Postpartum perineal pain is a significant factor affecting women's postpartum functioning and nursing. Due to breastfeeding, the use of painkillers is relatively limited, and a considerable number of them are associated with side effects [1,2]. Many non-pharmacological methods of pain management are not included in treatment regimens, and the use of conservative therapies for postpartum perineal pain management could be considered a complementary method given the few adverse effects and often low cost [3].

Existing reviews fail to offer a comprehensive overview, as they are outdated. Although the topic of postpartum perineal pain management has been well-researched, new studies and approaches are published every year that shed light on various conservative treatments. 

Therefore, this study aimed to identify and map the existing evidence on the effects of non-pharmacological, conservative therapies such as electrophysical agents, complementary and alternative medicine, and physical therapy, on managing early postpartum perineal pain. This will fill the critical gap in the field of non-pharmacological, conservative approaches to postpartum pain management.

This scoping review followed the Joanna Briggs Institute (JBI) scoping review methodology and was reported according to PRISMA-ScR guidelines. The protocol was prospectively registered (INPALSY). The PCC (participant, concept, context) framework was used as recommended. Electronic databases: PubMed, EBSCO, CINAHL, Ovid, and Google Scholar were searched from May 2012 to December 2023. Literature was included if it described the use of non-pharmacological methods for early postpartum pain management (up to 7 days after delivery) and investigated at least one of the following outcomes: pain, discomfort, healing process, edema, quality of life, and analgesics consumption. Conservative therapies of interest for this review were electrotherapy (e.g., transcutaneous electrical nerve stimulation and radiofrequency), therapeutic ultrasound, exercise (e.g., pelvic floor muscle training), manual modalities (e.g., manual therapy, massage, drainage techniques), complementary methods (e.g., acupressure, acupuncture), light therapies (e.g., laser therapies, infrared light, red light), thermotherapy (warm or cold applications, water immersion).

A total of 852 records from 2012-2024 were identified through the database search, and 5 additional studies were found through citations. After exclusion and screening of full-text articles, 29 publications on interventions in this setting were included in the final analysis: 23 randomized controlled trials (RCTs), 3 pilot RCT studies, 2 quasi-experimental studies - using a pre and post-test design, and 1 observational, case-control study. The studies were divided into 4 intervention groups: 1) electrotherapy (e.g., radiofrequency, transcutaneous electrical nerve stimulation – TENS), 2) light therapies (low-level laser therapy – LLLT, infrared light – IRF), 3) thermotherapy (warm pads and sitz baths, cold pads and cryo-gel),  and 4) complementary methods (acupuncture and acupressure). We found no research about pelvic floor muscle training or manual therapy as a conservative method for postpartum pain relief.

Two RCTs described the efficacy of radiofrequency in the management of postpartum perineal pain in the first two days after delivery. One study reported lower total analgesic consumption and a decrease in walking discomfort; the other reported a more significant decrease in pain and discomfort in the study group. Three RCTs, on the other hand, have investigated the use of TENS in women after perineal delivery with episiotomy. Despite inconsistencies in their results, they suggest TENS may be associated with lower pain intensity at post-treatment when compared to control, at least for a short time. However, it is unclear whether the two studies were sufficiently powered.  

Light therapies were analyzed in 4 studies in which the Numeric Rating Scale (NRS), Visual Analogue Scale (VAS), and redness, oedema, ecchymosis, discharge, and approximation of the wound edges (REEDA) scale, as well as the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), were used, and found no statistically significant differences between the study groups.

Thermotherapy were included in 12 studies (7 addressing cold, 4 heat, and 1 combined protocol). In the case of cryotherapy, two different protocols of application were used in the studies – protocol with the single application and assessment pre-post, and the protocol with up to 6 applications and evaluation up to 24/48h after the intervention. Short-term NRS/VAS pain scores decreased significantly compared to controls in all studies as well as the NRS pain score after 48 hours in one study. Two RCTs on using of warm compresses during the second stage of labor showed that the intervention positively affected pain relief during labor and on the first day after delivery. One study compared warm water and IRF and found significant pain reduction in both groups, favoring IRF. 

Seven papers on interventions using various methods of acupuncture and acupressure were analyzed.  The results were inconclusive, as some studies reported a more significant decrease in pain compared to the application of cold compresses or the standard care group and fewer requests for pain medication compared to the control group. In the case of Battlefield acupuncture (BFA) or ear acupressure, no statistically significant differences in pain were noted between the groups. The methodology of the interventions and the measurement points varied considerably, ranging from assessments 2, 6, and 12h after the intervention to 1-3 and up to 14 days after the intervention.

This scoping review provides novel and much needed evidence, presenting data on the effectiveness of a wide range of non-pharmacological, conservative therapies for managing postpartum perineal pain. From the above results, the least effective appears to be the use of light therapy (e.g. lasers) as their results were insufficient to support the claim that LLLT or IRF therapy reduces pain or accelerates healing in early postpartum. The same appears in acupuncture, acupressure, and the use of heat after delivery. In contrast, using warm compresses during labor, cold compresses after delivery, or electrotherapy appear promising, at least in a short-term evaluation. The methods distinguished in the review were radiofrequency and TENS as well as cryotherapy, which was supported by convincing data. This provides an encouraging perspective on incorporating non-pharmacological, conservative methods into postpartum pain management regimens. Due to different methodologies and measurement points, a detailed data meta-analysis would be necessary to draw appropriate conclusions.

The results obtained showed some promising opportunities for the use of non-pharmacological, conservative methods in postpartum pain management, especially radiofrequency, TENS or cold application-based thermotherapy. Further studies could focus on the use of radiofrequency for postpartum perineal pain, as this modality has been the least studied. However, the research should have a sufficiently powered sample to interpret the results appropriately. Furthermore, a minimum effective dose and number of treatments need to be established. Our review did not find data on pelvic floor muscle training and manual therapy in the early postpartum period. It is suggested that these methods be studied to determine their effectiveness in reducing postpartum perineal pain.

Mackenzie J., Murray E., Lusher J. Women's experiences of pregnancy related pelvic girdle pain: a systematic review. Midwifery. 2018;56: 102-111.
Woods A.B., Crist B., Kowalewski S, Carroll J, Warren J, Robertson J. A cross-sectional analysis of the effect of patient-controlled epidural analgesia versus patient controlled analgesia on postcesarean pain and breastfeeding. J Obstet Gynecol Neonatal Nurs. 2012;41(3):339-46.
Smith C.A., et al. The effectiveness and safety of complementary health approaches to managing postpartum pain: A systematic review and meta-analysis. Integrative Medicine Research, 2022, 11.1: 100758.

Continence 12S (2024) 101387
DOI: 10.1016/j.cont.2024.101387