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RCOG review clarifies pain relief options for women during pregnancy and breastfeeding

News 13 December 2018

A new Scientific Impact Paper from the Royal College of Obstetricians and Gynaecologists (RCOG) sets out guidance on the management of pain medication for women during pregnancy and breastfeeding.

A team of leading doctors undertook the review following reported concerns over the use of codeine during breast feeding.

The findings support use of appropriate pain relief options, as advised by NHS guidance. It recommends that, where possible, all drugs should be avoided during the first trimester – up to 12 weeks of pregnancy – but some will need to be continued to prevent harm to a woman.

It found that paracetamol has an excellent safety profile and is recommended as a first line pain medication during pregnancy and breastfeeding.

Nonsteroidal anti-inflammatory drugs (NSAIDS) – such as ibuprofen – should be avoided unless clinically indicated, such as for a severe migraine, within the first trimester and should not be taken after 30 weeks of gestation due to increased risk to the baby. However, NSAIDS are safe to use during breastfeeding.

Opioids should only be taken based on the advice of a doctor or midwife, but the review notes all opioids are equally safe during pregnancy.

The review also highlights the important difference between codeine and dihydrocodeine (DHC) during breastfeeding and emphasises that DHC is safe to take during breastfeeding but codeine should be avoided. This is important because a number of women may need – in addition to paracetamol and NSAIDs –opioids opioids for the first few days after birth.

The review cautions that the lowest effective dose should be used when taking any pain relief medication – even those bought over the counter – for the shortest possible duration to minimise any potential risks to the mother and baby.

Before taking any medicine when pregnant or breastfeeding, a woman should always ask for advice from a pharmacist, obstetrician, midwife or GP. 

As the cold and flu season arrives, the RCOG review also found that it is important to ensure that women are aware that many over-the-counter remedies for coughs and colds may contain paracetamol, and if taken alongside paracetamol may lead to accidental overdose.

In a bid to avoid flu, the RCOG continues to encourage pregnant women to have the flu jab. Earlier this week, Public Health England urged pregnant women to have the flu jab, after a fall in take-up compared to this time last year. Only around 40% of pregnant women have had the vaccine so far.

Dr Dina Bisson, Consultant Obstetrician and lead author of the review, said:

“It is absolutely essential that pain is managed appropriately during pregnancy and breastfeeding. Many women may develop headaches, lower back pain and pelvic pain during pregnancy and breastfeeding, while others may have chronic conditions, where pain management is necessary. If pain is not adequately managed, this can have a negative impact on a woman’s physical and mental well-being. 

“Women should be encouraged to try non-medical treatments, such as adequate rest, hot and cold compresses, massage, physiotherapy and exercise. But if pain relief drugs are required, it is important that doctors and midwives are able to advise on appropriate medication and hopefully this review will be helpful.”

Dr Pat O’Brien, Consultant Obstetrician and Spokesperson for the Royal College of Obstetricians and Gynaecologists, said:

“We are concerned by reports of a fall in the number of pregnant women taking up the flu-vaccine this year. Flu can occasionally be serious for pregnant women as it increases risk of complications, such as bronchitis, a chest infection that can develop into pneumonia. The best way to avoid getting this is to have the flu vaccination. Women who are pregnant should be reassured that current evidence shows the flu vaccine is safe to use.

“It is also important, as this latest review shows, that women who are trying to conceive, or are already pregnant, should always check the mixture of ingredients in cough and cold remedies to avoid accidental overdose of paracetamol and any medication that contains caffeine. We strongly advise women to talk to a pharmacist, GP, obstetrician or midwife before taking any medications, including those that can be bought over-the-counter.”


Note to Editors

For media enquiries please contact the RCOG press office on +44 (0)20 7045 6773 or email

The RCOG review followed advice issued in 2013, the Medicines and Healthcare Products Regulatory Authority (MHRA) and European Medicines Agency (EMA) on the use of codeine in pregnancy, following the death of a baby who had been breastfed in 2005.

It examined existing evidence-based guidance from the Medicines and Healthcare Products Regulatory Authority (MHRA) and European Medicines Agency (EMA) on use of painkillers during pregnancy and breastfeeding. It found:

  • Paracetamol - With its excellent safety profile, paracetamol is widely used as the first line pain relief drug treatment throughout pregnancy and during breast feeding.
  • NSAIDS - Where possible women should avoid taking NSAIDs before 30 weeks of pregnancy. If needed and based on the advice of a doctor, a woman is encouraged to take the lowest effective dose for the shortest possible duration. After 30 weeks of gestation women should not take NSAIDs. NSAIDS are safe to use during breast feeding
  • Opioids - These can be taken during all stages of pregnancy, however, the lowest effective dose of opioids should be used for the shortest possible time, and based on the advice of a doctor or midwife. After giving birth, if a woman experiences more severe pain and is in need of additional pain relief, then opioids can be used but codeine should be avoided when breastfeeding.

The above information should not replace medical guidance from a healthcare professional.

The review does not cover pain relief options during labour and childbirth.

For more information about pain relief during pregnancy, after childbirth and breastfeeding, please visit NHS Choices.

For more information about the flu vaccination in pregnancy, please visit NHS Choices.

Please cite this paper as: Bisson DL, Newell SD, Laxton C, on behalf of the Royal College of Obstetricians and Gynaecologists. Antenatal and Postnatal Analgesia.

Scientific Impact Paper No. 58. BJOG 2018; DOI: 10.1111/1471-0528.15510

Scientific Impact Papers advise on emerging or controversial scientific issues of relevance to obstetrics and gynaecology, together with the implications for future practice. These papers are produced by the RCOG’s Scientific Advisory Committee.

About the RCOG
The RCOG is a medical charity that champions the provision of high quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision. Visit our website and follow us on Twitter @RCObsGyn.