Cochrane for Clinicians

Putting Evidence into Practice

Single-Dose Oral NSAIDs and Acetaminophen for Perineal Pain in the Early Postpartum Period

 

Am Fam Physician. 2021 Dec ;104(6):575-577.

Author disclosure: No relevant financial affiliations.

Clinical Question

Is a single dose of an oral nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen effective for acute perineal pain in the early post-partum period?

Evidence-Based Answer

In patients with acute perineal pain at four hours' postpartum, a single dose of an oral NSAID (number needed to treat [NNT] = 4; 95% CI, 3 to 6)1 and a single dose of oral acetaminophen (NNT = 3; 95% CI, 2 to 6)2 are each effective at achieving adequate pain relief. Both NSAIDs (NNT = 5; 95% CI, 4 to 8) and acetaminophen (NNT = 5; 95% CI, 4 to 7) are effective at reducing the need for further analgesia. It is unclear whether an NSAID or acetaminophen is superior. It should be noted that these data are based on studies in which a majority of patients underwent episiotomy.1,2 (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

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SUMMARY TABLE

Outcomes of Oral NSAIDs and Acetaminophen on Pain Relief for Acute Perineal Pain

OutcomesAssumed risk with placebo or acetaminophenCorresponding risk with medication (95% CI)NNT* (95% CI)ParticipantsQuality of evidence

Adequate pain relief (4 hours)

Placebo

NSAID

284 per 1,000

543 per 1,000 (466 to 634 per 1,000)

4 (3 to 6)

1,573

Low

Acetaminophen

NSAID

205 per 1,000

315 per 1,000 (219 to 454 per 1,000)

9 (4 to 71)

342

Low

Placebo

Acetaminophen

27%

58% (43% to 78%)

3 (2 to 6)

1,279

Low

Adequate pain relief (6 hours)

Placebo

NSAID

321 per 1,000

615 per 1,000 (542 to 696 per 1,000)

3 (3 to 5)

2,079

Very low

Acetaminophen

NSAID

200 per 1,000

364 per 1,000 (122 to 1,000 per 1,000)

NA

99

Very low

Need for additional analgesia (4 hours)

Placebo

NSAID

305 per 1,000

119 per 1,000 (79 to 177 per 1,000)

5 (4 to 8)

486

Moderate

Acetaminophen

NSAID

405 per 1,000

223 per 1,000 (109 to 458 per 1,000)

NA

73

Very low

Placebo

Acetaminophen

30.5%

10.4% (6.4% to 16.8%)

5 (4 to 7)

1,132

Low

Need for additional analgesia (6 hours)

Placebo

NSAID

438 per 1,000

140 per 1,000 (114 to 175 per 1,000)

3 (3 to 4)

1,012

Very low

Acetaminophen

NSAID

571 per 1,000

160 per 1,000 (69 to 383 per 1,000)

2 (2 to 5)

59

Low


NA = not applicable; NNT = number needed to treat; NSAID = nonsteroidal anti-inflammatory drug.

*—The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

Information from references 1 and 2.

SUMMARY TABLE

Outcomes of Oral NSAIDs and Acetaminophen on Pain Relief for Acute Perineal Pain

OutcomesAssumed risk with placebo or acetaminophenCorresponding risk with medication (95% CI)NNT* (95% CI)ParticipantsQuality of evidence

Adequate pain relief (4 hours)

Placebo

NSAID

284 per 1,000

543 per 1,000 (466 to 634 per 1,000)

4 (3 to 6)

1,573

Low

Acetaminophen

NSAID

205 per 1,000

315 per 1,000 (219 to 454 per 1,000)

9 (4 to 71)

342

Low

Placebo

Acetaminophen

27%

58% (43% to 78%)

3 (2 to 6)

1,279

Low

Adequate pain relief (6 hours)

Placebo

NSAID

321 per 1,000

615 per 1,000 (542 to 696 per 1,000)

3 (3 to 5)

2,079

Very low

Acetaminophen

NSAID

200 per 1,000

364 per 1,000 (122 to 1,000 per 1,000)

NA

99

Very low

Need for additional analgesia (4 hours)

Placebo

NSAID

305 per 1,000

119 per 1,000 (79 to 177 per 1,000)

5 (4 to 8)

486

Moderate

Acetaminophen

NSAID

405 per 1,000

223 per 1,000 (109 to 458 per 1,000)

NA

73

Very low

Placebo

Acetaminophen

30.5%

10.4% (6.4% to 16.8%)

5 (4 to 7)

1,132

Low

Need for additional analgesia (6 hours)

Placebo

NSAID

438 per 1,000

140 per 1,000 (114 to 175 per 1,000)

3 (3 to 4)

1,012

Very low

Acetaminophen

NSAID

571 per 1,000

160 per 1,000 (69 to 383 per 1,000)

2 (2 to 5)

59

Low


NA = not applicable; NNT = number needed to treat; NSAID = nonsteroidal anti-inflammatory drug.

*—The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

Information from references 1 and 2.

Practice Pointers

Perineal pain is common following vaginal delivery. Achieving adequate pain relief is important to improve patients' well-being, mobility, and ability to care for their child. NSAIDs and acetaminophen are commonly used postpartum for analgesia. The authors of these two Cochrane reviews sought to demonstrate whether a single dose of an NSAID or acetaminophen can significantly reduce early postpartum perineal pain.1,2

The first Cochrane review evaluated the effectiveness of NSAIDs from 35 randomized controlled trials (RCTs; N = 5,136) that examined 16 different NSAIDs.1 Sixteen of the 35 studies took place in the United States and eight in other high-income countries (Canada, United Kingdom, Belgium, Spain, France, and Italy). Eleven studies were done in low- and middle-income countries—six in Venezuela, and five in India, Malaysia, Thailand, and Iran. Participants had perineal trauma requiring repair following vaginal delivery. Nearly all of the studies (34 of 35) evaluated postepisiotomy pain, and one study evaluated patients with first- or second-degree perineal tears. Episiotomies are not routinely recommended,

Author disclosure: No relevant financial affiliations.

References

1. Wuytack F, Smith V, Cleary BJ. Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period. Cochrane Database Syst Rev. 2021;(1):CD011352.

2. Abalos E, Sguassero Y, Gyte GML. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev. 2021;(1):CD008407.

3. ACOG Committee on Obstetric Practice. ACOG committee opinion no. 742: postpartum pain management. Obstet Gynecol. 2018;132(1):e35–e43.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at https://www.aafp.org/afp/cochrane.

 

 

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