Acute pain management after vaginal delivery with perineal tears or episiotomy

Xavier Luxey; Adrien Lemoine; Geertrui Dewinter; Girish P Joshi; Camille Le Ray; Johan Raeder; Marc Van de Velde; Marie-Pierre Bonnet; PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy

doi:10.1136/rapm-2024-105478

Acute pain management after vaginal delivery with perineal tears or episiotomy

Xavier Luxey, Adrien Lemoine, Geertrui Dewinter, Girish P Joshi, Camille Le Ray, Johan Raeder, Marc Van de Velde, Marie-Pierre Bonnet, PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy

Section for Surgical Pathophysiology

14 Citations (Scopus)

Abstract

BACKGROUND: A vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored.

OBJECTIVE: The aim of this systematic review was to evaluate the literature and to develop recommendations for pain management after a vaginal delivery with perineal trauma.

EVIDENCE REVIEW: MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and systematic reviews assessing pain after a vaginal delivery with perineal tears or episiotomy until March 2023. Cochrane Covidence quality assessment generic tool and the RoB Vis 2 tool were used to grade the quality of evidence.

FINDINGS: Overall, 79 studies (69 RCTs and 10 systematic reviews and meta-analyses) of good quality of evidence were included. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment. Epidural morphine (≤2 mg) is recommended among women with labor epidural analgesia and severe perineal tears, with adequate respiratory monitoring. Local anesthetic infiltration, topical local anesthetic, ointment application, and pudendal nerve block are not recommended due to insufficient or lack of evidence. Ice or chemical cold packs are recommended for postpartum pain first-line treatment due to their simplicity of use. Transcutaneous nerve stimulation and acupuncture are recommended as adjuvants. When a perineal suture is indicated, a continuous suture compared with an interrupted suture for the repair of episiotomy or second-degree perineal tears is recommended for the outcome of pain. For women with first-degree or second-degree perineal tears, no suturing or glue compared with suturing is recommended for the outcome of pain.

CONCLUSIONS: Postpartum pain management after a vaginal delivery with perineal trauma should include acetaminophen, NSAIDs, and ice or chemical cold packs. Epidural morphine should be reserved for severe perineal tears. A surgical repair technique should depend on perineal tear severity.

Original language	English
Journal	Regional Anesthesia and Pain Medicine
Volume	50
Issue number	6
Pages (from-to)	503-513
Number of pages	11
ISSN	1098-7339
DOIs	https://doi.org/10.1136/rapm-2024-105478
Publication status	Published - 1 Jun 2025

Keywords

Complementary Therapies
Epidemiology
Obstetrics
Pain Management
analgesia
Acute Pain/therapy
Pain Management/methods
Humans
Randomized Controlled Trials as Topic/methods
Lacerations/diagnosis
Pregnancy
Delivery, Obstetric/adverse effects
Perineum/injuries
Analgesia, Obstetrical/methods
Female
Episiotomy/adverse effects

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10.1136/rapm-2024-105478

Cite this

Luxey, X., Lemoine, A., Dewinter, G., Joshi, G. P., Le Ray, C., Raeder, J., Van de Velde, M., Bonnet, M.-P., & PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy (2025). Acute pain management after vaginal delivery with perineal tears or episiotomy. Regional Anesthesia and Pain Medicine, 50(6), 503-513. https://doi.org/10.1136/rapm-2024-105478

Luxey, X, Lemoine, A, Dewinter, G, Joshi, GP, Le Ray, C, Raeder, J, Van de Velde, M, Bonnet, M-P & PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy 2025, 'Acute pain management after vaginal delivery with perineal tears or episiotomy', Regional Anesthesia and Pain Medicine, vol. 50, no. 6, pp. 503-513. https://doi.org/10.1136/rapm-2024-105478

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title = "Acute pain management after vaginal delivery with perineal tears or episiotomy",

abstract = "BACKGROUND: A vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored.OBJECTIVE: The aim of this systematic review was to evaluate the literature and to develop recommendations for pain management after a vaginal delivery with perineal trauma.EVIDENCE REVIEW: MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and systematic reviews assessing pain after a vaginal delivery with perineal tears or episiotomy until March 2023. Cochrane Covidence quality assessment generic tool and the RoB Vis 2 tool were used to grade the quality of evidence.FINDINGS: Overall, 79 studies (69 RCTs and 10 systematic reviews and meta-analyses) of good quality of evidence were included. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment. Epidural morphine (≤2 mg) is recommended among women with labor epidural analgesia and severe perineal tears, with adequate respiratory monitoring. Local anesthetic infiltration, topical local anesthetic, ointment application, and pudendal nerve block are not recommended due to insufficient or lack of evidence. Ice or chemical cold packs are recommended for postpartum pain first-line treatment due to their simplicity of use. Transcutaneous nerve stimulation and acupuncture are recommended as adjuvants. When a perineal suture is indicated, a continuous suture compared with an interrupted suture for the repair of episiotomy or second-degree perineal tears is recommended for the outcome of pain. For women with first-degree or second-degree perineal tears, no suturing or glue compared with suturing is recommended for the outcome of pain.CONCLUSIONS: Postpartum pain management after a vaginal delivery with perineal trauma should include acetaminophen, NSAIDs, and ice or chemical cold packs. Epidural morphine should be reserved for severe perineal tears. A surgical repair technique should depend on perineal tear severity.",

keywords = "Complementary Therapies, Epidemiology, Obstetrics, Pain Management, analgesia, Acute Pain/therapy, Pain Management/methods, Humans, Randomized Controlled Trials as Topic/methods, Lacerations/diagnosis, Pregnancy, Delivery, Obstetric/adverse effects, Perineum/injuries, Analgesia, Obstetrical/methods, Female, Episiotomy/adverse effects",

author = "Xavier Luxey and Adrien Lemoine and Geertrui Dewinter and Joshi, \{Girish P\} and \{Le Ray\}, Camille and Johan Raeder and \{Van de Velde\}, Marc and Marie-Pierre Bonnet and Henrik Kehlet and \{PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy\}",

note = "{\textcopyright} American Society of Regional Anesthesia \& Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.",

year = "2025",

month = jun,

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doi = "10.1136/rapm-2024-105478",

language = "English",

volume = "50",

pages = "503--513",

journal = "Regional Anesthesia and Pain Medicine",

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T1 - Acute pain management after vaginal delivery with perineal tears or episiotomy

AU - Luxey, Xavier

AU - Lemoine, Adrien

AU - Dewinter, Geertrui

AU - Joshi, Girish P

AU - Le Ray, Camille

AU - Raeder, Johan

AU - Van de Velde, Marc

AU - Bonnet, Marie-Pierre

AU - PROSPECT Working Group of the European Society of Regional Anesthesia and Pain Therapy

A2 - Kehlet, Henrik

N1 - © American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.

PY - 2025/6/1

Y1 - 2025/6/1

N2 - BACKGROUND: A vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored.OBJECTIVE: The aim of this systematic review was to evaluate the literature and to develop recommendations for pain management after a vaginal delivery with perineal trauma.EVIDENCE REVIEW: MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and systematic reviews assessing pain after a vaginal delivery with perineal tears or episiotomy until March 2023. Cochrane Covidence quality assessment generic tool and the RoB Vis 2 tool were used to grade the quality of evidence.FINDINGS: Overall, 79 studies (69 RCTs and 10 systematic reviews and meta-analyses) of good quality of evidence were included. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment. Epidural morphine (≤2 mg) is recommended among women with labor epidural analgesia and severe perineal tears, with adequate respiratory monitoring. Local anesthetic infiltration, topical local anesthetic, ointment application, and pudendal nerve block are not recommended due to insufficient or lack of evidence. Ice or chemical cold packs are recommended for postpartum pain first-line treatment due to their simplicity of use. Transcutaneous nerve stimulation and acupuncture are recommended as adjuvants. When a perineal suture is indicated, a continuous suture compared with an interrupted suture for the repair of episiotomy or second-degree perineal tears is recommended for the outcome of pain. For women with first-degree or second-degree perineal tears, no suturing or glue compared with suturing is recommended for the outcome of pain.CONCLUSIONS: Postpartum pain management after a vaginal delivery with perineal trauma should include acetaminophen, NSAIDs, and ice or chemical cold packs. Epidural morphine should be reserved for severe perineal tears. A surgical repair technique should depend on perineal tear severity.

AB - BACKGROUND: A vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored.OBJECTIVE: The aim of this systematic review was to evaluate the literature and to develop recommendations for pain management after a vaginal delivery with perineal trauma.EVIDENCE REVIEW: MEDLINE, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs) and systematic reviews assessing pain after a vaginal delivery with perineal tears or episiotomy until March 2023. Cochrane Covidence quality assessment generic tool and the RoB Vis 2 tool were used to grade the quality of evidence.FINDINGS: Overall, 79 studies (69 RCTs and 10 systematic reviews and meta-analyses) of good quality of evidence were included. Acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment. Epidural morphine (≤2 mg) is recommended among women with labor epidural analgesia and severe perineal tears, with adequate respiratory monitoring. Local anesthetic infiltration, topical local anesthetic, ointment application, and pudendal nerve block are not recommended due to insufficient or lack of evidence. Ice or chemical cold packs are recommended for postpartum pain first-line treatment due to their simplicity of use. Transcutaneous nerve stimulation and acupuncture are recommended as adjuvants. When a perineal suture is indicated, a continuous suture compared with an interrupted suture for the repair of episiotomy or second-degree perineal tears is recommended for the outcome of pain. For women with first-degree or second-degree perineal tears, no suturing or glue compared with suturing is recommended for the outcome of pain.CONCLUSIONS: Postpartum pain management after a vaginal delivery with perineal trauma should include acetaminophen, NSAIDs, and ice or chemical cold packs. Epidural morphine should be reserved for severe perineal tears. A surgical repair technique should depend on perineal tear severity.

KW - Complementary Therapies

KW - Epidemiology

KW - Obstetrics

KW - Pain Management

KW - analgesia

KW - Acute Pain/therapy

KW - Pain Management/methods

KW - Humans

KW - Randomized Controlled Trials as Topic/methods

KW - Lacerations/diagnosis

KW - Pregnancy

KW - Delivery, Obstetric/adverse effects

KW - Perineum/injuries

KW - Analgesia, Obstetrical/methods

KW - Female

KW - Episiotomy/adverse effects

UR - https://www.scopus.com/pages/publications/85194001095

U2 - 10.1136/rapm-2024-105478

DO - 10.1136/rapm-2024-105478

M3 - Review

C2 - 38772634

SN - 1098-7339

VL - 50

SP - 503

EP - 513

JO - Regional Anesthesia and Pain Medicine

JF - Regional Anesthesia and Pain Medicine

IS - 6

ER -

Acute pain management after vaginal delivery with perineal tears or episiotomy

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