(702) Pain Management After Vaginal Birth: A Systematic Review To Support Clinical Practice Guideline Development

To assess the evidence for key aspects of pain management following vaginal birth, higher-order perineal trauma, and peripartum tubal ligation to inform new clinical practice guidelines.

Study Design:

We conducted a systematic review and narrative synthesis of studies addressing post-vaginal birth pain management (opioid medications, non-opioid medications, and nonpharmacologic methods). Studies assessed opioid use, analgesia effects, patient-centered outcomes, and disparities in the general population, patients with opioid use disorder (OUD), chronic pain, and psychiatric conditions. Ovid MEDLINE, Elsevier's Scopus, Elsevier’s Embase, Google Scholar, PubMed, and Web of Science were searched to identify relevant articles. Articles were screened and abstracted by two researchers. Quality was assessed using the RAND/UCLA Appropriateness Methodology approach.

Results:

Of 2,255 studies screened, 21 were included: 1 high-quality (clinical practice guideline); 7 moderate-quality (RCTs); and 13 low-quality (non-RCTs, observational studies). Two reported that multimodal, non-opioid interventions (e.g. scheduled ibuprofen and acetaminophen) reduced opioid use without increasing pain after vaginal birth. Inpatient strategies and nonpharmacologic studies were limited with mixed results. Three discharge prescribing studies after vaginal birth showed variability and racial/ethnic disparities. Receiving discharge opioid prescriptions was linked to persistent use and opioid-related adverse events. Higher-order perineal trauma and tubal ligation were associated with increased opioid use after discharge. Patients with chronic pain and psychiatric conditions had increased opioid exposure and persistent use.

Conclusion:

Multimodal oral opioid-sparing strategies provide adequate pain control while limiting opioid use after vaginal birth. Nonpharmacologic methods may provide low-risk enhancement in pain management. There are significant evidence gaps for postpartum pain management in patients with OUD, chronic pain, and psychiatric conditions.