Treating Acute Pain in Pregnancy

Varinder Rai, Regional Medicines Information Manager, London Medicines Information ServiceExample from Northampton General HospitalPublished
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Summary

Summary of the example

Miscarriage happens to 1 in 4 pregnancies and about 100 women per month attend the A&E department in Northampton General Hospital each month with either threatened or inevitable miscarriage. At a parent panel for the baby loss charity ‘Saying Goodbye’ the feedback was that pain relief in miscarriage is lacking, which the patients interpret as an absence of care.  Anecdotally, the women offered pain relief have less mental health issues post loss.  Discussion with prescribers showed that there was reluctance to prescribe for these women as they were unsure what of appropriate choices of medication. A Guideline for Prescribing and Administration of Acute Pain Relief and Anti-emetics in Pregnancy was developed and implemented in Northampton General Hospital.

Why we think it’s important

Pain relief choices for a non-pregnant patient seem simple to prescribers but when a pregnancy is involved this adds a complication. This guideline was developed due to the lack of pain relief given to women at various gestation losses but it also covers the pregnant patients who attend for non-pregnancy related pain problems.  There is information available nationally but in the high pressured Emergency Department (ED) environment it is often overlooked unless presented in a simple way. Anti-emetics were included in this guideline for this reason.

Women also fed back that they were nervous of taking pain relief as they were still hoping for a successful pregnancy, so it was important to develop any guideline to look at the safest medication available for each stage of viable pregnancies. It is important that the care provided for patients, as much as possible, does not impact negatively on their future mental or physical health and providing pain relief choices with acute pain in pregnancy could ensure this.

Learn more about the example

Aims and objectives of the work

To improve the management of acute pain in pregnant women within the ED with new guidelines Objectives include:

  • Developing pain in pregnancy guidelines and easy to use resources for the healthcare professionals working in ED
  • Develop and provide training to the Obstetrics and Gynaecology teams
  • Measure change with regards to appropriate pain relief

Methodology

The notes of pregnant women attending A&E with PV bleeding or other conditions (including non-pregnancy related issues) at NGH were audited over 1 week at three stages:

  1. Baseline (Pre-guideline launch) June 2018
  2. Post-guideline launch December 2018
  3. Following additional multidisciplinary team training February 2019

Data collection reviewed pain scores and whether these were acted on appropriately.

Staff involved in the development of the guideline included the midwifery staff, bereavement midwives, Obstetrics and Gynaecology Consultant and Emergency Department Consultants.  The training was given to the Obstetrics and Gynaecology medical staff, Emergency Department doctors, nurses and healthcare assistants.

Key findings

A total of 84 patients were audited at three stages. The gestation ranged from 3 weeks to 27 weeks.

Baseline Post Guideline Launch Post Education
Appropriate Pain Relief 47% 62.5% 100%

(for patients only managed by ED staff)

85%

(for patient managed by ED and Obs&Gynae staff)

Offered medication but decline. 9% 37% 23%
Number of pregnant women audited 25 32 26

The development of this guideline also changed the view of staff within the department towards the pain experienced by this patient group allowing the care to become more patient centred.  The training was developed with the help of the Saying Goodbye Charity and included non-pharmacological support of pain as well as anticipatory pain relief supplies for early discharge from the hospital.

The results showed a significant improvement of the pain management of this group of women.  Most surprising was the increase in patient declining the pain relief.  This could be that the patients felt more reassured that they could have pain relief if necessary or could be that they are still not confident in taking pain relief in pregnancy.  Further study will examine this, if there are barriers to accepting pain relief and how they can be overcome.  More education about the new guideline has also been organised for the Obstetrics and Gynaecology teams and the care will be re-audited after this is complete.

Documents

Guideline for Prescribing and Administration of Acute Pain Relief and Anti-emetics in Pregnancy in the Emergency Department and Urgent Care NGH-GU-1189 October 2018 (contact author directly)

Poster: Treating Acute Pain in Pregnancy (Conference poster) – see attached

Poster: Acute Pain in Pregnancy – Medication Choices (Ward poster)  – see attached

Attachments

Background

National guidance, data and publications

Bisson DL, Newell SD, Laxton C (2018) Antenatal and Postnatal Analgesia Scientific Impact Paper No.59 on behalf of the Royal College of Obstetricians and Gynaecologists.

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15510

 

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