Guest post: “We should not be normalising postnatal pain”

[MumsnetGuestPosts]

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.

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 [email protected].

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.

I think the treatment and dismissal of the pain women experience during and after birth is appalling.

There is an expectation for women to 'just get on with it', despite having gone through an incredibly physically traumatic experience that often results in 1st-4th degree tears, episiotomies, c-sections, infections, subsequent incontinence.... if men regularly experienced such physical trauma there would be uproar, and certainly no expectation to 'grin and bare it'.

I went into hospital in agony when I was in labour and I was examined by a MW who said because I was only 1cm dilated I couldn't have anything and sent me home. I was obviously in severe pain and I couldn't walk or talk properly because of the contractions. As I was leaving the ward a different MW stopped me and asked where I was going, and when I said I was being sent home she pulled a face that involuntary said I can tell you're in a lot of pain, I don't think you should go.

By the time I got home I could feel my baby coming and went straight back to the hospital who said it was too late to administer any pain relief and I gave birth 20 minutes later. If the initial MW hadn't ignored my obvious pain I honestly believe I wouldn't have had such a traumatic and painful experience. Instead, she only paid attention to how many cm I was dilated and ignored the other signs of my labour.

I suffered a bad second degree tear that resulted in a secondary infection as a result of a very fast and unmanaged birth, and I was offered only paracetamol. I could barely walk and I couldn't sit down, but that didn't matter, my obvious pain and discomfort were dismissed because 'everyone else gets on with it' and it wasn't standard to give anything stronger. In the end it was only when I got home and my GP examined me and diagnosed me with an infection did I get the antibiotics and pain relief that I needed.

The NHS need to change their attitude and care towards women pre and post-partum. If we say we are in pain, LISTEN, do NOT ignore us. We are not secondary citizens and we do NOT deserve to be left in pain. If any other group of people were systematically ignored and left in pain there would be outrage.

I'm disgusted and embarrassed to admit that after three children, I didn't even know that pain relief post birth was available.
The afterpains after my last were so painful, I thought something was wrong and that I was dying- much worse than labour- but I'd already been discharged so was dealing with it alone and frightened at home.
The maternity post labour ward itself is a festering holding bay where they put you before discharge. They don't particularly want you to be comfortable, they want you out so as to free up beds.

Best bit of advice I ever had from mn was to take my own pain relief to hospital when I had my DCs. Getting any from a midwife was nigh on impossible.

Yeah, I agree about bringing your own pain relief! I did get pain relief the second time around after an ELC. But had absolutely NONE the first time round despite having had surgery to do a third degree tear repair and had retained placenta. I wasn’t even offered anything. I was transferred to a different hospital at midnight, went into theatre a few hours later (delirious with pain at this point) and was wheeled into an empty ward by a porter. I had no idea where I was. Late the next morning I was told to have a shower. I hadnt slept in over 48 hours at this point. That I had to take my baby with me. I fainted in the shower from the pain and pulled the emergency cord and was shouted at!! In my debrief a year later (due to PTSD) I was told I should have asked for pain. I was confused and actually seeing things from the pain and lack of sleep. The care was appalling.

So yes, take your own pain relief would be my advice.

I was told off for taking my own paracetamol. Because they want to keep track of what you are having. You can’t win!
I can’t really add much except that I agree with what everyone else is saying. Adequate pain relief, but also help with your baby when you are really not in a fit state to even get out of your bed, would go a long way.

loopy yy, a decade on from my EMCS and the 3 days post natal 'care' still brings me to tears. The theatre team were wonderful and caring but after that it was every woman for herself.

I stood my ground two years after that for my planned CS and refused to get up and change nappies for the first 24hrs while I was still hooked up to the catheter. I wasn't popular. I didn't care. I knew I had to rest so I wasn't in huge pain like the first time.

My post hysterectomy care was very good. I wasn't allowed out of bed for 36hrs and there was pain relief on tap. The nurses were scathing about post CS care.

Thanks for starting this campaign. It's essential to start treating women who have given birth humanely so they can recover and care for their new little one.

I had a routine ELCS but my baby was transferred to a NICU 3 hours drive away. I was discharged 24 hours post section and my parents drove me to the new hospital, where I was checked into the postnatal ward.

As anyone who has had a section can imagine, I was in agony after a three hour drive only a day after the section. I requested oromorph but had to wait almost four hours for it. Luckily I had bought my own paracetemol and ibuprofen with me.

I was told off for taking my own paracetamol. Because they want to keep track of what you are having. You can’t win!

Yeah, that's why I never told them. Not like they were any help, anyway. I kept my own log and DH knew about it. They CBA'd. I got lucky with my second one in that I could leave straight off the delivery suite. Most postnatal units are barbaric. Prisoners wouldn't be expected to share sleeping quarters and one toilet with so many people.

Sounds as though midwives haven’t got a clue when it comes to pain management if the general nurses on the wards can manage to organise post op analgesia.

I wonder if it’s because midwives have it drummed into them that birth is a natural process and there’s no need for fuss. C sections, retained placenta, tears and other physical trauma isn’t normal though and therefore pain management is essential.

It’s not rocket science.

Also, do they have access to doctors to prescribe the more effective analgesia? How often do midwife led units have a doctor write stuff up for them? Perhaps these places need a nurse prescriber or a physician’s associate to come in regularly and do a pain check on new mothers.

I'm really shocked reading these posts, and so sorry for all the new Mums suffering such pain. I didn't mean to suggest previously that having tight controls of opiates and stronger pain relief should mean you don't get any! As I said, the strong stuff they used in the 80's was freely available for after pains alone, quite apart from recover from LSCS and other complications when of course adequate pain relief is essential. The particular drug I mentioned that used to be given is no longer licensed in the UK and not suitable for a breastfeeding mother. But that doesn't mean other alternatives shouldn't be available!
I'm really glad someone is addressing this - for a profession that swears by evidence based practice there seems to be a distinct lack of it as regards post natal pain relief.

And WOW !! NICE recommendations read like they've quoted straight out of a 1950's midwifery text book I keep for novelty's sake! I'm really shocked now. Off message re: pain relief but hey, look after your mental health by looking after yourself ladies. A gentle walk and some fresh air should do it. 🤔👍🤣

Not to mention asking about resumption of sexual intercourse 2-6 weeks after the birth.... now it's true, I know some people are straight back at it, my lovely childminder drunkenly confessed she and her hubby had done the act in the maternity ward bathroom, a confession that still leaves me profoundly shocked!
But I'm pretty sure most people are in no way ready for many weeks. I hear gales of hollow laughter at the suggestion that 2 weeks is a good time to ask. I really think I must take this up with NICE.
ITS NOT NICE, it's bloody ridiculous!

nonsuch

My comment about buckets of OxyContin wasn’t aimed at you - apologies if it seemed that way. I was actually agreeing with you, the attitude that a few painkillers when in actual pain leads to addiction and so women must Suffer is a really prevalent one, and frankly a bit shit.

It’s all a bit biblical isn’t it? Woman till thy field in pain and all that.

I was told by my consultant about 14 months after I had my daughter that I should've expected to be in pain for years after having my daughter. 5 years on and I'm now on slow release morphine everyday and still in pain every day

I had a section in 98 and 😡that women still left to struggle in the same way.
I had inadequate pain relief but the biggest issue was that every time I stood up I passed out (as in full on faint.)
I was in a room on my own for some reason but midwife wouldn't let DH stay overnight with me. No-one came to help me despite calling and DS v distressed. I was so frightened that I would drop him if I fainted. The whole night was horrendous.

My Sis in law had a planned CS and no complications. She was sent home with morphine to inject for the first week. This was last year, so maybe it's a postcode lottery?

I had a 3 day long, painful and tramatising birth and SPD and a 4th degree tear. I was only given paracetamol which did nothing. It was only when I had an infection and burst stitches due to swelling that I finally got some better painkillers. I had so many physical problems and yet doctors just say, it's normal and it will pass and fob me off. It made the pain and stress last years instead of months. They act like we're being pathetic and should just suck it up.

I had a c section with a ga so no help of an epidural

I was prescribed paracetamol, prodded and told to stop crying the next day whilst trying to drag myself to scbu.

It is outrageous.

Remove MW from post natal care. They don't want to do it and there isn't enough staff to cover. Use nurses instead. Provide 24 hour care and pain relief. It's not difficult.

Mixed experiences; 3 planned sections. First and last - paracetamol / ibuprofen and oromorphine available. Second - was not allowed anything stronger than paracetamol. Also contracted a stomach bug with horrendous cramps / diarrhoea on recovery. Doctors seemed to not believe me and foreign health care could not understand why I did not want to have a wash (I felt faint and sick!). Best experience was my 3rd, they asked when I wanted to get out of bed - opted to have catheter and stay in bed for 24hours this was seen as fine. Next day I was up and about and asked to have a script of oromorph to take home with me. Can honestly say I had zero pain the whole time. If patients could rest for 24 hours and get strong pain relief it would be so much better for everyone. I had no issues establishing breastfeeding and the doctor told me to take medication on time always to keep on top of the pain.

I took 30/500 cocodomols into hospital with me for the day after the birth for this reason. Glad I did as the paracetamol they offered me wouldn't have touched the sides!

My experience in February this year was far from good, as a nurse myself I was appalled, I had an emergency section at 2am. This was after labour since midday. This was under a GA as it needed to be very quick. Once transferred to the recovery suite my husband and Mother had to leave, a midwife had let us all stay in the theatre for quite a while after as there was no where else she could allow them to see me and baby and after it had looked like husband was going home without a wife or baby I assume she felt sympathy for us.

Once on the recovery bit, I'd say around 03.30 at the latest, I was only spoken to when a nurse came in to do checks on baby as he had to have four hourly BM and oxygen levels. I wasn't particularly in pain at this point but had said I was unhappy with being in the hospital gown with a very large amount of blood on the sheets/me/gown/everywhere. I stayed awake awkwardly holding my baby until my husband arrived at 10am. I was given breakfast, toast and tea, which was put where I'd have to move to get it, excellent when you're not allowed to move and couldn't if i wanted to. I have a foggy memory of this, and would still have been confused from GA but was unattended with baby. Then the pain hit me like a truck, my husband asked several times for pain relief and when I was brought some they didn't tell me me what it was just put it on the side, when asked I was told pain killers. I had to ask again what it was, going forward 4/6 hourly medication rounds weren't done on time and several times I had to press my buzzer and request pain relief this wasn't done quickly and was greeted with rolling eyes. When asked to move from the one bay to another 12 hours post section they didn't help me walk, or offer a chair. Overnight once husband had to leave they offered no help, actually a lady across from me who hadn't had a section and could move much easier helped me to get out the chair, and to pick things up and my husband had tried to make things as easy as possible. I forced myself to walk about and in the morning got dressed put makeup on and got myself discharged so I could be home with help from husband and parents and be looked after myself. I was discharged with two days pathetic pain relief for after major surgery, luckily I have a very good GP who I called said I'd had a section and did a script to be collected with decent pain killers for a month.

Overall those two days and nights were the worst of my life and I get upset thinking about them, the combination of the experience that lead to the EMCS and my treatment after had put me off more children, I could never do it again.

Oh and another thing I hated, whilst being immobile/covered in blood/half naked/tubes everywhere/sweating/in pain was endless people coming through the curtain to sign me up to baby stuff, get my details, checks. I had to tell one woman politely to go away as no I don't want to get registered for baby photography, I am in hell!

The thought of only being given paracetamol after a section is hideous. I had codeine after sterilisation which I'm sure is far more minor surgery and I was very glad of it indeed.