Within minutes of delivering my fourth child, something went wrong. The birth had been complicated by a failed epidural and then a grand finale of baby getting stuck with the umbilical cord looped tightly around her neck. As the pediatricians tended to her bruised little body, I became aware that my own would not stop bleeding. The doctors called a “code crimson.” They worked to stop the hemorrhaging, administering medications to stimulate extra contractions and aid in clotting and scabbing. They aggressively palpated my uterus—which involves getting hold of it and squeezing it, basically. They shot another medication into my arm, a Hail Mary before sending me to the operating room. It worked, but not before causing immediate nausea that had me violently dry-heaving. Afterward, the attending remarked apologetically, “You’ll feel like you were hit by a bus tomorrow.”
Later, in a bed in the postpartum unit of the hospital, the night nurse informed me that I would receive Tylenol and Motrin for pain. These were what every patient was offered, the standard of care. If I needed anything “like oxy,” she’d have to call the doctors. I wasn’t concerned, having avoided opioids with my last three births. Within hours, however, my pain was so severe that I was sweating and my heart was racing. My insides were twisting, burning; I clenched my entire body, my knuckles white as the moon. My legs shook from contractions that felt nearly as intense as those during childbirth itself. I repeatedly asked for more medicine, but the nurse responded that these were routine afterpains, the normal feeling of a uterus shrinking when it’s no longer holding a baby. I asked if she had read my chart, if she’d seen that I had hemorrhaged. I was not “the standard” patient. She said I should try adding Motrin to the Tylenol I’d taken, and then wait and see if it worked. “You’re gonna contract every time when baby nurses, and that’s what’s supposed to happen,” she told me. “It’s natural.”
Resigned, I swallowed the Motrin, waited another four hours for more Tylenol, and clutched my belly for the rest of the night. I winced every time my baby latched on and sucked. When I saw my night nurse again, I rated my pain as an 8 out of 10 and hoped she’d take the hint. But she didn’t. When I asked my day nurse about more pain management, she also insisted the pain was normal.
Twenty-four hours after my admission, a third nurse tried to coach me through: “Envision your uterus like a stretched-out elastic. It’s shrinking down now, and it’s normal.” Tears streaming down my face between jagged, gasping breaths, I pulled myself up and gripped the bars of the bed to remain there while my breasts leaked all over my gown. I was shaking. “Please,” I said. “Please, I’m suffering. Please help me. Please call the doctor.”
Three hours later, the doctor examined me. I wailed each time she pressed on my belly. Then she prescribed a single pill of oxycodone. The nurses had to page her again for a subsequent dose. At discharge, I got five pills. I rationed them, taking one a night when the baby would be cluster-feeding and stimulating more pain. I stayed in bed that first week, unable to interact with my older children or new baby, inconsolable between hormones and pain. Despite focusing my clinical and academic career on reproductive health and advocacy, I hadn’t been able to get the amount of pain relief I’d needed. I hadn’t wanted to be a bad patient or seem like I was seeking out drugs. I hadn’t wanted the nurses to dislike me or the doctors to judge me. But I’d ended up betraying my own body instead. The hospital wasn’t going to just give me the drugs I’d needed—I had to suffer for them first, to wail for them.
Of course, there’s a good reason nurses are hesitant to give new moms oxycodone. The opioid crisis in America rages on, with overdoses from prescription drugs killing over 232,000 Americans between 1999 and 2018. In particular, the rate of opioid use during pregnancy increased by more than fivefold between 2000 and 2009, placing unborn fetuses and newborns at higher and higher risk. Opioids are responsible for a growing amount of deaths in pregnant women, as well as raising the costs of hospital care. Hospitals have understandably revised their prescribing practices to prevent further damage.
But in the case of childbirth and postpartum pain, I think the pendulum has swung too far, making opioids too hard to get, and without enough measures to ease pain otherwise (Tylenol, really?). The narrative that suffering during childbirth is normal, even something to aspire to, doesn’t help. The field of abdominal surgery, for example, has responded to the opioid crisis by instituting methods to hasten recovery and post-operative complications, like having patients drink a carbohydrate-rich beverage prior to surgery to avoid post-anesthesia nausea. These precautions in turn reduce pain and the need for opioids. In contrast, few advances have addressed postpartum pain for pesky patients who have complicated births and need more than the “standard of care.” And yet hospitals still seem to be trying to reduce opioids. “There is tremendous pressure from hospital administration and regulatory agencies not to prescribe opioids,” one local obstetrician confided to me. “We are all scrutinized, and none of us wants to be accused of contributing to the crisis.”
Patients are left to absorb the shift physically and psychologically. When I posted my own experience of postpartum pain on social media, a couple dozen women replied with stories of their own (I am referring to them by their first names to protect their privacy). After her C-section, Kesley, a first-time mom with no history of drug abuse, had to ask for “every single dose of oxycodone,” which made her feel high-maintenance. “They also sent me home with a script that only had enough doses for a day and a half.” This preventive measure of prescribing too few pills resulted in Kesley not just feeling frustrated, but seeking extras from friends.
Arguing for more pain meds was hard for other women I spoke to. Vanessa experienced “the worst pain of my life” from a complication during a C-section at a hospital that touts its pain management skill; the night nurse threatened that Vanessa would have to stay another day if she called for more meds. Following her C-section, Jessica was prescribed morphine due to an Advil allergy “at a dose that just barely touched the pain,” she explains. “I should’ve been more assertive, but it’s so hard when you’re in one of those lame green gowns and they’re in their fancy white coats”. After a vaginal birth that caused severe tears, another woman was given Percocet in the hospital but discharged with only Motrin on the doctor’s insistence that it was “enough.”
Getting adequate help with pain management can be particularly difficult for postpartum patients who aren’t white. Growing evidence indicates that Black patients in the United States are less likely than white patients to receive adequate pain medication and management, and mothers of color are three times as likely to die of pregnancy-related causes as white mothers. Melissa, a Black mother, told me about a uterine tear that was repeatedly dismissed. “A nurse grabbed me by the arm and, almost shaking me, said, ‘Stop screaming. Stop it. It’s not necessary. Stop. Get ahold of yourself,’ ” Melissa recalls. “I felt myself dying, and no one wanted to listen to or believe me.” The doctor later confirmed that she almost died, and warned her that her new daughter should be her last child, for safety reasons. While recovering, Melissa was told Tylenol dispensed via IV was the standard of care. When she asked for narcotics, the doctor “asked why I felt I needed stronger meds and if I was aware of the opioid crisis.”
Opioids are not right for every birthing mother. But the solution to the opioid crisis should not lie in so stringently limiting the drugs for all patients. Women deserve better than bearing significant pain in a vulnerable and formative moment of their lives because of the opioid crisis and an overtaxed system. Instead, women should feel supported in choosing the best pain management strategies for themselves. Hospitals have not consistently created appropriate pathways for ensuring that those who do want narcotic pain control can access it safely and with minimal friction while they’re in the aftermath of childbirth. One easy step is figuring out who is low-risk for taking opioids as a matter of course. The American College of Obstetricians and Gynecologists recommends early and universal screening for opioid dependence with all pregnant patients as part of a routine that includes taking history and bloodwork. But according to providers and clinic administrators I’ve spoken with, as well as women who’ve been through childbirth, such screening doesn’t seem to be widely practiced. Those with low risk should be provided the choice of opioids, and those who screen higher can be educated about alternative approaches to pain management. Those alternative approaches could stand to be further researched, but in the meantime, many of them have virtually no side effects. They include mindfulness, breathing and movement exercises, TENS units, and CBD oils. Imagine how nice it would be to have a nurse help you choose from a variety of calming gadgets and tinctures as you recover post-birth.
No matter the method of management, postpartum patients should be given pain journals. Women are commonly asked to report when their infants eat or void during their time as an inpatient—why not add an additional category? The opportunity to track and reflect upon pain instead of rating it on a scale of 1 to 10 whenever a medical professional happens to ask might help providers address it sooner and more effectively. These logs could also help doctors identify patients who are overusing opioids, according to Kimberly Waibogha, a doctoral-level social worker with over a decade of experience working with opioid-dependent clients. Women getting opioids should be sent home with pamphlets to cover their appropriate use and disposal, as well as a hotline to call if they spot early warning signs that they are becoming dependent. The point is that the larger structure of postpartum care should bear the burden of the opioid crisis. Women shouldn’t have to bear it with their own bodies.