Pain medications post partum

Elvish, BSN, DNP, RN, NP · Nov 20, 2011

You should ask your anesthesia providers about doing TAP blocks for C-sections. Are Obstetricians and PP nurses love them.

I saw that - it looks really cool. I will have to ask anesthesia next time I see them come up to check on folks post-epidural/spinal. :up:

**LibraSunCNM, BSN, MSN, CNM** · Nov 20, 2011

I have seen pts come to me with PCA epidural Fentanyl, no bupivicaine (our standard numbing agent) so they can get up and walk around and do pretty well. That said, I am surprised anyone can keep an epidural in for 2 days like that. I don't know if it's just me or if it's our anesthesia dept. or what, but if my pt is moving around well and sitting up and rolling side to side, her epidural tends to migrate out of place within about 12 hours. I am only too glad to pull it and start PO meds anyway.

That's interesting. Our post-op epidurals are a mix of fentanyl, bupivicaine, and epinephrine, on a PCA. I haven't had too many patients' epidurals fall out, although it does happen occasionally. Those rare moms who have it out early seem to me to do just as well, pain-wise, on orals, with less of the risks that come with keeping the epi in.

allnurses Guide · Nov 20, 2011

I totally agree. However, we do get them up out of bed post-op day one. The mix of meds in the epidural post-op is such that they can be up and moving around with full sensation. But the moms who get the epi out earlier seem to do just as well on the oral meds as the moms do a day later.
I haven't heard of any other hospitals where the epidural stays in post-op, much less for 2 days, but we have a very, ahem, controversial MD running our anesthesia program and I personally suspect it's all about lining the coffers charging the patients' insurance for as many bags of epi medicine they can (I'm told each bag costs about $150, and each patient goes through at least 3 in their post-op course). But that's just my opinion.

That maybe the real issue. I don't really think about the money side a lot since I am military.

dscrn · Nov 20, 2011

I haven't heard of keeping the epidural in for another day post c-section. What about pp bleeding, uterine atony, risk of PE/DVT, pneumonia etc. IMO there are man-oo be up and moving posty more benefits for the patient to be up walking right away then leaving epidural in for another day.

Epidural dose post recovery room is different concentration-mom's are up oob in 4-6 hrs, able to ambulate very well,,,I think this encourages moms to be up and about and there is not the narcotic fogginess,,,

rn/writer, RN · Nov 21, 2011

Vag moms get 600 mg ibuprofen q 6hr prn. We have a couple of docs who schedule it (which we nurses dislike because it seems like they don't trust us enough to assess pain as we should), but I'd say about half the time the mom turns it down and will maybe ask for it 2-3 hours later. That's another problem with scheduling it. If the mom didn't want it at midnight (or asked not to be awakened for it) and she requests it at 0230, now pharmacy has to reenter it and change the whole schedule.

Vag moms can also have 1-2 Percocet or Norco q 4 hr, but unless they have big lacs, epidural site pain or serious deep muscle pain (or something like a groin pull) from extended pushing, a lot of them don't want the narcs.

Section moms come from L&D with either Duramorph or a hydromorphone PCA. They get toradol q 6 hrs, as well. Both the PCA and the toradol get dc'd 18-24 hrs post-op. Then the moms get switched to the ibuprofen and the Percs or the Norco. We can get an order for breakthrough meds if the Duramorph moms need it.

All the moms can have ice packs, Dermoplast spray, Tucks pads or ointment and Aqua K pads (on the epidural site). Most say the Aqua Ks offer little comfort. They like the ice packs better.

Our patients generally say they are greatly satisfied with their pain relief options. We encourage them to prevent pain rather than chase it. Most are relieved to hear that taking a combination of meds is okay and should keep their pain well managed.

I really dislike it when docs are stingy with pain meds. We had a short spell of some residents not ordering toradol to go with the Duramorph. After a few middle-of-the-night phone calls, they finally understood that they needed to include both the toradol and maybe even some Percocet in small doses for breakthrough.

The biggest challenge with the Duramorph is the gosh-awful itching some of the patients complain about. Benadryl, Nubain or Narcan are nice tricks to have up your sleeve when that happens.

To the OP, I did have a question about giving 600 mg ibuprofen q 4 hr. Giving it at that rate would cause the patient to exceed the recommended limitation of 2400 mg in 24 hr. But maybe that was a misprint?

I'm glad your hospital is taking this seriously. Your patients will benefit from better pain management, and so will the staff who will feel like they are providing better care.

NickB · Nov 21, 2011

Of course it depends on the Doc but generally:

Vag with no tear or epis. = Motrin 400 q 4 prn or motrin 800 q 8.

Vag with tear or epis. = Motrin 400 q 4 or motrin 800 q 8 and 1 percocet 5/325 q 4 prn as well as epifoam and tucks pads.

C-section = Toradol 15 or 30 q6 (depending on blood loss); Dilaudid 1mg or 2mg IM q 3 or 4 (MD dependent); 2 percocet 5/325 q 4 prn (when tolerating PO) and motrin 800 q 8 after 4 doses of toradol have been given or if pt would prefer PO meds.

Hope this helps.

shortstuff31117 · Nov 21, 2011

We have standing orders. For lady partsl deliveries we give Naproxen 500mg Q8. We also have standing orders for Vicodin or Percocet 1-2 tabs Q4 PRN (we use either the 5/325, or the 10/500). Its nursing judgement as to whether pt. gets vicodin or percocet.

C-Sections typically get duramorph in their spinal which most of the time keeps them comfortable for 12-24 hours, with maybe a need for something else once or twice before the duramorph wears off. They also get toradol in the OR, usually 30mg IM, and 30mg IV. Then we give it 30mg IV Q6 for 8 doses. Very effective medication. After their 8 doses, they get the Naproxen like the vag deliveries. If they don't get duramorph, or if it's ineffective, they have a morphine PCA ordered (if they are unable to take POs yet).

Everyone has standing orders for stool softeners, anti-nausea meds, MOM, typical stuff like that. If we have someone who is a chronic user of pain meds, we will usually use plain oxycodone, 5-10mg Q4 in between the percocet for those people.

Of course the vag deliveries get tucks and dermaplast as well.

I find that our pain meds are really effective for the majority of our pts.

Hushi05 · Dec 7, 2011

We use ibuprofen 800 mg for lady partsl postpartums and add Percocet if there are lacerations. For lady partsls we also use Epifoam and Tucks (witch hazel) pads.

Post c/s we use Percocet after the morphine PCA is turned off or after the Duramorph wears off. Sometimes we add Toradol if the PCA or Duramorph isn't enough. Occasionally our anesthesiologist prescribes clonidine 0.1 mg sublingual and/or rectal Tylenol as an adjunct after c/s.

CanadianGirl79 · Jan 10, 2012

Wow...in the Toronto Canada area, C-sections usually get naproxen or diclofenec q12 scheduled, and tylenol prn, in varying doses. Oxycodone or morphine q4 prn as well.

Vag get ibuprofen, tylenol, and oxycodone or morphine q4.

Occasionally, someone will have a PCA pump, depends on the hospital and the circumstances around the delivery.

sKris · Jan 17, 2012

I find this discussion really interesting. I've had three c-sections--2 in the states and one in Germany. With my first c-section I was given narcotics like most of you described and sent home with a bottle of Percocet. My second c-section I was in Germany and there if you breast feed you can ONLY have Tylenol. At first I was shocked and thought there was no way that that would be enough. They also provided a sand bag that you laid over the incision site. Remarkably the Tylenol and sand bag were far more effective than all the narcotics and my recovery was much better. They also had me up and walking very soon after surgery.My third c-section was state side and after my two experiences I chose to refuse all narcotics and just do Tylenol and IB. My recovery was so much faster and i felt more like me not being on all sorts of drugs. My nurses thought I was crazy but I was very happy with my choice. I made a rice bag, but it wasn't heavy enough and wasn't as effective. Still I would choose the no-narc route if I had to do it again. I'm not suggesting that patients shouldn't be offered effective pain management or narcotics but it just makes me think that sometimes we jump to them too quickly and ignore other pain management options.

melmarie23, MSN, RN · Jan 23, 2012

for lady partsl deliveries we have prn orders for Motrin 600mg q6h, Tylenol 650mg q4h and oxycodone 5-10mg q3h. We have standing orders for Dermoplast and Tucks pads. Ice packs live in the room. Most use just the motrin, ice and tucks.

for c-sections they usually get Toradol 30mg IV right before leaving the OR and then we have toradol 15mg q6h x 24 scheduled (then switch to Motrin first day post op). They also have prn orders for oxycodone 5-10mg q3 and if they need additional pain relief we call anesthesia for orders (usually morphine). At 24hrs post op, they are typically on the same med orders as our lady partsl delivery patients. Typcially, most use the scheduled toradol plus the prn oxy.

rn/writer, RN · Jan 23, 2012

for lady partsl deliveries we have prn orders for Motrin 600mg q6h, Tylenol 650mg q4h and oxycodone 5-10mg q3h. We have standing orders for Dermoplast and Tucks pads. Ice packs live in the room. Most use just the motrin, ice and tucks.
for c-sections they usually get Toradol 30mg IV right before leaving the OR and then we have toradol 15mg q6h x 24 scheduled (then switch to Motrin first day post op). They also have prn orders for oxycodone 5-10mg q3 and if they need additional pain relief we call anesthesia for orders (usually morphine). At 24hrs post op, they are typically on the same med orders as our lady partsl delivery patients. Typcially, most use the scheduled toradol plus the prn oxy.

10 mg of oxy q 3 hours seems a little much for a vag mom.

And 15 mg Toradol seems too little for a section. Unless they are on Duramorph. Yeah, I know you said the section moms can also have the PRN oxy, but ours are either on Duramorph or a PCA for the first 18-24 hours and they get 30 mg Toradol q 6 besides. Then they switch to 1-2 Percocets q 4 hours, not 3 and ibuprofen in place of the Toradol.