Postpartum Pain Management Research Articles

Postpartum Opioid Prescribing in Patients with Opioid Use Prior to Birth.

This study aimed to describe opioid prescribing patterns for pregnant patients with a history of or active opioid use to inform postpartum pain management strategies. We conducted a retrospective cohort analysis of all patients with a history of opioid use disorder (OUD) or chronic pain seen at a single outpatient clinic specializing in opioid use and OUD in pregnancy from January 2019 to August 2021. Patient characteristics, delivery outcomes, and opioid prescribing information were collected through electronic health record fields. We used descriptive statistics to characterize differences in receipt of an opioid prescription, prescription size, and receipt of a prescription refill across three patient groups: patients with OUD on medication, patients with OUD maintaining abstinence, and patients with chronic pain using opioids. In the study period, the institutional average rate of opioid prescribing after cesarean and vaginal birth were 80.0 and 2.8%, respectively. Of the 69 patients included in this study, 46 (66.7%) had a history of OUD on medication, 14 (20.3%) had a history of OUD maintaining abstinence, and 9 (13.0%) had a history of chronic pain. Receipt of an opioid prescription after childbirth was more common after cesarean birth (12/23, 52.2%) than vaginal birth (3/46, 6.5%). Refills were common in patients who received an opioid proscription (cesarean: 5/12, 41.7%; vaginal: 1/3, 33.3%). Compared with institutional averages, postpartum opioid prescribing rates for people with a history of OUD or chronic pain were 50 to 60% lower for cesarean birth and three times higher for vaginal birth. Future work is needed to balance opioid stewardship and harm reduction with adequate pain control in these high-risk populations. · Opioid prescribing rates for patients with OUD/chronic pain were 60% lower for cesarean birth than institutional averages.. · Opioid prescribing rates for patients with OUD/chronic pain were three times higher for vaginal birth than institutional averages.. · Refill rates following birth were high overall for cesarean (40%) and vaginal (33%) birth.. · More work is needed to balance opioid prescribing with adequate pain control in high-risk patients..

Obstetric pain management for pregnant women with opioid use disorder: A qualitative and quantitative comparison of patient and provider perspectives (QUEST study).

Patients with opioid use disorder (OUD) may experience inadequate pain management especially during childbirth. This study assessed and compared patient and provider perspectives on analgesia during and after delivery in women with OUD. Prospective cohort, mixed method design including semi-structured interviews and structured surveys with pregnant or recently pregnant patients (n = 17) and provider (n = 15) groups. Prenatal clinics and hospital postpartum units. Patients were pregnant women with OUD currently treated with methadone (n = 1) or buprenorphine (n = 16). Providers were obstetricians (n = 5), obstetric nurses (n = 5) and anesthesiologists (n = 5). Validated questionnaires were completed by both groups; patient interviews were conducted during the third trimester and at 5 days post-delivery. Patient topics included pain management preferences, analgesia satisfaction and attitudes toward pain. Provider topics included labor and postpartum pain management perspectives. Interviews were independently coded and qualitatively analyzed for major themes. Five major themes emerged from patient interviews: (1) neuraxial blockade was endorsed for labor pain; (2) otherwise, limited pain control options were perceived; (3) no consensus around use of opioids for pain; (4) non-opioid options should be available; and (5) provider communication and health-care system issues act as barriers to adequate pain management. Provider perspective themes included the following: (1) unique challenges in pain management for patients with OUD; (2) confusion on how to plan for and make perinatal adjustments to medication for OUD; (3) discrepant views on use of opioids for pain management; (4) endorsement of non-pharmacological and non-opioid options; and (5) need for improved provider collaboration in developing pain management plans. Patients with opioid use disorder and health-care providers prioritize pain management during and after childbirth, but have discrepant views on use of opioids and other pain management options. Inadequate care coordination and discrepancies in opinions need to be addressed both within care teams and between patients and providers. Clinicians would benefit from better evidence to guide clinical care of patients with OUD for patient-centered pain management.

Inequities in Inpatient Obstetrics Pain Management and Evaluation: Age, Race, Mental Health, and Obesity.

To evaluate disparities of pain management among patients giving birth in inpatient Obstetrics units based on age, race, BMI, and mental health diagnoses. A retrospective cohort study was performed and included all individuals giving birth at a tertiary-care institution in 2019. Patient-reported pain scores, and inpatient narcotic administration and dosing for pain control were collected. Models were adjusted for race, age, BMI, and diagnoses of anxiety, depression, opioid use disorder, and/or schizophrenia. 4788 Individuals met the inclusion criteria. A higher proportion of African American patients reported severe pain (n = 233/607, 38.4%) and received narcotics (n = 653/1141, 57.2%) compared to patients of other races. Despite controlling for several possible confounders, African American patients (OR 1.55, 95% CI 1.08-2.22), patients with increased BMI (OR 1.02, 95% CI 1.01-1.03), and patients with a mental health diagnosis (OR 2.33, 95% CI 1.32-4.12) were more likely to have worse pain at rest. Older patients were more likely to be administered narcotics (n = 447/757, 59.0%) compared to younger patients (patients aged 18-26: n = 577/1257, 52.3%; patients aged 27-35: n = 1451/2774, 52.3%; p < 0.001), despite younger patients being more likely to have severe pain (OR 1.50; 95% CI 1.20-1.86; p = 0.001). Patients who are Non-Hispanic African American and patients with obesity and mental health diagnoses experience inequities in postpartum pain management. Pain is complex and multifactorial and can be impacted by cultural, social, environmental factors and more. Further studies on factors that influence pain perception and management in inpatient obstetrics units are needed.

Perspectives on clinicians’ roles and postpartum pain management: a qualitative analysis

Pain is a common postpartum complaint, yet data suggest that approaches to postpartum pain management vary widely. Given the goal of improving quality and equity in postpartum pain management, we aimed to examine whether and how clinicians’ perspectives on postpartum pain management differed by clinician roles.

Biases in the management of postpartum pain: a qualitative analysis of clinicians’ perspectives

Biases in the management of postpartum pain: a qualitative analysis of clinicians’ perspectives

Variations in Postpartum Opioid Prescribing Practices among Obstetrician-Gynecologists.

There have been many efforts to combat the United States opioid crisis that has been occurring for the past two decades, specifically with postpartum patients that often were prescribed opioids. Prior studies described how accounting for usage of inpatient opioids on the day prior to discharge had an impact on how much discharge opioids were prescribed on the day of discharge. These studies provided a guideline to use the inpatient opioid amount from the day before discharge to determine discharge opioid quantity and minimize how much was being prescribed. In July 2018, the American College of Obstetrics and Gynecologists (ACOG) published Committee Opinion 742, guidelines for obstetricians-gynecologists about post-partum pain management. Prescription pain medications (including opioids, if necessary) require a shared decision-making approach between the physician and patient to determine the medication type and quantity. This study aimed to determine if there were differences in prescribing practices based on the specific post-operative day that opioid prescriptions were written, and if there were differences in the prescribing practices for cesarean deliveries following the publication of ACOG Committee Opinion 742. This retrospective chart review included patients who had a live cesarean birth at one rural Midwest facility anytime between July 1, 2017 and February 28, 2021. This study excluded those with chorioamnionitis and those discharged after more than four days. Opioid amounts were converted to oral morphine milligram equivalents (MME) for comparison, and total MME was calculated for each prescription. Patients were stratified into two groups based on the day that their discharge opioid medication prescriptions were written (i.e., a day prior to discharge or the day of discharge). Patients were also stratified based on date of delivery, before or after the publication of ACOG Committee Opinion 742. Of 411 cesarean patients, 93.9% (n = 386) had opioids prescribed at discharge, 86% (n = 330) of whom received a prescription written on the day of discharge. There was no difference in the quantity of MMEs, doses per day, or dosage from discharge prescriptions between those written on the day of discharge and those written on a prior day. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 (63.9%, n = 263) received discharge prescriptions with fewer average MMEs (159.53 ± 61.64) than those whose deliveries occurred before the publication (36%, n = 148; 187.35 ± 53.42; χ2 (1, N = 411) = 17.71; p < 0.001), and they were prescribed fewer doses per day. After cesarean sections, the specific post-operative day did not seem to impact the prescribing trends as there were no differences in MMEs, doses per day, or dosage between prescriptions that were written on the day of discharge and before the day of discharge. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 received discharge prescriptions with fewer MMEs, fewer doses per day, and the same dosage than those whose deliveries occurred before the publication, reflecting the overall national trend of decreasing prescription opioids over these years.

Ropivacaine perineal infiltration for postpartum pain management in episiotomy repair: a double-blind, randomised, placebo-controlled trial.

To investigate whether perineal infiltration of ropivacaine after episiotomy would decrease the incidence of postpartum pain compared with placebo. Two-centre, double-blind, randomised, controlled trial. Two French maternity units, October 2017 to April 2020. 272 women undergoing epidural analgesia with vaginal singleton delivery and mediolateral episiotomy at term (≥37 weeks) were randomly allocated perineal infiltration of ropivacaine (n= 135) or placebo (n= 137) in a 1:1 ratio before episiotomy repair. Patients were followed at short term (12, 24, 48 h), mid-term (day 7) and long-term (3 and 6months). The primary outcome was the rate of perineal pain, defined by a Numerical Pain Rating Scale (NPRS) exceeding 3/10, in the mid-term (day 7) postpartum period. Secondary outcomes were perineal pain (NPRS) and analgesic intake, quality of life (SF-36), postpartum depression (EPDS), pain neuropathic component (DN4) and sexual health (FSFI). Perineal pain occurred to an equal extent in the ropivacaine and placebo groups at day 7 (34.2% versus 30.4%, odds ratio 1.1, 95% confidence interval 0.7-1.8, p= 0.63). Similar results were recorded in the short and long term. High rates of dyspareunia and postpartum depression were documented in both groups. No differences were highlighted between the groups in terms of analgesic intake, adverse events, pain neuropathic component and postpartum quality of life. This study did not demonstrate any benefit of ropivacaine infiltration over placebo.

Perspectives of Postpartum Pain Management Among Patients With Prenatal Opioid Exposure [A252

INTRODUCTION: Opioid-sparing protocols can reduce postpartum opioid prescribing in opioid-naïve patients; however, patients with a history of opioid use disorder (OUD) and chronic pain are typically excluded from evaluations. We assessed the postpartum pain experience in patients who were not opioid-naïve before delivery. METHODS: We conducted a phone survey assessing maternal postpartum pain experiences for all patients with OUD and chronic pain on opioids prenatally who delivered between January 2020 and August 2021 at a single hospital. In this IRB exempt study, verbal informed consent was obtained for all participants. Analyses included simple descriptive statistics. RESULTS: Of 24 patients successfully contacted, 17 (71%) participated. Patients were predominantly White (100%, 17/17), publicly insured (76%, 13/17), multiparous (82%, 14/17), had a vaginal delivery (53%, 9/17), and had an average age of 32. Patients were most commonly identified as having OUD (88%, 15/17) followed by chronic pain (12%, 2/17). About a quarter (4/17, 24%) reported poor pain control (7/10 or greater) in the hospital and one week after discharge. Among patients with vaginal deliveries, 11% (1/9) used opioids postpartum, 78% (7/9) used acetaminophen, and 67% (6/9) used ibuprofen. Among cesarean births, 50% (4/8) used opioids postpartum, 100% (8/8) used acetaminophen, and 75% (6/8) used ibuprofen. Of the 69% (11/16) who reported breastfeeding, 45% (5/11) reported some pain interference. CONCLUSION: Many patients on maintenance opioids prenatally reported poor postpartum pain control. Non-opioid medications were not optimized in patients undergoing cesarean delivery, suggesting an opportunity for better opioid-sparing pain management strategies.

Nurses' Perspectives on Postpartum Pain Management.

Introduction:There is variation in postpartum opioid use by prescriber characteristics that cannot be explained by patient or birth factors. Thus, our objective was to evaluate nursing training, clinical practices, and perspectives on opioid use for postpartum pain management.Materials and Methods:In this survey study, postpartum bedside nurses at a single, large academic center were asked about training, factors influencing clinical decisions, and viewpoints regarding pain management and opioid use. Findings were summarized using descriptive analyses.Results:A total of 92 nurses completed the survey. A majority (77%) reported having received some formal training on opioid use for pain management. About a quarter (25.7%) felt their training was not adequate. Regarding clinical practices, the majority (71% and 70%, respectively) reported that “routine habit” and “patient preference” most influenced the type and amount of pain medication they administered. Finally, nurses' perspectives on pain management demonstrated a wide range of beliefs. Most nurses strongly agreed with the importance of maximizing nonopioid pain medication before opioid administration. The majority agreed that patient-reported pain score is important to consider when deciding to administer opioids. Conversely, most nurses disagreed that patients should be encouraged to endure as much pain as possible before using an opioid. Similarly, beliefs about the reliability of use of vital signs in assessing pain intensity varied widely.Conclusions:Bedside nurses rely on routine habits, patient preference, and patient-reported pain score when administering opioids for postpartum pain management. Increased training opportunities to improve consistency and standardization of opioid administration may be beneficial.

Reducing Implicit Bias in Maternity Care: A Framework for Action

Reducing Implicit Bias in Maternity Care: A Framework for Action

Racial differences in postpartum pain management and opioid use after cesarean

Several studies conclude that black patients experience disparities in postpartum pain management. We examined pain management differences in black and non-black patients including difference in discharge opioid use.

Understanding the postpartum cesarean pain experience in publicly insured individuals

Although recent work has focused on interventions to decrease opioid use in the postpartum period, few reports have explored birthing individuals’ perspectives on the postpartum pain experience. Our objective was to qualitatively assess patient experiences related to postpartum pain management. This is a prospective qualitative study of patients’ experiences with postpartum pain management after cesarean delivery at a single large tertiary care center (12/2020-7/2021). Individuals were eligible if they had publicly funded prenatal care, were English- or Spanish-speaking, and underwent cesarean birth. Purposive sampling was used to ensure a racially/ethnically diverse cohort. Participants underwent in-depth interviews using a semi-structured interview guide at two time points: postpartum day 2-3 and 2-4 weeks after hospital discharge. Interviews addressed perceptions and experiences of postpartum pain management and recovery. Data were analyzed using the constant comparative method. Of 41 participants, 56.1% identified as non-Hispanic Black and 36.6% as Hispanic. The majority (58.9%) had experienced a prior cesarean birth (Table 1). Thematic analysis yielded four overarching domains with subthemes. First, participants consistently reported themes of hesitancy and perceived judgement regarding opioid use. In the theme of desire for non-pharmacologic pain management, subthemes included desire for multimodal pain management, importance of mobility, and the neonate as a motivator in recovery. Finally, we identified a theme of frustrations about limitations of daily life caused by experience of pain, which addressed activities of daily living, caring for family and the neonate, and the impact on mood (Table 2). Understanding experiences regarding postpartum cesarean pain management and recovery is essential to improving patient-centered care. This analysis highlights the need to improve counseling about and provisions of opioid use, increase use of non-pharmacologic methods of pain control, and focus on strategies to enhance patient preparedness for post-cesarean recovery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Impact of postpartum pain and birth pain management on the pelvic floor function. A retrospective study including over 300 mothers

ObjectivesIt is known that pregnancy and childbirth bring biological, psychological and social changes in a woman’s life. Studies regarding the pelvic floor function focus on the year after delivery, but unfortunately, long-term studies are rare. Furthermore, an association between postpartum pain and birth pain management on the pelvic floor function has rarely been examined. The aim of this study is the evaluation of the pelvic floor function years after delivery in order to detect possible risk factors. Study DesignThis is a retrospective cohort study. All women who delivered in our hospital between 2015 and 2016 were contacted by mail between 2018 and 2019 and asked to participate. The letters included study information, declaration of consent, the “Pelvic floor questionnaire for pregnant women and women after childbirth” (PFQ), contact information and pre-paid envelopes. Questions about pain after childbirth and the management of birth related fear and pain were particularly of interest in the surveys. The interested participants were asked to return the completed declaration of consent and the questionnaire. Overall, 308 women were included in the analysis. Due to the large number of participants, different subgroups were defined in order to compare influencing factors adequately. ResultsNo significant association between the mode of delivery and the total score of the PFQ was found after 3–4 years in primiparous women (p = 0.688). Our study also showed that recorded pain after childbirth and insufficient pain and fear management after childbirth had a negative impact on the pelvic floor function (total scores: pain after childbirth p = 0.00; no pain management p = 0.04; no fear management p = 0.021). ConclusionNo association was found between delivery mode and pelvic floor function in primiparous women three to four years after childbirth. On the other hand, a negative impact of birth related pain and fears on the pelvic floor function years after delivery was significant. Therefore, these revealing findings should certainly be considered in postpartum management.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1.

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

Patient Experience with Postpartum Pain Management in the Face of the Opioid Crisis.

Professional societies have urged providers to reduce opioid use for pain management. Accordingly, the objective of this study was to assess patient experiences related to postpartum pain management in an effort to better understand potential paths to achieve such a reduction. This is a planned secondary analysis of a prospective observational study of opioid use following birth. In the primary study, women who received opioids as inpatients were queried about their pain management, including questions about pain experience, pain satisfaction, perceived areas for practice improvement, and the opportunity to leave additional comments. Participants who were prescribed opioids upon discharge completed postdischarge surveys with a similar opportunity for qualitative input. Data were analyzed using the constant comparative method to identify themes and subthemes. Of the 493 women enrolled in the primary analysis, 125 provided qualitative data. Three overarching themes regarding pain management were identified: positive experiences (n = 22), negative experiences (n = 19), and beliefs and preferences on opioid use and pain management (n = 28). Women with positive experiences reported satisfaction with timely pain medication administration and appreciation of open dialogue with their care team. In contrast, several negative experiences centered on tardy administration of pain medications, resulting in increased pain. Patients also perceived judgment, accusation, and excessive lecturing by staff when requesting opioid medications. Finally, participants expressed the necessity for opioids for postpartum pain management, as well as their desires for limiting opioid use, improved options for multimodal pain management, and increased communication with providers about pain regimens. Understanding women's perspectives and experiences regarding postpartum pain control is essential to improving care. Amid growing research on the role of maternity care providers in addressing the opioid crisis, women's voices are rarely solicited. These findings stress the importance of open and frequent dialogue between patients and providers and a need for multimodal pain management options.

248 Nurses’ perspectives on postpartum pain management

There is variation in postpartum (PP) opioid use based on bedside nurse (RN) that is not explained by patient, delivery, or prescriber factors. Thus, our objective was to evaluate RN training, clinical practices, and perspectives on opioid use for PP pain management. In this survey study, PP bedside RNs at a single, large, academic center were queried about their formal training, clinical practices, and perspectives on PP pain management and opioid use. Survey findings were summarized using descriptive analysis. Of 166 PP RNs at this site, 80 (48%) completed the survey. A majority (77%) reported receiving some formal training on opioid use for pain management, which was largely in the form of online modules (45%) and leadership emails (44%). Almost one third (29%) felt their training was inadequate. Regarding clinical practices, the majority (71% and 70%, respectively) reported that ‘standard habit’ and ‘patient preference’ most influenced the type and amount of pain medication they administered. The majority (94%) felt opioid use is necessary for most patients after cesarean delivery, whereas 5% felt similarly regarding vaginal delivery. Finally, RN perspectives on pain management demonstrated a wide range of beliefs (Figure). Most RNs strongly agreed with the importance of maximizing non-opioid pain medication prior to opioid administration. The majority agreed that patient reported pain score is important to consider when deciding to administer opioids. Conversely, most RNs disagreed that patients should be encouraged to endure as much pain as possible prior to using an opioid. There was a large range of perspectives regarding the impact of opioid use on breastfeeding and patient satisfaction. Similarly, beliefs about the reliability of use of vital signs in assessing pain intensity varied widely (Figure). Bedside RNs rely on standard habit, patient preference, and patient-reported pain score when administering opioids for PP pain management. Increased training opportunities to improve consistency and standardization of opioid administration may be beneficial.

867 Standardized order sets do not eliminate racial/ethnic inequities in postpartum pain evaluation and management

To quantify the extent to which a standardized pain management order set reduced racial/ethnic inequities in post-Cesarean pain evaluation and treatment. A follow-up retrospective cohort study comparing previously reported racial/ethnic inequities in post-Cesarean pain management (baseline period: 07/01/14–06/30/16) to data after implementation of a standardized pain management order set (03/01/17–02/28/18). Medical records were queried for number of pain assessments; pain scores> 7; scheduled non-opiate doses, and as needed opiate doses (converted to 5mg oxycodone tablet equivalents, OTE). Outcomes were grouped into 0-< 24 and 24-48 hours postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black (NHB), non-Hispanic White (NHW), Asian, and other). Analyses included logistic regression for the categorical outcome of pain score> 7 (severe pain), and linear regression. Main effect and interaction terms were used to calculate the difference-in-difference from baseline to follow-up. Before order set implementation (N=1701), we demonstrated NHW women had lower pain scores, more frequent pain assessments, and received more opiates than NHB women (% pain scores> 7 NHW/NHB 0-< 24h: 20%/28%; 24-48h: 25%/37%). After implementation (N=888), severe pain remained more common among NHB women (% pain scores> 7 NHW/NHB 0-< 24h: 23%/31%; 24-48h: 26%/38%). Pain management processes changed after implementation (Table), with overall fewer assessments, less opiates and more non-opiate analgesics. However, racial/ethnic inequities in number of assessments and treatment were unchanged (Table, all p for interaction > 0.05), with the exception of an increase in NSAID doses 24-48 hours postpartum for Hispanic women. A standardized pain management order set reduced overall postpartum opiate use, but did not reduce racial/ethnic inequities in pain evaluation and treatment. Future work should investigate racial equity-focused education and interventions designed to eliminate inequities in pain management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

344 Ketorolac use for postpartum pain management in women with inflammatory bowel disease (IBD)

Non-steroidal anti-inflammatory drugs (NSAIDs) are known to have deleterious effects on small bowel and colonic mucosa. Obstetricians have avoided using NSAIDs for postpartum pain in women with IBD. To achieve adequate pain relief, these patients often require opioids, which pose additional risks of dependence/abuse. Several studies have shown that oral Ibuprofen is the NSAID most associated with disease flare in the IBD population, yet no studies have evaluated IV Ketorolac for pain relief in women with IBD postpartum. We sought to investigate the risk of disease flare and efficacy of Ketorolac for pain relief during the immediate postpartum period in women with IBD. This was a retrospective cohort study of patients with IBD in pregnancy who delivered at a single tertiary care institution from 2012-2020. Of 366 patients in the cohort, 246 received IV Ketorolac. Visual analog pain score of 1-10 documented by nursing staff at standardized time points were extracted from EMR and compared between groups. IBD flare was defined as any documented flare symptom or admission for worsening disease within 6 weeks postpartum. Patients who received Ketorolac reported significantly lower pain scores (p=0.0035) and required less IV and PO opioid medications (p<0.0001) during hospital stay compared to those who did not. Incidence of IBD flare postpartum did not differ between groups nor based on mode of delivery. Following cesarean delivery, patients given Ketorolac had significantly lower peak pain scores (p<0.0001) and pain scores at 12 hours postpartum (p=0.03). A composite of post-operative complications (abscess, ileus, SBO, re-operation) were also significantly lower in the Ketorolac group (p=0.001). Ketorolac significantly decreases postpartum pain scores and opioid use in women with IBD, and most notably in women undergoing cesarean delivery. Ketorolac use was not associated with an increased risk of IBD flare postpartum. For women with IBD, Ketorolac should be considered for pain management in postpartum period, to optimize pain control and allow for reducing opioid use.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period.

Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period.

Obstetric Physicians' Beliefs and Knowledge on Guidelines and Screening Tools to Reduce Opioid Use After Childbirth.

To examine obstetric physicians' beliefs about using professional or regulatory guidelines, opioid risk-screening tools, and preferences for recommending nonanalgesic therapies for postpartum pain management. A qualitative study design was used to conduct semi-structured interviews with obstetric and maternal-fetal medicine physicians (N=38) from two large academic health care institutions in central Pennsylvania. An interview guide was used to direct the discussion about each physicians' beliefs in response to questions about pain management after childbirth. Three trends in the data emerged from physicians' responses: 1) 71% of physicians relied on their clinical insight rather than professional or regulatory guidelines to inform decisions about pain management after childbirth; 2) although many reported that a standard opioid patient screening tool would be useful to inform clinical decisions about pain management, nearly all (92%) physician respondents reported not currently using one; and 3) 63% thought that nonpharmacologic pain management therapies should be used whenever possible to manage pain after childbirth. Key physician barriers (eg, lack time and evidence, being unaware of how to implement) and patient barriers (eg, take away from other responsibilities, no time or patience) to implementation were also identified. These findings suggest that obstetric physicians' individual beliefs and clinical insight play a key role in pain management decisions for women after childbirth. Practical and scalable strategies are needed to: 1) encourage obstetric physicians to use professional or regulatory guidelines and standard opioid risk-screening tools to inform clinical decisions about pain management after childbirth, and 2) educate physicians and patients about nonopioid and nonpharmacologic pain management options to reduce exposure to prescription opioids after childbirth.