Post Partum pain management

[ragingmomster, BSN, MSN, RN]

Hi all,

I'm looking for input for a post partum pain management project in relation to our patients in medication assisted therapy programs.

Our post-partum order sets are usually followed by our OBs.

lady partsl - Percocet 1-2 every 4 PRN and Motrin q8

C-section - Toradol in the OR, then every 8 hours x 3, Morphine PCA x 12-24 hours (1mg q10 min max 6/hr); then switch over to the same meds as PPV

Is anyone in the US using Indocin before cesareans leave the OR?

Is anyone NOT ordering Percocet or other opiates for lady partsl deliveries?

TIA,

Dawn

[Elvish, BSN, DNP, RN, NP]

More than anything I am surprised you guys are doing Morphine PCA. We do a spinal dose of Duramorph in the OR which is good for 24h, along with 30 Toradol q6h x 24hr, then switch to q6h Motrin & q4 Percocet if needed (same thing as lady partsls).

A lot of pts still itch with the Duramorph but the n/v is way less than with PCA.

[boquiabierta]

We don't typically order opiates for lady partsls. They're almost always fine with just 600 mg Motrin Q6. Occasionally we will add Percocet Q4, but often if they need something else just Tylenol is enough.

C-sections get Duramorph in their spinal sometimes but not always. A PCA is realllly rare (in a year+ on my unit I've had exactly one pt on one). They get one 30 mg dose of Toradol followed by 15 mg Q6h (until IV is out, then switch to Motrin) plus Percocet Q3-4 as needed. If that's not enough we'll add oxycodone or Dilaudid. Most patients do fine with less, though.

[haunani, BSN, RN]

Our standards:

lady partsl:

Motrin q6h

Tylenol #3 q3-4h OR Norco 5/325 q3-4h

C/S:

First 24h is IV meds only.

Duramorph in the spinal (lasts 24h) They will often have a slow drip of Nubain hung to help with the itching.

Toradol q6h

Dilaudid q2h

PCA Dilaudid (0.2 q10min) for those who were under General Anesthesia

After 24h, same as lady partsl.

[ashleyisawesome, BSN, RN]

lady partsl:

Motrin q6 PRN

Tylenol #3s q4 PRN

Tylenol q4 PRN

Some doctors will order Vicodin instead of the T3s.

C/S:

Usually a duramorph spinal dose in the OR that lasts 24h, plus toradol q6x3, and percocet q4 PRN for breakthrough pain.

If they are unable to get duramorph for whatever reason, they get a dilaudid PCA for ~24h, and sometimes toradol q6. Once the PCA is d/c'd they get Percocet q4 PRN and Motrin q6 PRN. If their pain is unrelieved with the percocet and motrin, they will usually order IV dilaudid or morphine q2-4h PRN.

[cayenne06, MSN, CNM]

I don't usually put in an order for narcotics after an NSVB unless there is an indication (significant lacs etc). Motrin and tylenol is usually enough. I am always happy to throw in some oxycodone (while inpatient) if needed.

I usually make sure there are IV and PO prns for post op moms for the first 12-24 hours, then just PO.

I have also used nitrous for repairs a few times, and I really really like that option.

I have a Thing about tylenol in opiates though. Inpatient, it's usually not a problem (since we can keep track of all their meds) but I wish we would just stop doing it as a general rule. I am very careful about giving outpatient narc prescriptions, but I still worry about someone taking a handful of them. I always give a plain narcotic if I am going to prescribe one. I've had a few clinicians tell me they prescribe narcs+apap specifically to reduce the risk of abuse, but I've worked with drug dependent people for a looooooooong time, and I've never known someone who was really deterred by that. Drug addiction is hard enough, I don't want to add acute liver failure to their list of problems.

[Strawberrygirl2]

We rarely use PCA for c-section pain. (We routinely use Duramorph/Astromorph, because it is awesome...) The most common reason that we would use PCA would be for patients with hx of opiate dependence/tolerance or hx rapid opiate metabolism. We use hydromorphone PCA (unless there is a shortage or the pt doesn't respond well, then we using morphine, or, even less frequently, a fentanyl PCA).

Otherwise, for c-sections we typically do 15-30mg Toradol q6x4. Our PACU orderset includes fentanyl, dilaudid, demerol and morphine a la cart. Honestly, for quickly escalating immediate c-section pain, a dose of fentanyl and a little white lie that it is "strong stuff that's really going to tie you over" often gets the anxiety out and keeps pain controlled until the patient start orals. (Just my anecdotal experience hehe. Doesnt' always work obviously...). After Toradol we switch to 600mg ibu q6. We also encourage Percocet q4. Sometimes we give a little extra oxy if needed.

For vag our standard recommendation to patients is 600mg ibu q6. We also offer Tylenol or Norco in addition that. (Midwife patients less frequently get Norco ordered). Rarely do we offer Percocet or oxy for vag deliveries.

[MJC2118, APRN]

For lady partsl deliveries:

Motrin 800 mg q8h scheduled

Norco 5/325 1-2 tabs q6h PRN

For C/S:

Duramorph through spinal

Toradol 30 mg q6h PRN

Norco 5/325 1 tab q4h

If general anesthesia, will do a PCA

[ngiam12, ADN, BSN, MSN, RN]

Hi there!

It is so interesting to read about what other hospitals do for pain management. We actually recently started a non-pharmacologic pain management program as well, but that's a different story for a different day!

lady partsls are written for 600mg Motrin q6 and 500-1000mg Tylenol q6. They're no longer written for oxycodone.

C-sections often receive ITM (most often Astromorph) which lasts for 24 hours. They are written for 15-30mg Toradol q6 x24 hours and Tylenol 500-1000mg q6. Similarly, after 24h they can have Motrin 600 q6 and 5-10mg Oxycodone q4. Very rare when we see a PCA pump! Though, now that I say that, I'll probably have one on my next shift, haha!

Thx y'all!

Nicole

[quazar]

Pretty much what the rest are saying:

lady partsl deliveries: Tylenol q4-6 PRN, Motrin 600-800q6-8PRN, Norco 1-2q4PRN. Percocet used to be the drug of choice probably 8-10 years ago, but Norco has become the favorite.

C-sections: Duramorph in the spinal, morphine 1-2 IV or 25mcg fentanyl in the PACU, toradol 15-30 q6h x 4 doses, starting with the first in the PACU. Norco or Percocet upon discharge from PACU. PCAs only used for patients who got general anesthesia.

One thing that I loved for c-section post op that my current facility isn't doing is the on-q pump. I really liked those things, and so did our patients. I wish more facilities would use them. Post Operative & Pain Management| MyON-Q

[southernbelle08]

Depends on the OB where I work and I only work on the PP side of it when pulled, so haven't memorized the orders as well as if I were there all the time.

lady partsl - Most give 1-2 5-7.5mg (again, dose depends on specific OB) Loratab. A couple give Tylenol #3. They also typically write 800mg Ibuprofen PRN.

C-Section: Some of our OBs use Exparel with their c-sections and that eliminated their use of PCA pumps for them. They typically have IV pain medication on their order set for severe pain and then PO. Usually Loratab or Percocet. Some schedule 30mg Toradol x 3 doses. Others have 30mg Toradol as a PRN order for the duration of their stay. A few used to do Caldalor also, but I haven't given that the past few times I have worked on that unit, so I guess maybe they are getting away from it. Also, some gave Ofirmev IV but again, haven't given that in a while. The frustrating part is everyone has their own specific orders. OBs in the same practice don't even use the same order set!

[lenoxs27]

Interesting that facilities are getting away from PCA use. Here are our orders;

SVD- Ibuprofen 600mg q6 PRN and Norco 5/325 1-2 tab q4 PRN

C-section- Exparel in OR, Morphine PCA x 24h, Toradol 30mg q6 x 5 doses PRN, Ibuprofen 600mg q6 PRN (after Toradol completed), and Norco 5/325 1-2 q4 PRN