This updated review investigates the effectiveness and safety of drug and non-drug pain relief in women experiencing after-birth pains following vaginal birth. Giving an agent for pain relief was compared to an inactive placebo, to no treatment, or to a different type of agent in randomised controlled trials.

What is the issue?

Women may experience cramping pain and discomfort following the birth of their baby, as the uterus contracts and returns to its normal pre-pregnancy size. These pains usually last for two to three days after the birth. Women who have previously had a baby are more likely to experience after-birth pains. Breastfeeding stimulates the uterus to contract and increases the severity of the pains.

Types of pain relief used to treat the pain include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs) ibuprofen and naproxen, opioids including codeine, and non-medicine methods such as herbal preparations and transcutaneous electrical nerve stimulation (TENS).

Why is this important?

Management of pain after birth is important, as the pain can affect a mother carrying out her normal activities as well as bonding with and caring for her baby. After-pains can interfere with establishing breastfeeding.

What evidence did we find?

We searched for evidence from randomised controlled trials (October 2019) and identified 28 studies (2749 mothers) who were in hospital after uncomplicated single births. Most of the evidence is low-certainty because the studies did not include sufficient numbers of women. Many of the studies excluded breastfeeding women.This makes the evidence less relevant to a broader group of women. No studies reported evidence on adverse events in the newborn infants.

NSAIDs are probably better than placebo (a dummy treatment) in giving adequate pain relief as reported by the women (11 studies, 946 women; moderate-certainty evidence), and they may reduce the need for additional pain relief (4 studies, 375 women; low-certainty evidence). There may be little difference between NSAIDs and placebo in the risk of adverse events in the mother (9 studies, 598 women; low-certainty evidence).

NSAIDs are probably better than opioids in providing adequate pain relief as reported by the women (5 studies, 560 women; moderate-certainty evidence) and may reduce the risk of adverse events in the mother (3 studies, 255 women; low-certainty evidence). NSAIDs may slightly reduce the need for additional pain relief compared with opioids (2 studies, 232 women; low-certainty evidence).

Opioids may be better than placebo for adequate pain relief as reported by the women (5 studies, 299 women; low-certainty evidence) and for the need for additional pain relief (3 studies, 273 women; low-certainty evidence). Opioids may increase the risk of adverse events in the mother compared with placebo (3 studies, 188 women; low-certainty evidence).

Very low-certainty evidence means we are uncertain if paracetamol is better than placebo for adequate pain relief as reported by the women, the need for additional analgesia, or risk of maternal adverse events (2 studies, 123 women).

Very low-certainty evidence means we are uncertain if there are any differences between paracetamol and NSAIDs for adequate pain relief as reported by the women, or the risk of maternal adverse events (2 studies, 112 women).

Very low-certainty evidence means we are uncertain if NSAIDs are better than herbal pain relief for adequate pain relief as reported by the women (4 studies, 394 women), the need for additional pain relief (1 study, 90 women) or risk of maternal adverse events (1 study, 108 women).

Very low-certainty evidence means we are uncertain if there is any difference between TENS and no TENS for adequate pain relief as reported by the women (1 study, 32 women).

What does this mean?

NSAIDs may be better than placebo and are probably better than opioids at relieving after-birth pains following vaginal birth. The quality of the evidence was poor and we are uncertain about the effectiveness of other forms of pain relief. Future trials should recruit adequate numbers of women and ensure greater relevance by including breastfeeding women. Further research could also include a survey of women after delivery to capture their experience of after-birth pains following vaginal birth.