Acute pain management after vaginal delivery with perineal tears or episiotomy

Abstract

BackgroundA vaginal delivery may be associated with acute postpartum pain, particularly after perineal trauma. However, pain management in this setting remains poorly explored.ObjectiveThe 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 reviewMEDLINE, 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.FindingsOverall, 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.ConclusionsPostpartum 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.

Efficacy of energy‐based devices on episiotomy pain and healing: A systematic review and meta‐analysis

“…While this review included one study comparing LLLT to therapeutic ultrasound, it did not assess infrared irradiation or other energy‐based devices. 30 Similarly, another recently published meta‐analysis comparing various methods for pain relief and healing after perineal trauma found that cold application and perineal education were the most effective interventions. However, it included only one study on infrared irradiation and none on LLLT.…”

Efficacy of energy‐based devices on episiotomy pain and healing: A systematic review and meta‐analysis

“…While this review included one study comparing LLLT to therapeutic ultrasound, it did not assess infrared irradiation or other energy‐based devices. 30 Similarly, another recently published meta‐analysis comparing various methods for pain relief and healing after perineal trauma found that cold application and perineal education were the most effective interventions. However, it included only one study on infrared irradiation and none on LLLT.…”

Clinical guidance paper VVOG-CRGOLFB prevention and management of obstetrical perineal trauma

“…Finally, local application of cold packs in the first 24 h after vaginal delivery may reduce perineal pain in the first two days postpartum (RR 0.73, 95 % CI 0.57–0.94 and Hedges’ g = −0.36, 95 % CI −0.54 to 0.18, p < 0.001), though their effect on edema and wound healing remain uncertain. [26] , [79] , [80] , [81] , [82] These recommendations are in line with the Belgian guidelines on primary postpartum care. [21]…”

Paracetamol in pregnancy: Navigating clinical uncertainty and avoiding the communication pitfalls of the “measles, mumps, and rubella” - autism controversy: A narrative review

“…Migraine during pregnancy associates with preeclampsia and gestational hypertension (Negro et al, 2017[ 80 ]). Finally, since there are no safer alternatives (i.e., Nonsteroidal anti-inflammatory drugs carry known risks of miscarriage and fetal complications (Antonucci et al, 2012[ 5 ]; Daniel et al, 2014[ 24 ]), and opioids present risks of neonatal abstinence syndrome (Kocherlakota, 2014[ 61 ])), paracetamol represents the only recommended antipyretic/analgesic (Louwen et al, 2025[ 73 ]; Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]).…”

“…The President's advice to “fight like hell not to take” paracetamol creates a false dichotomy between medication use and enduring suffering (Horton, 2025[ 53 ]; Pearson and Ledford, 2025[ 84 ]). This ignores decades of clinical experience showing appropriate paracetamol use balances treatment of maternal conditions with fetal safety (Louwen et al, 2025;[ 73 ] Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]).…”

“… Provide clear guidance on use: “For fever, treat promptly with paracetamol. For pain, use the lowest dose that helps, for the shortest time needed” (Louwen et al, 2025[ 73 ]; Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]). This follows professional guidelines (Louwen et al, 2025[ 73 ]; Szubert et al, 2025[ 98 ]).…”

Efficacy of energy‐based devices on episiotomy pain and healing: A systematic review and meta‐analysis

“…While this review included one study comparing LLLT to therapeutic ultrasound, it did not assess infrared irradiation or other energy‐based devices. 30 Similarly, another recently published meta‐analysis comparing various methods for pain relief and healing after perineal trauma found that cold application and perineal education were the most effective interventions. However, it included only one study on infrared irradiation and none on LLLT.…”

Clinical guidance paper VVOG-CRGOLFB prevention and management of obstetrical perineal trauma

“…Finally, local application of cold packs in the first 24 h after vaginal delivery may reduce perineal pain in the first two days postpartum (RR 0.73, 95 % CI 0.57–0.94 and Hedges’ g = −0.36, 95 % CI −0.54 to 0.18, p < 0.001), though their effect on edema and wound healing remain uncertain. [26] , [79] , [80] , [81] , [82] These recommendations are in line with the Belgian guidelines on primary postpartum care. [21]…”

Paracetamol in pregnancy: Navigating clinical uncertainty and avoiding the communication pitfalls of the “measles, mumps, and rubella” - autism controversy: A narrative review

“…Migraine during pregnancy associates with preeclampsia and gestational hypertension (Negro et al, 2017[ 80 ]). Finally, since there are no safer alternatives (i.e., Nonsteroidal anti-inflammatory drugs carry known risks of miscarriage and fetal complications (Antonucci et al, 2012[ 5 ]; Daniel et al, 2014[ 24 ]), and opioids present risks of neonatal abstinence syndrome (Kocherlakota, 2014[ 61 ])), paracetamol represents the only recommended antipyretic/analgesic (Louwen et al, 2025[ 73 ]; Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]).…”

“…The President's advice to “fight like hell not to take” paracetamol creates a false dichotomy between medication use and enduring suffering (Horton, 2025[ 53 ]; Pearson and Ledford, 2025[ 84 ]). This ignores decades of clinical experience showing appropriate paracetamol use balances treatment of maternal conditions with fetal safety (Louwen et al, 2025;[ 73 ] Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]).…”

“… Provide clear guidance on use: “For fever, treat promptly with paracetamol. For pain, use the lowest dose that helps, for the shortest time needed” (Louwen et al, 2025[ 73 ]; Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]). This follows professional guidelines (Louwen et al, 2025[ 73 ]; Szubert et al, 2025[ 98 ]).…”

Efficacy of energy‐based devices on episiotomy pain and healing: A systematic review and meta‐analysis

“…While this review included one study comparing LLLT to therapeutic ultrasound, it did not assess infrared irradiation or other energy‐based devices. 30 Similarly, another recently published meta‐analysis comparing various methods for pain relief and healing after perineal trauma found that cold application and perineal education were the most effective interventions. However, it included only one study on infrared irradiation and none on LLLT.…”

Clinical guidance paper VVOG-CRGOLFB prevention and management of obstetrical perineal trauma

“…Finally, local application of cold packs in the first 24 h after vaginal delivery may reduce perineal pain in the first two days postpartum (RR 0.73, 95 % CI 0.57–0.94 and Hedges’ g = −0.36, 95 % CI −0.54 to 0.18, p < 0.001), though their effect on edema and wound healing remain uncertain. [26] , [79] , [80] , [81] , [82] These recommendations are in line with the Belgian guidelines on primary postpartum care. [21]…”

Paracetamol in pregnancy: Navigating clinical uncertainty and avoiding the communication pitfalls of the “measles, mumps, and rubella” - autism controversy: A narrative review

“…Migraine during pregnancy associates with preeclampsia and gestational hypertension (Negro et al, 2017[ 80 ]). Finally, since there are no safer alternatives (i.e., Nonsteroidal anti-inflammatory drugs carry known risks of miscarriage and fetal complications (Antonucci et al, 2012[ 5 ]; Daniel et al, 2014[ 24 ]), and opioids present risks of neonatal abstinence syndrome (Kocherlakota, 2014[ 61 ])), paracetamol represents the only recommended antipyretic/analgesic (Louwen et al, 2025[ 73 ]; Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]).…”

“…The President's advice to “fight like hell not to take” paracetamol creates a false dichotomy between medication use and enduring suffering (Horton, 2025[ 53 ]; Pearson and Ledford, 2025[ 84 ]). This ignores decades of clinical experience showing appropriate paracetamol use balances treatment of maternal conditions with fetal safety (Louwen et al, 2025;[ 73 ] Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]).…”

“… Provide clear guidance on use: “For fever, treat promptly with paracetamol. For pain, use the lowest dose that helps, for the shortest time needed” (Louwen et al, 2025[ 73 ]; Luxey et al, 2025[ 74 ]; Szubert et al, 2025[ 98 ]). This follows professional guidelines (Louwen et al, 2025[ 73 ]; Szubert et al, 2025[ 98 ]).…”