Guide to Pain Management in Low-Resource Settings

Strategies for ensuring eff ective 
postoperative analgesia
Be proactive
Eff ective postoperative pain management begins pre-
operatively. Patients are often very anxious and dis-
tressed by the hospital and procedure experience, and 
this distress may exacerbate pain postoperatively. Pre-
operative information and education regarding pain 
control has been shown to signifi cantly reduce pa-
tients’ and guardians’ anxiety and analgesic consump-
tion. Education improves understanding and com-
pliance with the analgesic administration regimen. 
Important information may need to be repeated or 
provided in written form as patients or their guardians 
may not remember everything they had been told dur-
ing the perioperative period.
Most patients recovering from anesthesia in the re-
covery room are comfortable because of the proactive 
and aggressive pain management by the anesthesia care 
provider. Unfortunately, when the patient is discharged, 
the intensity or continuity of pain care is disrupted. Th
 e 
pain of surgery often outlasts the pain medication or lo-
cal anesthetic administered in the perioperative period. 
To avoid this problem, administer the fi rst postoperative 
analgesic dose before the eff ects of the intraoperative 
analgesics wear off  completely.
Use preemptive or preventive analgesia
Preemptive analgesia implies that giving analgesia be-
fore the noxious stimulus is more eff ective than giving 
the same analgesia after  the stimulus. While this con-
cept has not been convincingly proven in all clinical 
studies, what is clear is that more analgesia is often re-
quired to treat pain that is already established than to 
prevent or attenuate pain that is still developing. One 

Pain Management in Ambulatory/Day Surgery
121
should therefore aim to preempt or prevent pain if pos-
sible or proactively treat pain as early as possible.
Avoid analgesic gaps 
Analgesic gaps subject the patient to recurring pain and 
unsatisfactory analgesia. Such gaps tend to occur when 
the eff ect of a prior analgesic dose or technique is al-
lowed to wear off  before the subsequent dose is given. 
An appropriate dosing interval based on knowledge of 
the pharmacology of the agent is important to minimize 
this gap.
Apply a multimodal analgesia strategy
Multimodal analgesia implies the use of several analge-
sics or modalities that act by diff erent mechanisms in 
combination to maximize analgesic effi
  cacy  and  mini-
mize side eff ects.  Th
  is strategy allows the total doses 
and side eff ects of analgesics to be reduced.
Paracetamol, a nonsteroidal anti-infl ammatory 
drug (NSAID), and local analgesia should be routinely 
used as components of a multimodal analgesic strat-
egy, unless there is a specifi c reason not to use one of 
these agents, as they are synergistic or additive. In other 
words, the combination provides better analgesia than 
one of the individual drugs alone. Potent opioids, espe-
cially the long-acting ones like morphine and metha-
done, should preferably be avoided or used sparingly as 
postoperative analgesics for minor surgery because of 
their associated side eff ects, especially nausea and vom-
iting, respiratory depression, and sedation. Postopera-
tive nausea and vomiting (PONV) can be quite distress-
ing, and some patients may prefer to tolerate the pain 
rather than use opioids. PONV and pain are the two 
most common causes of delayed discharge and also for 
unanticipated admission in day-case surgery. However, 
if the severity of pain warrants the use of opioids, the 
shorter-acting agents such as fentanyl should preferably 
be used by careful titration to eff ect in the immediate 
postoperative period. 
Alternatively, the “weaker” opioids such as tra-
madol or codeine should be used. Th
  e “weaker” opi-
oids have the advantages of minimal sedative and re-
spiratory depressant eff ects, a low potential for abuse, 
and not being subject to stringent opioid restrictions, 
and thus they may be more easily dispensed to appro-
priate patients. Th
 ey therefore fi ll an important gap 
in the analgesic ladder between the mild non-opioid 
analgesics and the more potent opioids, especially for 
day-cases.
An often forgotten or neglected part of the 
multimodal approach is the use of nonpharmacological 
therapies. Psychological and physical therapies comple-
ment medications and should be used whenever possi-
ble. Physical therapies include splinting and immobiliz-
ing painful areas, application of cold or hot compresses, 
acupuncture, massage, and transcutaneous electrical 
nerve stimulation (TENS). Psychological therapies in-
clude behavioral and cognitive coping strategies such 
as psychological support and reassurance, guided imag-
ery, relaxation techniques, biofeedback, procedural and 
sensory information, and music therapy. Studies suggest 
that these nonpharmacological therapies improve pain 
scores and reduce analgesic consumption.
Pearls of wisdom
•  Discuss the options and plan the method of post-
operative pain management with the patient and/
or guardian preoperatively.
•  Be proactive; begin postoperative pain manage-
ment preoperatively. Th
 is strategy will reduce 
intraoperative anesthetic requirements and facili-
tate earlier recovery and discharge.
•  Give preemptive or preventive analgesia. Preven-
tion is better than cure. Much larger amounts of 
an analgesic are required to treat established pain 
than to prevent it.
•  Use a multimodal approach to pain management, 
incorporating both pharmacological and non-
pharmacological methods.
•  Provide a supply of eff ective analgesics and infor-
mation on their use before discharge.
•  Give appropriate and eff ective analgesics regular-
ly (around-the-clock) rather than p.r.n. or “as re-
quired” for the fi rst 24 to 48 hours postoperative-
ly, when the pain intensity is likely to be highest. 
Make provision for management of breakthrough 
pain (rescue analgesics).
•  Always provide a contact number that a patient 
or guardian can call if necessary.
References
[1]  Finley GA, McGrath PJ. Parents’ management of children’s pain follow-
ing minor surgery. Pain 1996;64:83–7.
[2]  Rawal N. Analgesia for day-case surgery. Br. J Anaesth 2001;87:73–87
[3]  Shnaider I, Chung F. Outcomes in day surgery. Current Opinion in An-
esthesiology. 2006;19:622–629.
[4]  Wolf AR. Tears at bedtime: a pitfall of extending paediatric day-case 
surgery without extending analgesia. Br J Anaesth 1999;82:319–20.

123
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Katarina Jankovic
Chapter 17
Pharmacological Management of Pain in Obstetrics
Case report
Charity, a 28-year-old offi
  ce worker living in Nyeri, ar-
rives late one evening at Consolata Hospital. She is in 
her fi rst pregnancy and is accompanied by her mother 
Jane, an experienced mother who thought it would be 
about the right time to see the obstetrician, since Char-
ity’s contractions had become more and more regular. 
On admission, Charity says she would like to try to go 
through the labor without pain killers, but as contrac-
tions become stronger, she starts screaming for help. 
What could you do to relieve the pain?
Do all women in labor have pain 
that requires analgesic treatment?
Th
  e pain of labor and delivery varies among women, 
and even for an individual woman, each childbirth may 
be quite diff erent. As an example, an abnormal fetal pre-
sentation, such as occiput posterior, is associated with 
more severe pain and may be present in one pregnancy, 
but not the next. It may be estimated that one in four 
women in labor require analgesia.
What are the application routes    
for analgesia if needed?
Pharmacological approaches to manage childbirth pain 
can be broadly classifi ed as either systemic or regional. 
Systemic administration includes the intravenous, in-
tramuscular, and inhalation routes. Regional techniques 
are comprised of spinal and epidural anesthesia. Epidu-
ral anesthesia has gained popularity in the last decade 
and has almost replaced systemic analgesia in many 
obstetric departments, mostly in developed countries. 
Regional techniques are widely acknowledged to be the 
only consistently eff ective means of relieving the pain 
of labor and delivery, with signifi cantly better analgesia 
compared to systemic opioids.
What are the advantages                   
of systemic analgesics?
Systemic analgesics may be administered by individu-
als who are not qualifi ed to perform epidural or spinal 
blocks, and so they are often used in situations when an 
anesthesiologist is not available. Th
  ey also are useful for 
patients in whom regional techniques are contraindicat-
ed. Th
  e most popular agents are opioids (e.g., morphine, 
fentanyl, butorphanol, pethidine [meperidine], and tram-
adol). While the sedative side eff ects of opioids are gener-
ally unwanted and irritating for the patient, in the labor-
ing woman sedation induces relief and general relaxation. 
Analgesic eff ects sometimes appear to be secondary.
A systematic review of randomized trials of 
parenteral opioids for labor pain relief was able to 
show that satisfaction with pain relief provided by 
opioids during labor was low, and the analgesia from 

124
Katarina Jankovic
opioids only slightly better than placebo. Interest-
ingly, midwifes have rated pethidine much better than 
parturients, probably because sedation was confused 
with analgesia.
Which route of administration 
for systemic analgesia should be 
preferred, and why?
If an anesthesiologist is not available, pethidine (me-
peridine) is usually the drug of choice. It remains the 
best investigated and most often used opioid in labor. 
Th
  e dose of pethidine commonly prescribed is 1 mg/
kg i.m. up to the maximum dose of 150 mg/kg. Th
 e in-
tramuscular route is not recommended because it is 
not dependable—the rate of drug-absorption may vary. 
Intravenous administration is more reliable, and the 
maximum total dose of 200 mg is reported to produce 
signifi cantly lower pain scores and no diff erence in ma-
ternal or neonatal complications. Higher doses have to 
be strictly avoided, since pethidine may provoke sei-
zures. Th
  is is due to the drug’s unique pharmacological 
structure, which gives it a special place among the opi-
oids.
What is the clinical relevance                 
of opioids passing                                  
the placenta barrier?
Opioids cross the placenta and may aff ect the fetus. Th
 is 
is manifested in utero by changes in fetal heart rate pat-
terns (e.g., decreased heart rate variability 25 minutes 
after i.v. administration and 40 minutes after i.m. ad-
ministration of pethidine) and in the neonate by central 
nervous system depression (e.g., slowing of respiratory 
rate and changes in muscle tone).
Th
  e adverse eff ects of pethidine and its active 
metabolite norpethidine on the fetus may—in rare in-
stances—need to be reversed by an opioid antagonist. 
Th
  e appropriate i.m. dose of naloxone would be 10 μg/
kg body weight. But ideally, naloxone—as most drugs in 
pain management, should be titrated intravenously to 
its eff ect (the cumulative dose would be, as for i.m. ap-
plication, 10 μg/kg).
If I have various opioids available, which one I 
would choose, and why?
Onset time and context-sensitive half-life of all available 
opioids are comparable, and so the potential to induce 
respiratory depression in the neonate is the primary 
reason for selecting a particular opioid. Regarding this 
potential, pethidine (meperidine) may be preferred over 
others, as long as maximum daily doses (500 mg) are 
respected. Pethidine remains the only opioid with dose-
dependent neurotoxicity. Th
 ere is no evidence in the 
scientifi c literature that any other opioid is signifi cantly 
more eff ective than pethidine. Also, pethidine is widely 
available and aff ordable. If available, nalbuphine, butor-
phanol, or tramadol may be also be used. Th
 ese opioids 
are not “pure” agonists of the mu-receptor, but mixed 
agonists and antagonists, which is the reason for their 
unique safety regarding respiratory depression.
However, as with other opioids, respiratory 
depression may be avoided with pethidine. To achieve 
that outcome in the neonate, it is recommended to 
observe a certain time corridor for the application of 
pethidine to the parturient. Side eff ects are more like-
ly to occur if delivery is between 1 and 4 hours after 
administration of pethidine. As a result, the classic 
teaching is that the neonate should be delivered within 
1 hour or more than 4 hours after the last pethidine 
application. Timing of delivery, however, is diffi
  cult 
to predict with precision. In addition, the metabolite 
norpethidine is pharmacologically active, with a pro-
longed half-life in the neonate of up to 2½ days. Th
 us, 
neonatal behavior might be aff ected, and diffi
  culties 
with breastfeeding are possible, regardless of the tim-
ing of maternal administration.
Pentazocine should not be used because of its 
potential to cause dysphoria and sympathetic stimula-
tion. Th
  eoretically, the opioid best suited for providing 
systemic labor analgesia would be remifentanil, which is 
metabolized by nonspecifi c plasma and tissue esterases. 
Th
  erefore, although remifentanil rapidly transfers across 
the placenta, fetal esterases will inactivate this new opi-
oid. Data regarding the use of remifentanil in parturi-
ents are limited, however, and so the drug cannot yet be 
recommended widely.
It must be noted, though, that only a few drugs 
are considered “safe” regarding placental passage and 
breastfeeding, but lack of data makes it advisable to 
rely on individual judgment, if only a limited number of 
drugs are available. 
Breast-feeding during maternal treatment with 
paracetamol (acetaminophen) should be regarded as 
safe. Short-term use of nonsteroidal anti-infl ammatory 
drugs (NSAIDs) seems to be compatible with breast-
feeding. For long term-treatment, short-acting agents 

Pharmacological Management of Pain in Obstetrics
125
without active metabolites, such as ibuprofen, should 
perhaps be preferred.
Th
  e use of aspirin (acetylsalicylic acid) in sin-
gle doses should not pose any signifi cant risks to the 
suckling infant. Aspirin, due to its causal association 
with Reye syndrome, generally
 
is not recommended in 
breastfeeding mothers. However, the absolute
 
transfer 
of aspirin into milk is negligible (< 2.4%),
 
about 1 mg/L 
of milk, when following clinical doses. It is unlikely
 
that 
there is enough aspirin in milk after the mother’s use of 
an
 
82-mg tablet to predispose the infant to Reye syn-
drome, but
 
this is not certain.
Th
  e use of pethidine (meperidine) in the peri-
natal period is increasingly
 
controversial. Although the 
drug is used commonly in obstetrics, such
 
use is gain-
ing disfavor as more sedation is reported in newborns. 
When administered to mothers, the drug has been 
found to produce
 
neonatal respiratory depression, de-
creased Apgar scores, lower
 
oxygen saturation, respi-
ratory acidosis, and abnormal neurobehavioral
 
scores. 
Pethidine is metabolized to norpethidine, which is
 
ac-
tive and has a half-life of approximately 62 to 73 hours in
 
newborns. Because of this prolonged half-life, neonatal 
depression
 
after exposure to pethidine may be profound 
and prolonged. Th
  e transfer of fentanyl into human milk 
is low. In women receiving
 
doses varying from 50 to 400 
μg intravenously during labor,
 
the amount found in milk 
was generally below the limit of detection
 
(<0.05 μg/L).
Postpartum anesthesia
Nonopioid analgesics
Non-opioid analgesics generally should be the fi rst 
choice for pain management in breastfeeding postpar-
tum women, as they do not aff ect maternal or infant 
alertness.
•  Acetaminophen and ibuprofen are safe and eff ec-
tive for analgesia in postpartum mothers.
•  Parenteral ketorolac may be used in mothers who 
are not subject to hemorrhage and have no his-
tory of gastritis, aspirin allergy, or renal insuffi
  -
ciency.
•  Diclofenac suppositories are available in some 
countries and are commonly used for postpartum 
analgesia. Levels in breast milk are extremely low.
•  COX-2 inhibitors such as celecoxib may have 
some theoretic advantages if maternal bleeding is 
a concern. Th
  e possible advantages must be bal-
anced against higher cost and possible cardiovas-
cular risks, which should be minimal with short-
term use in healthy young women.
Both pain and opioid analgesia can have a 
negative impact on breastfeeding outcomes; thus, 
mothers should be encouraged to control their pain 
with the lowest medication dose that is fully eff ective. 
Opioid analgesia postpartum may aff ect babies’ alert-
ness and suckling vigor. However, when maternal pain 
Table 1
Relative infant dose and clinical signifi cance of selected
 
analgesic agents
Drug
Relative Infant 
Dose (%)
Clinical Signifi cance
AAP*
 
Approval
Ibuprofen
0.6
None detected in infants; no adverse
 
eff ects.
Yes
Ketorolac
0.16 to 0.4
Milk concentrations are
 
very low; no untoward eff ects 
reported.
Yes
Naproxen
3.0
Long
 
half-life; may accumulate in infant. Bleeding, diarrhea 
reported
 
in one infant. Short-term use acceptable; avoid 
chronic use.
Yes
Indomethacin
0.4
Milk
 
concentrations low; plasma concentrations low-to-un-
detectable
 
in infants; caution with chronic administration.
Yes
Morphine
5.8
Oral
 
bioavailability poor; milk concentrations generally low; 
considered
 
safe; observe for sedation.
Yes
Methadone
2.6, 5.6, 2.4, 1.0
Milk
 
concentrations low; approved for use in breastfeeding 
mothers;
 
will not prevent neonatal abstinence syndrome.
Yes
Meperidine (pethidine)
1
Neurobehavioral delay, sedation noted from long
 
half-life 
metabolite; avoid.
Yes
Fentanyl
<3
Milk concentrations
 
low; no untoward eff ects from expo-
sure in milk.
Yes
*American
 
Academy of Pediatrics. Transfer of drugs and other chemicals
 
into human milk. Pediatrics 2001.

126
Katarina Jankovic
is adequately treated, breastfeeding outcomes improve. 
Especially after cesarean birth or severe perineal trauma 
requiring repair, mothers should be encouraged to ad-
equately control their pain.
Intravenous medications
•  Pethidine should be avoided because of reported 
neonatal sedation when given to breastfeeding 
mothers postpartum, in addition to the concerns 
of cyanosis, bradycardia, and risk of apnea, which 
have been noted with intrapartum administra-
tion.
• Th
  e administration of moderate to low doses of 
intravenous (i.v.) or intramuscular (i.m.) mor-
phine is preferred because transfer to breast milk 
and oral bioavailability in the infant are lowest 
with this agent.
•  When patient-controlled i.v. analgesia (PCA) is 
chosen after cesarean section, morphine or fen-
tanyl is preferred to meperidine.
•  Although there are no data on the transfer of na-
lbuphine, butorphanol, or pentazocine into milk, 
there have been numerous anecdotal reports of 
a psychotomimetic eff ect when these agents are 
used in labor. Th
  ey may be suitable in individuals 
with certain opioid allergies or other conditions 
described in the preceding section on labor.
•  Hydromorphone (approximately 7 to 11 times as 
potent as morphine) is sometimes used for ex-
treme pain in a PCA, i.m., i.v., or orally. Following 
a 2-mg intranasal dose, levels in milk were quite 
low, with a relative infant dose of about 0.67%. 
Th
 is correlates with about 2.2 μg/day via milk. 
Th
  is dose is probably too low to aff ect a breast-
feeding infant, but this drug is a strong opioid, 
and some caution is recommended.
Oral medications
•  Hydrocodone and codeine have been used world-
wide in millions of breastfeeding mothers. Th
 is 
history suggests that they are suitable choices, 
even though there are no data reporting their 
transfer into milk. Higher doses (10 mg hydroco-
done) and frequent use may lead to some seda-
tion in the infant.