Evaluation of Pain Management Strategies in Cesarean Delivery

Evaluation of Pain Management Strategies in Cesarean Delivery

Background:

The number of drug overdose deaths in the United States increased nearly 30% from 2019 to 2020; since 1999 this number has quadrupled. Roughly 75% of overdose deaths in 2020 involved an opioid analgesic agent, increasing prescription-opioid death rate by 17%.¹ The United States has guidance on prescriptive practices for opioid analgesic agents that are inconsistently implemented. Variation in opioid prescribing is noted across hospital systems and opioids prescribed at hospital discharge.²

The most frequent reason for hospitalization in the United States is delivery.³ An estimated 4 million births occur annually, with one in three births involving cesarean delivery.⁴ A recent 2019 study showed that 75% of cesarean deliveries resulted in a peripartum opioid prescription, furthering the concern that this patient population is at risk.⁵

Purpose/Objectives:

Due to the significant rise in opioid abuse in the United States, The American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control (CDC) are advocating for a multimodal pain approach to decrease opioid prescribing. ^1,6 Both organizations are advocating for an approach that encourages the utilization of two or more agents in differing classes to manage pain.

An institutional internal audit found inconsistent prescriptive practices with opioids and adjuvant use. The audit recognized a need for a pain management cesarean subphase to provide prescribing guidance to the obstetricians. A postpartum pain management cesarean delivery subphase was created in alignment with ACOG and the CDC to implement a multimodal pain approach to reduce or eliminate the need for opioids to be prescribed inpatient. The purpose of the study is to evaluate the impact of the postpartum pain management cesarean subphase on opioid consumption in cesarean patients.

Method:

The study is a single center, retrospective, cohort evaluation. All cesarean patients initiated on the cesarean delivery subphase  were divided into pre- and post-implementation groups with data obtained from June 1, 2018 to November 20, 2020. The predominant reasons women were excluded from the study were if they had an allergy to acetaminophen, non-steroidal anti-inflammatory agent (NSAID), and/or opioid analgesic agent or initiated on patient controlled analgesia (PCA) pump. Primary outcome was a comparison of morphine milligram equivalents (MME) pre- versus post-implementation of pain management cesarean delivery subphase. Secondary outcomes include: use of multimodal agents, prescription for opioids at discharge, prescription for multimodal agents at discharge, and length of stay. The primary outcome was analyzed as a two-sample t-test. In order to detect a 10% reduction in opioid use, the primary outcome was powered at 80%. Secondary outcomes were analyzed utilizing descriptive statistics.

Results:

A total of 476 subjects were screened for inclusion, with 300 subjects meeting inclusion criteria. The most common reason for exclusion was PCA prescribed during hospitalization. Baseline characteristics were comparable between groups. Opioid analgesic use inpatient statistically declined in the post-implementation group (P< 0.001). Use of multimodal agents increased through the standardization of the cesarean subphase. There was a non-significant change in total MME prescribed at discharge. However, there was an increased prescribing of multimodal agents upon discharge in the post-implementation group. Postpartum length of stay decreased by 6 hours in the post-implementation group.

Conclusions: Overall, this study adds to the scarce literature evaluating pain management strategies post cesarean delivery. Postpartum women are commonly prescribed opioids upon hospital discharge. Utilization of a power plan enforced a multimodal pain management approach and can reduce opioid prescribing in-hospital and may decrease inpatient opioid use. Standardization in MME prescribing and variation in multimodal prescriptive practices upon discharge still needs to be addressed.

References: 1. Hedegaard H, Minino AM, Warner M. Drug overdose deaths in the United States, 1999-2019. NCHS Data Brief, no 394. Hyattsville, MD: National Center for Health Statistics. 2020.
2. Jena AB, Goldman D, Karaca-Mandic P. Hospital Prescribing of Opioids to Medicare Beneficiaries. JAMA Intern Med. 2016;176(7):990-997.
3. Badreldin N, Grobman WA, Chang KT, Yee LM. Opioid prescribing patterns among postpartum women. Am J Obstet Gynecol. 2018;219(1):103.e1-103.e8. doi:10.1016/j.ajog.2018.04.003
4. Nelson DB, Spong CY. Initiatives to Reduce Cesarean Delivery Rates for Low-risk First Births. JAMA. 2021;325(16):1616–1617. doi:10.1001/jama.2021.0084
5. Peahl AF, Dalton VK, Montgomery JR, Lai YL, Hu HM, Waljee JF. Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women [published correction appears in JAMA Netw Open. 2019 Aug 2;2(8):e1911235]. JAMA Netw Open. 2019;2(7):e197863. Published 2019 Jul 3. doi:10.1001/jamanetworkopen.2019.7863
6. The American College of Obstetrics and Gynecologists. Opioid Use and Opioid Use Disorder in Pregnancy. Number 711. Aug. 2017.