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Current prescribing practices in the UK for post-operative analgesia following caesarean section
Abstract Number: F-24
Abstract Type: Original Research
Background: Current controversies exist in the UK about safety of analgesic medication in postpartum women. The Medicines and Health Products Regulatory Agency (MHRA)(1) and European Medicines Agency (EMA)(2) recently recommended that codeine is avoided as post-operative analgesia in breastfeeding mothers due to fears about transmission to neonates and resulting respiratory depression(3,4). This survey aimed to establish how these recommendations have affected individual prescribing practices in the UK.
Methods: An Obstetric Anaesthetists’ Association (OAA) survey on prescribing practices for post-operative analgesia following caesarean section (CS) was produced and sent to Consultant members of the OAA in 2015. 599 responded giving a response rate of 46%.
Results: 72% of respondents prescribe opiate based medication for women who have a CS under regional anesthesia (RA). 99% prescribe opiate based medication following a CS under general anesthesia (GA). 6% continue to prescribe codeine for CS under RA; 4% for CS under GA. Alternatives to codeine include dihydrocodiene, tramadol, oral morphine with the addition of IM, IV and PCAS morphine in the GA group. 39% routinely ask mothers about breastfeeding prior to prescribing analgesia. 76% would prescribe the same analgesia irrespective of whether patients were planning to breastfeed. Only 16% routinely counsel mothers on potential complications for her baby from post-operative analgesia. 61% of responders were aware of local hospital guidance which specifically mentions avoidance of codeine in breastfeeding mothers.
Discussion: This UK survey shows a low codeine prescribing rate suggesting MHRA and EMA recommendations are being followed. Combine this with a minority asking about breastfeeding and a majority not altering prescribing habits despite this and it suggests that an effective pain medication is under-utilised in the non-breastfeeding population.
Conclusion: Low post-operative analgesia counselling rates in this patient group could be seen as a missed opportunity to individualize patient medication. A patient information leaflet on analgesia side effects and implications for breastfeeding may be a way to open discussions and educate mothers about breastfeeding and post-operative analgesia.
1. MHRA. Codeine for analgesia: restricted use in children because of reports of morphine toxicity. Drug Safety Update July 2013 Volume 6 issue 12: A1
2. European Medicines Agency. Restrictions on use of codeine for pain relief in children – CMDh endorses PRAC recommendation. Press Release. EMA/385716/2013. 28 June 2013.
3. Madadi P, Ross CJD, Hayden MR et al. Pharmacogenetics of neonatal opioid toxicity following maternal use of codeine during breastfeeding: A case-control study. Clinical Pharmacology & Therapeutics 2009;85:31–36
4. Koren G, Cairns J, Chitayat G Leeder SJ. Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine prescribed mother. Lancet 2006;368:704