Rectal analgesia for the relief of perineal pain after childbirth: a randomised controlled trial of diclofenac suppositories

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1 BJOG: an International Journal of Obstetrics and Gynaecology October 2004, Vol. 111, pp DOI: /j x Rectal analgesia for the relief of perineal pain after childbirth: a randomised controlled trial of diclofenac suppositories Jodie M. Dodd, Hedyeh Hedayati, Elizabeth Pearce Neil Hotham, Caroline A. Crowther Objective To evaluate rectal diclofenac in the relief of perineal pain after trauma during childbirth. Design A randomised, double-blind trial. Setting Delivery Suite, Women s and Children s Hospital, South Australia. Population Women with a second-degree (or greater) perineal tear or episiotomy. Methods Women were randomly allocated to either diclofenac or placebo suppositories (Anusol), using a computer-generated randomisation schedule with stratification for parity and mode of birth. Treatment packs contained two 100 mg diclofenac or two placebo suppositories, the first being inserted when suturing was complete, and the second hours after birth. Women were asked to complete questionnaires at 24 and 48 hours after birth relating to their degree of perineal pain using the validated Short Form McGill Pain Questionnaire. Main outcome measures Pain scores at 24 and 48 hours after birth. Results A total of 133 women were recruited, with 67 randomised to diclofenac suppositories and 66 to placebo. Women in the diclofenac group were significantly less likely to experience pain at 24 hours while walking (RR 0.8; 95% CI 0.6 to 1.0), sitting (RR 0.8; 95% CI 0.6 to 1.0), passing urine (RR 0.6; 95% CI 0.4 to 1.0) and on opening their bowels (RR 0.6; 95% CI 0.2 to 0.9) compared with those women who received placebo. These differences were not sustained 48 hours after birth. Conclusions The use of rectal non-steroidal anti-inflammatory drug suppositories is a simple, effective and safe method of reducing the pain experienced by women following perineal trauma within the first 24 hours after childbirth. INTRODUCTION Perineal trauma affects at least 65% of women in resource-rich countries 1 and scarce data from underresourced countries suggests 35 45% of women who give birth in a hospital setting experience an episiotomy. 2 The experience of perineal pain after childbirth is strongly associated with the occurrence of perineal trauma, and is reported to be most severe in the immediate postnatal period. 1,3 However, the degree of perineal pain and discomfort associated with perineal trauma is often underestimated, 4 interfering with basic daily activities and impacting on motherhood experiences, 5 with 20 25% of women continuing to experience distress and discomfort Maternal and Perinatal Clinical Trials Unit, Department of Obstetrics and Gynaecology, The University of Adelaide, Women s and Children s Hospital, North Adelaide, South Australia, Australia Correspondence: Dr J. M. Dodd, Maternal and Perinatal Clinical Trials Unit, Department of Obstetrics and Gynaecology, The University of Adelaide, Women s and Children s Hospital, 72 King William Street, North Adelaide, South Australia 5006, Australia. D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology for up to two weeks after birth. 1,3 An estimated 10% of women suffer pain in the three months after childbirth, 3,5 although this may be a significant under-estimate of the size of the problem, with a recent Australian study reporting that 94% of women experienced one or more health problems up to six months after birth, including perineal pain. 6 Strategies to reduce perineal trauma and the appropriate repair of any perineal damage sustained are important for avoiding and alleviating pain. Factors that may influence the severity of pain experienced include mode of birth, 7 degree of perineal trauma, 8 type of suture material 9,10 and perineal repair technique. 11,12 The provision of safe and effective pain relief for perineal trauma using rectal analgesia is one of several therapies used in clinical practice, which also include oral analgesics, local anaesthetics, therapeutic ultrasound and non-pharmacological applications such as baths and ice packs. 13 Evidence of the efficacy and safety of rectal analgesia is limited. 14 In general medical care, the rectal route of analgesic administration has been favoured when oral preparations cause gastric irritation, nausea or vomiting. 15 Studies assessing the efficacy of rectal analgesia in post-operative pain relief have indicated significant reduction in the level

2 1060 J.M. DODD ET AL. of pain experienced, 15 and reduced requirements for additional analgesia. 16,17 This randomised, double-blind, placebo-controlled trial was designed to evaluate the efficacy of rectal diclofenac. The hypotheses of the trial were that the use of rectal diclofenac suppositories after perineal trauma associated with childbirth would reduce maternal pain 24 and 48 hours after birth (as measured by the McGill Pain Questionnaire); reduce use of other analgesia; increase time from birth to the use of first analgesia; improve maternal satisfaction with perineal pain relief; and reduce perineal pain after discharge from hospital. METHODS Women were recruited from the antenatal clinic and delivery suite of the Women s and Children s Hospital, Adelaide, South Australia between July 2002 and January Women with a second-degree tear or greater, or an episiotomy, who gave written informed consent were eligible. Women were ineligible if there was a history of sensitivity to non-steroidal anti-inflammatory drugs, preeclampsia, severe asthma, gastric or duodenal ulcer, major postpartum haemorrhage (defined as blood loss greater than 1000 ml), or required a manual removal of placenta or caesarean section. Study information leaflets were distributed to women presenting to the women s assessment service and the antenatal clinic of the Women s and Children s Hospital, South Australia. A member of the study team was available to counsel all potentially eligible women at greater than 36 weeks of gestation attending the hospital for routine antenatal visits. Women could be recruited up to the time of perineal repair after birth. Ethical approval was obtained from the research and ethics committee of the Women s and Children s Hospital. Eligible women who had given their written informed consent were randomly allocated to receive either diclofenac suppositories or placebo suppositories (Anusol) by the midwife taking the next sequential treatment pack from one of four boxes corresponding to the woman s parity and mode of birth. The randomisation schedules were prepared by a researcher not involved in patient care, using a computer-generated random number table with variable blocks, and stratification for parity (primiparous vs multiparous) and mode of birth (spontaneous vaginal birth vs instrumental vaginal birth). Each treatment pack contained two 100 mg diclofenac suppositories or two placebo suppositories (Anusol) wrapped in foil to mask treatment allocation and an instruction sheet, which were prepared by staff not involved in trial recruitment or data collection. The first suppository was inserted when suturing was completed, and the second was offered hours after birth. The women involved in the study were blinded to the allocated treatment group. All women were asked to complete questionnaires prior to their discharge from hospital at 24 and 48 hours after birth relating to their degree of perineal pain. Questionnaires at 10 days and six weeks after birth were distributed and returned by post. Women who did not respond to the questionnaire within one to two weeks were contacted and the questionnaire was completed over the telephone. The questionnaires used the validated Short-Form McGill Pain Questionnaire (SF-MPQ) made up of 15 descriptors of pain qualities, descriptors 1 11 being sensory dimensions and affective dimensions. 18 Each descriptor was then graded according to severity as 0 ¼ no, 1 ¼ mild, 2 ¼ moderate, 3 ¼ severe pain. The SF-MPQ includes a present pain intensity scale which is scored as 0 ¼ no pain, 1 ¼ mild pain, 2 ¼ discomforting pain, 3 ¼ distressing pain, 4 ¼ horrible pain and 5 ¼ excruciating pain. The visual analogue scale (VAS) component asked women to score their pain from 0 ¼ no pain to 100 ¼ worst possible pain. Using the SF-MPQ, women were asked to rate the pain they experienced at rest and with movement. At 24 hours, 48 hours, 10 days and six weeks after birth, women were asked to indicate the presence of pain on walking, sitting, voiding and on opening their bowels, as described by Kettle et al. 19 Additional questions at 10 days and six weeks after birth related to satisfaction with a rectal route of analgesic administration, whether they would participate in the study again, whether they would recommend a friend participate in the study, and the treatment group they thought they had been allocated to. The primary outcomes were pain scores at 24 and 48 hours after birth with rest and movement, as described in the SF-MPQ (sensory, affective, present pain intensity and visual analogue components), and pain at 24 and 48 hours after birth while sitting, walking, voiding and defecating. The secondary outcomes were the incidence of use of additional analgesia; time from birth to first additional analgesia use; pain at 10 days and six weeks after birth while sitting, walking, voiding and defecating; use of analgesia after discharge from hospital; and maternal satisfaction with relief of perineal pain. Sample size calculations were based on previous research carried out by Corkhill et al. 11 which showed a mean pain score of 43.5 (SD 21.8) using the 101-point Numerical Rating Scale for perineal pain at 24 hours postperineal repair, without the use of rectal analgesia. To detect a clinically significant reduction in pain scores of 35% from 43.5 to 32.6 (with a similar standard deviation), it was necessary to recruit 128 women to the trial (5% level of significance with 80% power). 11 Analysis was by intention-to-treat, using a mixed model analysis of variance to analyse the 24 and 48 hour visual analogue scores from the SF-MPQ. The other SF-MPQ variables were not normally distributed, and were analysed by Wilcoxon rank sum tests at each time point. Categorical

3 variables were compared using m 2 tests or Fisher s exact tests where appropriate at each time point. A P value of less than 0.05 was taken as significant. The analysis was performed blinded to treatment groups and on an intention-totreat basis. A RANDOMISED TRIAL OF DICLOFENAC SUPPOSITORIES FOR PERINEAL PAIN RELIEF 1061 RESULTS Table 1. Maternal demographics and labour outcomes at trial entry. Values are presented as mean [SD], median (interquartile range) or n (%) of women. Variables Diclofenac (n ¼ 67) Placebo (n ¼ 66) Maternal age (years) 29 [5] 30 [6] Caucasian 54 (81) 54 (82) Maternal weight (kg) 71 [18] 68 [13] Maternal height (cm) 165 [6] 165 [6] Primiparous 45 (67) 42 (64) Spontaneous vaginal birth 44 (66) 42 (64) Instrumental vaginal birth 23 (34) 24 (36) 2nd degree tear 43 (64) 38 (58) Episiotomy 24 (36) 28 (42) Gestational age at birth (weeks/days) 40 (39 41) 40 (39 41) Induction of labour 23 (34) 23 (35) Length of labour (hours) 8 (5 11) 7 (5 11) Regional analgesia 38 (57) 31 (47) Primary postpartum 8 (12) 3 (5) haemorrhage (600 ml) Birthweight (kg) 3.5 [0.5] 3.5 [0.5] Apgar score <7 at 5 minutes 0 (0) 1 (2) Infant admission to nursery 22 (33) 27 (41) Local anaesthetic for perineal repair 53 (79) 47 (71) Vicryl for perineal repair 63 (94) 63 (95) Continuous suture to vaginal layer 60 (90) 60 (91) Continuous suture to muscle layer 21 (31) 26 (39) Subcuticular suture to skin 56 (84) 56 (85) Perineal repair by medical officer 58 (87) 59 (89) Fig. 1. Trial flowchart. During the study period, a total of 762 women who gave birth at the Women s and Children s Hospital sustained perineal trauma requiring suturing during childbirth. A total of 447 potentially eligible women were approached in the antenatal period for participation in the trial, of whom 243 (54%) provided provisional written consent. Of these women, 133 became eligible after birth. All 133 women were included in the analysis, with 67 randomised to receive diclofenac suppositories and 66 to receive placebo. The two groups were well balanced for demographic characteristics at trial entry, and labour and birth outcomes, including perineal repair technique (Table 1). Study outcome data were available for 98% of women at 24 hours, 98% of women at 48 hours, 96% of women at 10 days and 85% of women at six weeks after birth. There were no statistically significant differences between the two groups in compliance with the treatment protocol, and similar numbers of women in each group received both suppositories (44, 70% diclofenac group vs 45, 71% placebo group, P ¼ 0.84; see Fig. 1). Using the SF-MPQ, there were no statistically significant differences between the two groups for sensory, affective and total pain scores at rest or with movement, both at 24 and 48 hours after birth. Significantly fewer women in the diclofenac group described their pain as discomforting or worse using the present pain intensity score with movement 24 hours after birth (22/49 diclofenac vs 37/54 placebo; relative risk [RR] 0.7; 95% confidence intervals [CI] 0.5 to 0.9; P ¼ 0.02), a benefit not sustained at rest (31/58 diclofenac vs 32/56 placebo; RR 0.9; 95% CI 0.7 to 1.3; P ¼ 0.69). There were no statistically significant differences in present pain intensity scores 48 hours after birth with rest (23/56 diclofenac vs 23/55 placebo; RR 1.0; 95% CI 0.6 to 1.5; P ¼ 0.94) or with movement (22/54 diclofenac vs 26/54 placebo; RR 0.9; 95% CI 0.6 to 1.3; P ¼ 0.44). Using visual analogue scales, women in the diclofenac group experienced significantly less pain at 24 hours at rest (RR 1.1; 95% CI 1.9 to 0.3; P ¼ 0.01) and with movement (RR 1.4; 95% CI 2.3 to 0.5; P ¼ 0.004), and were significantly less likely to experience pain at 24 hours while walking (RR 0.8; 95% CI 0.6 to 1.0), sitting (RR 0.8; 95% CI 0.6 to 1.0), passing urine (RR 0.6; 95% CI 0.4 to 1.0) and on opening their bowels (RR 0.46; 95% CI 0.22 to 0.98) when compared with those women who received placebo. These benefits were not shown at 48 hours after birth (Table 2). To prevent one woman experiencing pain described as discomforting or more severe with movement at 24 hours after birth, the number of women needed to treat to benefit is five (NNTB 5, 95% CI 3 to 21). There were no statistically significant differences between the two groups in the need for additional analgesia prior to discharge from hospital (54, 81% diclofenac vs 57, 86% placebo; RR 0.9; 95% CI 0.8 to 1.1; P ¼ 0.37), the time from birth to first use of analgesia (6.3 hours

4 1062 J.M. DODD ET AL. Table 2. Primary outcome measures. Values are presented as mean [SD], number of women (%) or median (interquartile range). Variable Diclofenac (n ¼ 67) Placebo (n ¼ 66) RR (95% CI) P 24 hours after birth at rest SF-MPQ total score (n ¼ 56/53) 6 (3 11) 7 (3 12) 0.33 Visual analogue score 2.8 [0.3] 3.9 [0.3] 1.1 ( 1.9 to 0.3) 0.01 Present pain intensity score (n ¼ 58/56) 31 [53.4] 32 [57.1] 0.9 (0.7 to 1.3) hours after birth with movement SF-MPQ total score (n ¼ 57/53) 6 (2 13) 9 (5 14) 0.15 Visual analogue score 3.3 [0.3] 4.7 [0.3] 1.4 ( 2.3 to 0.5) Present pain intensity score (n ¼ 49/54) 22 [44.9] 37 [68.5] 0.7 (0.5 to 0.9) hours after birth other activities Pain with walking (n ¼ 61/55) 33 (54) 39 (71) 0.8 (0.6 to 1.0) 0.06 Pain on sitting (n ¼ 60/57) 36 (60) 43 (75) 0.8 (0.6 to 1.0) 0.07 Pain passing urine (n ¼ 58/57) 17 (29) 26 (46) 0.6 (0.4 to 1.0) 0.07 Pain on opening bowels (n ¼ 38/24) 8 (21) 11 (48) 0.6 (0.2 to 0.9) hours after birth at rest SF-MPQ total score (n ¼ 57/57) 4 (2 9) 4 (3 6) 0.86 Visual analogue score 2.6 [0.3] 3.0 [0.3] 0.4 ( 1.2 to 0.4) 0.34 Present pain intensity score (n ¼ 56/55) 23 [41.1] 23 [41.8] 1.0 (0.6 to 1.5) hours after birth with movement SF-MPQ total score (n ¼ 60/55) 4.5 ( ) 4 (2 9) 0.90 Visual analogue score 2.9 [0.3] 3.6 [0.3] 0.6 ( 1.6 to 0.3) 0.17 Present pain intensity score (n ¼ 54/54) 22 [40.7] 26 [48.2] 0.9 (0.6 to 1.3) hours after birth other activities Pain with walking (n ¼ 60/54) 34 (57) 33 (61) 1.1 (0.7 to 1.7) 0.63 Pain on sitting (n ¼ 60/57) 40 (65) 36 (68) 1.0 (0.7 to 1.2) 0.70 Pain passing urine (n ¼ 58/57) 19 (33) 18 (34) 1.0 (0.6 to 1.6) 0.89 Pain on opening bowels (n ¼ 38/24) 10 (21) 13 (37) 0.6 (0.3 to 1.1) 0.10 diclofenac vs 5.8 hours placebo, P ¼ 0.67) and the need for and frequency of analgesia use after discharge from hospital (42, 66% diclofenac vs 36, 57% placebo; RR 1.1; 95% CI 0.9 to 1.5; P ¼ 0.45) (Table 3). There were no statistically significant differences between the two groups at 10 days after birth in the number of women experiencing perineal pain (37, 60% diclofenac vs 35, 59% placebo; RR 1.0; 95% CI 0.8 to 1.4; P ¼ 0.97), or Table 3. Secondary outcome measures. Values are presented as number of women (%) or median (interquartile range). Variable Diclofenac (n ¼ 67) Placebo (n ¼ 66) RR (95% CI) P Use of additional analgesia Additional analgesia prior to discharge 54 (81) 57 (86) 0.9 (0.8 to 1.1) 0.37 Time from birth to first analgesia (hours) 6.4 ( ) 5.8 ( ) 0.67 Two suppositories received 44 (70) 45 (71) 1.0 (0.8 to 1.2) 0.84 Additional analgesia after discharge (n ¼ 64/61) 42 (66) 36 (57) 1.1 (0.9 to 1.5) days after birth Perineal pain present (n ¼ 62/59) 37 (60) 35 (59) 1.0 (0.8 to 1.4) 0.97 Pain with walking (n ¼ 59/57) 19 (32) 20 (35) 0.9 (0.6 to 1.5) 0.74 Pain on sitting (n ¼ 59/57) 25 (42) 19 (33) 1.3 (0.8 to 2.0) 0.32 Pain passing urine (n ¼ 56/56) 12 (21) 12 (21) 1.0 (0.5 to 2.0) 1.00 Pain on opening bowels (n ¼ 59/55) 22 (37) 26 (47) 0.8 (0.5 to 1.2) 0.28 Six weeks after birth Perineal pain present (n ¼ 59/62) 13 (22) 12 (23) 1.0 (0.5 to 1.9) 0.90 Pain with walking (n ¼ 56/46) 4 (7) 2 (1) 1.6 (0.3 to 8.6) 0.69 Pain on sitting (n ¼ 55/46) 5 (9) 3 (7) 1.4 (0.4 to 5.5) 0.72 Pain passing urine (n ¼ 53/46) 5 (9) 0 (0) Undefined 0.06 Pain on opening bowels (n ¼ 56/47) 13 (23) 11 (23) 1.0 (0.5 to 2.0) 0.98

5 A RANDOMISED TRIAL OF DICLOFENAC SUPPOSITORIES FOR PERINEAL PAIN RELIEF 1063 six weeks after birth (13, 22% diclofenac vs 12, 23% placebo; RR 1.0; 95% CI 0.5 to 1.9; P ¼ 0.90). There were no differences identified in the experience of pain walking, sitting, voiding or defecating 10 days or six weeks after birth (Table 3). At 10 days after birth, women in the diclofenac group were significantly more likely to report moderate or extreme satisfaction with their level perineal pain relief (54, 89% diclofenac vs 43, 75% placebo, P ¼ 0.04). This difference was not seen at six weeks after birth (P ¼ 0.44). The use of a rectal route of administering pain relief was acceptable to women, with approximately 84% of women indicating that they were moderately or extremely satisfied. Significantly more women in the diclofenac group correctly identified their treatment allocation at 10 days (30/61 diclofenac vs 11/59 placebo; P ¼ 0.004) and at six weeks after birth (23/55 diclofenac vs 12/51 placebo; P ¼ 0.05). DISCUSSION The use of diclofenac suppositories was effective in reducing the experience of perineal pain 24 hours after childbirth for women while walking, sitting and on opening their bowels. Diclofenac was effective in reducing the severity of pain experienced during movement, with fewer women describing their pain as discomforting, horrible or excruciating. However, these differences were not seen 48 hours after childbirth. The reduction in pain experienced by women given nonsteroidal anti-inflammatory rectal suppositories was not reflected in the need for less additional analgesia prior to discharge from hospital, greater time from birth to first use of analgesia, or in less need for and frequency of other analgesia use after discharge from hospital. Women s perception of pain is subjective and the use of analgesia will be influenced by many factors in addition to the level of pain experienced. These findings may reflect a policy of regular analgesia being offered and accepted on a routine basis to women in the postnatal period while in hospital. The use of suppositories for the longer term relief of pain and acceptability of a rectal route of analgesia are less well reported. This study specifically addressed these questions. There were no differences between the two treatment groups with regards to the pain scores reported or in the number of women experiencing perineal pain at 10 days and six weeks after birth. The terminal half-life of diclofenac in plasma is 1 to 2 hours after oral administration. After rectal administration, absorption is complete in less than 40 minutes. While the half-life is longer after rectal administration, the total area under the curve is similar for both preparations. Diclofenac is almost completely protein bound, and as a result, minimal amounts of the drug are excreted in breast milk an important consideration for women who are breastfeeding. 19 While rectal suppositories may be effective in reducing pain experienced after childbirth, drug effectiveness becomes a secondary consideration if women are not prepared to use a rectal route of administration. In determining the acceptability of rectal analgesic suppositories, Carroll et al. 20 interviewed 400 surgical patients (both male and female), who were asked to choose between an intramuscular route of pain relief and rectal suppositories. Given a choice, only 18% of patients surveyed chose rectal suppositories as an acceptable method of pain relief. This current study assessed women s acceptance of the rectal route for postnatal analgesia administration. Women receiving diclofenac suppositories in our study were more satisfied with their pain relief, and overall women who took part in the study had a high degree of acceptance for the rectal route of administering analgesia. In assessing the effectiveness of blinding within the trial, women were asked to nominate which group they thought they belonged to the diclofenac group or the placebo group. Women in the diclofenac group were significantly more likely to correctly identify their treatment allocation at 10 days after birth (P ¼ 0.004), a difference that was maintained at six weeks after birth (P ¼ 0.01), suggesting that their pain improved, thereby allowing correct identification of treatment group. While the current study did not detect the occurrence of any adverse side effects associated with non-steroidal antiinflammatory drug suppository administration, care should be maintained in prescribing this medication. 21 Since the completion of the current study, the Drugs and Therapeutics Committee of the Women s and Children s Hospital has developed a clinical guideline for the use of nonsteroidal anti-inflammatory drug suppositories in the management of postpartum pain, indicating cautious use of these drugs in women with hypovolaemia, pre-eclampsia, gastrointestinal bleeding or ulceration, asthma, allergies to aspirin or other non-steroidal anti-inflammatory drugs or haematological conditions associated with prolonged bleeding time. 22 There appears to be a clear advantage in using nonsteroidal anti-inflammatory drug suppositories to provide short term pain relief for perineal pain after childbirth. There does not appear to be any longer term benefits of reduced perineal pain or reduced need for analgesia. Given the short half-life of non-steroidal anti-inflammatory drug suppositories, these findings are not unexpected. CONCLUSIONS The use of rectal non-steroidal anti-inflammatory drug suppositories is a simple and effective method of reducing the pain experienced by women following perineal trauma within the first 24 hours after childbirth, improving satisfaction with pain relief and having a high degree of acceptability by women.

6 1064 J.M. DODD ET AL. Acknowledgements The authors would like to thank the women who participated in the trial; Ms J Coffey and the midwives on delivery suite (WCH) for their support and assistance in running the trial; and Ms K Willson for statistical advice. References 1. Albers L, Garcia J, Renfrew M, McCandlish R, Elbourne D. Distribution of genital tract trauma in childbirth and related postnatal pain. Birth 1999;26: Maduma-Butshe A, Dyall A, Garner P. Routine episiotomy in developing countries. BMJ 1998;316: Sleep J, Grant A, Garcia J, Elbourne D, Spencer JAD, Chalmers I. West Berkshire perineal management trial. BMJ 1984;289: Steen M, Cooper K, Marchant P, Griffiths-Jones M. A randomised controlled trial to compare the effectiveness of icepacks and Epifoam with cooling maternity gel pads at alleviating postnatal perineal trauma. Midwifery 2000;16: Glazener C, Abdalla M, Strooud P, Naji S, Templeton A, Russel IT. Postnatal maternal morbidity: extent, causes, prevention and treatment. Br J Obstet Gynaecol 1995;102: Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol 1998; 105: Reading AE, Sledmere CM, Cox DN, Campbell S. How women view post-episiotomy pain. BMJ 1982;284: Harrison RF, Brennan M, Reed JV, Wickham EA. A review of postepisiotomy pain and its treatment. Curr Med Res Opin 1987;10(6): Spencer JAD, Grant A, Elbourne D, Garcia J, Sleep J. A randomised controlled comparison of glycerol-impregnated catgut with untreated chromic catgut for the repair of perineal trauma. Br J Obstet Gynaecol 1986;93: Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair [Cochrane review]. The Cochrane Library, Issue 4. Chichester, UK: Wiley, Corkhill A, Lavender T, Walkinshaw SA, Alfirevic Z. Reducing postnatal pain from perineal tears by using lignocaine gel: a double blind randomised trial. Birth 2001;28(1): Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair [Cochrane review]. The Cochrane Library, Issue 4. Chichester, UK: Wiley, Grant A, Sleep J. Relief of perineal pain and discomfort after childbirth. In: Chalmers I, Enkin M, Keirse MJNC, editors. Effective Care in Pregnancy and Childbirth. Oxford: Oxford Univ. Press, 1989: Hedayati H, Parsons J, Crowther CA. Rectal analgesia for pain from perineal trauma following childbirth [Cochrane review]. The Cochrane Library, Issue 4. Chichester, UK: Wiley, Nissen I, Jensen KA, Ohrstrom JK. Indomethacin in the management of post-operative pain. Br J Anaesth 1992;69(3): Simms C, Johnson CM, Bergesio R, Delfos SJ, Avraamides EA. Rectal indomethacin for analgesia after appendicectomy in children. Anaesth Intensive Care 1994;22(3): Scott RM, Jennings PN. Rectal diclofenac analgesia after abdominal hysterectomy. Aust N Z J Obstet Gynaecol 1997;37(1): Melzack R. The short-form McGill pain questionnaire. Pain 1987;30: Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson RB. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002;359: Carroll M, Day F, Hennessy A, Buggy D, Cooney C. Patient attitudes to perioperative suppository administration of postoperative analgesia. Ir J Med Sci 1996;165(4): MIMS. Voltaren: non steroidal inflammatory agents, full prescribing information, Drugs and Therapeutics Committee, Women s and Children s Hospital. The use of non-steroidal anti-inflammatory drugs (NSAIDs) for treatment of acute pain in women. Adelaide, South Australia: Women s and Children s Hospital, Accepted 21 January 2004