Perineal pain management is critical in postnatal care as many women experience perineal pain after childbirth, especially after having sustained perineal trauma. The most common strategy for perineal pain is the use of non-steroidal anti-inflammatory drugs (NSAIDs).  NSAIDs are conventional medications, but their safety and effectiveness needs evaluation. Francesca Wuytack with its colleagues conducted a study that aims to determine the efficacy of a single dose of an oral NSAID for the relief of acute perineal pain in the early postpartum period.

The method involved a systematic search of Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2016), ProQuest Dissertations and Theses, OpenSIGLE, the ISRCTN Registry and ClinicalTrials.gov (31 March 2016) and review of reference lists of research papers and contacted experts in the field. The data was collected from randomised controlled trials (RCTs) that evaluated a single dose of an NSAID v/s a single dose of placebo, paracetamol or another NSAID for women with perineal pain in the early postpartum period. The cross-over trials and Quasi-RCTs were excluded. The risk of bias, inclusion criteria (identified papers) and data extraction, including calculations of pain relief scores, were assessed independently for accuracy by two review authors (FW and VS).  The discrepancies were resolved through discussion and consensus.

A total of 28 studies were included which examined 13 different NSAIDs and involved 4181 women (none of whom were breastfeeding). These studies were published between 1967 and 2013, with the majority published in the 1980s. Out of 4181 women included in the survey, 2642 received an NSAID and 1539 received placebo or paracetamol. There was no clarity observed in bias risk due to inadequate reporting, but in most of the studies, blinded participants and personnel were included complete outcome data and outcomes.  The secondary issues including perineal pain based prolonged hospitalisation or re-hospitalisation; breastfeeding (thoroughly or mixed) at discharge and six weeks; perineal pain at six weeks; maternal views; postpartum depression; effective measures of disability due to perineal pain were not reported in any of the studies.

NSAID versus placebo

Adequate pain relief was achieved at four hours {risk ratio (RR) 1.91, 95 (CI) 1.64 to 2.23, 10 studies, 1573 participants (low-quality evidence)}. At six hours {RR 1.92, 95% CI 1.69 to 2.17, 17 studies, 2079 participants (very low-quality evidence)} adverse effects were reported more in women who received a single dose NSAID as compared to women who received a placebo. There was less requirement of additional analgesia in women who received an NSAID versus women in the placebo group at the period of four hours and 6 hours after initial administration. There was an incidence of fourteen adverse effects {drowsiness, abdominal discomfort, weakness, dizziness, headache, moderate epigastralgia and not specified} found in NSAID group and eight in the placebo group {drowsiness, light headed, nausea, backache, dizziness, epigastric pain and not specified (1)}. No differences were found in overall maternal adverse effects between NSAIDs and placebo at six hours post-administration (RR 1.38, 95% CI 0.71 to 2.70, 13 studies, 1388 participants (very low-quality evidence)). Maternal adverse effects were assessed at four hours post-administration in one small study (with two treatment arms), but there was no incidence of maternal adverse effects found (one study, 90 participants (low-quality evidence)). There was no incidence of neonatal adverse effects in any of the included studies.

NSAID versus paracetamol

Adequate pain relief was observed at four hours (RR 1.54, 95% CI 1.07 to 2.22, three studies, 342 participants) in NSAIDs versus paracetamol but it was not found at six hours post-administration. At the period of four hours, there was no additional need for analgesia between two groups, but at six hours, there was less additional analgesia requirement in women in the NSAID group as compared to paracetamol group. There was no difference found in maternal adverse effects at four hours after drug administration (one study). There were no differences observed in the number of maternal adverse effects, with one case of pruritis in the NSAID group and one case of sleepiness in the paracetamol group after six hours of drug administration. Comparative analysis of different NSAIDs and different doses of the same NSAID indicates no differences in efficacy on any of the primary outcome measures. The study deduced that NSAIDs (compared to placebo and paracetamol) offers more significant pain relief for acute postpartum perineal pain and reduces the need of additional analgesics in women who are not breastfeeding and who sustained perineal trauma. The quality of the evidence (GRADE) was low with the evidence for all outcomes rated as low or very low due to the inclusion of studies with high risk of bias and inconsistent findings.

Future insights are required in this context, and there is a need for further evaluation of adverse effects of NSAIDs including neonatal adverse effects and the compatibility of NSAIDs with breastfeeding and other important secondary outcomes of this review. Women with episiotomies were included only, but future research is required in women with and without perineal trauma, including perineal tears. There is still the requirement for further high-quality studies in future that can determine the efficacy of NSAIDs versus paracetamol and the effectiveness of multimodal treatments.