What is the typical medication regimen for post Normal Vaginal Delivery (NVD) discharge?

Post Normal Vaginal Delivery Discharge Medication

For opioid-naïve women after uncomplicated vaginal delivery, discharge with scheduled acetaminophen (650 mg every 6 hours or 975 mg every 8 hours) plus ibuprofen (600 mg every 6 hours) as first-line therapy, reserving a short course of low-dose opioids (5-10 tablets of hydrocodone 5 mg) only for severe pain uncontrolled by non-opioid analgesics. 1, 2

Primary Discharge Regimen (First-Line)

Non-opioid multimodal analgesia should be the foundation of post-NVD pain management:

• Acetaminophen: 975 mg orally every 8 hours OR 650 mg every 6 hours (maximum 4 grams daily) 1, 2
• Ibuprofen: 600 mg orally every 6 hours 1, 2
• Non-pharmacologic adjuncts: Ice packs, heating pads, hydrocortisone cream, or local anesthetic application to the perineum 1

This combination provides superior analgesia compared to either agent alone, with research demonstrating that ibuprofen plus paracetamol achieves at least 50% pain relief in 69-73% of patients versus only 7% with placebo (NNT 1.5-1.6). 3

Expected Pain Duration and Recovery

Pain after vaginal delivery is typically mild-to-moderate and self-limited:

• Median time to pain resolution: 14 days (interquartile range 7-24 days) 1
• Median time to analgesic cessation: 11 days (interquartile range 5-17 days) 1
• Median time to opioid cessation: 0 days (interquartile range 0-2 days) 1

Opioid Prescribing (Reserve for Severe Pain Only)

Opioids should NOT be prescribed routinely at discharge if the patient is not using them in the hospital. 1, 2 If severe pain persists despite scheduled non-opioid therapy:

• Hydrocodone 5 mg: Prescribe 5-10 tablets maximum 1, 2
• Shared decision-making: Counsel patients about benefits, risks, side effects, and potential for misuse before prescribing 1, 2
• Risk awareness: Approximately 1 in 300 opioid-naïve women exposed to opioids after delivery will develop persistent opioid use 1

The Society for Maternal-Fetal Medicine and ACOG emphasize that opioids should be used "on an as-needed basis as rescue but not first-line medications" for postpartum pain management. 1

Critical Red Flags Requiring Evaluation

Severe pain after vaginal delivery is unusual and should prompt evaluation for unrecognized complications: 1, 2

• Significant perineal lacerations (third or fourth degree)
• Hematoma formation
• Infection or endometritis
• Retained products of conception
• Uterine atony or subinvolution

Special Populations

Women with Opioid Use Disorder

Continue maintenance therapy (methadone or buprenorphine) throughout the postpartum period: 1, 2

• Start with multimodal non-opioid approach (acetaminophen + NSAIDs) 1, 2
• If pain persists beyond 24 hours, add full opioid agonists (fentanyl or hydromorphone) rather than increasing buprenorphine 1, 2
• Avoid opioid agonist-antagonists (nalbuphine, butorphanol) as they can precipitate withdrawal 1

Women with Preeclampsia

Avoid NSAIDs if possible, especially with acute kidney injury: 2

• Use acetaminophen as the preferred analgesic 2
• Consider alternative pain management strategies if NSAIDs are contraindicated

Common Pitfalls to Avoid

Never prescribe routine opioids at discharge if the patient is not using them in the hospital - this practice contributes to unnecessary opioid exposure and leftover medications available for diversion. 1, 2

Never dismiss severe persistent pain as "normal" - it warrants thorough evaluation for complications such as infection, hematoma, or unrecognized laceration. 1, 4

Never prescribe large quantities of opioids - studies show that median opioid consumption after cesarean delivery is only 20 tablets despite prescriptions for 40 tablets, with 95% of women not disposing of leftover medication. 1

Never use codeine during pregnancy or breastfeeding - it should be avoided due to variable metabolism and risk to the infant. 2

Evidence Supporting Multimodal Approach

Recent implementation studies demonstrate that standardized multimodal analgesia protocols significantly reduce opioid exposure while improving pain control. One large study of 12,898 cesarean deliveries showed that scheduled acetaminophen plus NSAIDs reduced opioid use from 67.5% to 45.4% while decreasing severe pain episodes from 56.6% to 46.3%. 5 While this data is from cesarean deliveries, the principle of scheduled multimodal analgesia applies equally to vaginal deliveries where pain is typically less severe. 1

Medication Counseling at Discharge

Provide clear instructions to patients:

• Take acetaminophen and ibuprofen on a scheduled basis (not "as needed") for the first 3-5 days 1, 2
• Use opioids only if pain interferes with mobilization, breastfeeding, or infant care despite scheduled non-opioids 1, 2
• Dispose of unused opioid medications properly to prevent diversion or accidental exposure 1
• Return for evaluation if pain worsens or does not improve as expected 1