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Guest post: “We should not be normalising postnatal pain”
Sunita Sharma, Lead Obstetrician for postnatal care at Chelsea and Westminster Hospital NHS Trust, explains her research into postnatal pain management and calls for MNers’ input
Lead Obstetrician for postnatal care
Posted on: Mon 25-Jun-18 11:18:33
(85 comments )
I’m the Lead Obstetrician for postnatal care at Chelsea and Westminster Hospital NHS Foundation Trust, London. Such roles are relatively new in the National Health Service (NHS) and I have been working specifically in this field for nearly four years. These roles offer obstetricians an opportunity to actively engage with the wider team in delivering care beyond pregnancy and labour to our mums.
Our initial project included developing a mum and baby app to provide our new parents with information to support them in the immediate postnatal period, and more recently the creation of digital storytelling modules where new mothers have kindly shared their postnatal experiences to support reflection and learning amongst health professionals and other mothers. Both projects are supported by our hospital charity CW+ and have enabled us to explore newer ways of empowering mothers and staff.
We have also undertaken other pieces of work aimed at enhancing the experience on the postnatal ward. It was only at the Royal Society of Medicine Conference on medical innovation in 2016 that I came across the concept of design thinking in healthcare - truly my lightbulb moment in terms of realising how our operational efforts could translate into a really positive difference for our mothers. This methodology encourages a human-centered approach, which goes beyond clinical outcomes, and requires professionals to truly understand the emotional experience (feelings, pains, anxiety, concerns) of those who use and deliver our service. This discovery stage (i), is then followed by stages of defining the need (ii), brainstorming and developing (iii) empathetic models of care and finally delivering (iv) care. Further reading revealed that this methodology had also successfully informed the Better Births report, the NHS 5-Year Forward View for maternity care.
In October 2016, we adopted this design thinking approach to postnatal care in our hospital and have started to gain new insights into the real-life experiences of the new mothers and the team providing care. Part of this work involved running a Whose Shoes? workshop, bringing together a range of staff and mothers/ partners and babies (see above image) to start a journey of healthcare improvement. We are now working on a number of the identified themes through the NHS Early Adopters Maternity Transformation Programme in Northwest London.
The local teaching programme now emphasises the need to treat and manage pain after childbirth with the same significance as one would outside of maternity settings like in gynaecology or surgery.
A Fellowship in Quality Improvement - Collaboration for Leadership in Applied Health Research and Care (CLAHRC) - in 2017, offered me the opportunity to focus on improving experiences associated with pain in the postnatal period. This is a theme that repeatedly came up in my postnatal clinics, an observation in keeping with the Mumsnet survey's findings of postnatal care. My own low pain threshold and clear recollection of my first childbirth (before I chose a career in maternity!) motivated me further. This was when the overriding clinical need was to get me out of the bed and mobilised ahead of the day 1 obstetric ward round, irrespective of my pain management. Beyond my personal account, several studies report that poor management of acute or persistent pain after childbirth can be associated with symptoms of postnatal depression at three, six and 12 months, and can negatively impact breastfeeding and mother-baby bonding. Therefore getting correct pain management after childbirth is so important.
To understand why the pain management strategies were not translating into good experiences, we undertook surveys of mothers and staff on the postnatal ward. We found that mothers sought regular reassurance about the safety of painkillers whilst breastfeeding, but that this reassurance didn’t always materialise in a busy ward setting. On the other hand, staff were genuinely surprised that this should even be a concern to a mother when a health professional was prescribing and dispensing medications. In addition, having gone through most of the pregnancy avoiding medications, the sudden transition to being offered a range of them really worried some mothers.
With time, I noted further preconceptions, biases and opinions unique to the postnatal period. This led me to explore how pain is assessed postnatally compared to other areas of healthcare. The expectation of pain or discomfort after childbirth means that mothers did not always seek support or pain relief medications, even at times when it may have been needed. It was not routine midwifery practice to use an objective tool like a visual analogue score (0-10 pain intensity scale at rest and on moving), where women assess their pain’s intensity to guide staff as to their needs. Using quality improvement methodology, our team has started to incorporate this into our routine clinical care, with positive feedback from staff who have started using it. The local teaching programme now emphasises the need to treat and manage pain after childbirth with the same significance as one would outside of maternity settings like in gynaecology or surgery.
Two years ago, I naively believed an operational approach would have long fixed this problem but as I’ve delved deeper, the intricacies of managing pain after childbirth are now becoming clearer. Working with a design approach and with the support of our maternity voices partnership team, we have started the journey towards optimising pain management in our service.
Through this blog (my first ever) I want to achieve two aims:
1) To empower new mothers and mothers-to-be to work with their local Maternity Voices group to have their knowledge and insights help design how healthcare is delivered; and
2) To raise awareness that poorly managed pain after childbirth is an avoidable outcome with possibly significant negative consequences for the mother and her baby. Mothers should feel confident to assess the intensity of their pain after childbirth and work jointly with their health professional to address this. Defining this pain as part of the ‘normal’ experience after childbirth cannot be right and this must change.
I would welcome suggestions on how mothers feel that hospital postnatal services should be designed to optimise pain management. You can contact me via Twitter or email at Sunita.firstname.lastname@example.org.
Image: Parents and Chelwest Maternity Voices co-chairs (back row - extreme left and right) who took part in the Whose Shoes event on postnatal care in July 2017.
You can find out more about the Mumsnet Better Postnatal Care campaign here.
By Sunita Sharma
Totally agree. I couldn't go and visit my babies in nicu as much as I would have liked because moving hurt so much.
The new trend for offering only paracetamol post c section needs to end. Major abdominal surgery needs something a bit stronger. Diflofenac suppositories are amazing. Bring them back!
This is long overdue. I "only" had a 2 degree tear but this meant i was in pain except when i lay down. I couldn't sit up straight to breastfeed my baby because of the pain. However I persevered. When I asked for help to be handed my baby (as it hurt to lean over too) I was told "ok but you must move yourself in the future to stop you getting DVT". Hormonal and in huge amounts of pain from having to move, and being given what I felt was a telling off I burst into tears. Two years later I still don't understand why my pain wasn't treated more seriously. Add to that and having to wait for ages for a doctor to sign off me being given paracetamol (not morphine for goodness sake!) I felt like I wasn't being listened to and wondered if I was overreacting. THEN add to that I didn't know whether I could take pain killers or which ones when breastfeeding (as you say above) and I felt lost in limbo. I can easily see why women get post natal depression.
I now tell my pregnant friends to take paracetamol with them into hospital and to not be afraid to use it.
Being given only paracetamol after a c section that needed the incision extending and the baby manhandling out *and where the spinal wore off halfway? Yeah. No.
No other abdominal surgery is managed by such low pain relief after.
Also shoving women on overcrowded, loud wards, expecting them to be responsible for an infant and then giving them only paracetamol. Maybe paracetamol, if the staff can be arsed, is not helping. All this is linked - it’s great you’re looking at it but at the same time it’s not simply better painkillers post birth, it’s the entire care process.
The whole atmosphere of a postnatal ward is not conducive to recovery and calm - pain on top of that is awful.
Also far too many women left in too much pain postnatally due to birth injury. Too many women stitched badly, too many women not given the pain relief they need in labour. Trauma increases perception of pain as well.
The entire way women are treated and managed before during and after labour needs an overhaul. Have a look at some of the birth injury threads on here to see the sheer shock a lot of women are left in.
Hi. This means so much to me and I’d like to thank you for posting about this. It’s so great to hear that these issues are being recognised and things are changing for new mothers.
Women in all clinical situations are chronically under treated for pain. There is a tendency to assume their distress is due to anxiety.
Saying that, I have noticed a definite shift in attitudes towards pain in general and frequently experience difficulty with obtaining pain relief for my disabled service users and the elderly in palliative care. It’s as though HCPs have suddenly lost the ability to empathise.
Yes to all of this!! Fantastic and long overdue. Well done.
I had major abdominal surgery (c-section) with only paracetamol to relieve the pain. I had ONE subsequent checkup with an actual doctor (six week post partum checkup) and she had no intention of even looking at my incision until I asked her to. I found it terrifying that I'd had this major operation and had basically just been left on my own with no follow up.
I was refused physiotherapy (or any other treatment) despite still having stomach pain and numbness five months later. I was just told that nobody can predict how long pain after c-section will last because it's different for everyone, and that was the end of it. I basically feel like I've been stitched up and left to get on with it. The mental trauma of feeling uncared for and afraid is as bad as the physical pain.
I'm not sure paracetamol post c section is new. I took the painkillers offered to me and was congratulated by the nurse for "managing without the strong painkillers". To which my response was "the other women are having stronger painkillers!!!???"
I've just recovered from shingles and the painkillers I've been prescribed were way in excess of those for the major abdominal surgery that is c section. It's almost as if women are still being punished for "original sin".
Maternity and labour wards need re-education- Mother’s who have just given birth deserve pain relief just like any other patients. When I asked for the oramorph the doctor had prescribed , the midwife suggested paracetamol instead. 2nd baby when I asked for painkillers the midwife said I was walking too fast to need them. I had a post dural headache from spinal and was walking too fast because I would start throwing up if I spent long upright. The fundamental midwife attitude seemed to be giving birth doesn’t need pain relief afterwards.
I was appalled when I first heard that woman were fobbed off after a c-section with a couple of paracetamol. I had my daughter by EMCS in 2016 and I was given paracetamol, ibuprofen and tramadol. I found the combination very good for controlling pain.
I would have been sent home with codeine, but I've reacted poorly to that in the past so I was allowed to take some tramadol home on discharge. I could never have managed with just paracetamol, and I wouldn't consider myself someone who is wimpy about pain!
Really important issue. Thank you very much for the post.
After both my DC my GP surgeries (I’d moved in between DC) came up trumps on pain relief and healthcare for other postnatal issues. Was very lucky.
When in hospital the nurses were so busy that would miss times for the pain relief.
After DC1 I was given a cup of something pink and fizzy called only “cocktail”: was like being Alice in Wonderland and “drink me” - I just did.
I had a third degree tear and was offered paracetamol once after my operation then was sent home with strong pain relief after struggling in hospital for 3 days
I am 4-5 weeks pregnant and this is honestly terrifying
I was refused all pain relief because I was still able to talk and told it’s my first birth this is just the beginning, it’s too early for pain relief even though I was begging for anything.
5 minutes later baby was coming out and midwifes said oops too late for anything now best get pushing. I felt stupid but also very angry. I was exhausted having been having very irregular contractions for 30 hours before. No one would believe me when I said I was in extreme pain.
When dd arrived I had tearing and whilst the nurses were stitching me up I said I can feel everything stop and they laughed and said you can’t feel that but I could feel every needle prick and ended up kicking one in the face. Only then did they re administer the local anaesthetic. I just can’t go through with that again. Any time I think of having another dc I think to this time and think no.
Initially after my emcs, my pain was handled very well. I was given two weeks' supply of paracetamol, ibuprofen and dihydrocodeine. I was given liquid morphine for the first two days as well. I was also sensibly advised to take the full course of painkillers even if I was feeling better. I had other problems once it turned out that I had ongoing pain and no one could pin point the cause - that's when I felt quite abandoned as initially no one really took responsibility for my care. I'd been signed off by the midwives and ended up getting batted back and forth between my GP and the hospital. I had many, many courses of antibiotics but it took a female registrar to tell me that I should be on regular painkillers really quite late on in the process. That helped. My baby is now 20 weeks old and I still don't feel right but I just don't have the energy to try to get answers right now.
I had a c-section in November, and because of my pre-pregnancy BMI I was offered 1.5 paracetomol. I was in agony and crying. The staff frequently forgot to bring them and my husband brought in ibuprofen from home.
I was fearful of being given only paracetamol after my last c section, so I asked the consultant beforehand. He said that 'they were not in the business of leaving women in pain, of COURSE you will get appropriate pain relief".
This was not the case, I was only offered paracetamol after the first day. I had severe SPD that had not gone away and with the c section as well, I was in a great deal of pain. We tried but they refused to offer any other pain killers. It was most depressing.
Sobbing begging for something stronger than paracetamol was one of the most humiliating experiences of my life.
The drugs trolley was delayed for hours and everything had worn off, I’d had an EMCS and sepsis and I couldn’t handle the pain that was all consuming.
I still feel overwhelming guilt because I was incapable of looking after dd through this. It took a very very long time to bond.
Even when the pain relief was working, I could barely move because of the agony, I was sent to have a shower the morning after birth and I could barely stand, couldn’t bend to pick up my clothes or towel so had to open the shower into the corridor naked to ask for help. I couldn’t lie down, stand up, sleep.
The midwives weren’t being deliberately cruel, but there was nothing they could do. It was total fucking torture.
So please, look at keeping some pain relief on the ward so they aren’t reliant on a trolley doing the rounds, so this doesn’t happen to other women.
Oh and dd is now 2 and the scar/ stomach still hurts. I’ve been fobbed off with being told that it’s normal so many times I’ve given up. Surely it’s not acceptable to still have pain two years later?
Loopytiles how old is your DC1? I wonder if you were given Aspav which was dished out liberally in the early 80's. 500mg Aspirin 10mg Papaveretum x 2 tabs, big orange fizzy tabs. Not use for LSCS but for after pains too. They were very popular! Banned now, it's quite shocking to think how freely used they were now.
Should have read "not just for LSCS..."
And on the other hand consider how OxyContin / Oxycodone has been handed out like smarties in the USA, allowing the Sackler family of Purdue Pharma to amass billions through hard sell techniques and contributing significantly to the opiate addiction epidemic in the USA. My niece developed appendicitis during a short trip to NY and was given a month supply to take away after. My sister promptly threw it away. Knee replacements get it for three days only typically in UK. We are lucky to have tight regulations on this.