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Am J Perinatol 2021; 38(07): 637-642
DOI: 10.1055/s-0040-1721075
SMFM Fellowship Series Article

Post-Cesarean Opioid Use after Implementation of Enhanced Recovery after Surgery Protocol

Caitlin A. MacGregor 
1   Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
2   Department of Obstetrics and Gynecology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
,
Mark Neerhof
1   Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
,
Mary J. Sperling
3   Care Transformation, NorthShore University HealthSystem, Evanston, Illinois
,
David Alspach
4   Department of Anesthesiology, NorthShore University HealthSystem, Evanston, Illinois
,
Beth A. Plunkett
1   Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
,
Alexandria Choi
1   Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
,
Rebecca Blumenthal
4   Department of Anesthesiology, NorthShore University HealthSystem, Evanston, Illinois
› Author Affiliations Funding None.
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Abstract

Objective This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD).

Study Design We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m2 and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m2, without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score.

Results All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5–182.5) in PRE compared with 0.0 (IQR: 0.0–72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26–4.27) compared with 2.37 days (IQR: 2.21–3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04).

Conclusion ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD.

Key Points

  • ERAS protocol was associated with decreased postoperative opioid use after CD.

  • ERAS protocol was associated with shorter length of stay after CD.

  • ERAS protocol was associated with decreased postoperative pain after CD.

Keywords

cesarean delivery - enhanced recovery after surgery - length of stay - multidisciplinary - obstetrics - opioid use - patient education


Publication History

Received: 13 July 2020

Accepted: 07 October 2020

Article published online:
02 December 2020

© 2020. Thieme. All rights reserved.

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