Highlights
- Significant hospital-level variation exists in opioid prescribing after vaginal births involving operative procedures or severe lacerations, with rates ranging from 0% to nearly 67%.
- Patients with third- or fourth-degree lacerations are significantly more likely to receive postdischarge opioids (11.6%) compared to routine vaginal births.
- The median amount of opioids prescribed (60 OMEs) and the variance in those amounts (25–135 OMEs) suggest a lack of consensus on adequate pain control for postpartum complications.
- Standardization of discharge prescribing practices represents a critical opportunity to improve maternal safety and curb the risk of long-term opioid use.
Background
The opioid epidemic continues to be a public health crisis in the United States, prompting a rigorous re-evaluation of prescribing patterns across all surgical and medical specialties. In obstetrics, much of the focus regarding opioid stewardship has been directed toward cesarean deliveries, which traditionally involve higher pain scores and more frequent opioid utilization. However, vaginal births—particularly those involving operative interventions (forceps or vacuum assistance) or significant perineal trauma (third- and fourth-degree lacerations)—remain a neglected area of standardized pain management.
Current clinical guidelines, including those from the American College of Obstetricians and Gynecologists (ACOG), advocate for a multimodal approach to postpartum pain, prioritizing non-opioid analgesics like acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Despite these recommendations, specific guidance for the management of pain following complex vaginal deliveries is sparse. This lack of clear, evidence-based protocols likely contributes to the wide disparities in clinical practice observed across different healthcare institutions.
Key Content
Methodological Advances in Assessing Prescribing Variance
A recent large-scale retrospective cohort study by Latack et al. (2026) utilized data from 67 hospitals to evaluate postdischarge opioid prescribing for 14,690 opioid-naive, nulliparous patients. By focusing on nulliparous patients with term births, the study controlled for prior opioid exposure and focused on the population most likely to experience primary obstetric interventions. The researchers employed adjusted logistic regression models to isolate the effect of hospital-level practices from patient-level clinical characteristics.
Analysis of Procedural Risk Factors
The study identified two primary clinical scenarios associated with increased opioid prescribing: operative vaginal birth and high-degree perineal lacerations. While the overall opioid prescribing rate for the entire cohort was low (1.8%), the rates rose sharply in the presence of complications:
- Third- or Fourth-Degree Lacerations: 11.6% of these patients received an opioid prescription.
- Operative Vaginal Birth: While these patients were less likely to receive a prescription than those with severe lacerations, those who did received the highest median amount (75 Oral Morphine Equivalents [OMEs]).
These findings underscore that clinicians perceive these specific types of vaginal delivery as necessitating more aggressive pain management than routine births, yet the “standard” dose remains poorly defined.
Inter-Hospital Variation: The “Lottery” of Care
The most striking finding of the synthesis is the degree of variation between hospitals. For patients with third- or fourth-degree lacerations, the probability of receiving an opioid prescription ranged from 0% at some institutions to 66.7% at others. Similarly, for operative births, the amount of opioids prescribed varied from a low of 25 OMEs to a high of 135 OMEs. This level of variance cannot be explained by clinical necessity alone; rather, it reflects deeply ingrained institutional cultures and individual provider preferences rather than a unified evidence-based standard.
Comparative Evidence and Multimodal Alternatives
The synthesis of current literature suggests that multimodal analgesia is highly effective for perineal pain. Studies comparing scheduled NSAIDs and acetaminophen versus PRN (as-needed) opioids consistently show that non-opioid regimens provide equivalent or superior pain relief with fewer side effects (e.g., constipation, sedation). Furthermore, the use of local adjuncts such as cooling pads, topical lidocaine, and proper wound care instructions significantly reduces the perceived need for systemic opioids.
Expert Commentary
The data presented by Latack and colleagues highlight a critical gap in obstetric quality improvement. The massive variation in prescribing—ranging from zero to two-thirds of patients for the same clinical indication—suggests that at many hospitals, opioids are being prescribed as a “just in case” measure rather than a response to specific patient needs. From a mechanistic perspective, perineal pain is primarily inflammatory, making NSAIDs the physiological gold standard for treatment.
There is also a significant health equity and policy dimension to these findings. High-degree lacerations and operative births are often associated with higher maternal morbidity. If pain management is inconsistent, it may exacerbate the postpartum recovery burden for vulnerable populations. Clinicians should be encouraged to adopt a “shared decision-making” model, where patients are educated on the efficacy of non-opioids and prescriptions are reserved for those whose pain remains refractory to multimodal therapy after a period of observation.
Controversies remain regarding the threshold for prescribing. Some argue that a small “rescue” supply of opioids (e.g., 5-10 tablets) prevents unnecessary emergency room visits for pain, while others contend that any postdischarge opioid exposure in an opioid-naive patient increases the risk of chronic use and diversion. The wide OME range (up to 135 OMEs) suggests that some providers are still prescribing amounts far in excess of what is necessary for short-term acute pain.
Conclusion
While the overall rate of opioid prescribing after vaginal delivery is low, the significant variation at the hospital level for operative births and severe lacerations indicates a lack of standardized care. This variation exposes patients to unnecessary risks and highlights an opportunity for the development of national postpartum pain management guidelines specifically tailored to vaginal birth complications. Future research should focus on patient-reported outcomes to determine the minimum effective dose for these procedures and to evaluate the impact of standardized order sets on both patient satisfaction and opioid reduction.
References
- Latack KR, Sarosi E, Moniz MH, Gunaseelan V, Waljee JF, Bicket MC, Townsel CD, Kane Low L, Peahl AF. Variation in Postdischarge Opioid Prescribing After Childbirth and Associated Procedures. Obstetrics and gynecology. 2026-05-28. PMID: 42208072.
- American College of Obstetricians and Gynecologists. ACOG Practice Advisory: Optimizing Postpartum Pain Management. 2018 (reaffirmed 2021).
- Bicket MC, et al. Prescription Opioid Analgesics for Acute Pain Management After Surgery: A Systematic Review. JAMA Network Open. 2017.