The patient is 4 days postpartum after a physiological delivery. Complaints of unbearable pain in the perineum and lumbar pain. There were minor internal tears. On examination, there is no inflammation, no swelling. Pain relief with ketoprofen is of little help. Can you please advise how to anaesthetise or partially relieve the pain?
During normal delivery pain is common but it should go after few hours. Could you further elaborate the place of pain? How about oxydone, methadone injections etc?
this is the perineal branch of the pudendal nerve
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I can give you reference to how to block this nerve
often injured with episiotomy or internal tears
I would suggest that the cause of the pain needs to be investigated - this is not a usual level of pain. I would suggest ensuring that urinary and bowel function is normal, and that there is no sign of infection. Have swabs been taken and cultured from the perineum?
An osteopathic/physio/chiropractic assessment of the lumbar spine may be useful.
Ensure that there are no issues like retained swab, or tears which have not been sutured. Another common source of significant pain is a haemotoma.
Piles can be surprisingly painful.
I would suggest that paracetomol and ibuprofen are usually adequate, and morphine based analgesia can cause constipation which can be a source of significant pain. Ensure that dietary precautions and/or laxatives are utilised as appropriate.
If all of these issues have been addressed/investigated, I would say that pudendal nerve block is the most effective.
The pain being experienced by the patient may be secondary to the presence of either a progressing infralevator or supralevator hematoma.It will be advisable to do a serial packed cell volume and do some radiological imaging to rule this out .
Volodymyr, it is important to find the reason of the pain.
- Infection (endometritis, perineal, UTI)?
- Urinary retention?
- Haematoma or other trauma?
- Neurological? (for example from sacral plexus or pudendus?)
Women postpartum generally can receive both paracetamol and NSAID, some few days of Oxykodon can be okay if the neonatologists are fine with it (or if she is not breastfeeding). In some cases, epidural or nerve block can help postpartum also. But the priority is to find out what's the problem, not just releive pain.
Discard a sacrococcygeus trauma as it has been suggested. I agree with the pudendal block option
I think deep breathing is effective in unbearable pain
Benson or chanting is effective during pain management can be trail
Perineal branch block of the pudendal nerve
This usually originates from hypersensitivity of the pudendal nerve, what can be done is blocking that nerve, it helps them a lot. In Colombia it is performed by anesthesiologists specializing in pain under ultrasound-guided vision or fluoroscopy; with subsequent neuromodulation, others who can help are gynecologists specializing in pelvic floor, since the pain caused by involvement of the pudendal nerve if not resolved can cause chronic pain and that is terrible, which is why mutual work with pain would be ideal
This is uncommon, examine the patient, rule of infection, other trauma, retained swabs
URINE C&S
VAGINAL SWAB C&S
CONSIDER ORTHO REFERRAL-more details on delivery needed
Anti biotics broad spectrum
Analgesics NSAID/TRAMADOL
Anti inflammatory PAPASE
Central Sensitisation.
Use drug acting on decreasing or modifying central sensitisation
Alternate between cold and hot therapy. Put a thin lining covering over the perinea and place an ice pad for 10-15 minutes as tolerated. Sit on warm water for 15-25 minutes, where possible add some hazel witch oil into the water. Do this at least 3 times a day. And take Ibrupofen according to Dr's intructions.
Physiotherapy improves blood flow in the perianeam thus regulating pain physiologically,plus cold compress and paracetamol. Exclude possibilities of hematoma and early sepsis
Physiotherapy (Perineal massage or using a cushion when sitting it provide some relief) and Ibuprofen according to Dr's instructions.
After excluding hematoma and/or infection what would be a source of pain is in soft tissue. Usually the mixed TENS therapy with electrodes next to painful area offer good chance to resolve pain. Adding local anesthetic and perhaps massage could improve outcome. If ineffective then check the some form of pudendal block.
1.First need to re examine p/v for haematoma or injury or to see whether injury become infected or not.
2. X ray pelvis to see pubic symphisis injury or coccyx bone (tail bone)injury.
3.if there in no injury then aceclophen ¶cetamol &serratiopeptedase-1tab thrice daily, antibiotics
4.Sitz bath thrice daily
5.haemoglobin &blood sugar to be done as anaemia causes delayed healing and there is chances for infection in case of DM
I get USG tobrule out internal injury .
Try deep breathing exercise and followed with kegel exercise. Squeezing lower part of body including anus perineum abdomen with breathing holding for a second much can be possible to you and slowly release will surely increase blood circulation and gradually will help you
meperidine, is a synthetic opioid analgesic medication used to treat moderate to severe pain. It is similar in action to morphine but has a different chemical structure. Pethidine works by binding to opioid receptors in the brain and spinal cord, blocking pain signals and producing pain relief. I think this drug is the best choice in such cases but not for long use .
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