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A comparison of acute pain management strategies after cesarean delivery

Published:September 14, 2021DOI:https://doi.org/10.1016/j.ajog.2021.09.003

      Background

      There are approximately 1.2 million cesarean deliveries performed each year in the United States alone. While traditional postoperative pain management strategies previously relied heavily on opioids, practitioners are now moving toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics. Multimodal pain management systems have been adopted by other surgical specialties including gynecology, although the data regarding their use for postoperative cesarean delivery pain management remain limited.

      Objective

      To determine if a multimodal pain management regimen after cesarean delivery reduces the required number of morphine milligram equivalents (a unit of measurement for opioids) compared with traditional morphine patient-controlled analgesia while adequately controlling postoperative pain.

      Study Design

      This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6-week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded. The statistical analyses included the Student t test, Wilcoxon rank-sum, and Hodges–Lehman shift, with a P value <.05 being considered significant.

      Results

      During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria—378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (28 [14–41] morphine milligram equivalents vs 128 [86–174] morphine milligram equivalents; P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001).

      Conclusion

      Transition to a multimodal pain management regimen for women undergoing cesarean delivery resulted in a decrease in opioid use while adequately controlling postoperative pain. A multimodal regimen was associated with early successful exclusive breastfeeding.

      Key words

      Introduction

      There are over 1.2 million cesarean deliveries performed each year in the United States, with 1 in 3 of the opioid-naïve women becoming persistent prescription opioid users after cesarean delivery.
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      Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naive women.
      Opioid use in the postpartum period is associated with significant side-effects including nausea, emesis, itching, and decreased ambulation, which may interfere with a woman’s ability to effectively care for her newborn.
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      • Carvalho B.
      Optimal pain management after cesarean delivery.
      ,
      ACOG Committee Opinion no
      742: postpartum pain management.
      As a strategy to combat the ongoing opioid epidemic, physicians have tried to reduce opioid exposure and use in patients. With this goal, postoperative pain management strategies have evolved and physicians have moved away from the traditional strategies that relied heavily on opioids toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics, with opioid administration prescribed only as needed. These newer protocols are often referred to as multimodal pain management regimens.

      Why was this study conducted?

      Traditional postcesarean delivery pain management has relied heavily on opioids, which are associated with side-effects, excretion in the breastmilk, and a risk of dependency. The focus has now shifted to medication regimens that decrease opioid use while providing adequate pain management.

      Key findings

      A transition from a traditional morphine patient-controlled analgesia to a multimodal pain management regimen significantly decreased the amount of opioids used in the postoperative period (as measured in morphine milligram equivalents) while controlling pain adequately, if not better. The use of a multimodal regimen was also associated with early exclusive breastfeeding in women with cesarean delivery.

      What does this add to what is known?

      Studies related to enhanced recovery after surgery protocols and multimodal pain management regimens have shown many benefits including a decrease in the postoperative complications, length of hospital stay, and hospital costs. However, there are mixed results with regard to decreasing opioid consumption. Our study demonstrates a decrease in opioid consumption with the use of a multimodal regimen.
      The traditional postoperative pain management strategies include continuous infusion of opioids via an epidural catheter, patient-controlled analgesia (PCA), or long-lasting intrathecal opioid injections. Although intrathecal injections of morphine have been the gold standard for postoperative cesarean delivery pain management, studies have shown that despite the long-lasting effects of intrathecal opioids, women still need additional analgesic administration, including additional opioids, for adequate pain control.
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      Optimal pain management after cesarean delivery.
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      • et al.
      Intrathecal morphine versus intrathecal hydromorphone for analgesia after cesarean delivery: a Randomized Clinical Trial.
      Continuous infusion strategies are also associated with an increased need for the close monitoring of side-effects by nursing or anesthesia staff.
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      • Weiniger C.F.
      • Sultan P.
      • et al.
      Society for Obstetric Anesthesia and Perinatology consensus statement: monitoring recommendations for prevention and detection of respiratory depression associated with administration of neuraxial morphine for cesarean delivery analgesia.
      Other pain management techniques, including the local infiltration of anesthetic agents via transversus abdominis plane (TAP) blocks and subcutaneous injections, have also been adopted. Although TAP blocks have been shown to improve incisional pain in patients who undergo neuraxial anesthesia, the procedure does not provide pain control beyond 12 hours,
      • Sutton C.D.
      • Carvalho B.
      Optimal pain management after cesarean delivery.
      and the data suggesting a reduction in opioid requirement are mixed.
      • Warren J.A.
      • Carbonell A.M.
      • Jones L.K.
      • et al.
      Length of stay and opioid dose requirement with transversus abdominis plane block vs epidural analgesia for ventral hernia repair.
      • Ma N.
      • Duncan J.K.
      • Scarfe A.J.
      • Schuhmann S.
      • Cameron A.L.
      Clinical safety and effectiveness of transversus abdominis plane (TAP) block in post-operative analgesia: a systematic review and meta-analysis.
      • Pirrera B.
      • Alagna V.
      • Lucchi A.
      • et al.
      Transversus abdominis plane (TAP) block versus thoracic epidural analgesia (TEA) in laparoscopic colon surgery in the ERAS program.
      Other surgical fields including gynecology and gynecologic oncology have adopted the use of multimodal pain management strategies. These multimodal pathways have resulted in a decreased length of hospital stays, readmission rates, and postoperative complications; they have also decreased hospital costs. However, there are mixed results with regard to decreasing the opioid consumption.
      • Wilson R.D.
      • Caughey A.B.
      • Wood S.L.
      • et al.
      Guidelines for antenatal and preoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1).
      • Teigen N.C.
      • Sahasrabudhe N.
      • Doulaveris G.
      • et al.
      Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial.
      • Mullman L.
      • Hilden P.
      • Goral J.
      • et al.
      Improved outcomes with an enhanced recovery approach to cesarean delivery.
      Although there are robust data supporting the benefits of multimodal regimens in other surgical fields, the data on their benefits in obstetrical patients have become more available in recent years, and the emerging literature seems promising.
      • Teigen N.C.
      • Sahasrabudhe N.
      • Doulaveris G.
      • et al.
      Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial.
      ,
      • Peahl A.F.
      • Smith R.
      • Johnson T.R.B.
      • Morgan D.M.
      • Pearlman M.D.
      Better late than never: why obstetricians must implement enhanced recovery after cesarean.
      • Altenau B.
      • Crisp C.C.
      • Devaiah C.G.
      • Lambers D.S.
      Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control.
      • Hadley E.E.
      • Monsivais L.
      • Pacheco L.
      • et al.
      Multimodal pain management for cesarean delivery: a double-blinded, placebo-controlled, randomized clinical trial.
      • Smith A.M.
      • Young P.
      • Blosser C.C.
      • Poole A.T.
      Multimodal stepwise approach to reducing in-hospital opioid use after cesarean delivery: a quality improvement initiative.
      • Hedderson M.
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      • Hunt E.
      • et al.
      Enhanced recovery after surgery to change process measures and reduce opioid use after cesarean delivery: a quality improvement initiative.
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      • Hitti J.E.
      • Delgado C.M.
      • et al.
      An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost.
      • Combs C.A.
      • Robinson T.
      • Mekis C.
      • et al.
      Enhanced recovery after cesarean: impact on postoperative opioid use and length of stay.
      There are sufficient data to suggest that all components of a multimodal strategy are safe,
      • Sutton C.D.
      • Carvalho B.
      Optimal pain management after cesarean delivery.
      ,
      • Altenau B.
      • Crisp C.C.
      • Devaiah C.G.
      • Lambers D.S.
      Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control.
      ,
      • Macones G.A.
      • Caughey A.B.
      • Wood S.L.
      • et al.
      Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3).
      and now, studies demonstrating their clinical benefit are necessary.
      This study aimed to determine if a multimodal pain management regimen after cesarean delivery reduces the number of morphine milligram equivalents (MME—the unit of measurement for opioids calculated by the number of milligrams of morphine an opioid dose is equivalent to) compared with traditional morphine PCA while adequately controlling postoperative pain. We hypothesized that there would be a decrease in the opioid consumption (measured in MME) in the patients who received the multimodal regimen for postoperative pain management.

      Materials and Methods

      This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at our institution before and after a transition from a traditional morphine PCA to a multimodal pain management regimen. Pregnant women undergoing cesarean delivery at Parkland Hospital during the study period were included. Women requiring general anesthesia were excluded as they also received intraoperative TAP blocks after the transition. In addition, women with current or past substance abuse disorder were excluded. This study was approved by the institutional review board at The University of Texas Southwestern Medical Center at Dallas, Texas.

      Pain management regimen

      Intraoperative analgesia before and after the transition included either an epidural, a spinal injection, or a continuous spinal epidural. If an epidural catheter was used for intraoperative analgesia, it was removed before transfer to the recovery room. At the time of this study, our institution did not routinely use long-lasting intrathecal opioids.
      We have previously published our experience with a morphine PCA for postcesarean delivery pain control and have continued this regimen for some time at our institution.
      • Yost N.P.
      • Bloom S.L.
      • Sibley M.K.
      • Lo J.Y.
      • McIntire D.D.
      • Leveno K.J.
      A hospital-sponsored quality improvement study of pain management after cesarean delivery.
      Our obstetrical service uses a single standardized postoperative order set for all cesarean deliveries, which is used universally by physicians who place all postoperative orders. Before the transition, the order set included a morphine PCA and scheduled ibuprofen for the first 12 hours, followed by continued scheduled ibuprofen with hydrocodone-acetaminophen as needed thereafter. After the transition, the order set contained a multimodal regimen comprised of scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed for breakthrough pain (Table 1). On arrival to the recovery room, the patient received a dosage of ketorolac 30 mg intravenously (IV) and acetaminophen 1000 mg orally (PO). Ketorolac 15 mg IV was then given every 8 hours during the first 24 hours after the cesarean delivery and was transitioned to scheduled ibuprofen 600 mg PO every 8 hours for the remainder of the postoperative course. In the initial 12 hours after cesarean delivery, the patients received either oxycodone 5 mg PO or hydromorphone 0.5 mg IV as needed for breakthrough pain based on their numeric pain score. After 12 hours, the patients received either 5 mg or 10 mg oxycodone PO as needed for breakthrough pain. The patients continued to receive scheduled acetaminophen 1000 mg PO every 8 hours throughout their postoperative course. Women with medication allergies or contraindications to a specific medication in either regimen, received the appropriate regimen excluding the contraindicated medication, per current institutional practice. The standard postoperative care for women undergoing cesarean delivery remained the same before and after the transition, with the care dictated by institutional protocols and an established postcesarean delivery order set. Pain was serially measured by the nursing staff using the Numeric Rating Scale for Pain. The foley catheter was left in place, and the patients remained nil per os and were nonambulatory with sequential compression devices in place until 12 hours postcesarean delivery.
      Table 1Pain management order set before and after the transition
      Pain management orderTraditional PCA order setMultimodal regimen
      First 12 h after cesarean deliveryMorphine PCA on arrival to recovery room:
      • Morphine 1 mg IV (patient-administered) every 6 min as needed
      • Morphine 4 mg IV every 5 min as needed for pain score ≥7, up to 3 dosages (nurse-administered “loading dose”)
      • Morphine 2 mg IV every 5 min as needed for pain score ≥7 for a total of 2 dosages (nurse-administered “nurse bolus”), only if 4 mg loading dosage×3 have been consumed
      Motrin 600 mg PO every 6 h, scheduled
      Ketorolac 30 mg IV×1 dosage on arrival to recovery room, then 15 mg IV every 8 h×2 dosages, scheduled

      Acetaminophen 1 g PO every 8 h, scheduled

      Oxycodone 5 mg PO every 4 h as needed for a pain score of 4–6

      Hydromorphone
      • 0.5 mg IV every 15 min as needed for pain score ≥7 for the first 2 h
      Followed by:
      • 0.5 mg every 2 h, for up to 10 h
      >12 h after cesarean deliveryHydrocodone-acetaminophen 5–325 mg
      • One tab every 4 h as needed for pain score 4–6,
      • Two tabs every 4 h as needed for pain score ≥7
      Motrin 600 mg PO every 6 hours, scheduled (continued)
      Acetaminophen 1 g PO every 8 h, scheduled (continued)

      Motrin 600 mg PO every 6 h, scheduled (to begin 24 h after cesarean delivery)

      Oxycodone
      • 5 mg PO every 4 h as needed 1 tab for pain score of 4–6
      • 10 mg PO (2 tabs) for pain score ≥7, 1 dosage only
      • If still with pain score ≥7 after 1 dosage, notify provider
      IV, intravenous; PCA, patient-controlled analgesia; PO, orally.
      Macias et al. A multimodal pain management regimen for postcesarean delivery care. Am J Obstet Gynecol 2022.

      Data analysis

      The maternal demographics and perinatal outcomes of the patients were obtained from an obstetrical quality database, which contains the data extracted from the electronic medical records of patients. The data are extracted by dedicated research nurses according to standard protocols and definitions contained within a manual of operations, and they are routinely validated with cross-checks. Additional data were collected from the electronic medical records prospectively by research personnel for a 6-week period before and after the transition. The data included the baseline demographics, serial pain scores, the amounts of opioids used, breastfeeding goals on arrival and breastfeeding plans at discharge, adverse events (postpartum hemorrhage, return to operating room, or wound infection), and the time to discharge. The opioid doses were collected in milligrams and were converted to MME, with the conversion ratios obtained from the Journal of Pain Research (Table 2) per our current institutional standards.
      • Treillet E.
      • Laurent S.
      • Hadjiat Y.
      Practical management of opioid rotation and equianalgesia.
      Table 2Conversion factor for opioids to oral morphine milligram equivalents
      OpioidConversion factor
      Hydrocodone1
      Hydromorphone PO4
      Hydromorphone IV11
      Morphine IV3
      Oxycodone1.5
      Practical management of opioid rotation and equianalgesia.
      Adapted from Treillet et al.
      • Treillet E.
      • Laurent S.
      • Hadjiat Y.
      Practical management of opioid rotation and equianalgesia.
      IV, intravenous; PO, orally.
      Macias et al. A multimodal pain management regimen for postcesarean delivery care. Am J Obstet Gynecol 2022.
      The primary outcome was postoperative opioid use, defined as MME, in the first 48 hours after surgery. The secondary outcomes included serial pain scores at 2, 12, 24, and 48 hours after arrival to the recovery room, the cumulative MME used within the first 12 hours and 24 hours after surgery, the time to discharge and the rate of compliance with intended exclusive breastfeeding. Pain scores ≤4 were considered good pain control based on previous studies.
      • Gerbershagen H.J.
      • Rothaug J.
      • Kalkman C.J.
      • Meissner W.
      Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods.
      Uncommon adverse events including postpartum hemorrhage requiring transfusion, return to the operating room, and wound infections were also examined.

      Statistical analysis

      Over 12,000 women deliver a viable neonate at our institution each year, and approximately 30% of these deliveries, or 3600 women, are via cesarean delivery. With this, we estimated that approximately 75 deliveries per week would occur via cesarean delivery mode, with >95% of those women receiving spinal or epidural anesthesia. Based on the available data from a quality improvement project, the average opioid usage over the first 48 hours at our institution before the study was 98±78 MME. It was deemed that a 15% reduction in the MME would be the smallest clinically significant measure. All statistical analyses were based on the total cohort of patients meeting the inclusion criteria regardless of the postpartum pain management strategy employed, ie, an intention to treat analysis. To have a 90% power to detect a 15% reduction in MME, a total sample size of 788 women would be required. If approximately 90% of women would meet the inclusion criteria, 6 weeks of data collection would be necessary in each group. The statistical analyses included the Student t test and the Wilcoxon rank-sum for continuous data and Pearson chi-square for categorical data. The Hodges-Lehman statistic was used to estimate the shift in location between the 2 groups for MME and pain scores. A P value of <.05 was considered statistically significant. All statistical analyses were performed using Statistical Analysis Software 9.4 (SAS Institute Inc, Cary, NC).

      Results

      There were 877 women who underwent cesarean delivery during the 2 epochs included in the study period. There were 422 women delivered from March 15, 2020 to April 30, 2020 in the traditional PCA group, and after exclusions, 378 were included in the analysis (Figure 1). Owing to the conditions related to the COVID-19 pandemic, the date of the order set transition was delayed. Therefore, in the posttransition multimodal regimen group, there were 455 women who delivered from July 8, 2020 to August 18, 2020, and after exclusions, 400 were included in the analysis. There was no significant difference between the baseline demographic characteristics of the 2 groups (Table 3).
      Figure thumbnail gr1
      Figure 1Study inclusion criteria
      PCA, patient-controlled analgesia.
      Macias et al. A multimodal pain management regimen for postcesarean delivery care. Am J Obstet Gynecol 2022.
      Table 3Study demographics
      CharacteristicTraditional PCA groupMultimodal groupP value
      n378400
      Age (y) mean+SD29.9+5.930.1+6.4.668
      Race or ethnicity.999
       Black86 (23)91 (23)
       White12 (3)12 (3)
       Hispanic267 (71)283 (71)
       Other13 (3)14 (4)
      Parity.527
       091 (24)84 (21)
       1122 (32)121 (30)
       291 (24)103 (26)
       >274 (20)92 (23)
      BMI
       Categorical.129
       <2513 (3)23 (6)
       25–<3063 (17)84 (21)
       30–<35135 (35)143 (36)
       35–<40103 (27)85 (21)
       ≥4064 (17)65 (16)
      Data are presented as number (percentage), unless stated otherwise.
      BMI, body mass index; PCA, patient-controlled analgesia; SD, standard deviation.
      Macias et al. A multimodal pain management regimen for postcesarean delivery care. Am J Obstet Gynecol 2022.
      There was a significant reduction in MME use in the first 48 hours after delivery. At 12 hours postcesarean delivery, women in the multimodal group required a median of 22 (11–33) MME, compared with the traditional PCA group that used 102 (68–140) MME, P<.001. This difference persisted at 24 and 48 hours, with the multimodal group requiring a cumulative 25 (13–38) MME and 28 (14–41) MME at 24 and 48 hours postcesarean delivery, and the traditional PCA group having consumed 114 (76–151) MME at 24 hours and 128 (86–174) MME at 48 hours, (P<.001) (Figure 2). The discrepancy was not limited to the management of acute pain in the first 12 hours after surgery, as the multimodal group used a median of 3 (3–5) MME from 12 to 24 hours after surgery compared with 10 (5–15) MME for the traditional group, P<.001. This difference persisted for >24 hours after delivery, with the women in the multimodal group using 3 (2–5) MME from 24 to 48 hours after surgery compared with 15 (10–21) MME for the traditional group (P<.001, Table 4).
      Figure thumbnail gr2
      Figure 2Cumulative MME used between traditional PCA and multimodal postoperative pain management regimens at 12, 24, and 48 hours after cesarean delivery
      The asterisk indicates the level of significance (P<.05), obtained using the Wilcoxon rank-sum test, comparing the traditional and multimodal arms.
      MME, morphine milligram equivalents; PCA, patient-controlled analgesia.
      Macias et al. A multimodal pain management regimen for postcesarean delivery care. Am J Obstet Gynecol 2022.
      Table 4Opioid requirements and corresponding pain scores in the first 48 hours after cesarean delivery for women receiving traditional patient-controlled analgesia and multimodal pain regimens
      Postoperative factorsTraditional group n=378Multimodal group n=400P valueHL
      Total MME required (h):
       0–12102 (68–140)22 (11–33)<.00181(75–87)
       12–2410 (5–15)3 (3–5)<.00162 (5.5–7.0)
       24–4815 (10–21)3 (2–5)<.00112 (10.5–13.5)
      Pain score (h):
       20 (0–0)0 (0–0).008
      The pain scores for the multimodal group were higher at 2 and 12 hours but lower at 48 hours compared with the traditional group.
      0 (0–0)
       121 (0–4)3 (0–6)<.001
      The pain scores for the multimodal group were higher at 2 and 12 hours but lower at 48 hours compared with the traditional group.
      −0.5 (−1.0 to 0.0)
       241 (0–5)0 (0–5).150 (0–0)
       480 (0–4)0 (0–1).002
      The pain scores for the multimodal group were higher at 2 and 12 hours but lower at 48 hours compared with the traditional group.
      0 (0–0)
      Data are presented as median (interquartile range). P values are obtained using Wilcoxon rank-sum test.
      CI, confidence interval; HL, Hodges-Lehman shift (95% CI); MME, morphine milligram equivalents.
      Macias et al. A multimodal pain management regimen for postcesarean delivery care. Am J Obstet Gynecol 2022.
      a The pain scores for the multimodal group were higher at 2 and 12 hours but lower at 48 hours compared with the traditional group.
      More women in the multimodal group reported a pain score of ≤4 by 48 hours compared with the traditional morphine PCA group (88% vs 77%; P<.001). The median pain scores in both the groups remained well below the established threshold for adequate pain control (pain score ≤4) throughout the postoperative course. Initially, the median pain score was higher in the multimodal group at 2 hours postcesarean delivery (0 [0–0]) than the traditional group (0 [0–0]), P=.008. This finding persisted at 12 hours, with median pain score in the multimodal group of 3 (0–6) vs 1 (0–4) in the traditional group, P<.001. However, there was no difference at 24 hours, and by 48 hours postcesarean delivery, the median pain score in the multimodal group was lower (0 [0–1]) than the traditional group (0 [0–4]), P=.002 (Table 4). Of the women who exclusively planned to breastfeed on admission, fewer women used a formula before discharge in the multimodal group than the traditional group (9% vs 12%; P<.001). There was no difference in the time to discharge between the 2 groups, with both the traditional PCA group and the multimodal group most often discharged on postoperative day 2 (traditional PCA group 2.9 days [2.5–3.2] vs the multimodal group 2.9 days [2.4–3.2]; P=.32). The rates of adverse events such as postpartum hemorrhage, return to operating room, or wound infection were no different between the 2 groups (Table 5).
      Table 5Postoperative adverse events between the traditional group and the multimodal group
      Adverse eventsTraditional group n=378Multimodal group n=400P value
      PPH (>1000 mL)105 (27.8)112 (28).962
      Wound infection4 (1)1 (0.3).158
      Return to OR2 (0.5)1 (0.3).529
      OR, odds ratio; PPH, postpartum hemorrhage.
      Macias et al. A multimodal pain management regimen for postcesarean delivery care. Am J Obstet Gynecol 2022.

      Discussion

      Principal findings

      In this prospective observational study, there were 4 findings. First, there was a reduction in the opioid use with the implementation of a multimodal pain management regimen when compared with a traditional morphine PCA. Second, this reduction persisted over time as the patients transitioned to oral pain medications. Third, postoperative pain remained adequately controlled regardless of the regimen, with lower pain scores at 48 hours in the multimodal group despite a lower opioid requirement. Fourth, even though the time to discharge was not different between the 2 groups as the protocols and practices did not change during the study period, the continuation of exclusive breastfeeding at discharge was significantly higher in the multimodal group among those women with plans to exclusively breastfeed on arrival. Put another way, more women in the multimodal group who entered the delivery experience intending to exclusively breastfeed were successful than the traditional PCA group.

      Results

      This study compared traditional patient-controlled analgesia to a multimodal medication regimen without the simultaneous implementation of other enhanced recovery after surgery (ERAS) measures. Most previous studies on multimodal pain management used variable complex regimens, including transversus abdominus plane blocks, long-acting intrathecal morphine, and prolonged epidural use. The use of comprehensive ERAS protocols has shown mixed results, with some studies showing a decrease in opioid use,
      • Mullman L.
      • Hilden P.
      • Goral J.
      • et al.
      Improved outcomes with an enhanced recovery approach to cesarean delivery.
      whereas others showing no difference.
      • Teigen N.C.
      • Sahasrabudhe N.
      • Doulaveris G.
      • et al.
      Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial.
      ,
      • Hadley E.E.
      • Monsivais L.
      • Pacheco L.
      • et al.
      Multimodal pain management for cesarean delivery: a double-blinded, placebo-controlled, randomized clinical trial.
      While we plan to implement other portions of the ERAS for cesarean delivery guidelines in the future, we were able to demonstrate that a dramatic decrease in postoperative opioid use was possible with a change to a simple medication regimen alone.

      Clinical implications

      The use of a multimodal postoperative pain management regimen alone, without other ERAS measures, can provide a meaningful change to current practice even in facilities with limited resources. Other studies such as the randomized control trial by Hadley et al
      • Hadley E.E.
      • Monsivais L.
      • Pacheco L.
      • et al.
      Multimodal pain management for cesarean delivery: a double-blinded, placebo-controlled, randomized clinical trial.
      did not demonstrate a difference in opioid consumption. However, nonnarcotic pain medications such as acetaminophen and ibuprofen were not scheduled after surgery and were only administered as needed, which was a limitation recognized by the authors. The regimen used in our study included scheduled acetaminophen and ibuprofen with other medications as needed. Primarily, our study showed that a multimodal regimen can decrease opioid consumption. In this way, a multimodal regimen has the potential to decrease postoperative sedation and the risk of developing substance use disorder. In addition, as demonstrated by Teigen, et al
      • Teigen N.C.
      • Sahasrabudhe N.
      • Doulaveris G.
      • et al.
      Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial.
      and as now supported by our findings, such regimens may improve participation in activities such as breastfeeding.

      Research implications

      Following the findings of this study, we have permanently adopted a multimodal postcesarean pain regimen, with plans to implement other ERAS protocol measures systematically to measure their impact on postcesarean delivery care. Future research should focus on the utility of other ERAS measures such as early feeding, ambulation, and foley catheter removal. In addition, more information is needed to guide discharge prescriptive practices, specifically with regard to opioids. Studies have shown that many patients are discharged with more opioids than they consume and that many patients do not properly dispose of their remaining medication.
      • Bateman B.T.
      • Cole N.M.
      • Maeda A.
      • et al.
      Patterns of opioid prescription and use after cesarean delivery.
      • Holland E.
      • Bateman B.T.
      • Cole N.
      • et al.
      Evaluation of a quality improvement intervention that eliminated routine use of opioids after cesarean delivery.
      • Sanchez Traun K.B.
      • Schauberger C.W.
      • Ramirez L.D.
      • et al.
      Opioid prescribing trends in postpartum women: a multicenter study.
      • Badreldin N.
      • Grobman W.A.
      • Chang K.T.
      • Yee L.M.
      Opioid prescribing patterns among postpartum women.
      These findings are concerning given the ongoing opioid epidemic, and though postdischarge medication use is not addressed in this study, future studies are necessary to guide opioid prescribing practices.

      Strengths and limitations

      The strengths of our study include the large sample size and our standardized order sets and treatment protocols. Through the use of a standardized operative technique for cesarean delivery and standardized nursing and provider protocols, intraoperative and postoperative care for patients undergoing cesarean delivery was uniform both before and after the transition of regimens and between the patients within the groups. Therefore, we reduced the possibility for confounding and conflicting results that could have hindered other quality improvement studies. Our study is limited to inpatient opioid use only as we did not measure the opioid use after discharge, though traditionally, our patients are discharged with prescriptions for scheduled ibuprofen and <30 tablets of an oral narcotic. This practice did not change during the study period. The pain score interpretation and analysis are difficult in general
      • van Dijk J.F.
      • Vervoort S.C.
      • van Wijck A.J.
      • Kalkman C.J.
      • Schuurmans M.J.
      Postoperative patients’ perspectives on rating pain: a qualitative study.
      , as the interpretation of the numeric pain scale and the numeric value of pain is subjective; this makes these numbers difficult to interpret. Though statistical differences existed between our 2 treatment groups, a meaningful clinical difference was not observed, given the propensity for our patients to assess their pain level as “zero.” This was a single center report from a large academic hospital, which may limit the generalizability of our findings to other populations.

      Conclusions

      We found that a transition from a traditional morphine PCA to a multimodal pain management regimen significantly reduced opioid use in the postpartum period, without a detrimental effect on the pain scores. These findings support the adoption of such regimens moving forward, with or without other ERAS protocol measures. Future efforts to further explore pain management strategies should incorporate the use of a multimodal pain regimen as secondary benefits such as improved breastfeeding may be identified.

      Supplementary Data

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