equivalents. Poisson regression was used to calculate risk ratios and 95% confidence intervals, stratified by mode of delivery and adjusted for suspected confounders. Mean postpartum pain score was a secondary outcome.

RESULTS

The cohort included 6094 births; 2351 births (38.6%) had an antepartum Edinburgh Postnatal Depression Scale score. Of these, 11.5% had a maximum score ≥10. Significant opioid use was observed in 10.6% of births. We found that individuals with antepartum depressive symptoms were more likely to have significant postpartum opioid use, with an adjusted risk ratio of 1.5 (95% confidence interval, 1.1-2.0). When stratified by mode of delivery, this association was more pronounced for cesarean births, with an adjusted risk ratio of 1.8 (95% confidence interval, 1.1-2.7), and was no longer significant for vaginal births. Mean pain scores after cesarean delivery were significantly higher in parturients with antepartum depressive symptoms.

CONCLUSION

Antepartum depressive symptoms were associated with significant postpartum inpatient opioid use, especially following cesarean delivery. Whether identifying and treating depressive symptoms in pregnancy may impact the pain experience and opioid use postpartum warrants further investigation.

A comparison of postpartum opioid consumption and opioid discharge prescriptions among opioid-naïve patients and those with opioid use disorder

BACKGROUND

Management of patients with opioid use disorder during the acute postpartum period remains clinically challenging as obstetricians aim to mitigate postdelivery pain while optimizing recovery support.

OBJECTIVE

This study aimed to evaluate postpartum opioid consumption and opioids prescribed at discharge among patients with opioid use disorder treated with methadone, buprenorphine, and no medication for opioid use disorder, as compared with opioid-naïve counterparts.

STUDY DESIGN

We conducted a retrospective cohort study of pregnant patients who underwent delivery at >20 weeks' gestation at a tertiary academic hospital between May 2014 and April 2020. The primary outcome of this analysis was the mean daily quantity of oral opioids consumed after delivery while inpatient, in milligrams of morphine equivalents. Secondary outcomes included the following: (1) quantity of oral opioids prescribed at discharge, and (2) prescription for oral opioids in the 6 weeks after hospital discharge. Multiple linear regression was used to compare differences in the primary outcome.

RESULTS

A total of 16,140 pregnancies were included. Patients with opioid use disorder (n=553) consumed 14 milligrams of morphine equivalents per day greater quantities of opioids postpartum than opioid-naïve women (n=15,587), (95% confidence interval, 11-17). Patients with opioid use disorder undergoing cesarean delivery consumed 30 milligrams of morphine equivalents per day greater quantities of opioids than opioid-naïve counterparts (95% confidence interval, 26-35). Among patients who underwent vaginal delivery, there was no difference in opioid consumption among patients with and without opioid use disorder. Compared with patients prescribed methadone, patients prescribed buprenorphine, and those prescribed no medication for opioid use disorder consumed similar opioid quantities postpartum following both vaginal and cesarean delivery. Among patients undergoing cesarean delivery, opioid-naïve patients were more likely to receive a discharge prescription for opioids than patients with opioid use disorder (77% vs 68%; P=.002), despite lower pain scores and less inhospital opioid consumption.

CONCLUSION

Patients with opioid use disorder, regardless of treatment with methadone, buprenorphine, or no medication for opioid use disorder consumed significantly greater quantities of opioids after cesarean delivery but received fewer opioid prescriptions at discharge.

Associations between postpartum pain type, pain intensity and opioid use in patients with and without opioid use disorder: a cross-sectional study

BACKGROUND

Pain is a multidimensional construct. The purpose of this cross-sectional, single-centre study was to evaluate the relationship between postpartum pain type with pain intensity and opioid use in people with and without opioid use disorder (OUD).

METHODS

Postpartum pain type was coded from McGill Pain Questionnaire and Patient-Reported Outcome Measurement Information System (PROMIS) inventories in people with or without OUD after childbirth in a 4-month period. The co-primary outcomes were pain intensity (0-10 scale) and total inpatient oxycodone (mg). Multivariable linear mixed-effects models assessed between- and within-person relationships for pain type (primary predictor) and outcomes.

RESULTS

There were 44 522 unique pain scores and types from 2610 people. Pain types were associated with pain intensity (P<0.001). Between-person comparisons showed affective pain was associated with a small but higher total oxycodone dose (difference 1.04 mg compared with no affective pain, P<0.001). Among people with OUD, within-person comparisons showed that the presence of affective pain resulted in pain scores 1 point higher than when affective pain was not present (P=0.002); between-person comparisons showed that people with affective pain had pain scores 6 points higher (P=0.048). Within-person and between-person comparisons among OUD showed that nociceptive/neuropathic pain was associated with a higher total oxycodone dose (1.6 and 11.4 mg, respectively).

CONCLUSIONS

Postpartum pain type was associated with pain intensity and opioid use. Further research is required to address the multiple dimensions of postpartum pain in people with and without OUD to improve treatment of postpartum pain.

Low-intensity ultrasound promotes uterine involution after cesarean section: the first multicenter, randomized, controlled clinical trial

OBJECTIVE

To evaluate the clinical efficacy and safety of low-intensity ultrasound (LIUS) in promoting uterine involution and relieving postpartum pain.

METHODS

The randomized controlled clinical trial in this study was conducted at five centers in three regions across China from June 2014 to December 2014. A total of 498 subjects were randomly divided into two groups. The LIUS group received ultrasound treatment, and the control group received sham ultrasound treatment. The fundal height and visual analogue scale (VAS) scores of the subjects following cesarean section were recorded separately before and after five treatments. The incidence of adverse events was recorded, while the records on lochia duration were obtained by telephone follow-up. The Full Analysis Set (FAS) comprised all subjects randomized who received at least one treatment. The Per-Protocol Set (PPS) comprised all patients who did not seriously violate the study protocol and had good compliance with complete report forms. Efficacy analyses were performed based on the FAS and PPS. All safety analyses were performed based on the safety set (SS), which included all patients who received at least one treatment.

RESULTS

In the analysis of PPS and FAS, the LIUS group performed better than the control group in reducing the fundal height, shortening the duration of lochia, and relieving postpartum pain, with a significant difference between the two groups (p < 0.0001). In the SS analysis, there were no treatment-related adverse events observed in either group.

CONCLUSIONS

The LIUS therapy is safe and effective, which contributes to uterine involution and the alleviation of postpartum pain.

Does pain after delivery unequivocally lead to postpartum depression? The moderating role of religious coping

OBJECTIVE

The objective of this work is to explore whether the relationship between pain after delivery and postpartum depression is increased or decreased by the use of religion as a coping strategy (moderation).

METHODS

A longitudinal cohort study was conducted. The sample was evaluated on three occasions: third trimester of pregnancy (religious coping), after birth (pain severity) and four months after delivery (postpartum depression). Participants were 122 women (mean age = 31.29; SD = 4.9: range = [22, 42 years]) with low obstetric risk.

RESULTS

Both pain severity and religious coping contributed to postpartum depression (r = .20, p = .029 and r = .28, p = .04, respectively). Religious coping exacerbated the relationship between pain after delivery and postpartum depression (B = -0.11, t = -2.48, p = .014, [-0.20, -0.02]). Depression was highest in participants using religious coping irrespective of pain severity levels.

CONCLUSION

These findings support the importance of person-environment interaction studies and provide new evidence on the deleterious role of religious coping in the well-being of women after childbirth.

A Case Study of Chronic Iliopsoas Tendinopathy and Sacroiliac Joint Dysfunction Masquerading As Pelvic Girdle Pain

Pain related to pregnancy can occur anytime between conception to the postpartum period. Pregnancy and the following months after birth are a time of physical change to the woman’s body, with significant hormonal effects. We present a case of a young female with chronic pain several years after her second pregnancy that presented a diagnostic challenge. She was initially diagnosed with persistent pelvic girdle pain (PGP) type 2, responded somewhat to appropriately targeted pelvic floor therapy, with a plateau in her progress. The diagnosis was revised to PGP type 4, with some improvement in pain with customized therapy. Her treatment again changed with a focus on sacroiliac joint (SIJ) dysfunction and iliopsoas tendinopathy with excellent and complete resolution of her pain. The overlapping nature of these diagnoses caused a significant challenge in creating a tailored physical therapy approach to her pain that eventually led to her final diagnosis being one of exclusion. Treatment was focused on optimization of joint mobility and tissue lengthening, with the resolution of her pain.

Patient Experience with Postpartum Pain Management in the Face of the Opioid Crisis

INTRODUCTION

Professional societies have urged providers to reduce opioid use for pain management. Accordingly, the objective of this study was to assess patient experiences related to postpartum pain management in an effort to better understand potential paths to achieve such a reduction.

METHODS

This is a planned secondary analysis of a prospective observational study of opioid use following birth. In the primary study, women who received opioids as inpatients were queried about their pain management, including questions about pain experience, pain satisfaction, perceived areas for practice improvement, and the opportunity to leave additional comments. Participants who were prescribed opioids upon discharge completed postdischarge surveys with a similar opportunity for qualitative input. Data were analyzed using the constant comparative method to identify themes and subthemes.

RESULTS

Of the 493 women enrolled in the primary analysis, 125 provided qualitative data. Three overarching themes regarding pain management were identified: positive experiences (n = 22), negative experiences (n = 19), and beliefs and preferences on opioid use and pain management (n = 28). Women with positive experiences reported satisfaction with timely pain medication administration and appreciation of open dialogue with their care team. In contrast, several negative experiences centered on tardy administration of pain medications, resulting in increased pain. Patients also perceived judgment, accusation, and excessive lecturing by staff when requesting opioid medications. Finally, participants expressed the necessity for opioids for postpartum pain management, as well as their desires for limiting opioid use, improved options for multimodal pain management, and increased communication with providers about pain regimens.

DISCUSSION

Understanding women's perspectives and experiences regarding postpartum pain control is essential to improving care. Amid growing research on the role of maternity care providers in addressing the opioid crisis, women's voices are rarely solicited. These findings stress the importance of open and frequent dialogue between patients and providers and a need for multimodal pain management options.

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.

A randomized controlled trial of liposomal bupivacaine for pain following obstetrical laceration

BACKGROUND

Postpartum pain management is critical after vaginal delivery involving a second, third, or fourth degree laceration as patients heal from their repair. Uncontrolled postpartum pain can affect both the physical and mental recovery period, extend hospital stays, and increase the potential for serious adverse reactions with pain medications. In light of the opioid crisis and increase in dependency after utilization, finding alternatives for pain management after procedures is paramount. The need for a safe, effective, long-acting medication to treat postpartum and postoperative pain has reached a critical point in the current healthcare climate.

OBJECTIVE

To minimize pain after vaginal delivery, we assessed the effectiveness of liposomal bupivacaine vs plain bupivacaine injected into the perineum after second, third, or fourth degree lacerations. We hypothesized that the liposomal bupivacaine study group would have less vaginal pain, analgesic usage, and improved quality of life compared with the plain bupivacaine control group.

MATERIALS AND METHODS

This is a single-blinded randomized controlled trial with 120 subjects enrolled at Walter Reed National Military Medical Center, Bethesda, Maryland, from February 2018 to February 2019. After vaginal delivery and repair, study participants were randomized into 20-mL liposomal bupivacaine (study group) or 20-mL 0.25% plain bupivacaine (control group) injected into and around the perineal body bilaterally. On postpartum days 1, 3, and 7, pain scores and analgesics were recorded. Our primary outcome was vaginal pain score at postpartum day 3, analyzed with Wilcoxon rank-sum test. Our secondary outcomes included vaginal pain at postpartum days 1 and 7, pain with bowel movement, sleep disturbance, and pain's impact on activity, stress, and mood. Desired statistical power was achieved with 48 patients per group (total of 96 patients).

RESULTS

A total of 60 patients were randomized to each group; 108 patients completed the study. Most patients (94%) had regional anesthesia. There was no statistically significant difference in the demographics between these groups. There were 25 obstetric anal sphincter injuries, equally distributed between the 2 groups (P>.99). There was no significant difference between vaginal pain scores at postpartum day 3 (control, 2 [1-3]; study, 2 [0-3]) (P=.63). This was also seen at postpartum day 1 (control, 2 [0-3]; study, 2 [0-3]) (P=.82) and postpartum day 7 (control, 1 [0-3]; study, 1 [0-2]) (P=.47). Cumulative pain scores for postpartum days 1, 3, and 7 failed to reach significance (study, 5 [3-8]; control, 6 [3-8]) (P=.83). Secondary analysis of pain with bowel movement and impact on sleep, activity, stress, and mood found no differences. Given that only 3 patients required outpatient opioids, there were insufficient data to calculate morphine equivalent differences.

CONCLUSION

After obstetric lacerations, there is no proven benefit to lateral and intraperineal injection of liposomal bupivacaine over plain bupivacaine in postpartum vaginal pain scores, quality of life scores, or pain medication utilized. This may be due to low pain scores and opioid usage, both groups benefiting from the intervention, or ineffective perineal injection location.

Scheduled versus as-needed postpartum analgesia and oxycodone utilization

Background: An optimal approach for providing sufficient postpartum analgesia while minimizing the risk of opioid misuse or diversion has yet to be elucidated. Moreover, there is scant literature on the efficacy of around-the-clock (ATC) scheduled dosing of opioid analgesia compared to pro re nata (PRN; as-needed) dosing for postpartum pain management. Here we evaluate a quality improvement intervention that aimed to proactively provide pain relief with a multimodal analgesic regimen that includes oxycodone at scheduled time intervals. This new protocol stands in stark contrast to many contemporary postpartum pain management regimens in which oral opioid medications are reserved for treating breakthrough pain.Objective: Our aim was to determine how inpatient oxycodone use is affected by as-needed compared to ATC scheduled dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications. We also sought to determine the effect of each modality on patient satisfaction with pain control.Methods: Retrospective cohort study of singleton deliveries at ≥37 weeks of gestation at a tertiary hospital from 2013 to 2016. In month 21 of the 48-month study period, a new institutional protocol for postpartum pain management was implemented which consisted of scheduled dosing of a multimodal analgesic regimen. Prior to this, patients received pain relief only as needed, by reporting elevated pain scores to nursing staff. Patients were excluded for the following: NSAID or opioid allergies, protocol deviations, transition month deliveries, history of drug abuse, positive urine toxicology, delivery with general anesthesia, prolonged hospitalization, postpartum hemorrhage, hypertensive disorders of pregnancy, incomplete records. Outcomes evaluated were the percentage of patients receiving oxycodone and mean oxycodone use per inpatient day (milligrams). Segmented regression analysis of interrupted time series was performed to estimate linear time trends of oxycodone consumption pre- and post-protocol implementation. Results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) standardized survey were also compared before and after implementation.Results: A total of 19,192 deliveries were included. After adjusting for confounders, a significant downward trend in the percentage of patients receiving oxycodone was noted among both cesarean (0.004% decrease per month; p < .006) and vaginal deliveries (0.005% decrease per month; p < .0001) before implementation of the scheduled pain management protocol. Among cesarean deliveries, there was no shift at the time of implementation, and no change in the slope of the trend after implementation. Among vaginal deliveries, there was an upward shift at implementation (+7.4%, p < .0001) but no change in the slope of the trend after implementation. Regardless of mode of delivery, no trend in monthly mean oxycodone consumption per day existed before or after implementation of the new protocol, and there was no shift at the time of implementation. Scheduled multimodal analgesia was associated with an improvement in HCAHPS scores for patient reported pain control after cesarean section (63 versus 71% reporting "Always" well controlled; p < .001) but had no effect after vaginal delivery.Conclusion: After cesarean delivery, scheduled multimodal analgesia that includes ATC dosing of acetaminophen, ibuprofen, and low-dose oxycodone, with the option to decline any of these medications, does not increase the percentage of women who receive oxycodone or mean oxycodone consumption per inpatient day compared to as-needed analgesia. After vaginal delivery, scheduled multimodal analgesia is associated with an increase in the percentage of women who receive oxycodone but no change in mean oxycodone consumption per inpatient day.

Biased Partner Perceptions of Women's Pain Self-Efficacy in Postpartum Pain During Intercourse: A Dyadic Longitudinal Examination

Postpartum pain during intercourse is a prevalent and distressing problem that has substantial consequences for affected couples. Partner perceptions-such as how partners perceive women's pain self-efficacy-contribute to an individual's pain experience. This study examined whether partners under- or over-estimate women's intercourse pain self-efficacy at 3-months postpartum and the implications of this bias for women's pain and couples' sexual functioning at 3- and 6-months postpartum. Women who reported pain during intercourse and their partners (N = 89 couples) completed online measures assessing pain self-efficacy (own or partner perceptions), pain intensity, and sexual functioning at 3- and 6-months postpartum. Analyses were based on the Truth and Bias Model of Judgement and Response Surface Analysis. Partners were accurate in their estimates of women's pain self-efficacy (ie, their estimates were positively correlated with women's), but they also underestimated it by perceiving women to be less efficacious than women themselves reported. When couples showed greater agreement for lower levels of pain self-efficacy at 3 months, women reported greater pain intensity and both partners reported poorer sexual functioning at 3- and 6-months postpartum. Findings may inform interventions that promote pain self-efficacy to improve partner support and couples' sexual functioning. PERSPECTIVE: When women report-and their partners perceive-low levels of women's self-efficacy for managing painful intercourse, women report greater postpartum pain during intercourse and couples indicate poorer sexual functioning. These findings suggest that interventions aimed at promoting couples' agreement at high pain self-efficacy may improve their adjustment to postpartum pain.

[Effect of auricular acupuncture on postpartum rehabilitation of primipara with cesarean]

OBJECTIVE

To explore the postoperative effect of auricular acupuncture on primipara with cesarean in order to promote postpartum rehabilitation.

METHODS

A total of 120 primiparas with cesarean were randomly divided into an observation group and a control group, 60 cases in each group. The routine treatment and care after surgery were given in the two groups. On the basis treatment, auricular acupuncture was applied at penqiang (TF₅), shenmen (TF₄), jiaogan (AH_6a), pizhixia (AT₄), neishengzhiqi(TF₂), pi(CO₁₃), wei(CO₄) in the observation group, even-needling technique at all points. The needles were retained for 30 min, 3 times a day, the acupuncture was alternately every other day for 5 days continuously. The postpartum pain, anus exhaust time, incidence of postpartum hemorrhage, urinary retention and constipation, and postpartum average hospitalization day were recorded and compared between the two groups.

RESULTS

Twenty-seven cases of postpartum uterine contraction pain (45.0%), 25 cases of wound pain (41.7%), 19 cases of breast distending pain (31.7%) and 11 cases of muscle soreness (18.3%) in the observation group, which was significantly lower than 38 cases (63.3%), 36 cases (60.0%), 30 cases (50.0%) and 21 cases (35.0%) respectively in the control group (P<0.05). The anus exhaust time in the observation group was earlier than that in the control group (P<0.05), and the average hospitalization time was shorter than that in the control group (P<0.05). The incidence of postpartum hemorrhage, urinary retention and constipation in the observation group was lower than that in the control group (P<0.05).

CONCLUSION

Auricular acupuncture can effectively relieve postpartum pain in primipara with cesarean, promote postpartum exhaust and shorten hospitalization days, and reduce the incidence of postpartum complications such as postpartum hemorrhage, urinary retention and constipation, it is conducive to postpartum rehabilitation.

Opioid prescribing patterns among postpartum women

BACKGROUND

Women commonly receive opioid prescriptions following hospitalization. The rise of the opioid epidemic in the United States underscores the importance of a better understanding of prescribing patterns. Although delivery is the most frequent reason for hospitalization in the United States, there is inadequate knowledge regarding opioid prescribing at postpartum hospital discharge.

OBJECTIVE

We sought to describe opioid prescribing patterns at the time of discharge following delivery in a large, diverse cohort, and to describe the relationship of these patterns with objective and subjective measures of pain prior to discharge.

STUDY DESIGN

This is a retrospective cohort study of all deliveries at a single, high-volume tertiary care center over a 1-year period. Women were excluded from analysis if they had evidence of recent opioid use, or their labor, delivery, or postpartum course was notable for rare, nonroutine events anticipated to increase pain. Medical records were queried for demographic and clinical data, including whether an opioid prescription was provided at discharge, and if so, details of that prescription. The primary outcome was amount of opioid morphine milligram equivalents prescribed at discharge, described separately for women after vaginal and cesarean deliveries. Among women who received a prescription, we additionally assessed associations between prescription quantity and subjective (patient-reported pain score) and objective (inpatient opioid requirement during the final 24 hours of hospitalization) assessments of pain. Descriptive and bivariable analyses were performed.

RESULTS

Of the total 12,611 women, 12,326 were eligible for inclusion. Of 9038 women postvaginal delivery and 3288 women postcesarean delivery, 30.4% and 86.7% received an opioid prescription at discharge, respectively. Of women receiving discharge opioid prescriptions, median morphine milligram equivalents received was 200 (interquartile range: 120-300) following vaginal and 300 (interquartile range: 200-300) following cesarean delivery. Nearly half (45.7%) of women postvaginal delivery and 18.5% of women postcesarean delivery who received an opioid prescription used 0 morphine milligram equivalent during the final hospital day. Similarly, 26.5% and 18.5% of women after vaginal and cesarean delivery, respectively, reported a pain score of 0 of 10 prior to discharge. Regardless of delivery mode, the amount of opioids prescribed did not differ between those who reported a pain score of 0 of 10 and those who reported a pain score of >0 of 10 immediately prior to discharge. Similarly, for women who underwent cesarean delivery, the morphine milligram equivalents prescribed did not differ between those who used 0 morphine milligram equivalents and those who used >0 in the 24 hours prior to hospital discharge.

CONCLUSION

Postpartum women are commonly prescribed opioids at the time of postpartum hospital discharge. There is a wide range of morphine milligram equivalents prescribed at hospital discharge following delivery, highlighting a lack of standardization. Furthermore, regardless of objective and subjective measures of pain prior to discharge, women received similar amounts of prescription morphine milligram equivalents following either vaginal or cesarean deliveries.

Postpartum depression screening and pelvic floor symptoms among women referred to a specialty postpartum perineal clinic

BACKGROUND

Postpartum depression and pelvic floor disorders are both common conditions that affect women; however, the association between the 2 has yet to be determined.

OBJECTIVE

The aims of our study are to: (1) determine the prevalence of a positive postpartum depression screen in a specialty postpartum perineal clinic, and (2) identify risk factors for postpartum depression in this population.

STUDY DESIGN

A retrospective chart review was performed of 294 women referred to a specialty postpartum perineal clinic at the University of Michigan from March 30, 2012, through May 3, 2016. Women who completed a new patient intake form, including the Edinburgh Postnatal Depression Scale, were included. The prevalence of a positive Edinburgh Postnatal Depression Scale screen (≥10) was determined. Bivariate analyses were used to compare demographics, delivery characteristics, referral indications, and postpartum pelvic floor symptoms between women with and without a positive Edinburgh Postnatal Depression Scale screen. Significant variables identified in the analyses were then used to perform logistic regression to identify factors independently associated with a positive Edinburgh Postnatal Depression Scale screen.

RESULTS

In all, 15.6% (46/294) of women had a positive postpartum depression screen. Average age was 30.6 ± 4.8 years, average body mass index was 28.9 ± 5.06 kg/m², 68.0% (200/294) were Caucasian, 79.6% (234/294) were primiparous, and 86.0% (245/285) were breast-feeding. Using multivariable logistic regression, women with a positive postpartum depression screen had higher odds of being non-Caucasian (adjusted odds ratio, 2.72; 95% confidence interval, 1.27-5.832; P = .01), having a history of depression and/or anxiety (adjusted odds ratio, 2.77; 95% confidence interval, 1.23-6.24; P = .01), having been referred for pain (adjusted odds ratio, 2.61; 95% confidence interval, 1.24-5.49; P = .01), and reporting urinary incontinence during and after pregnancy (adjusted odds ratio, 3.81; 95% confidence interval, 1.57-9.25; P = .003).

CONCLUSION

Urinary incontinence during and after pregnancy and referral for pain were pelvic floor symptoms independently associated with a positive postpartum depression screen in women referred to a specialty perineal clinic. Therefore, consideration should be given to depression screening in women presenting with perinatal urinary incontinence and persistent postpartum pain, as these women may be at increased risk of developing postpartum depression.

Evaluation of the effects of ice massage applied to large intestine 4 (hegu) on postpartum pain during the active phase of labor

BACKGROUND

The uterus continues to contract after childbirth. The pain caused by the contractions of the uterus can be as severe as labor pain. The study was aimed to evaluate the effects of ice massage applied to the large intestine 4 (LI4) on postpartum pain during the active phase of labor.

MATERIALS AND METHODS

The study was designed as a randomized controlled trial with three groups and carried out in two stages. The study sample comprised of 150 pregnant women, who were referred to a maternity hospital. In the experimental group, ice massage was applied to LI4 during four contractions within the active phase of labor. In the placebo group, pressure was applied to LI4 using silicone balloons and the third group was the control group. The Visual Analog Scale (VAS) and The McGill (Melzack) Pain Questionnaire (MPQ) were compared among the experimental, placebo, and control groups.

RESULTS

The mothers in the ice application group had the lowest mean VAS score. It was determined that ice massage applied to LI4 during the active phase of labor did not lead to any statistical differences in mothers in the first 24 hours postpartum in terms of the characteristics of the pain with MPQ and VAS.

CONCLUSIONS

In the study, the perception of pain was tried to be minimized by applying pressure with ice balloons to LI4. However, although the application was determined to have made no difference in the pain intensity, the mothers' statements in the ice application group suggested that they felt more comfortable than did the mothers in the other groups.

Research summaries for normal birth

In this column, the authors summarize four research studies relevant to normal birth. Topics of the studies summarized include the harms of screening for macrosomia late in pregnancy, the risk factors for and impact of postpartum pain in childbearing women, the effects of a breastfeeding approach called "biological nurturing" on reflexive behavior in newborns, and the effects of prenatal yoga on labor and birth outcomes.