Post-partum Non-pharmacologic Pain Management

Hypothesis Use of an abdominal binder postpartum after a vaginal delivery will be associated with lower pain scores and reduced need for pharmacologic analgesics.

Background A significant part of postpartum care involves management of patients' pain and discomfort. Etiologies of this pain include perineal pain, incisional pain, uterine involution pain, and pelvic girdle and lower back pain. Postpartum pain management primarily focuses on the former three types of pain: perineal, incisional and uterine involution. In a review of the management of postpartum pain, Eshkevari et al discuss several well-established pain management strategies employed for postpartum patients, including ibuprofen and other NSAIDs for uterine involution pain and inflammation; local anesthetics for perineal lacerations or episiotomies; warm or cold compresses for perineal pain; and opioids for post-operative or poorly controlled postpartum pain.

Data regarding management of pelvic girdle and lower back pain is scarce and the limited literature available primarily focus on the pregnant patient. Different proposed treatment or management strategies during pregnancy include physical therapy, targeted exercises, acupuncture, NSAIDS and opioids. Approximately 25% of postpartum women endorse pelvic girdle and/or lower back pain, and these types of pain can persist for as long as several weeks to 1-2 years after delivery. Therefore, management remains key for the postpartum patient as well. The proposed pathophysiology behind pelvic girdle pain and lower back pain in the context of pregnancy is widening of the pubic symphysis and increased laxity in the sacro-iliac joints (SIJ) secondary to both biomechanical shear forces of increased weight bearing and elevated levels of relaxin, a polypeptide hormone that increase laxity of ligaments. A prospective study investigating the impact of abdomino-pelvic belts at different positions on the laxity of the SIJ found that use of the abdomino-pelvic belt significantly decreased mobility of the SIJ. Additionally, pelvic belts or abdominal binders may help provide stability to muscles of the abdomen, back and spine.

Studies investigating the use of abdominal binders for pain management in post-operative patients following both cesarean section and gynecologic surgery have had mixed results. A randomized control trial examining impact of abdominal binders on patient reported pain and symptom distress found no significant difference in pain on post-operative days one and two, and the difference in distress on post-operative day two was no longer statistically significant after correction for multiple measures. Another study involving gynecologic surgery patients randomized to abdominal binder or control groups found that there was no overall significant difference in morphine use or pain scale between the groups, and the benefits were limited to a significant effect on post-operative ambulation for a subset of patients with highest risk of complications: patients > 50 years, cancer patients, and those with vertical incision. In contrast, a more recent randomized controlled trial assessing abdominal binders following cesarean delivery found that pain and symptom distress scores were significantly lower at all time points in comparison to a control group.

A common theme in the current literature regarding postpartum pain management is the need for more research. In light of the current opioid abuse epidemic, which affects approximately 2.1 million people and the U.S Department of Health and Human Services declared a public health emergency in 2017, there is a renewed emphasis utilizing non-opioid methods on pain control. As a primary source of pain in the postpartum period is associated with musculoskeletal pelvic discomfort, the use of a supportive abdomino-pelvic belt may be a non-pharmacologic modality that could reduce pain and decrease narcotic requirements in postpartum patients. No studies have directly assessed the effectiveness of abdominal binders on pain management in postpartum patients. This study aims to examine how use of an abdominal binder might impact postpartum pain, and the use of pharmacologic analgesia following vaginal delivery.