1. Original Article
Pharmacological and non pharmacological treatment
for relief of perineal pain after vaginal delivery
Tratamento farmacológico e não farmacológico no alívio da dor perineal pós-parto normal
Joyce Hasegawa1, Lucila Coca Leventhal2
ABSTRACT Descritores: Dor; Períneo; Período pós-parto; Analgesia obstétrica;
Objective: To identify the types of pharmacological and non- Parto
pharmacological treatments used during hospitalization, in the relief
of perineal pain after vaginal deliveries. Methods: Data were obtained
from medical files of patients who had vaginal deliveries during 2007. INTRODUCTION
Results: The mean age of mothers was 32.4 years, and 97.7% of Perineal trauma is a significant problem that affects
them suffered perineal trauma. As to treatment for relief of perineal women worldwide who had vaginal deliveries, as it may
pain after a vaginal delivery, 98.5% used drugs, the most frequent of cause pain and discomfort during the postpartum period.
which were non-steroidal anti-inflammatory drugs, and 62.3% of them
Several factors are responsible for perineal trauma, e.g.,
also used non-drug treatments, especially ice packs. Conclusion:
It is important that healthcare professionals, who attend to new
size of fetus, poor adaptation of the fetal presentation
puerperas, know how to assess and treat perineal pain. Considering to the pubic symphysis, anomalous fetal positions, and
the high rates of perineal trauma following vaginal deliveries, we need episiotomies(1-2).
to offer patients treatment alternatives for perineal pain, based on Perineal loss of integrity may cause the woman
scientific evidence. postpartum discomfort and may negatively influence
psychological and physical function, especially pain(3).
Keywords: Pain; Perineum; Postpartum period; Analgesia, obstetrical; In breastfeeding, pain inhibits the release of
Delivery oxytocin, the hormone responsible for the ejection
reflex (let-down reflex) and production of breast
milk. Even when there is a normal production of
RESUMO
maternal milk, pain, fatigue and anxiety may impede
Objetivo: Identificar os tipos de tratamentos farmacológicos e
the delivery of milk to the newborn, increasing
não farmacológicos utilizados no alívio da dor perineal após o
parto normal, utilizados pela puérpera no período de internação. maternal anxiety even more and blocking the release
Métodos: Os dados foram obtidos por meio dos prontuários of oxytocin(4).
médicos de puérperas que tiveram parto normal no ano de 2007. It is important to point out that there is no reliable
Resultados: A média de idade das puérperas foi de 32,4 anos e evidence that the routine use of the episiotomy has a
97,7% sofreram trauma perineal. Quanto ao tratamento para o alívio beneficial effect. Episiotomies provoke a greater loss
da dor perineal, após o parto normal 98,5% utilizaram fármacos, of blood and increase the incidence of dyspareunia
sendo o anti-inflamatório não esteroidal o mais frequente, e 62,3% and perineal pain after birth. They are indicated in
utilizaram também o tratamento não farmacológico, o fármaco
situations of fetal distress, large fetuses, prematurity,
mais utilizado foi bolsa de gelo. Conclusão: É importante que os
if the perineum has little elasticity, or there is vulvar
profissionais que atendem à puérpera, saibam avaliar e tratar a dor
perineal. Considerando as elevadas taxas de traumatismo perineal edema, and the threat of perineal laceration(5-6).
após o parto normal ainda presentes em nossa população, precisa- Among the practices employed to avoid trauma,
se oferecer às puérperas alternativas de tratamento para a dor we mention protection of the perineum and perineal
perineal, com base em evidências científicas. massage during the final expulsion period(7).
Final paper presented at Faculdade de Enfermagem do Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
Nurse from Faculdade de Enfermagem do Hospital Israelita Albert Einstein – HIAE, São Paulo (SP), Brasil.
1
Obstetric nurse; PhD in Obstetric Nursing from Escola de Enfermagem da Universidade de São Paulo – USP; Lecturer at the Child-maternal Nursing Department of Faculdade de Enfermagem of Hospital
2
Israelita Albert Einstein – HIAE, São Paulo (SP), Brazil.
Corresponding author: Lucila Coca Leventhal – Avenida Professor Francisco Morato, 4.293 – Butantã – CEP 05521-200 – São Paulo (SP), Brasil – Tel.: 11 3746-1001 – e-mail: lucila0308@hotmail.com
Received on Jan 17, 2009 – Accepted on Mar 12, 2009
einstein. 2009;7(2 Pt 1):194-200

2. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery 195
In an American research study carried out with physical therapy equipment, such as ultrasound and
1,573 women in the postpartum period, 67% of transcutaneous electrical nerve stimulation (TENS)(2).
primiparas without episiotomies and 82.3% of those Ultrasound is a device that emits sound waves (16 to
with episiotomies reported perineal pain two weeks 18 kHz) with a frequency of 3 MHz, which is not audible
after birth(8). to the human ear. It requires continual assistance of the
The physical factors associated with perineal pain operator during treatment and; therefore, has a high
interfere in various activities of puerparas, such as cost relative to the physical therapist’s time. TENS is a
walking, sitting, sleeping, self-care, caring for the low frequency device (varying from 1 to 250 HZ) that
newborn, appetite, sexual dysfunction, which can lead sends electrical impulses through the skin. It possesses
to maternal exhaustion and hinder the experience significant advantages such as low cost, few side effects,
of maternity, in some cases even leading to marital and it is effective in decreasing pain and consumption
problems(1). of analgesics(15-16).
In a study conducted with puerperas who had vaginal
deliveries in the city of São Paulo, the prevalence of pain
was 96% higher during the first 24 hours, and perineal OBJECTIVE
pain was the most frequently cited. The women referred To identify which types of drugs and non-drugs
interference of pain in breastfeeding, sleeping, caring treatments are used during hospitalization in relief of
for the baby, locomotion, and elimination (voiding and maternal perineal pain after a vaginal delivery.
evacuating)(9).
Despite the use of measures to prevent pain, there
are several treatments for relief of perineal pain. METHODS
Pharmacological and non-pharmacological methods This is a quantitative, descriptive, exploratory, and
are used to treat this discomfort(2,10). retrospective study. This study was developed at
According to the Dictionary of Drug Administration the maternity of Hospital Israelita Albert Einstein
in Nursing, 2007/2008(11), pharmacological pain relief (HIAE). The maternity has 45 puerperium beds, four
methods include non-steroidal anti-inflammatory drugs, delivery rooms, four prepartum/delivery/puerperium
oral analgesics, local anesthetics and opioids. rooms, three prepartum rooms, and one screening
Several factors should be considered in oral room. During the year 2007, at this hospital there
analgesic preparations, such as intensity of pain, were 2,931 births; 2,283 (77.9%) of them were by
probability of the medication causing constipation, caesarian section, 569 were normal (19.3%), and 83
gastric irritation, passage of the drug to maternal milk, by forceps (2.8%).
and more serious adverse effects, such as prolonged From July 3rd to July 11th, 2008, the period during
bleeding time(10). which the authors were available, data were collected
According to these criteria, paracetamol and in medical files. All files of women who had vaginal
ibuprofen are considered the safest ones for use during deliveries during the period of February 1st to April 29th,
lactation, due to their short time of action and of reports 2007, were analyzed, totaling 130 patient files.
of adverse effects on the newborn(12). For this study, an instrument that had been
For non-pharmacological methods, we have observed developed by the authors themselves was used,
in practice the use of ice packs, hot compresses, and with open-ended and closed questions, containing
sitz-baths. three parts. The first part has identification data of
Ice packs during the first 24 hours postpartum is a the women, such as age, level of schooling, marital
traditional method used for the immediate symptomatic status, among others. The second part was composed
relief of pain since it anesthetizes the perineum, but of data on gestation and delivery, such as type of
this relief is generally short-lived, and there is no laceration and newborn birthweight. The third part
evidence of any long-term benefit. After 24 hours, heat consisted of information on pharmacological and non-
is recommended because it increases circulation to pharmacological methods of relieving pain used by the
the region. Forms of heat used are hot compresses or puerpera during hospitalization.
sitz-baths. It helps to reduce perineal edema, to avoid According to resolution 196/1996 of the National
the formation of hematomas, to relieve discomfort, Council of Health, the project was approved by the
to promote recovery of the wound by cleaning the Ethics in Research Committee of HIAE (Ethics in
perineum and anus, and reduces inflammation(13-14). Research Committee approval protocol # 842), and
Recently, new non-drug methods have been authorization was requested from this Committee to
investigated for relief of pain. They are composed of not use the informed consent form.
einstein. 2009;7(2 Pt 1):194-200

3. 196 Hasegawa J, Leventhal LC
Data were analyzed using descriptive statistics Table 2. Data on pregnancy and delivery
and, presented in the form of tables using descriptive Data on pregnancy and delivery n %
statistics. Gestational age
37 - 41 weeks 123 94.6
32 - 36 weeks 7 5.4
RESULTS Parity
Nullipara 61 46.9
In July 2008, 130 patient medical files of puerperas who Primipara 52 40.0
had vaginal deliveries were identified during the period Multipara 17 13.1
from February to April 2007. Anesthesia
Maternal age varied from 20 to 44 years, and most Yes 128 98.5
No 2 1.5
of them were between 20 and 34 years old (90/130;
Perineal trauma
69.2%); the mean was 32.4, the median was 32, and the
Yes 127 97.7
standard deviation, 3.9. Most of them had remunerated No 3 2.3
occupations (92.3%), had more than 12 years of NB sex
schooling (98.4%), were married (93.8%), and white Female 67 51.5
(96.9%), as can be observed on Table 1. Male 63 48.5
Birth weight
Table 1. Distribution of sociodemographic characteristics of puerperas studied < 2,500 g 5 3.9
2,500 – 3,500 g 103 79.2
Sociodemographic characteristics n % ≥ 3,500 g 22 16.9
Age group (years) NB: newborn.
20 – 34 years 90 69.2
≥ 35 years 40 30.8
Occupation
Table 3 shows that the most widely used drugs
Remunerated job 120 92.3 were non-steroidal anti-inflammatory drugs (91.5%),
Housewife 10 7.7 followed by oral analgesics (88.5%). Several patients
Schooling had more than one type of drug prescribed.
8 - 11 years 1 0.8
12 and more years 128 98.4
No record 1 0.8 Table 3. Distribution of pharmacological groups treatment
Marital status Pharmacological treatment n %
Married 122 93.8 Non-steroidal anti-inflammatory drugs 119 91.5
Single 5 3.9 Oral analgesics 115 88.5
Separated 3 2.3 Local anesthetic 71 54.6
Skin color Opioids 21 16.1
White 126 96.9 Did not use 2 1.6
Yellow 4 3.1
According to gestation and delivery data presented As to the non-pharmacological treatment (Table 4)
on Table 2, we note that all women of this study had used by 81 (62.3%) patients during hospitalization, ice
prenatal accompaniment, with seven or more clinical packs were the most frequently used (61.5%), and they
visits (100.0%); most mothers delivered at a gestational were prescribed up to six times a day for 20 minutes
age of 37 to 41 weeks (94.6%). As to parity, 46.9% were each time. The second most common treatment used
nulliparas, 40.0% primiparas, and 13.1% multiparas; was the warm sitz-baths (2.3%), and for some women
80.8% of them had not had abortions/miscarriages in more than one non-drug treatment was prescribed.
their other gestations. Most women were anesthetized
(98.5%). In 128 patients anesthetized, the most Table 4. Distribution of non-pharmacological groups treatment
frequent type of anesthesia used was double anesthetic Non-pharmacological treatment n %
block (79.7%), followed by rachianesthesia (10.9%) Ice packs 80 61.5
and epidural block (9.4%). It was also noted that 127 Warm sitz-bath 3 2.3
(97.7%) puerperas had perineal trauma. Hot compresses 1 0.8
Did not use 49 37.7
As to data on newborns, most were female (51.5%),
with predominant weight between 2,500 to 3,500 g
(79.2%), as presented on Table 2. Table 5 shows a high percentage of use of non-
Of the 130 medical files selected, 98.5% women steroidal anti-inflammatory drugs, especially in women
used pharmacological treatment and 62.3% used non- with newborns weighing more than 3,500 g. The use of
pharmacological treatment. opioids was also greater (27.3%) among these patients.
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4. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery 197
Table 5. Distribution of women who used pharmacological and non-pharmacological Table 7. Distribution of women who used pharmacological and non-pharmacological
treatment per newborn birth weight treatment per parity
NB weight NB < 2,500 g NB 2,500 – 3,500 g NB > 3,500 g Parity Nulliparas Primiparas Multiparas
Pharmacological Pharmacological treatment n (%) n (%) n (%)
n (%) n (%) n (%)
treatment Non-steroidal anti-inflammatory drugs 56 (91.8) 48 (92.3) 15 (88.2)
Non-steroidal anti- 4 (80.0) 94 (91.3) 21 (95.4) Oral analgesics 54 (88.5) 45 (86.5) 16 (94.1)
inflammatory drugs Local anesthetics 42 (68.8) 23 (44.2) 6 (35.3)
Oral analgesics 4 (80.0) 90 (87.4) 21 (95.4) Opioids 8 (13.1) 11 (21.5) 2 (11.7)
Local anesthetics 3 (60.0) 59 (57.3) 9 (40.9) Did not use 1 (1.6) 1 (1.9) -
Opioids - 15 (14.5) 6 (27.3) Non-pharmacological treatment
Did not use 1 (20.0) 1 (0.9) - Ice pack 42 (68.8) 31 (59.6) 7 (41.2)
Non-pharmacological treatment Warm sitz-bath - 3 (5.7) -
Ice pack 4 (80.0) 62 (47.7) 14 (63.6) Hot compresses 1 (1.6) - -
Warm sitz-bath - 2 (1.94) 1 (4.5) Did not use 17 (27.8) 20 (38.5) 12 (70.6)
Hot compresses - - 1 (4.5) Total 61 (100.0) 52 (100.0) 17 (100.0)
Did not use 1 (20.0) 41 (31.5) 7 (31.8)
Total 5 (100.0) 103 (100.0) 22 (100.0)
medical files from which we collected data, there were
NB: newborn
nursing notes about perineal pain, but these annotations
referred only to the presence or absence of the algesic
As to the non-drug treatment, ice-packs were the most
complaint. No record was found as to the application of
frequently used in the three groups.
a pain scale, report of improvement or worsening of the
According to the type of trauma, as shown on
pain and/or of any interference of pain in breastfeeding,
Table 6, women with episiotomies were those who most
in caring for the newborn, in sleeping, or in walking,
used a non-steroidal anti-inflammatory drug (94.6%);
among others.
patients with lacerations usually used ice packs.
In a study carried out in maternities in the city of
Belo Horizonte, the prescription of analgesics was noted
Table 6. Distribution of women who used pharmacological and non-pharmacological in 75.5%, and of non-steroidal anti-inflammatories in
treatment per type of trauma
77.8%, in the immediate postpartum period, and more
Type of trauma Episiotomy Laceration Intact perineum than one medication was prescribed simultaneously(17).
Pharmacological treatment n (%) n (%) n (%)
This shows the high rate of drugs prescribed for relief
Non-steroidal anti-inflammatory 106 (94.6) 11 (73.3) 2 (66.7)
drugs of pain.
Oral analgesics 99 (88.4) 14 (93.3) 2 (66.7) In the present study, among pharmacological
Local anesthetics 66 (59.2) 3 (20.0) 2 (66.7) treatments used, we noted that non-steroidal anti-
Opioids 19 (17.0) 1 (6.7) 1 (33.3) inflammatories were the most frequently used drugs
Did not use 1 (0.9) - 1 (33.3) in most cases. They make up the largest group of
Non-pharmacological treatment analgesics, have moderate potency, and are widely used
Ice pack 65 (58.8) 14 (93.3) 1 (33.3) in prevention and treatment of postoperative pain(18).
Warm sitz-bath 1 (0.9) 2 (14.3) - The non-steroidal anti-inflammatory drugs are
Hot compresses 1 (0.9) - - among the drugs most often used by patients. However,
Did not use 46 (41.1) 1 (6.7) 2 (66.7)
among the 27 non-steroidal anti-inflammatories
Total 112 (100.0) 15 (100.0) 3 (100.0)
marketed in Brazil, only 14 contained references to
safety for use during breastfeeding(12,17).
Regarding parity, as per Table 7, high indices were Oral analgesics were the second most frequently
noted of the use of drugs in all three categories. However, used drug in this study. A bibliographic review with the
nulliparas (68.8%) utilized more local anesthetics than objective of assessing analgesic efficacy and adverse
did primiparas (44.2%) and multiparas (35.3%). The effects of a single dose of dipyrone for acute postoperative
use of ice was also more frequently present among the pain, showed that dipyrone has efficacy similar to that of
nulliparas. ibuprofen (400 mg) and other analgesics often used to
treat moderate to intense postoperative pain. The most
common adverse effects were somnolence, stomach
DISCUSSION upsets, and nausea(19).
In the present study, we noted that a large number The third most commonly used drug in this study
of puerperas used pharmacological and non- was local anesthetic. A bibliographic review composed
pharmacological treatments for the relief of pain during of 976 women, with the objective of evaluating the
the postpartum period of hospitalization. In many effects of topically applied anesthetics in postpartum
einstein. 2009;7(2 Pt 1):194-200

5. 198 Hasegawa J, Leventhal LC
perineal pain showed no significant differences in pain The study was composed of patients who underwent
relief when the topic anesthetic was compared to the instrumentation during vaginal delivery. After 48
topical use of a placebo(1). hours postpartum, a statistically significant difference
When pain passes the most intense level, codeine was found in reduction of edema, hematomas and
derivatives are used, but they should be employed for pain. This was greater in the group that used the new
short durations, since prolonged use predisposes toward treatment. The authors point out that it is likely that
constipation, which is particularly important to avoid in the results of the new treatment were significant, since
treatment of perineal pain(10,20). it is a new type of therapy developed specifically for the
Lidocaine is a local anesthetic with good absorption, perineal region. The application is made in the form of
easy administration, and the patient herself may apply a sanitary pad that extends from the labia major to the
it. Nevertheless, a study conducted in Texas, USA, with anal region(25).
200 women divided into two groups, one receiving Despite hot compresses being one of the least used
placebo and the other, lidocaine, showed no significant methods, scientists confirm that the application of heat
difference between the two groups. Therefore, lidocaine interrupts pain and offers comfort to the patients. Some
was not effective in the relief of perineal pain(21). studies showed that temperatures over 40 °C (104o F)
Rectal analgesia includes the use of a local anesthetic block the chemical messengers of the cells responsible
that can relieve pain of any intensity, caused by perineal for alerting the body about pain, with an effect that may
trauma within the first 24 hours after the birth, and leads last for up to one hour. Nonetheless, relief is temporary,
to less use of other types of analgesia during the first 48 but in spite of the restricted duration of the effect of
hours when used as a rectal suppository. There is no heat, these discoveries may be useful for making the use
information available on the relief of pain with the use of artifices such as hot water bottles more common in
of rectal suppository for three days after delivery(22). the relief of pain(26).
As to non-drug treatment, the use of ice packs was The primary purposes in application of heat are to
the most common. Cold applications are therapeutically reduce inflammation and alleviate the pain. The time of
prescribed in order to provoke vasoconstriction. This application should be 20 minutes at most(23).
constriction reduces blood circulation in the area of A study was conducted with the objective of assessing
application, affording relief of pain caused by decreasing the effect of cold and hot treatment on the perineum
pressure on nerve endings. It is also used to decrease of women who suffered lacerations and episiotomies.
hemorrhage, deter inflammation, prevent suppuration, It comprised 90 women in three groups: 30 in the hot
and alleviate congestion(23). water bottle group, 30 in the ice pack group, and 30 in
With the objective of evaluating the effect of the warm sitz-bath group. The duration of treatment
cryotherapy in relief of perineal region pain in was established as 20 minutes. Perineal discomfort was
nulliparas, who had vaginal deliveries, a randomized and evaluated before, immediately after, and at half an
controlled clinical trial was carried out, with a sample hour, one hour, and two hours post-treatment. There
of 114 women, comparing the use of ice packs for 20 was no significant difference among the groups before,
minutes (Experimental) with the same time of use of a immediately after, and after treatment(27).
water bottle (Placebo) and one group without treatment Avoidance of perineal trauma is the best method
(Control) in a maternity located in the city of São Paulo. for prevention of pain(7), as was observed in the present
The mean initial temperature of the perineum in all study in which patients with episiotomies used more
three groups was 32.7 °C (90.86 °F). In the group with non-steroidal anti-inflammatory drugs.
ice packs, the perineal temperature dropped to 12.6 °C In an American study carried out with 23,244
(54.68 °F), in the water bottle group it increased to 30.9 women using multiple analysis logistic regression, it
°C (87.62 °F), and in the Control, to 34.2 °C (93.56 °F). was determined that the main risk factors for third and
There was a significant improvement of pain in all three fourth degree lacerations were: primiparity, newborn
groups, reducing from 4.6 to 3.3 in a 0 to 10 scale in the weighing more than 4 kg, use of forceps, and median
Control Group, to 2.1 in the Placebo Group, and to 1.6 episiotomy(28-29).
in the Experimental Group. In the comparison of pain In this study, we chose not to include forceps
among the groups, the Experimental Group had the deliveries due to the small number of cases.
lowest mean relatively to the Control Group(24). In the present research study, nulliparas used more
Another study was performed with the objective of local anesthetic than primiparas and multiparas. The
assessing the effectiveness and comparing the use of use of ice was also predominantly present among the
an ice pack and a local anti-inflammatory (Epifoam™), nulliparas. As to weight of the newborn, there was a high
with a new randomized and controlled-type treatment, percentage of non-steroidal anti-inflammatory drug use
in a maternity in the Northern region of England. among women who gave birth to babies weighing more
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6. Pharmacological and non pharmacological treatment for relief of perineal pain after vaginal delivery 199
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