Personalized analgesic management for cesarean delivery

Postoperative analgesic consumption for primary versus first repeat Cesarean delivery: a historical cohort study

PURPOSE

It is unclear if postoperative pain experience and opioid consumption differ in patients undergoing primary vs repeat Cesarean delivery (CD) as prior studies have yielded conflicting results and none used the same patients as their own controls. We sought to compare opioid consumption and pain scores in patients undergoing both a primary and a first repeat CD, using the same patients as their own controls.

METHODS

We conducted a single-centre historical cohort study of patients who underwent both a primary and a first repeat CD under neuraxial anesthesia between 1 January 2016 and 30 November 2022. The same standardized multimodal analgesic regimen was used for all patients. The primary outcome was opioid consumption in oral morphine equivalents (OME) at 48 hr after surgery. Secondary outcomes included area under the curve for pain scores at 24 and 48 hr, and opioid consumption at 24 hr.

RESULTS

We included 409 patients. In unadjusted analysis, there were no significant differences between primary and repeat CD in median [interquartile range] opioid consumption at 48 hr (45 [15-89] mg vs 45 [15-83] mg OME) or in any of the secondary outcomes. In the multivariable model adjusting for age, body mass index, anxiety, depression, priority, surgery duration, gestational age, receipt of postoperative ketorolac, and neuraxial type, repeat CD was still not associated with increased opioid consumption compared with primary CD (adjusted rate ratio, 1.20; 95% confidence interval, 0.95 to 1.51).

CONCLUSION

In this retrospective study, we found no differences in postoperative opioid consumption or reported pain scores in patients who underwent both a primary and a first repeat CD.

Does Preoperative Pain Belief Affect Postoperative Pain and Breastfeeding?

PURPOSE

This research was carried out to determine the relationship between pain belief of women who experienced cesarean section for the first time and their postcesarean pain and breastfeeding self-efficacy levels.

DESIGN

The research is a descriptive study.

METHODS

The study was conducted with 144 patients who had not undergone any surgical operation and had their first cesarean section. Data were collected with an introductory information form, pain beliefs questionnaire (PBQ), visual analog scale (VAS), and breastfeeding self-efficacy scale (BSES).

FINDINGS

The patients' PBQ organic belief score (3.06 ± 0.61) was higher than their PBQ psychological belief score (1.87 ± 0.83), and their pain beliefs were based on an organic cause. The postcesarean section pain of the women was moderate-severe (6.75 ± 1.71), breastfeeding self-efficacy levels were high and sufficient (57.88 ± 4.86), and their pain beliefs were of organic origin. There was no significant relationship between patients' pain beliefs and postcesarean pain and breastfeeding self-efficacy levels.

CONCLUSIONS

The results of our study indicate that working status, income status, and chronic illness were associated with patients' pain beliefs, but we observed no relationship between pain beliefs and postcesarean pain and breastfeeding self-efficacy levels.

In-Hospital Opioid Consumption After the Previous Cesarean Delivery Weakly Predicts Opioid Consumption After Index Delivery: A Retrospective Cohort Study

BACKGROUND

To predict opioid consumption and pain intensity after the index cesarean delivery, we tested a hypothesis that opioid consumption after the previous cesarean delivery of the same patient can predict the opioid consumption after the index cesarean delivery. We further tested a secondary hypothesis that the pain scores after the previous cesarean delivery can predict the pain scores after the index cesarean delivery.

METHODS

This is a retrospective cohort study of 470 women who underwent both previous and index cesarean deliveries at a single institution from January 2011 to June 2019. To predict the opioid consumption (primary outcome) and average pain scores (on 11-point numeric rating scale) after their index cesarean delivery, we used a linear regression model incorporating only the opioid consumption and average pain scores after the previous cesarean delivery, respectively (unadjusted models). Demographic and obstetric variables were then added as predictors (adjusted models). The bootstrap was used to compare these models with respect to proportion of variance of the outcome accounted for (R2).

RESULTS

Unadjusted models were weakly predictive of opioid consumption (R2 = 0.268; 95% confidence interval [CI], 0.146-0.368) and average pain scores (R2 = 0.176; 95% CI, 0.057-0.250). An adjusted model for opioid consumption was weakly predictive (R2 = 0.363; 95% CI, 0.208-0.478), but an adjusted model for average pain scores was not predictive of the outcomes (R2 = 0.070; 95% CI, -0.143 to 0.219). Adjusted models failed to explain variances of opioid consumption and average pain scores significantly better than unadjusted models (P = .099 and P = .141, respectively).

CONCLUSIONS

Opioid consumption and pain scores after women's previous cesarean delivery only explain 27% of variance of opioid consumption and 18% of variance of their pain after their index cesarean delivery. Therefore, previous cesarean delivery analgesic metrics are not robust enough to be used as clinically applicable predictors for index delivery.

Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG Clinical Consensus No. 1

SUMMARY

Pain in the postpartum period is common and considered by many individuals to be both problematic and persistent (1). Pain can interfere with individuals' ability to care for themselves and their infants, and untreated pain is associated with risk of greater opioid use, postpartum depression, and development of persistent pain (2). Clinicians should therefore be skilled in individualized management of postpartum pain. Though no formal time-based definition of postpartum pain exists, the recommendations presented here provide a framework for management of acute perineal, uterine, and incisional pain. This Clinical Consensus document was developed using an a priori protocol in conjunction with the authors listed. This document has been revised to incorporate more recent evidence regarding postpartum pain.

A Quality Improvement Project to Reduce Postcesarean Opioid Consumption

BACKGROUND

The opioid epidemic is a public health emergency in the United States, stemming in part from widespread misuse and overprescribing of opioids following surgery. Approximately 1 in 300 women with no prior exposure to opioids develops an opioid use disorder following cesarean birth. Effective management of postcesarean pain requires individualized treatment and a balance of the woman's goals for optimal recovery and ability to safely care for her newborn. The American College of Obstetricians and Gynecologists recommends a multimodal approach to pain management after cesarean birth.

METHODS

In April 2019, a multidisciplinary team was formed at New York University Langone Health to study opioid use postcesarean. The team used the Plan, Do, Study, Act process model for continuous quality improvement to launch a postcesarean pathway called "Your Plan After Cesarean," a standardized visual tool with quantifiable milestones. It facilitates integration of women's preferences in their postcesarean care, and emphasizes providers' routine use of nonpharmacological interventions to manage pain.

RESULTS

During the pilot period of the project, postcesarean high consumption of 55 to 120 mg of opioids was reduced from 25% to 8%. By January 2020, 75% of women postoperative cesarean took little-to-no opioids during their hospital stay. By February 2021, the total number of opioids consumed by women after cesarean birth in-hospital was reduced by 79%. Satisfaction among women with pain management after cesarean continued to be high.

CLINICAL IMPLICATIONS

Reduction in postcesarean opioid administration and the number of opioids prescribed at hospital discharge can be accomplished without having a negative effect on women's perceptions of post-op pain relief. These changes can potentially be a factor in helping to avoid an opioid-naive woman who has a cesarean birth from developing an opioid use disorder.

Enhanced Recovery After Cesarean: Current and Emerging Trends

Purpose of Review

What are the latest enhanced recovery elements for cesarean delivery?

Recent Findings

Enhanced recovery after cesarean delivery (ERAC) provides an evidenced-based system to improve maternal outcomes, functional recovery, maternal-infant bonding, and patient experience. Postsurgical recovery has evolved from a one-dimensional pain score to a holistic multidimensional approach emphasizing faster functional recovery. ERAC involves multidisciplinary efforts of the anesthesiologist, obstetrician, nursing, hospital, and patient. Components of ERAC include preoperative patient education, limited fasting, carbohydrate load, limiting opioids intra- and postoperatively, using scheduled non-opioid analgesics and supplementing with advanced therapies for women at higher risk for pain. ERAC protocols reduce opioid consumption, reduce length of stay, and improve maternal and neonatal outcomes.

Summary

Implementing ERAC standardized care will likely be the most important change you can make in your practice to improve outcomes, improve quality care, help address racial disparities, and minimize opioid exposure and potential for addiction.

Opioid Use and Misuse in Pregnancy

The rate of pregnant women with an opioid use disorder has risen drastically in the past 20 years, paralleling that in the general population. Pregnancies associated with opioid use, abuse, or dependence have significantly higher rates of complications, such as neonatal opioid withdrawal syndrome, intrauterine growth restriction, neural tube defects, stillbirth, increased maternal mortality, greater postpartum pain, and longer inpatient stays. Patient education about the risks and benefits of multimodal analgesia and empowering shared decision making may help curb the opioid epidemic. Tailoring pain management to individual needs might be the solution to the problem.