OB/GYN pain management SOP guidelines 2024 obstetrics gynaecology ward protocol

https://www.soap.org/assets/COE/SOAP%20consensus%20statement…

pain management obstetrics gynecology multimodal analgesia

ls /home/daytona/workspace/ && ls /home/daytona/skills/docx/

mkdir -p /home/daytona/workspace/obgyn-pain-sop && ls /home/daytona/workspace/ob…

~/obgyn-pain-sop/build_sop.js

const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  HeadingLevel, AlignmentType, BorderStyle, WidthType, VerticalAlign,
  ShadingType, PageNumber, Header, Footer, PageBreak, UnderlineType
} = require('docx');
const fs = require('fs');

// ── Helpers ────────────────────────────────────────────────────────────────

const NAVY   = "1F3864";
const TEAL   = "2E6B8A";
const LTBLUE = "D9E8F5";
const ORANGE = "C55A11";
const WHITE  = "FFFFFF";
const DGRAY  = "404040";

function hdr(text, level, color = NAVY) {
  const sizes = { 1: 36, 2: 28, 3: 24, 4: 22 };
  const hl    = [HeadingLevel.HEADING_1, HeadingLevel.HEADING_2,
                 HeadingLevel.HEADING_3, HeadingLevel.HEADING_4];
  return new Paragraph({
    heading: hl[level - 1],
    spacing: { before: 240, after: 120 },
    children: [
      new TextRun({
        text,
        bold: level <= 2,
        size: sizes[level] || 22,
        color,
        font: "Calibri",
      }),
    ],
  });
}

function para(text, opts = {}) {
  return new Paragraph({
    spacing: { after: 100, before: opts.before || 0 },
    alignment: opts.align || AlignmentType.JUSTIFIED,
    bullet: opts.bullet ? { level: opts.bulletLevel || 0 } : undefined,
    children: [
      new TextRun({
        text,
        size: 20,
        font: "Calibri",
        color: DGRAY,
        bold: opts.bold || false,
        italics: opts.italic || false,
      }),
    ],
  });
}

function boldPara(label, value) {
  return new Paragraph({
    spacing: { after: 80 },
    alignment: AlignmentType.JUSTIFIED,
    children: [
      new TextRun({ text: label, bold: true, size: 20, font: "Calibri", color: NAVY }),
      new TextRun({ text: value, size: 20, font: "Calibri", color: DGRAY }),
    ],
  });
}

function rule() {
  return new Paragraph({
    border: { bottom: { color: TEAL, size: 6, style: BorderStyle.SINGLE } },
    spacing: { after: 120 },
    children: [],
  });
}

function pageBreak() {
  return new Paragraph({ children: [new PageBreak()] });
}

function shadedPara(text, bgColor = LTBLUE, textColor = NAVY) {
  return new Paragraph({
    spacing: { before: 80, after: 80 },
    shading: { type: ShadingType.SOLID, color: bgColor },
    alignment: AlignmentType.LEFT,
    children: [
      new TextRun({ text, size: 20, font: "Calibri", color: textColor, bold: true }),
    ],
  });
}

function cell(text, opts = {}) {
  return new TableCell({
    width: opts.width ? { size: opts.width, type: WidthType.PERCENTAGE } : undefined,
    shading: opts.shading ? { type: ShadingType.SOLID, color: opts.shading } : undefined,
    verticalAlign: VerticalAlign.CENTER,
    children: [
      new Paragraph({
        alignment: AlignmentType.LEFT,
        spacing: { before: 60, after: 60 },
        children: [
          new TextRun({
            text,
            size: 18,
            font: "Calibri",
            bold: opts.bold || false,
            color: opts.textColor || DGRAY,
          }),
        ],
      }),
    ],
  });
}

function tableHeaderRow(cols) {
  return new TableRow({
    tableHeader: true,
    children: cols.map(c =>
      cell(c, { bold: true, shading: NAVY, textColor: WHITE })
    ),
  });
}

function makeTable(headers, rows, widths) {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    borders: {
      top:           { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      bottom:        { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      left:          { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      right:         { style: BorderStyle.SINGLE, size: 4, color: TEAL },
      insideH:       { style: BorderStyle.SINGLE, size: 2, color: "BBBBBB" },
      insideV:       { style: BorderStyle.SINGLE, size: 2, color: "BBBBBB" },
    },
    rows: [
      tableHeaderRow(headers),
      ...rows.map((r, ri) =>
        new TableRow({
          children: r.map((c, ci) =>
            cell(c, {
              width: widths ? widths[ci] : undefined,
              shading: ri % 2 === 0 ? "F2F8FC" : WHITE,
            })
          ),
        })
      ),
    ],
  });
}

// ── Document content ───────────────────────────────────────────────────────

const docChildren = [

  // ── COVER ──────────────────────────────────────────────────────────────
  new Paragraph({
    alignment: AlignmentType.CENTER,
    spacing: { before: 1200, after: 200 },
    children: [new TextRun({ text: "PAIN MANAGEMENT", bold: true, size: 56, font: "Calibri", color: NAVY })],
  }),
  new Paragraph({
    alignment: AlignmentType.CENTER,
    spacing: { after: 160 },
    children: [new TextRun({ text: "STANDARD OPERATING PROCEDURE", bold: true, size: 40, font: "Calibri", color: TEAL })],
  }),
  new Paragraph({
    alignment: AlignmentType.CENTER,
    spacing: { after: 80 },
    children: [new TextRun({ text: "Obstetrics & Gynaecology Ward", size: 32, font: "Calibri", color: ORANGE, bold: true })],
  }),
  new Paragraph({
    alignment: AlignmentType.CENTER,
    spacing: { after: 80 },
    children: [new TextRun({ text: "Tertiary / Teaching Hospital", size: 24, font: "Calibri", color: DGRAY })],
  }),
  new Paragraph({ spacing: { after: 400 }, children: [] }),

  // Document info box
  makeTable(
    [],
    [
      ["SOP Reference:",  "OBG-PM-001"],
      ["Version:",        "1.0"],
      ["Effective Date:", "May 2026"],
      ["Review Date:",    "May 2028"],
      ["Owner:",          "Department of Obstetrics & Gynaecology"],
      ["Approved By:",    "Head of Department / Clinical Governance Committee"],
      ["Classification:", "Clinical – Restricted to Healthcare Professionals"],
    ],
    [30, 70]
  ),

  pageBreak(),

  // ── 1. PURPOSE ─────────────────────────────────────────────────────────
  hdr("1.  PURPOSE", 1),
  rule(),
  para("This Standard Operating Procedure (SOP) establishes a consistent, evidence-based approach to the assessment and management of pain for all patients admitted to or cared for in the Obstetrics & Gynaecology (OB/GYN) ward. It covers three principal patient groups:"),
  para("Labour and delivery patients (antenatal, intrapartum)", { bullet: true }),
  para("Postoperative patients (caesarean section, gynaecological surgery)", { bullet: true }),
  para("Non-obstetric gynaecology patients (medical and procedural admissions)", { bullet: true }),
  para("The SOP promotes multimodal analgesia, appropriate opioid stewardship, and routine pain reassessment while ensuring the safety of both mother and neonate where applicable."),

  // ── 2. SCOPE ───────────────────────────────────────────────────────────
  hdr("2.  SCOPE", 1),
  rule(),
  para("This SOP applies to:"),
  para("All nursing, midwifery, obstetric, gynaecology, and anaesthetic staff working in the OB/GYN ward and affiliated theatres.", { bullet: true }),
  para("All patients aged 16 years and above admitted under the OB/GYN service.", { bullet: true }),
  para("Inpatient, day-surgery, and observation areas within the OB/GYN unit.", { bullet: true }),

  // ── 3. DEFINITIONS ─────────────────────────────────────────────────────
  hdr("3.  DEFINITIONS", 1),
  rule(),
  makeTable(
    ["Term", "Definition"],
    [
      ["Multimodal analgesia",   "Use of two or more analgesic agents or techniques with different mechanisms to achieve superior pain control with lower opioid doses and fewer side effects."],
      ["NRS",                    "Numerical Rating Scale: 0 (no pain) to 10 (worst imaginable pain)."],
      ["VAS",                    "Visual Analogue Scale: a 10 cm horizontal line used to quantify pain intensity."],
      ["FLACC",                  "Face, Legs, Activity, Cry, Consolability scale — used for non-verbal patients."],
      ["PRN",                    "Pro re nata — administered as needed based on clinical assessment."],
      ["PCA",                    "Patient-Controlled Analgesia: device allowing patient self-administration of a pre-programmed opioid dose."],
      ["TAP block",              "Transversus Abdominis Plane block — regional technique injecting local anaesthetic between the internal oblique and transversus abdominis muscles."],
      ["ESP block",              "Erector Spinae Plane block — regional technique used for multimodal post-caesarean analgesia."],
      ["Intrathecal morphine",   "Small-dose morphine administered into the CSF at the time of spinal anaesthesia to provide extended post-operative analgesia."],
      ["ERAC",                   "Enhanced Recovery After Caesarean — structured perioperative care pathway optimising recovery."],
      ["OUD",                    "Opioid Use Disorder — requires modified analgesic protocols."],
    ],
    [25, 75]
  ),

  pageBreak(),

  // ── 4. PAIN ASSESSMENT ──────────────────────────────────────────────────
  hdr("4.  PAIN ASSESSMENT", 1),
  rule(),

  hdr("4.1  Tools", 2),
  makeTable(
    ["Patient Group", "Recommended Scale", "When to Use"],
    [
      ["Communicative adult", "NRS (0–10)", "All routine assessments"],
      ["Non-verbal / sedated", "FLACC or Behavioural Pain Scale (BPS)", "ICU / high-dependency"],
      ["Paediatric (if applicable)", "Wong-Baker FACES", "Age < 8 years"],
      ["Labour pain", "NRS or verbal descriptor scale", "Every 30 minutes during active labour"],
    ],
    [30, 35, 35]
  ),
  para(""),

  hdr("4.2  Assessment Frequency", 2),
  makeTable(
    ["Clinical Setting", "Minimum Frequency"],
    [
      ["Active labour", "Every 30 minutes or after each contraction cluster"],
      ["Post-caesarean (first 24 hours)", "Every 1 hour"],
      ["Post-caesarean (24–72 hours)", "Every 4 hours, or with analgesic administration"],
      ["Post-gynaecological surgery (0–24 h)", "Every 2 hours"],
      ["Post-gynaecological surgery (> 24 h)", "Every 4–6 hours"],
      ["Medical gynaecology ward", "At admission, then at least 4-hourly; with each PRN dose"],
      ["After neuraxial opioid", "Respiratory rate and sedation every 1 h x 12 h; every 2 h x 12 h"],
    ],
    [40, 60]
  ),
  para(""),

  hdr("4.3  Pain Targets", 2),
  para("Target NRS < 4 at rest and < 6 on movement for all post-operative patients."),
  para("Document pain scores in the patient's nursing observation chart alongside vital signs."),
  para("Escalate to medical staff if pain is uncontrolled (NRS ≥ 7 despite initial treatment) or if there is a sudden change in pain character or location."),

  pageBreak(),

  // ── 5. ANALGESIC LADDER ────────────────────────────────────────────────
  hdr("5.  ANALGESIC LADDER – OB/GYN WARD", 1),
  rule(),
  para("A step-wise multimodal approach is used. Steps are cumulative; add the next step if pain is not controlled, rather than replacing prior agents."),
  para(""),

  hdr("Step 1 – Non-Opioid Baseline (all patients unless contraindicated)", 2),
  makeTable(
    ["Drug", "Dose & Route", "Frequency", "Key Notes"],
    [
      ["Paracetamol (Acetaminophen)", "1 g PO or IV", "Every 6 hours (regular)", "Max 4 g/day. Reduce to 500 mg QDS in hepatic impairment or weight < 50 kg. SAFE in pregnancy and breastfeeding."],
      ["Ibuprofen", "400 mg PO", "Every 8 hours with food (regular)", "Avoid in pregnancy (esp. ≥ 30 weeks — premature ductus arteriosus closure). Use post-delivery/post-op in absence of contraindications. Gastroprotection if high risk (omeprazole 20 mg OD)."],
      ["Diclofenac", "50 mg PO or 100 mg PR", "Every 8–12 hours", "As per ibuprofen. Suppository useful post-op when oral route restricted."],
      ["Ketorolac", "15–30 mg IV/IM", "Every 6 hours (max 5 days)", "Schedule IV for first 24–48 h post-caesarean, then transition to oral NSAID. Do NOT use in pregnancy."],
    ],
    [18, 22, 20, 40]
  ),
  para(""),

  hdr("Step 2 – Weak Opioid / Adjuncts (mild-moderate uncontrolled pain)", 2),
  makeTable(
    ["Drug", "Dose & Route", "Frequency", "Key Notes"],
    [
      ["Codeine phosphate", "30–60 mg PO", "Every 4–6 hours PRN", "Avoid in breastfeeding (risk of neonatal CNS depression). Avoid in known CYP2D6 ultra-rapid metabolisers."],
      ["Tramadol", "50–100 mg PO or slow IV", "Every 6 hours PRN", "Lower abuse potential than strong opioids. Use with caution in patients on SSRIs (serotonin syndrome risk). Reduce dose in renal impairment."],
      ["Nitrous oxide / oxygen (Entonox)", "50:50 mix, inhaled", "Intermittent PRN during labour contractions", "Labour analgesia only. Self-administered. Provides rapid but short-acting relief. Not suitable for prolonged use > 6 hours."],
    ],
    [18, 22, 20, 40]
  ),
  para(""),

  hdr("Step 3 – Strong Opioids (moderate-severe pain; specialist/senior review required)", 2),
  makeTable(
    ["Drug", "Dose & Route", "Frequency", "Key Notes"],
    [
      ["Morphine sulphate", "2.5–5 mg IV titrated; 5–10 mg SC/IM; 10–20 mg PO", "Every 3–4 hours PRN; titrate to effect", "Gold standard. Use with anti-emetic (ondansetron 4 mg IV or metoclopramide 10 mg IV). Monitor sedation and respiratory rate. Naloxone 400 mcg IV must be available."],
      ["Oxycodone", "2.5–5 mg PO (IR)", "Every 4–6 hours PRN", "Alternative if morphine poorly tolerated. Avoid in breastfeeding newborns < 1 month."],
      ["Pethidine (Meperidine)", "50–100 mg IM or slow IV", "Every 3–4 hours PRN", "Use in labour only. Avoid if delivery anticipated within 2–4 hours (neonatal respiratory depression). Avoid in patients on MAOIs."],
      ["Fentanyl PCA", "10–20 mcg IV bolus, lock-out 5–10 min", "PCA pump (anaesthesia prescribed)", "Post-major surgery with anaesthetist oversight. Continuous monitoring required."],
    ],
    [18, 22, 20, 40]
  ),
  para(""),

  hdr("Step 4 – Regional / Neuraxial Techniques (anaesthetist-led)", 2),
  makeTable(
    ["Technique", "Indication", "Agent / Dose", "Notes"],
    [
      ["Epidural analgesia", "Labour pain; post-major surgery", "0.0625–0.125% levobupivacaine + fentanyl 2 mcg/mL, 10–15 mL loading, then PCEA or infusion", "Gold standard for labour. Reduces opioid requirement. Midwifery monitoring per epidural protocol."],
      ["Combined spinal-epidural (CSE)", "Labour; transition to post-op", "Intrathecal bupivacaine 2.5 mg + fentanyl 15–25 mcg; epidural maintained", "Faster onset than epidural alone."],
      ["Intrathecal morphine", "Post-caesarean", "100–200 mcg with spinal bupivacaine (0.5% heavy, 2–2.5 mL)", "Provides 12–24 h analgesia. Mandatory respiratory monitoring per Section 4.2."],
      ["TAP block", "Post-caesarean, post-laparotomy", "20 mL 0.25% bupivacaine each side (bilateral)", "Effective for somatic incision pain; less effective for visceral pain. Given intra-operatively or in recovery."],
      ["ESP block", "Post-caesarean (alternative to TAP)", "20–30 mL 0.25% ropivacaine per side", "Evidence: comparable or superior to TAP (Mansour 2025 meta-analysis, PMID 40068734)."],
      ["Wound infiltration / CWI", "Post-caesarean, post-laparotomy", "0.5% levobupivacaine infiltration; or catheter delivering 0.25% bupivacaine at 4–8 mL/h", "Adjunct; reduces opioid requirement."],
    ],
    [20, 20, 30, 30]
  ),

  pageBreak(),

  // ── 6. LABOUR PAIN ─────────────────────────────────────────────────────
  hdr("6.  LABOUR PAIN MANAGEMENT", 1),
  rule(),

  hdr("6.1  Non-Pharmacological Methods (first-line adjuncts)", 2),
  para("Offer to all women in labour regardless of pharmacological analgesia:", { bold: false }),
  para("Continuous midwifery support / one-to-one care", { bullet: true }),
  para("Immersion in water (birthing pool) — first stage of labour", { bullet: true }),
  para("Breathing and relaxation techniques (Lamaze, hypnobirthing)", { bullet: true }),
  para("Ambulation and positional changes", { bullet: true }),
  para("TENS (Transcutaneous Electrical Nerve Stimulation) — early labour", { bullet: true }),
  para("Warm packs to lower back and perineum", { bullet: true }),
  para(""),

  hdr("6.2  Pharmacological Stepwise Protocol", 2),
  makeTable(
    ["Stage", "Recommended Analgesia", "Comments"],
    [
      ["Early labour (latent phase)", "Paracetamol 1 g PO, TENS, Entonox", "Reassess after 1 h. If inadequate, escalate."],
      ["Active labour (cervix ≥ 4 cm)", "Entonox + consider IM pethidine 50–100 mg OR request epidural", "Pethidine onset 20–30 min. Offer anti-emetic concurrently. Avoid if delivery < 2–4 h away."],
      ["Established labour — patient requests epidural", "Refer to obstetric anaesthetist immediately. Do not delay.", "Epidural is the most effective form of intrapartum analgesia."],
      ["Second stage", "Continue epidural; top-up if required. Entonox for crowning.", "Perineal infiltration with 10 mL 1% lidocaine prior to episiotomy."],
      ["Perineal repair (postnatal)", "Lidocaine 1% perineal infiltration + oral paracetamol/ibuprofen", "Diclofenac 100 mg PR (single dose) if significant perineal tear."],
      ["High-order perineal tear (3rd/4th degree)", "Epidural top-up in theatre + regular paracetamol + NSAID. Consultant review.", "Epidural morphine 3 mg (limited data; consider risks/benefits — SOAP 2024)."],
    ],
    [22, 38, 40]
  ),
  para(""),

  hdr("6.3  Epidural Monitoring Checklist", 2),
  para("Before epidural insertion: consent, IV access (at least 18 G), 500 mL crystalloid preload, full NIBP/SpO2 monitoring."),
  para("After each bolus / top-up: blood pressure every 5 minutes for 20 minutes, fetal heart rate monitoring, sensory level assessment."),
  para("Ongoing: maternal blood pressure every 30 minutes, FHR continuous CTG, sensory and motor block assessment hourly."),
  para("Document all observations on the epidural monitoring chart."),
  para("Hypotension (SBP < 100 mmHg or drop > 20% baseline): IV ephedrine 6–9 mg bolus OR phenylephrine 50–100 mcg bolus; lateral tilt; IV fluid bolus 250 mL."),

  pageBreak(),

  // ── 7. POST-CAESAREAN ──────────────────────────────────────────────────
  hdr("7.  POST-CAESAREAN SECTION ANALGESIA (ERAC Protocol)", 1),
  rule(),
  para("The Enhanced Recovery After Caesarean (ERAC) pathway is followed for all elective and emergency caesarean sections. Multimodal analgesia is standard per SOAP/ACOG 2024 consensus."),
  para(""),

  hdr("7.1  Intraoperative", 2),
  para("Intrathecal morphine 100–150 mcg at time of spinal (preferred where available)."),
  para("TAP block or ESP block bilateral if intrathecal morphine not given or for additional analgesia."),
  para("Wound infiltration with local anaesthetic prior to closure (if block not performed)."),
  para("IV paracetamol 1 g at end of surgery (if not given pre-operatively)."),
  para("Ketorolac 15–30 mg IV at end of surgery (on return to ward, if no intraoperative bleeding concerns)."),
  para(""),

  hdr("7.2  Post-Operative Hours 0–24", 2),
  makeTable(
    ["Agent", "Dose & Route", "Schedule"],
    [
      ["Paracetamol",    "1 g IV or PO",         "Every 6 hours REGULAR"],
      ["Ketorolac",      "15–30 mg IV",           "Every 6 hours REGULAR for 24 h, then switch to oral NSAID"],
      ["Ibuprofen",      "400 mg PO",             "Every 8 hours REGULAR (from when oral tolerated)"],
      ["Morphine",       "2.5–5 mg IV PRN",       "For breakthrough pain; titrated by nursing staff per standing order"],
      ["Ondansetron",    "4 mg IV",               "With each opioid dose; or PRN nausea"],
      ["Omeprazole",     "20 mg PO/IV",           "Once daily gastric protection if NSAID continued > 24 h"],
    ],
    [25, 35, 40]
  ),
  para(""),

  hdr("7.3  Post-Operative Hours 24–72", 2),
  para("Transition to regular oral analgesia as soon as tolerated (aim by 24 hours):"),
  para("Paracetamol 1 g PO every 6 hours (regular)", { bullet: true }),
  para("Ibuprofen 400 mg PO every 8 hours with food (regular)", { bullet: true }),
  para("Tramadol 50–100 mg PO every 6 hours PRN for breakthrough", { bullet: true }),
  para("Oral morphine (Sevredol) 5–10 mg every 4 hours PRN if tramadol inadequate; escalate to medical team.", { bullet: true }),
  para(""),
  para("Aim to discharge with a maximum 3-day supply of oral NSAID + paracetamol. Opioids on discharge only if clinically necessary; prescribe minimum effective quantity with clear tapering instruction."),
  para(""),

  hdr("7.4  Respiratory Monitoring After Neuraxial Opioid", 2),
  shadedPara("  MANDATORY MONITORING — Intrathecal Morphine or Epidural Opioid", "FFE0B2", "C55A11"),
  makeTable(
    ["Time Post-Dose", "Monitoring Required"],
    [
      ["0–12 hours",    "Respiratory rate + sedation score every 1 hour; consider continuous pulse oximetry"],
      ["12–24 hours",   "Respiratory rate + sedation score every 2 hours"],
      ["> 24 hours",    "Routine observations (every 4 hours)"],
    ],
    [30, 70]
  ),
  para(""),
  para("Sedation Score: 0 = Awake; 1 = Mild (occasionally drowsy, easy to rouse); 2 = Moderate (frequently drowsy, easy to rouse); 3 = Severe (somnolent, difficult to rouse). Score ≥ 2 or RR < 10: STOP opioids, call anaesthetist, prepare naloxone."),
  para("Naloxone dose: 40–100 mcg IV every 2 minutes until RR > 12, max 400 mcg. Infusion 2–4 mcg/kg/h if required."),

  pageBreak(),

  // ── 8. POST-GYNAECOLOGICAL SURGERY ────────────────────────────────────
  hdr("8.  POST-GYNAECOLOGICAL SURGERY ANALGESIA", 1),
  rule(),

  hdr("8.1  Laparoscopic Surgery (Day Case / Short Stay)", 2),
  para("Multimodal analgesia: paracetamol 1 g + ibuprofen 400 mg regular, combined."),
  para("Port-site local anaesthetic infiltration (bupivacaine 0.5%, 5 mL per port) intra-operatively."),
  para("Intraperitoneal bupivacaine 20 mL 0.25% (reduces visceral / shoulder-tip pain)."),
  para("Breakthrough: oral tramadol 50–100 mg PRN; or morphine 5 mg PO if not tolerated."),
  para("Discharge analgesia: paracetamol + ibuprofen for 5–7 days; no routine opioid on discharge for uncomplicated laparoscopy."),
  para(""),

  hdr("8.2  Open Gynaecological Surgery (Laparotomy / Hysterectomy)", 2),
  para("Follow ERAC principles as per Section 7 (post-caesarean protocol applies to comparable open abdominal surgery)."),
  para("Epidural analgesia (thoracic level T8–T10) recommended for major open procedures; managed by anaesthetic team."),
  para("If no epidural: TAP block bilaterally + regular paracetamol + NSAID + PRN opioid."),
  para("Target opioid minimisation: document daily opioid consumption; reduce by 20–30% per day when pain score permits."),
  para(""),

  hdr("8.3  Vaginal Surgery (Anterior/Posterior Repair, Colporrhaphy, Sling Procedures)", 2),
  para("Regular paracetamol 1 g QDS + NSAID (ibuprofen 400 mg TDS with food)."),
  para("Diclofenac 100 mg PR at end of procedure (single dose)."),
  para("Ice packs to perineum for first 24 hours."),
  para("Opioid PRN: codeine 30–60 mg every 6 hours; morphine 5 mg PO if codeine inadequate."),
  para(""),

  hdr("8.4  Hysteroscopy / Endometrial Biopsy (Ambulatory / Day Procedure)", 2),
  para("Pre-procedure: ibuprofen 400 mg or naproxen 500 mg orally 1 hour before procedure."),
  para("Paracervical block: 20 mL 1% lidocaine divided at 3 and 9 o'clock (or 4-point: 2, 4, 8, 10 o'clock) at cervicovaginal junction (evidence: Cochrane 2024; ACOG 2025)."),
  para("Intrauterine instillation of local anaesthetic (2% lidocaine, 5 mL) may be added."),
  para("Post-procedure: regular paracetamol + NSAID for 48 hours; TENS for uterine cramps."),
  para(""),

  hdr("8.5  IUD Insertion", 2),
  para("Oral NSAID (ibuprofen 400 mg or ketorolac 10 mg PO) 1 hour before insertion."),
  para("Paracervical block (10–20 mL 1% lidocaine at 3 and 9 o'clock) for nulliparous patients or those with prior pain history."),
  para("Topical lidocaine gel on ectocervix 3–5 minutes before tenaculum placement."),
  para("Post-insertion: paracetamol + ibuprofen for 24–48 hours."),

  pageBreak(),

  // ── 9. MEDICAL GYNAECOLOGY PAIN ────────────────────────────────────────
  hdr("9.  MEDICAL GYNAECOLOGY (NON-SURGICAL) PAIN MANAGEMENT", 1),
  rule(),

  hdr("9.1  Dysmenorrhoea (Primary)", 2),
  para("NSAIDs (ibuprofen 400 mg TDS or naproxen 500 mg BD) — first-line; start at onset of bleeding."),
  para("Paracetamol 1 g QDS as adjunct."),
  para("Heat application to lower abdomen (proven comparable to ibuprofen for mild-moderate pain)."),
  para("If inadequate: add codeine 30–60 mg every 6 hours PRN."),
  para(""),

  hdr("9.2  Pelvic Inflammatory Disease (PID)", 2),
  para("Treat underlying infection (antibiotics per microbiology/local protocol) as primary management."),
  para("Analgesia: paracetamol 1 g QDS regular + ibuprofen 400 mg TDS with food (in absence of contraindications)."),
  para("Severe pain: tramadol 50–100 mg TDS PRN; escalate if NRS ≥ 7."),
  para(""),

  hdr("9.3  Ectopic Pregnancy / Miscarriage (Pre-surgical)", 2),
  para("Paracetamol 1 g every 4–6 hours (max 4 doses/day) for pain relief while awaiting diagnosis or procedure."),
  para("Avoid NSAIDs if there is risk of haemorrhage or if patient is haemodynamically unstable."),
  para("IV morphine 2.5–5 mg titrated if severe pain; document response and vital signs."),
  para("Ensure patient is nil-by-mouth protocol observed if surgery anticipated."),
  para(""),

  hdr("9.4  Endometriosis", 2),
  para("Acute flare: NSAIDs (naproxen 500 mg BD or ibuprofen 400 mg TDS) — first-line."),
  para("Add paracetamol 1 g QDS for continuous background control."),
  para("Severe refractory pain: consider short course tramadol, or consult chronic pain / specialist gynaecology team."),
  para("Avoid long-term opioids for endometriosis-related pain without pain specialist review."),
  para(""),

  hdr("9.5  Ovarian Cyst (Pain Episode)", 2),
  para("NRS-guided stepwise analgesia per Section 5 ladder."),
  para("If cyst suspected rupture with haemodynamic compromise: do not delay surgical assessment for analgesia purposes — titrated IV morphine is safe and does not mask surgical signs."),
  para(""),

  pageBreak(),

  // ── 10. SPECIAL POPULATIONS ────────────────────────────────────────────
  hdr("10.  SPECIAL POPULATIONS", 1),
  rule(),

  hdr("10.1  Pregnant Patients (Antepartum)", 2),
  makeTable(
    ["Analgesic", "Safety in Pregnancy", "Notes"],
    [
      ["Paracetamol",       "SAFE — all trimesters",                     "First-line for all pain in pregnancy."],
      ["NSAIDs (ibuprofen)", "AVOID ≥ 20 weeks; AVOID ≥ 30 weeks (ductus)", "Short course < 20 weeks with specialist input only; AVOID in 3rd trimester."],
      ["Codeine",           "AVOID near term and breastfeeding",          "CYP2D6 variation risk. Use with caution in 1st/2nd trimester only."],
      ["Tramadol",          "LIMITED DATA — avoid unless necessary",      "May cause neonatal withdrawal if used near term."],
      ["Morphine / opioids", "Use for severe pain, minimum effective dose", "Monitor neonate for respiratory depression if given near delivery."],
      ["Aspirin",           "Low-dose (75–150 mg) SAFE for pre-eclampsia prophylaxis", "Analgesic doses AVOID in pregnancy."],
    ],
    [20, 30, 50]
  ),
  para(""),

  hdr("10.2  Breastfeeding / Postpartum", 2),
  para("Paracetamol and ibuprofen: SAFE — both first-line choices for post-delivery analgesia."),
  para("Codeine: AVOID — risk of neonatal CNS/respiratory depression via breast milk (especially CYP2D6 ultra-rapid metabolisers)."),
  para("Tramadol: low levels in breast milk; use with caution, minimum dose, short duration only."),
  para("Morphine: low oral bioavailability in neonate; short-term use acceptable at lowest effective dose."),
  para(""),

  hdr("10.3  Patients with Opioid Use Disorder (OUD)", 2),
  para("Continue Medications for Opioid Use Disorder (MOUD): buprenorphine or methadone throughout admission — do NOT discontinue perioperatively."),
  para("Prioritise NSAIDs and paracetamol on a scheduled basis (SOAP 2024 consensus)."),
  para("Avoid partial agonists (buprenorphine) for acute pain if patient is on full agonist opioids — consult addiction medicine/anaesthesia."),
  para("Document all opioid doses and prescriptions; use lowest effective doses with clear tapering plan."),
  para("Engage addiction medicine / pain specialist team for complex cases."),
  para(""),

  hdr("10.4  Hepatic Impairment", 2),
  para("Paracetamol: reduce dose to 500 mg QDS (max 2 g/day) in hepatic impairment (Child-Pugh B/C)."),
  para("NSAIDs: USE WITH CAUTION or avoid in severe hepatic impairment (risk of renal impairment and bleeding)."),
  para(""),

  hdr("10.5  Renal Impairment (eGFR < 30 mL/min)", 2),
  para("Avoid NSAIDs (deteriorate renal function, fluid retention, hyperkalaemia)."),
  para("Tramadol: reduce dose, avoid if eGFR < 10."),
  para("Morphine: metabolites accumulate — use with caution, shorter dosing intervals, monitor for sedation."),
  para("Paracetamol: SAFE at standard dose; extend interval to every 8 hours if eGFR < 10."),

  pageBreak(),

  // ── 11. ADVERSE EFFECTS & MONITORING ──────────────────────────────────
  hdr("11.  ADVERSE EFFECTS AND MONITORING", 1),
  rule(),
  makeTable(
    ["Drug / Class", "Key Adverse Effects", "Monitoring / Actions"],
    [
      ["Paracetamol",      "Hepatotoxicity (overdose)",                  "Check cumulative daily dose; LFTs if prolonged high-dose use."],
      ["NSAIDs",           "GI bleeding, renal impairment, fluid retention, cardiovascular risk, delayed ductus closure (fetus)", "Gastroprotection, assess renal function if prolonged use, avoid in high CV risk."],
      ["Opioids (all)",    "Nausea/vomiting, constipation, sedation, respiratory depression, pruritus (neuraxial)", "Sedation score + RR monitoring; anti-emetics PRN; laxatives with regular opioids; naloxone available."],
      ["Epidural/spinal",  "Hypotension, high block, urinary retention, post-dural puncture headache (PDPH)", "BP monitoring post-bolus; Trendelenburg + vasopressor for hypotension; blood patch for PDPH."],
      ["Local anaesthetics (systemic)", "LAST (Local Anaesthetic Systemic Toxicity): arrhythmia, CNS excitation/seizure", "Intralipid 20% available; inject in divided doses with aspiration; max dosing adherence."],
      ["Tramadol",         "Serotonin syndrome (with SSRIs/SNRIs), lowered seizure threshold", "Avoid or reduce dose in patients on serotonergic drugs."],
    ],
    [22, 35, 43]
  ),
  para(""),
  shadedPara("  EMERGENCY: Local Anaesthetic Systemic Toxicity (LAST)", "FFE0B2", "C55A11"),
  para("Stop injection immediately. Call for help (code blue if cardiac arrest). Intralipid 20% bolus 1.5 mL/kg IV over 1 minute, then infusion 15 mL/kg/h. Follow AAGBI LAST guidelines. Ensure Intralipid 20% is stocked in every area where regional blocks are performed."),

  pageBreak(),

  // ── 12. OPIOID STEWARDSHIP ────────────────────────────────────────────
  hdr("12.  OPIOID STEWARDSHIP", 1),
  rule(),
  para("12.1  Before prescribing any opioid, document: pain score, indication, prior analgesics given, relevant contraindications."),
  para("12.2  Prescribe the lowest effective dose for the shortest clinically appropriate duration."),
  para("12.3  Avoid opioid co-prescribing with benzodiazepines unless specifically indicated (anaesthesia/ICU)."),
  para("12.4  Regular oral opioids should NOT be prescribed for more than 72 hours without consultant review."),
  para("12.5  On discharge: prescribe no more than 3–5 days' supply of oral opioid when required; provide written tapering instructions."),
  para("12.6  Opioid prescriptions must include: drug name, dose, route, frequency, indication, and total quantity. No open-ended opioid prescriptions."),
  para("12.7  Conduct daily ward round review of opioid-prescribed patients; document plan to de-escalate or discontinue."),
  para("12.8  Report unexpected opioid use or patient requests for early refills to the prescribing team."),

  pageBreak(),

  // ── 13. NON-PHARMACOLOGICAL ADJUNCTS ──────────────────────────────────
  hdr("13.  NON-PHARMACOLOGICAL ADJUNCTS (All Patients)", 1),
  rule(),
  makeTable(
    ["Technique", "Evidence / Application"],
    [
      ["Cognitive-behavioural therapy (CBT) / relaxation", "Useful for chronic pelvic pain and endometriosis; can reduce analgesic requirements."],
      ["Heat therapy (warm packs)", "First-line adjunct for dysmenorrhoea; perineal warm packs post-delivery."],
      ["TENS", "Effective for early labour and dysmenorrhoea; self-managed."],
      ["Acupuncture / acupressure", "Adjunct for labour pain; evidence moderate. May be offered if requested and available."],
      ["Positioning and mobilisation", "Encouraged in all patients to reduce musculoskeletal pain; essential in post-operative recovery."],
      ["Ice packs", "Post-perineal repair, post-laparoscopy (port sites) for first 24 hours."],
      ["Mindfulness / hypnobirthing", "Adjunct for labour pain; reduces anxiety and perceived pain intensity."],
    ],
    [30, 70]
  ),

  pageBreak(),

  // ── 14. DOCUMENTATION ────────────────────────────────────────────────
  hdr("14.  DOCUMENTATION REQUIREMENTS", 1),
  rule(),
  para("All of the following must be documented in the patient's medical and nursing records:"),
  para("Pain score (NRS or scale used) at every assessment", { bullet: true }),
  para("Analgesic drug, dose, route, and time of administration", { bullet: true }),
  para("Response to analgesia (pain score at 30–60 minutes post-dose)", { bullet: true }),
  para("Adverse effects observed and actions taken", { bullet: true }),
  para("Sedation score and respiratory rate (for opioid-treated patients)", { bullet: true }),
  para("Regional block record (technique, agent, dose, time, operator, block level) — separate block chart", { bullet: true }),
  para("Epidural observations on dedicated epidural monitoring chart", { bullet: true }),
  para("Prescriber review of opioid plan at each ward round", { bullet: true }),
  para("Discharge analgesia plan and patient education provided", { bullet: true }),

  // ── 15. ROLES AND RESPONSIBILITIES ───────────────────────────────────
  hdr("15.  ROLES AND RESPONSIBILITIES", 1),
  rule(),
  makeTable(
    ["Role", "Responsibility"],
    [
      ["Nursing/Midwifery Staff",       "Routine pain assessment, administration of prescribed analgesia, monitoring for adverse effects, documentation, escalation."],
      ["Obstetric/Gynaecology Medical Officer", "First-line analgesic prescriptions, pain reassessment if uncontrolled, escalation to registrar/consultant."],
      ["OB/GYN Registrar / Consultant", "Management of complex or uncontrolled pain, prescribing Step 3–4 analgesia, OUD consultation, discharge analgesia plan."],
      ["Obstetric Anaesthetist",        "Neuraxial and regional techniques, epidural management, ERAC protocols, consultation for high-risk patients."],
      ["Pharmacist",                    "Review of analgesic prescriptions, drug interactions, renal/hepatic dose adjustments, patient counselling on discharge."],
      ["Pain Management Team",          "Consultation for refractory, chronic, or complex pain; OUD-related pain; and patients with multiple drug intolerances."],
    ],
    [30, 70]
  ),

  pageBreak(),

  // ── 16. ESCALATION PATHWAY ───────────────────────────────────────────
  hdr("16.  PAIN ESCALATION PATHWAY", 1),
  rule(),
  shadedPara("  STEP 1: Nurse / Midwife", LTBLUE, NAVY),
  para("Assess pain NRS. Give prescribed PRN analgesia. Reassess after 30–60 min. Document."),
  para(""),
  shadedPara("  STEP 2: If NRS ≥ 7 or uncontrolled after 2 PRN doses — Call Medical Officer", LTBLUE, NAVY),
  para("Medical officer reviews: adjust analgesia, add step-up agent, examine for new pathology."),
  para(""),
  shadedPara("  STEP 3: If still uncontrolled — Call OB/GYN Registrar", LTBLUE, NAVY),
  para("Registrar reviews: prescribe Step 3/4 analgesia, consider regional technique, consider surgical cause."),
  para(""),
  shadedPara("  STEP 4: Specialist Consultation", LTBLUE, NAVY),
  para("Obstetric anaesthetist (regional techniques), pain management team (chronic/complex), or relevant surgical/medical specialty."),
  para(""),
  para("Any patient in severe pain (NRS 8–10) unresponsive to analgesia warrants urgent medical review within 30 minutes. Document time of escalation and response."),

  // ── 17. TRAINING ────────────────────────────────────────────────────
  hdr("17.  TRAINING AND COMPETENCY", 1),
  rule(),
  para("All nursing and midwifery staff must complete pain assessment and opioid safety training on orientation and annually thereafter."),
  para("Epidural monitoring competency: all ward nurses caring for patients with epidurals must be assessed annually."),
  para("Naloxone administration: mandatory for all clinical staff working in OB/GYN inpatient areas."),
  para("LAST management (Intralipid protocol): mandatory for anaesthetic and surgical teams performing regional blocks."),
  para("Regional anaesthesia (epidural/spinal): performed by trained anaesthetists only; trainees under direct supervision."),

  // ── 18. REVIEW ───────────────────────────────────────────────────────
  hdr("18.  REVIEW AND AUDIT", 1),
  rule(),
  para("This SOP will be reviewed every 2 years or sooner if:"),
  para("New national or international guidelines are published.", { bullet: true }),
  para("A critical incident or adverse event relates to pain management in the OB/GYN ward.", { bullet: true }),
  para("Significant new evidence changes clinical recommendations.", { bullet: true }),
  para(""),
  para("Audit metrics to be monitored quarterly:"),
  para("Percentage of patients with documented pain scores at each assessment point.", { bullet: true }),
  para("Rate of uncontrolled pain (NRS > 7) at 24 hours post-operative.", { bullet: true }),
  para("Opioid use per patient per post-operative day (morphine milligram equivalents).", { bullet: true }),
  para("Naloxone use (opioid reversal events).", { bullet: true }),
  para("Post-dural puncture headache rate.", { bullet: true }),
  para(""),

  // ── 19. REFERENCES ───────────────────────────────────────────────────
  hdr("19.  REFERENCES", 1),
  rule(),
  para("1. Society of Obstetric Anesthesia and Perinatology (SOAP) / ACOG Consensus Statement on Pain Management for Obstetric Patients with Opioid Use Disorder. Anesthesia & Analgesia, 2024."),
  para("2. American College of Obstetricians and Gynecologists (ACOG). Pain Management for In-Office Uterine and Cervical Procedures. Clinical Consensus, May 2025."),
  para("3. Mansour MA, Baradwan S, Shama AA. Erector spinae plane block versus transversus abdominis plane block for analgesia after caesarean section: a systematic review and meta-analysis. Braz J Anesthesiol. 2025 Jul-Aug. PMID: 40068734."),
  para("4. Miller's Anesthesia, 10th Edition. Epidural analgesia in obstetrics — levobupivacaine/fentanyl combinations."),
  para("5. Enhanced Recovery After Caesarean (ERAC) Guidelines — SOAP/ACOG Collaborative."),
  para("6. WHO Obstetric, Gynaecology and Newborn Care HW Manual."),
  para("7. National Institute for Health and Care Excellence (NICE). Intrapartum care. CG190."),
  para("8. Royal College of Obstetricians and Gynaecologists (RCOG). Post-operative care guidance."),

  pageBreak(),

  // ── APPENDIX A ───────────────────────────────────────────────────────
  hdr("APPENDIX A — Quick Reference: Drug Doses at a Glance", 1),
  rule(),
  makeTable(
    ["Drug", "Adult Dose", "Route", "Frequency", "Max/24h"],
    [
      ["Paracetamol",  "1 g (500 mg if < 50 kg or hepatic impairment)", "PO / IV",     "Every 6 h",        "4 g (2 g if impaired)"],
      ["Ibuprofen",    "400 mg",                  "PO",        "Every 8 h",         "1200 mg"],
      ["Diclofenac",   "50 mg PO / 100 mg PR",    "PO / PR",   "Every 8–12 h",      "150 mg"],
      ["Ketorolac",    "15–30 mg",                "IV / IM",   "Every 6 h",         "90 mg; max 5 days"],
      ["Codeine",      "30–60 mg",                "PO",        "Every 4–6 h PRN",   "240 mg"],
      ["Tramadol",     "50–100 mg",               "PO / slow IV","Every 6 h PRN",   "400 mg"],
      ["Pethidine",    "50–100 mg",               "IM / slow IV","Every 3–4 h PRN", "400 mg"],
      ["Morphine",     "2.5–5 mg IV; 5–10 mg PO", "IV / SC / PO","Every 3–4 h PRN","Titrated by effect"],
      ["Oxycodone IR", "2.5–5 mg",                "PO",        "Every 4–6 h PRN",   "Titrated by effect"],
      ["Entonox",      "50:50 N₂O:O₂",           "Inhaled",   "Intermittent (contractions)","6 h continuous max"],
      ["Naloxone",     "40–100 mcg",              "IV",        "Every 2 min PRN",   "400 mcg total, then infusion"],
    ],
    [16, 24, 12, 20, 28]
  ),

  pageBreak(),

  // ── APPENDIX B ───────────────────────────────────────────────────────
  hdr("APPENDIX B — Pain Assessment Reference", 1),
  rule(),
  hdr("Numerical Rating Scale (NRS)", 2),
  makeTable(
    ["Score", "Descriptor", "Clinical Action"],
    [
      ["0",     "No pain",               "No analgesia needed"],
      ["1–3",   "Mild pain",             "Non-pharmacological + paracetamol if desired"],
      ["4–6",   "Moderate pain",         "Step 1–2 analgesia (paracetamol + NSAID ± weak opioid)"],
      ["7–9",   "Severe pain",           "Step 2–3 analgesia; reassess in 30 min; escalate if unimproved"],
      ["10",    "Worst imaginable pain", "Urgent medical review; Step 3/4 analgesia; consider new pathology"],
    ],
    [10, 30, 60]
  ),
  para(""),
  hdr("Sedation Score (for opioid monitoring)", 2),
  makeTable(
    ["Score", "Descriptor", "Action"],
    [
      ["0", "Fully awake",                         "Continue monitoring"],
      ["1", "Occasionally drowsy, easy to rouse",  "Monitor closely; reduce next opioid dose"],
      ["2", "Frequently drowsy, easy to rouse",     "STOP opioid; call medical officer; increase monitoring frequency"],
      ["3", "Somnolent, difficult to rouse",        "STOP opioid; call for URGENT help; consider naloxone"],
    ],
    [10, 45, 45]
  ),

  pageBreak(),

  // ── APPENDIX C ───────────────────────────────────────────────────────
  hdr("APPENDIX C — Document Version History", 1),
  rule(),
  makeTable(
    ["Version", "Date", "Author/Reviewer", "Summary of Changes"],
    [
      ["1.0", "May 2026", "OB/GYN Department / Clinical Governance", "Initial version"],
    ],
    [10, 15, 35, 40]
  ),
  para(""),
  para("Next scheduled review: May 2028"),
  para("For queries about this SOP contact: Head of Obstetrics & Gynaecology Department"),

];

// ── Build document ─────────────────────────────────────────────────────────

const doc = new Document({
  creator: "Orris AI — OB/GYN Pain Management SOP",
  title: "Pain Management SOP — Obstetrics & Gynaecology Ward",
  description: "Standard Operating Procedure for pain management in OB/GYN tertiary hospital ward",
  styles: {
    paragraphStyles: [
      {
        id: "Normal",
        name: "Normal",
        run: { font: "Calibri", size: 20, color: DGRAY },
        paragraph: { spacing: { after: 100 } },
      },
    ],
  },
  sections: [
    {
      headers: {
        default: new Header({
          children: [
            new Paragraph({
              alignment: AlignmentType.RIGHT,
              border: { bottom: { style: BorderStyle.SINGLE, size: 4, color: TEAL } },
              spacing: { after: 80 },
              children: [
                new TextRun({ text: "Pain Management SOP — Obstetrics & Gynaecology Ward  |  Ref: OBG-PM-001  |  v1.0", size: 16, font: "Calibri", color: TEAL }),
              ],
            }),
          ],
        }),
      },
      footers: {
        default: new Footer({
          children: [
            new Paragraph({
              alignment: AlignmentType.CENTER,
              border: { top: { style: BorderStyle.SINGLE, size: 4, color: TEAL } },
              spacing: { before: 80 },
              children: [
                new TextRun({ text: "CONFIDENTIAL — For use by authorised clinical staff only  |  Page ", size: 16, font: "Calibri", color: TEAL }),
                new TextRun({ children: [PageNumber.CURRENT], size: 16, font: "Calibri", color: TEAL }),
                new TextRun({ text: " of ", size: 16, font: "Calibri", color: TEAL }),
                new TextRun({ children: [PageNumber.TOTAL_PAGES], size: 16, font: "Calibri", color: TEAL }),
              ],
            }),
          ],
        }),
      },
      properties: {
        page: {
          margin: { top: 900, bottom: 900, left: 1000, right: 900 },
        },
      },
      children: docChildren,
    },
  ],
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync("/home/daytona/workspace/obgyn-pain-sop/Pain_Management_SOP_OBG.docx", buffer);
  console.log("SUCCESS: Document written.");
}).catch(err => {
  console.error("ERROR:", err);
  process.exit(1);
});

cd /home/daytona/workspace/obgyn-pain-sop && node build_sop.js

python3 /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/works…

ls -lh /home/daytona/workspace/obgyn-pain-sop/Pain_Management_SOP_OBG.docx && py…