Effective analgesia following perineal injury during childbirth: a placebo controlled trial of prophylactic rectal diclofenac. The prophylactic use of diclofenac (Voltarol) suppositories in perineal pain after episiotomy. A random allocation double-blind study. A comparative study of nonpharmacological methods to reduce pain in neonates.
To determine if diclofenac suppositories administered prophylactically produce effective and lasting analgesia following perineal injury.
                A randomised double blind placebo controlled trial.
                York District Hospital.
                One hundred women sustaining objective perineal injury (second degree tear or episiotomy) during spontaneous vaginal delivery at term.
                Suppositories were administered at the time of repair and approximately 12 hours later. The suppositories were randomised prior to issue by the pharmacy department and contained either 100 mg diclofenac or placebo.
                Pain scores assessed at 12, 24, 48 and 72 hours after delivery using a six point numerical scoring system and the use of additional analgesia and local treatments to the perineum.
                The mean pain score was significantly reduced in the diclofenac group at 24, 48 and 72 hours after delivery (0.86, 0.7 and 0.59, respectively) compared with the control group (1.64, 1.31 and 1.5; P < 0.005). In addition there was less supplementary analgesia required (eight women only at 72 hours compared with 15 in the control group) and this was limited to paracetamol or topical treatments to the perineum.
                Prophylactic rectal diclofenac provides effective analgesia after perineal repair and its effect appears to be maintained into the second and third postpartum days. One hundred and ten patients who had episiotomies to aid normal vaginal delivery without epidural analgesia were = allocated at random to receive either diclofenac (n = 56) or = placebo (n = 54) suppositories. Pain after episiotomy was assessed at 24 and 48 hours using a combination of a visual analogue scale, a modified pain score and a review of additional analgesia required. All patients in both groups were allowed routine hospital analgesia on request. Our data suggests that very few patients suffered severe pain, even in the placebo group. However, the prophylactic use of diclofenac suppositories significantly reduced perineal pain in the first 24 hours, although the difference was less marked by 48 hours. Overall additional analgesia requirement was correspondingly less in the diclofenac group. A randomized study was done to compare non pharmacological methods to reduce the pain of heel pricks in 104 stable term neonates. Non-nutritive sucking (NNS), rocking, massage, sucrose (20 percent), distilled water (DW) and expressed breast milk (EBM) were used as pain reducing agents. Duration of cry and Douleur Aiguë du Nouveau né (DAN) score were used to assess pain. Physiological parameters were also recorded before and after the stimulus. At 30 seconds after the stimulus, the pain scores were lowest in the sucrose group but this was not sustained at 1, 2 and 4 minutes. At 2 and 4 minutes pain scores were lowest in the NNS and rocking groups as compared to sucrose, distilled water, expressed breast milk and massage. The total duration of crying was also lowest in the NNS and rocking groups. Physiological parameters were comparable in all groups. Babies who were in Prechtl State 1 and 2 (sleeping) at the time of stimulus showed significantly lesser response to pain compared to babies who were awake. This was seen in all the intervention groups. In conclusion, our study suggests that rocking or giving a baby a pacifier are more effective non-pharmacological analgesics than EBM, DW, sucrose or massage for the pain of heel pricks in neonates. A calm or sleeping state before a painful procedure also appears to decrease crying and pain scores.
NSAID rectal suppositories are associated with less pain up to 24 hours after birth, and less additional analgesia is required. More research is required regarding long-term effects and maternal satisfaction with the treatment.