What medications are typically prescribed post-delivery?

Post-Delivery Medication Management

Post-delivery pain management should prioritize scheduled non-opioid analgesics (acetaminophen and NSAIDs) as first-line therapy, with opioids reserved only for severe breakthrough pain that interferes with recovery, breastfeeding, or infant care. 1

Pain Management After Vaginal Delivery

First-Line Approach (Opioid-Naïve Women)

Non-pharmacologic interventions:

• Ice packs, heating pads, hydrocortisone, and local anesthetic application to the perineum 1

Scheduled medications:

• Acetaminophen: 975 mg every 8 hours OR 650 mg every 6 hours by mouth 1
• Ibuprofen: 600 mg every 6 hours by mouth 1

Second-Line Options

If pain inadequately controlled with acetaminophen and ibuprofen:

• Ketorolac: 15-30 mg IV/IM every 6 hours for maximum 48 hours (if oral NSAIDs not tolerated) 1
• Epidural morphine or hydromorphone: Consider only for significant laceration repairs before catheter removal (requires 24-hour respiratory monitoring) 1

Rescue Therapy

Only for severe pain uncontrolled by above measures:

• Short course of low-dose opioids: 5-10 tablets of hydrocodone 5 mg 1
• Critical caveat: Severe pain after vaginal delivery is unusual and should prompt evaluation for unrecognized complications (hematoma, infection, undiagnosed laceration) 1

Pain Management After Cesarean Delivery

Intraoperative/Immediate Postoperative

Neuraxial opioids (most effective):

• Intrathecal morphine: 50-100 mcg OR diamorphine 300 mcg administered pre-operatively 1
• Epidural morphine: 2-3 mg OR diamorphine 2-3 mg (if combined spinal-epidural technique used) 1

Scheduled Postoperative Regimen

Standing orders for first 48 hours:

• Acetaminophen: 975 mg by mouth every 8 hours (scheduled, not as-needed) 1, 2
• Ketorolac: 30 mg IV every 6 hours for 24 hours, then switch to 1
• Ibuprofen: 600 mg by mouth every 6 hours 1

Evidence strongly supports scheduled dosing: Scheduled administration of acetaminophen and ibuprofen reduces opioid consumption by 64% and significantly improves pain scores compared to as-needed dosing 2

Rescue Opioid Therapy

Only if pain interferes with mobilization, breastfeeding, or infant care despite scheduled non-opioids:

• Oxycodone: Maximum 30 mg daily (six 5-mg tablets) as needed 1
• Critical discharge guideline: If women are NOT taking opioids in the hospital, do NOT prescribe at discharge 1
• If opioids needed at discharge: Use shared decision-making to prescribe no more than equivalent of twenty 5-mg oxycodone tablets 1

Alternative Approaches If Neuraxial Opioids Not Used

Consider these interventions:

• Single-injection local anesthetic wound infiltration 1
• Continuous wound local anesthetic infusion 1
• Fascial plane blocks (transversus abdominis plane or quadratus lumborum blocks) 1

Special Populations

Women with Preeclampsia with Severe Features

NSAIDs are safe and do NOT prolong severe-range hypertension:

• Ibuprofen 600 mg every 6 hours does not lengthen duration of severe-range hypertension compared to acetaminophen 3
• Exception: Avoid NSAIDs if acute kidney injury present (serum creatinine >1.0 mg/dL) 3

Opioid-Dependent Women

During labor and vaginal delivery:

• Continue daily maintenance medication (methadone or buprenorphine) throughout labor to prevent withdrawal 1
• Encourage early neuraxial analgesia (epidural or combined spinal-epidural) 1
• Avoid: Opioid agonist-antagonists (nalbuphine, butorphanol) as they precipitate withdrawal 1

Postpartum pain management:

• Multimodal approach with scheduled non-opioids as baseline 1
• Additional systemic opioids may be necessary but should not be routine 1
• For women on buprenorphine: Use full opioid agonists with strong mu-receptor affinity (fentanyl or hydromorphone) if additional analgesia needed 1

Additional Postpartum Medications (Non-Analgesic)

Uterotonic Agents

For prevention/control of postpartum hemorrhage:

• Oxytocin: 10-40 units added to 1000 mL non-hydrating diluent, infused at rate necessary to control uterine atony 4
• Intramuscular oxytocin: 10 units after placenta delivery 4

Antiemetic Prophylaxis

Multimodal approach recommended:

• 5-HT3 antagonists (ondansetron, granisetron) for intraoperative and postoperative nausea/vomiting 1
• Dexamethasone: Single IV dose after delivery (reduces nausea and improves analgesia) 1
• Combination regimens (5-HT3 plus droperidol or dexamethasone) more effective than single agents 1

Critical Opioid Safety Considerations

Risk of persistent opioid use:

• Approximately 1 in 300 opioid-naïve women exposed to opioids after cesarean delivery develop chronic use within one year 1
• Risk factors include: younger age, smoking, other substance use, chronic pain conditions, antidepressant or benzodiazepine use 1

Leftover medication hazards:

• Median opioid tablets dispensed after cesarean: 40; median consumed: 20 1
• 95% of women with unused medication do not dispose of it, creating diversion and accidental exposure risks 1

Opioid side effects to monitor:

• Nausea, dizziness, lethargy, constipation, respiratory depression 1

Common Pitfalls to Avoid

• Over-prescribing opioids at discharge: Most women do not need opioids after vaginal delivery; limit to ≤20 tablets after cesarean if needed 1
• As-needed dosing of non-opioids: Scheduled acetaminophen and NSAIDs provide superior pain control and reduce opioid consumption 2, 5
• Dismissing severe pain as normal: Unusual severe pain warrants evaluation for complications 1
• Using opioid agonist-antagonists in opioid-dependent women: These precipitate withdrawal 1