Anti-inflammatory drugs for relief of perineal pain after childbirth

What is the issue?

Following childbirth, many women experience pain in the perineum, an area between the anus and the vagina. This Cochrane review asked if this pain can be reduced by one dose of a non-steroidal anti-inflammatory drug (NSAIDs), such as aspirin or ibuprofen.

Why is this important?

The pain some women experience in the perineum after childbirth can be particularly acute if the perineum tears during the birth, or needs to be cut (a procedure known as an episiotomy). Even a woman without tearing or surgery often experiences a degree of discomfort in her perineum, which can affect her mobility as well as her ability to care for her baby. This review is part of a series of reviews on the effectiveness of different drugs for pain relief for perineal pain immediately after birth. It is looking specifically at NSAIDs, such as aspirin and ibuprofen.

What evidence did we find?

We found 28 studies with 4181 women that examined 13 different NSAIDs (aspirin, ibuprofen etc.). We included studies up to 31 March 2016. The studies we found only included women who had trauma of the perineum and who were not breastfeeding. Studies were conducted between 1967 and 2013, were small and not of high quality.

The studies showed that a single dose of a NSAID provided greater pain relief at either four hours (low-quality evidence) or six hours (very low-quality evidence) after administration when compared to a placebo (dummy pill) or no treatment in non-breastfeeding women who had sustained perineal trauma during childbirth. Women who received a single dose of NSAID were also less likely to need additional pain relief at four hours (low-quality evidence) or six hours (low-quality evidence) after initial administration compared to women who received placebo or no treatment. Not all of the studies assessed adverse effects of the intervention but some studies reported maternal adverse effects such as drowsiness, headache, weakness, nausea, gastric discomfort but there was no clear difference in the incidence of maternal adverse effects between groups at six hours post-administration (very low-quality evidence). One small study reported that there were no maternal adverse effects at four hours post-administration (low-quality evidence). None of the studies measured possible adverse effects on the baby.

A NSAID also appeared to be better than paracetamol in providing pain relief at four (but not six hours) after administration, although only three small studies looked at this comparison. Women who received a single dose of NSAID were also less likely to need additional pain relief at six (but not four) hours after administration compared to women who received paracetamol. There were no maternal adverse effects observed at four hours (one small study). Three small studies reported maternal adverse effects at six hours after administration but there were no clear differences between groups. Adverse effects on the baby were not reported in any of the included studies and all studies excluded women who were breastfeeding.

Comparisons of different NSAIDs and different doses of the same NSAID did not demonstrate any clear differences in their effectiveness on any of the main outcomes measured in this review. However, few data were available for some NSAIDs.

None of the included studies reported on any of this review's secondary outcomes, including: extended hospital stay or readmission to hospital due to perineal pain; breastfeeding, perineal pain at six weeks after having the baby; women's views, postpartum depression or measures of disability due to perineal pain.

What does this mean?

For women who are not breastfeeding, a single dose of a NSAIDs may help with perineal pain, after four and six hours. Paracetamol may be similarly helpful. No serious side effects were reported, but not all studies examined this. For women who breastfeed, there are no data and these women should seek help as some NSAIDs are not recommended for women who breastfeed.

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.

Read the full abstract...
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 strategy: 

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 placebo

Compared 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 paracetamol

NSAIDs 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.

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