How should I evaluate and manage back pain that began after a recent delivery in a postpartum woman without red‑flag symptoms?

Postpartum Back Pain: Evaluation and Management

Initial Assessment

For postpartum back pain without red-flag symptoms, begin with a focused history identifying pain location (lumbar vs. posterior pelvic), timing of onset, functional impact on infant care, and pre-existing back pain history, as these factors predict persistence and guide management. 1, 2

Key Historical Elements to Elicit

• Pre-pregnancy back pain history – the strongest predictor of persistent postpartum pain, present in most women with pain at 12 months 2, 3
• Pain during pregnancy – significantly correlates with postpartum persistence 2
• Physically heavy work – the strongest modifiable risk factor for pain lasting beyond 6 months 2
• Multiparity – increases risk of persistent pain 2
• Pain character and location – distinguish lumbar (midline, worse with flexion/standing) from posterior pelvic/sacroiliac pain (lateral, worse with weight-bearing) 4
• Functional interference – specifically assess impact on infant care, mobility, and daily activities 5

Physical Examination Focus

• Posterior pelvic provocation test for sacroiliac involvement 4
• Patrick's test (FABERE maneuver) for hip and sacroiliac pathology 4
• Lumbar range of motion – pain with flexion suggests discogenic or facet pain 4
• Neurologic examination – to exclude radiculopathy (though rarely present in uncomplicated postpartum back pain) 4
• Muscle endurance testing – particularly lumbar and hip abductors, as poor function predicts chronicity 6

Pain Assessment Tool

Use the Short-Form Brief Pain Inventory (SF-BPI) to comprehensively assess postpartum back pain, as it is the only validated tool with Class A recommendation for this population, evaluating multiple pain domains beyond simple intensity scores. 5

• The SF-BPI assesses seven pain domains including severity, location, temporal pattern, analgesia use, and functional interference 5
• Takes only 2-5 minutes to complete, making it practical for clinical use 5
• Available in 24 psychometrically validated translations 5
• While the Oswestry Disability Index is specific for lower back pain, SF-BPI has superior content validity for the postpartum context 5

Management Algorithm

First 6 Weeks Postpartum

Initiate conservative management immediately, as most women who recover become pain-free within 6 months, making early intervention critical. 2

• Patient education on expected recovery timeline and activity modification 7
• Pelvic belts for sacroiliac stabilization 7
• Acupuncture as an evidence-based non-pharmacologic option 7
• Aquatic exercises when feasible 7
• Avoid physically heavy work during the early postpartum period, as this is the strongest modifiable risk factor 2

6 Weeks to 6 Months Postpartum

If pain persists beyond 6 weeks, escalate to structured physiotherapy focusing on lumbar and hip abductor muscle strengthening, as poor muscle function is the key problem in persistent cases. 6

• Tailored postpartum exercise programs targeting core and pelvic stabilizers 7, 6
• Reassess functional status using SF-BPI at 2-6 week intervals 1
• Screen for depression and anxiety, as 13% of postpartum women develop depression which can amplify pain perception 1

Beyond 6 Months

For pain persisting beyond 6 months (affecting approximately 37% of women with postpartum back pain), refer for specialized multidisciplinary pain management, as this represents the transition to chronic pain. 2

• Approximately 5% of all pregnant women (or 20% of those with pregnancy-related back pain) will have pain at 3 years 6
• Women with combined lumbar and posterior pelvic pain have significantly greater disability and require more intensive intervention 6

Critical Monitoring Points

Red Flags Requiring Urgent Evaluation

While the question specifies absence of red-flag symptoms, remain vigilant for:

• Fever with back pain – consider epidural abscess, pyelonephritis, or septic thrombophlebitis requiring CT imaging and antibiotics 8
• Progressive neurologic deficit – requires urgent imaging
• Severe unilateral leg pain – consider ovarian vein thrombosis (80-90% right-sided) 8

Routine Follow-Up Schedule

• First week postpartum: Initial pain assessment and education 1
• 2-6 weeks: Comprehensive evaluation using SF-BPI, functional assessment, mental health screening 1
• 6 months: Reassess if pain persists, as most recovery occurs by this point 2
• 12 months: Final assessment for chronic pain development 2

Common Pitfalls to Avoid

• Do not attribute all postpartum back pain to epidural anesthesia – no association exists between epidural use and back pain at 1-2 months postpartum 3
• Do not rely solely on numeric pain scales (0-10) – these miss critical functional and quality-of-life impacts that SF-BPI captures 5
• Do not delay physiotherapy referral – early structured intervention prevents progression to chronic pain 6
• Do not overlook the impact on infant care – this is a unique postpartum pain domain requiring specific assessment 5

Prognosis

• 67% of women experience back pain immediately after delivery 2
• 37% have pain at 12 months postpartum 2
• Most recovery occurs within 6 months for those who will improve 2
• 10% report persistent pain up to 18 months regardless of delivery mode 5
• Younger age and greater weight predict new-onset postpartum back pain 3