Post-cesarean Pain Management Research Articles

Dexamethasone as an Adjuvant to Diclofenac and Acetaminophen for Post-Cesarean Pain Management: A randomized Placebo-Controlled Trial

Dexamethasone as an Adjuvant to Diclofenac and Acetaminophen for Post-Cesarean Pain Management: A randomized Placebo-Controlled Trial

Effectiveness of subarachnoid anesthesia with morphine as treatment of postoperative pain in cesarean section

Foundation: The Postoperative pain is considered time-limited pain, often poorly controlled. Its management requires a great challenge, since postoperative analgesia must provide the mother with adequate control and at the same time facilitate care for the baby. Objective: To evaluate the effectiveness of postoperative analgesia with the use of intrathecal morphine. Method: Observational, descriptive and cross-sectional study carried out at the Martín Chang Puga General Teaching Hospital in the Nuevitas municipality, province of Camagüey, between January 2021 and December 2022. The sample was made up of 36 patients to whom subarachnoid anesthesia was applied with Hyperbaric lidocaine plus morphine for cesarean section. Results: The age between 27-31 years predominated, 63.9% of those who underwent cesarean section did not report postoperative pain. Almost half of the sample (47.2%) studied presented side effects with the use of intrathecal morphine, with pruritus predominating. 80.5% of patients were satisfied with postoperative analgesia. Conclusion: The majority of patients found satisfaction with the analgesic treatment despite the presence of adverse effects, so it can be stated that the use of intrathecal morphine is effective in the management of post-cesarean pain.

A comparative evaluation of efficacy and safety of the combination of piroxicam with tramadol versus pentazocine in post-cesarean pain management

Background: Acute pain management enhances the overall quality of life for individuals having cesarean sections. Although it is a basic human right, pain treatment following a cesarean section lacks a gold standard. Multimodal analgesia is now recommended to aid recovery and mitigate the adverse effects of strong pain-relieving medications like opioids. Multimodal analgesic therapy, with the goal of obtaining synergistic or additive analgesia with fewer side effects, is by combining lesser amounts of each drug with different mechanisms of action. Aims and Objectives: The objective of the study was to compare the efficacy and safety of the combination of piroxicam with tramadol versus pentazocine in post-cesarean pain management. Materials and Methods: Following cesarean section after skin closure, cases were randomly assigned into two groups of thirty cases each. Group A was administered tramadol 100 mg+piroxicam 20 mg and Group B received pentazocine 30 mg+piroxicam 20 mg by intramuscular injection. Diclofenac 75 mg served as the rescue pain relief medication. The main focus was pain control, evaluated using the Visual Analog Scale (VAS). Secondary outcomes included sedation levels and the duration until additional pain relief was required. The safety profile of the medications was assessed by monitoring adverse drug reactions. Statistical analysis involved methods such as student’s t-test, analysis of variance, and post hoc testing. Results: Both the groups were comparable and statistically significant in VAS, time to rescue analgesia, and mean sedation score. Conclusion: The combination of piroxicam with tramadol versus pentazocine is effective and considered as an acceptable method of pain relief after cesarean delivery.

Regional Analgesia for Cesarean Delivery: A Narrative Review Toward Enhancing Outcomes in Parturients.

With the current surge on peripheral nerve blocks in post-cesarean pain management and the historical lack of unequivocal evidence supporting its universal use, this review intended to re-examine the extended scope of literature on regional anesthesia and postoperative analgesia in low-transverse cesarean section. A literature search was conducted up to April 2023 using PubMed to identify articles relevant to our search words "cesarean section", "neuraxial morphine", "post-cesarean analgesia", as well as the name of each individual nerve block. The literature search was ultimately narrowed to systematic reviews and randomized controlled trials published between 2012 and 2023. We define, describe, and discuss the evidence surrounding each individual regional anesthetic technique in the presence and absence of intrathecal morphine, which is used as the gold standard when appropriate. In the absence of neuraxial morphine, all regional anesthetic techniques have some level of analgesic benefit in the post-cesarean analgesia. Transversus Abdominis Plane blocks continue to have the most studies in their use. Newer fascia plane blocks including the anterior Quadratus Lumborum, and Erector Spinae Plane blocks provide significant analgesia. In addition, direct comparison among peripheral nerve blocks consistently favors the more proximal, centralized techniques. Conversely, in the presence of neuraxial morphine, no peripheral anesthetic technique has reliably and reproducibly demonstrated an added analgesic benefit regardless of the peripheral nerve block technique or location of local anesthetic injection in the post-cesarean population. Neuraxial morphine continues to be the gold standard for post-cesarean section analgesia, the benefit of additional single injection regional anesthetic is currently not evidence supported. In cases where neuraxial opioids have not or cannot be given, there is overwhelming evidence that regional anesthetic techniques improve post-cesarean section analgesia and decrease post-operative opioid consumption. Even though there is no consensus on the optimal peripheral nerve block, emerging evidence suggests more centralized abdominal fascia plane block trends towards better analgesia.

Morphine Spinal Anesthesia for Cesarean Section at the Regional Hospital of Saint Louis in Senegal: About 119 Cases Collected

Introduction: Post-operative pain management has been the subject of several studies worldwide. Cesarean section is a commonly performed procedure and can lead to severe pain. This study aimed to determine the quality of post-cesarean analgesia by intrathecal administration of 100 micrograms of morphine. Patients and Methods: We conducted an analytical and descriptive study with prospective data collection during one month. We included all women who underwent a spinal caesarean section. Results: During the study period, a total of 119 women were enrolled. The mean age of the parturients was 27.85. High blood pressure and obesity were the most common comorbidities in 9.242% and 5.09% of the women respectively, and 31.93% had a history of caesarean section. Cesarean sections were performed according to the level of urgency based on the colour code. Scheduled caesarean sections were performed in 64.7% of cases. Women had an APFEL score of 3 in 95% of cases. Bupivacaine 7.5mg was administered in 96.63% of cases. The average dose of ephedrine administered before fetal extraction was 3.96mg. Oxytocin was the most administered uterotonic in 73.94%. The APGAR score at birth was greater than 7 in 95.79% of cases. No patient expressed a need for additional analgesics after lifting the motor block. No respiratory or neurological complications of morphine were noted. Pruritus was present in 24.36% of cases, whereas nausea and vomiting were reported in 17.64%. There were no cases of acute urine retention. The average time for the resumption of bowel movement was 13.67 hours. Discussion and Conclusion: Morphine spinal analgesia is an effective technique for the management of post-cesarean pain. The reduction of the morphine dose to 100 micrograms and the preventive addition of dexamethasone are two key factors in accelerated rehabilitation after surgery.

A randomized trial of individualized opioid prescription protocol versus fixed quantity for post-cesarean pain management

To evaluate whether an individualized opioid prescription protocol (IOPP) with a shared decision-making component is non-inferior to a fixed quantity prescription of opioid tablets for outpatient cesarean pain management at 1-week post-discharge. We performed a non-inferiority open-label trial at 31 US sites (NCT04296396). Prior to hospital discharge, participants who had undergone cesarean delivery were randomly assigned to IOPP or fixed quantity (20 tablets of 5mg oxycodone) and followed through 90 days postpartum. In the IOPP group, individuals received education on post-operative pain expectations, opioid side effects, and the number of recommended tablets based on their morphine milligram equivalent (MME) use in the past 24 hours. They then selected a quantity of post-discharge tablets (up to 20) to be prescribed. The primary outcome was moderate to severe pain (≥ 4) at 1-week post-discharge on the Brief Pain Inventory (BPI, 0-10) in the last 24 hrs. Secondary outcomes were pain scores and post-discharge opioid prescriptions within 90 days. A planned sample size of 5500 tested non-inferiority of IOPP compared to fixed quantity assuming 90% power, type I error 0.025 1-sided and inferiority margin of 5%. From Sep 2020 through March 2022, of 9963 eligible individuals, 5520 (55%) were enrolled (n=2748 IOPP, n=2772 fixed). Baseline characteristics were similar between groups. In the IOPP group, participants requested a median of 14 tablets (IQR range 6-20). The primary outcome rate was not inferior between the IOPP and fixed groups (59% vs. 60%, Risk Difference -0.7; 95% CI -3.4, 2.0), and worst pain was similar throughout follow-up (Figure). The proportion filling an opioid prescription after discharge was similar between groups (7.6% vs 6.2%, relative risk 1.22, 95% CI [1.00, 1.48]). Reported opioid-related side effects were similar between groups (13.5% vs. 13.9%, p=0.7). Compared to fixed quantity opioid prescription, IOPP was non-inferior for outpatient post-cesarean pain management at 1-week post discharge.

Post-Caesarean Pain on Maternal Quality of Life

Background: Caesarean section (CS) is one of the commonest interventions that women go through during their fertile period. Over the past 30 years rate of CS use has increased by 10-15%. Moreover both acute and chronic pain after the caesarean section may hamper the patient quality of life and newborn’s care. Post-partum quality of life is an important concept. It has mingled with an individual’s physical health, mental state, independence, social contacts, and personal beliefs. Many quality-of-life scoring tools have been used on patients after CS to measure the post-operative health status and outcome.Methods: This narrational review was outlined by searching MEDLINE databases such as- Google Scholar and PubMed. Selected keywords were searched to identify articles. Randomized Controlled Trials, Observational Studies, Case control and Systemic reviews were included.Conclusion: Post-caesarean pain management is prioritized by women after a caesarean section.

Ultrasound-guided transversalis fascia plane block versus wound infiltration for both acute and chronic post-caesarean pain management - A randomised controlled trial.

Background and Aims:Ultrasound-guided transversalis fascia plane block (USG-guided TFPB) has recently been evaluated for post-caesarean acute pain management. We compared it with standard wound infiltration for both acute and chronic post-caesarean pain management.Methods:All patients undergoing caesarean section (CS) under subarachnoid block were included and randomised. Patients in group C received standard wound infiltration (20 ml of 0.375% ropivacaine) and group-T received bilateral USG-guided TFPB (20 ml of 0.375% ropivacaine) at the end of the surgery. Acute pain assessed using numeric rating scale (NRS), time to first request of analgesia and total rescue analgesic consumption in 24 hours. The incidence of chronic persistent post-surgical pain (CPSP), neuropathic pain component and quality of life (QoL) were assessed. Fisher’s exact test, Chi-square test, unpaired Student’s t-test and Mann-Whitney U test were used.Results:Sixty patients were included with 30 in each group. NRS score on rest at 6th and 24th hour and on active movement at 1st hour was significantly decreased in group T. The “time to first request of analgesia” was statistically higher in group T, that is, 10.77 ± 1.39 h versus 6.30 ± 1.60 h. Five (16.6%) and two (6.6%) patients in groups C and T, respectively, required rescue analgesia in first 24 hours. 30% (n = 6) and 10% (n = 2) patients in groups C and T, respectively, developed CPSP. The neuropathic pain component was significantly reduced and QoL was significantly improved in group T.Conclusion:TFPB is efficacious for management of both acute and chronic post-caesarean pain management.

Enhanced Recovery after Surgery Protocol to Improve Racial and Ethnic Disparities in Postcesarean Pain Management.

The objective of this study was to assess the efficacy of an enhanced recovery after surgery (ERAS) protocol and determine its effect on racial/ethnic disparities in postcesarean pain management. We performed an institutional review board-approved retrospective cohort study of scheduled cesarean deliveries before and after ERAS implementation at a single urban academic institution. Pre-ERAS, all analgesic medications were given postoperatively on patient request. The ERAS protocol included preoperative acetaminophen and celecoxib. Postoperatively, patients received scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Oral oxycodone was available as needed, and opioid patient-controlled analgesia was eliminated from the standard order set. The primary outcome was total opioid use in the first 48 hours after cesarean, pre- and post-ERAS, reported in total milliequivalents of intravenous morphine (MME). A secondary analysis of opioid use and pain scores by racial groups was also performed. Chi-square, independent t-tests, analysis of variance, Mann-Whitney U, and Kruskal-Wallis tests were used depending on variable and data normality. Pre-ERAS and post-ERAS groups included 100 women each. Post-ERAS, total opioid use in 48 hours was less (40.8 vs. 8.6 MME, p < 0.001) and visual analog scale (VAS) pain scores were lower on postoperative day 1 (POD1) and 2 (POD2) (POD1 maximum at rest: 6.7 vs. 5.3, p < 0.001). Pre-ERAS pain scores differed by race with non-Hispanic Black (NHB) patients reporting the highest mean and max VAS pain scores POD1 and POD2 (POD1, maximum VAS at rest: NHB-7.4, non-Hispanic White-6.6, Hispanic-5.8, Asian-4.4, p = 0.006). Post-ERAS, there were no differences in postoperative pain scores between groups with movement on POD1 and POD2. A standardized ERAS protocol for postcesarean pain decreases opioid use and may improve some racial disparities in postcesarean pain control. · ERAS protocols improve postoperative pain control and lower postoperative opioid use.. · Studies show that there are racial and ethnic disparities in postpartum pain control.. · Protocols standardize care and may decrease the effects of provider implicit bias..

Analgesia After Cesarean Delivery in the United States 2008-2018: A Retrospective Cohort Study

(Anesth Analg. 2021;133:1550–1558) Multimodal, opioid-sparing analgesia is currently recommended for postcesarean pain management in the United States. These regimens combine neuraxial morphine, scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) and scheduled acetaminophen. Recent studies have supported the use of scheduled acetaminophen plus opioids on an as-needed basis rather than acetaminophen-opioid combination drugs. This study aimed to investigate analgesia following cesarean delivery under neuraxial anesthesia in the United States and examine variations in analgesic regimens over time and between institutions.

Multimodal Analgesia Transversus Abdominis Plane Block-Ketorolac Combination being Superior to Paracetamol-Ketorolac as Postoperative Pain Management after Cesarean Section in an Indonesian Hospital

Aim: This study aimed to compare the outcome of multimodal analgesia using transversus abdominis plane block combined with ketorolac and multimodal analgesia oral paracetamol combined with ketorolac in postoperative pain after cesarean section. Background: Post-caesarean section pain resulted in prolonged recovery time, inhibited early breastfeeding initiation, and prolonged hospitalization. Multimodal analgesia is an important component of post-cesarean section pain management but has not been established in many Indonesian hospitals. Methods: This study was a retrospective, observational analytic study on 46 patients who received low-dose sub-arachnoid block anesthesia. A total of 24 subjects received bilateral transversus abdominis plane block employing ultrasonography-guided lateral approach, with Ropivacaine 0.25% in a total volume of 30cc combined with intravenous ketorolac 30 mg/8 h (Group B). A total of 22 subjects received oral paracetamol 500 mg/6 h combined with intravenous ketorolac 30 mg/8 h (Group A). Numeric Rating Scale (NRS), length of hospitalization, and mobilization time were analyzed using the T-test at a significance level of p&lt;0.05 (confidence interval of 95%). Results: The NRS and mean time to start mobilization of patients who received transversus abdominis plane block combined with ketorolac were significantly better than patients who received paracetamol combined with ketorolac (p&lt;0.05). There was no significant difference in the length of hospitalization between the two techniques (p&gt;0.05). Both modalities resulted in improvement in pain intensity over the mild pain range. Conclusion: Multimodal analgesia transversus abdominis plane block combined with ketorolac is superior to paracetamol combined with ketorolac for postoperative pain management after cesarean section.

Multimodal Analgesia Transversus Abdominis Plane Block-Ketorolac Combination being Superior to Paracetamol-Ketorolac as Postoperative Pain Management after Cesarean Section in an Indonesian Hospital

Aim: This study aimed to compare the outcome of multimodal analgesia using transversus abdominis plane block combined with ketorolac and multimodal analgesia oral paracetamol combined with ketorolac in postoperative pain after cesarean section. Background: Post-caesarean section pain resulted in prolonged recovery time, inhibited early breastfeeding initiation, and prolonged hospitalization. Multimodal analgesia is an important component of post-cesarean section pain management but has not been established in many Indonesian hospitals. Methods: This study was a retrospective, observational analytic study on 46 patients who received low-dose sub-arachnoid block anesthesia. A total of 24 subjects received bilateral transversus abdominis plane block employing ultrasonography-guided lateral approach, with Ropivacaine 0.25% in a total volume of 30cc combined with intravenous ketorolac 30 mg/8 h (Group B). A total of 22 subjects received oral paracetamol 500 mg/6 h combined with intravenous ketorolac 30 mg/8 h (Group A). Numeric Rating Scale (NRS), length of hospitalization, and mobilization time were analyzed using the T-test at a significance level of p&lt;0.05 (confidence interval of 95%). Results: The NRS and mean time to start mobilization of patients who received transversus abdominis plane block combined with ketorolac were significantly better than patients who received paracetamol combined with ketorolac (p&lt;0.05). There was no significant difference in the length of hospitalization between the two techniques (p&gt;0.05). Both modalities resulted in improvement in pain intensity over the mild pain range. Conclusion: Multimodal analgesia transversus abdominis plane block combined with ketorolac is superior to paracetamol combined with ketorolac for postoperative pain management after cesarean section.

Multimodal Analgesia Transversus Abdominis Plane Block-Ketorolac Combination being Superior to Paracetamol-Ketorolac as Postoperative Pain Management after Cesarean Section in an Indonesian Hospital

Aim: This study aimed to compare the outcome of multimodal analgesia using transversus abdominis plane block combined with ketorolac and multimodal analgesia oral paracetamol combined with ketorolac in postoperative pain after cesarean section. Background: Post-caesarean section pain resulted in prolonged recovery time, inhibited early breastfeeding initiation, and prolonged hospitalization. Multimodal analgesia is an important component of post-cesarean section pain management but has not been established in many Indonesian hospitals. Methods: This study was a retrospective, observational analytic study on 46 patients who received low-dose sub-arachnoid block anesthesia. A total of 24 subjects received bilateral transversus abdominis plane block employing ultrasonography-guided lateral approach, with Ropivacaine 0.25% in a total volume of 30cc combined with intravenous ketorolac 30 mg/8 h (Group B). A total of 22 subjects received oral paracetamol 500 mg/6 h combined with intravenous ketorolac 30 mg/8 h (Group A). Numeric Rating Scale (NRS), length of hospitalization, and mobilization time were analyzed using the T-test at a significance level of p&lt;0.05 (confidence interval of 95%). Results: The NRS and mean time to start mobilization of patients who received transversus abdominis plane block combined with ketorolac were significantly better than patients who received paracetamol combined with ketorolac (p&lt;0.05). There was no significant difference in the length of hospitalization between the two techniques (p&gt;0.05). Both modalities resulted in improvement in pain intensity over the mild pain range. Conclusion: Multimodal analgesia transversus abdominis plane block combined with ketorolac is superior to paracetamol combined with ketorolac for postoperative pain management after cesarean section.

Multimodal Analgesia Transversus Abdominis Plane Block-Ketorolac Combination being Superior to Paracetamol-Ketorolac as Postoperative Pain Management after Cesarean Section in an Indonesian Hospital

Aim: This study aimed to compare the outcome of multimodal analgesia using transversus abdominis plane block combined with ketorolac and multimodal analgesia oral paracetamol combined with ketorolac in postoperative pain after cesarean section. Background: Post-caesarean section pain resulted in prolonged recovery time, inhibited early breastfeeding initiation, and prolonged hospitalization. Multimodal analgesia is an important component of post-cesarean section pain management but has not been established in many Indonesian hospitals. Methods: This study was a retrospective, observational analytic study on 46 patients who received low-dose sub-arachnoid block anesthesia. A total of 24 subjects received bilateral transversus abdominis plane block employing ultrasonography-guided lateral approach, with Ropivacaine 0.25% in a total volume of 30cc combined with intravenous ketorolac 30 mg/8 h (Group B). A total of 22 subjects received oral paracetamol 500 mg/6 h combined with intravenous ketorolac 30 mg/8 h (Group A). Numeric Rating Scale (NRS), length of hospitalization, and mobilization time were analyzed using the T-test at a significance level of p&lt;0.05 (confidence interval of 95%). Results: The NRS and mean time to start mobilization of patients who received transversus abdominis plane block combined with ketorolac were significantly better than patients who received paracetamol combined with ketorolac (p&lt;0.05). There was no significant difference in the length of hospitalization between the two techniques (p&gt;0.05). Both modalities resulted in improvement in pain intensity over the mild pain range. Conclusion: Multimodal analgesia transversus abdominis plane block combined with ketorolac is superior to paracetamol combined with ketorolac for postoperative pain management after cesarean section.

NSS-Bridge Device for Post-Cesarean Delivery Analgesia: A Randomized Controlled Trial.

Percutaneous auricular nerve stimulation has been used for the treatment of symptoms associated with opioid withdrawal, including abdominal pain, nausea, and general discomfort. However, its potential utility for pain management and opioid minimization after surgery has not been investigated. The purpose of this study was to test the feasibility and acceptability of a trial protocol designed to assess the effectiveness of the NSS2-Bridge device as a non-pharmacologic alternative to opioids after cesarean delivery. In a randomized control design, healthy women receiving cesarean delivery were randomized to receive the active device, placebo device, or no device. Devices were placed on the ear following cesarean delivery and left in place for 5 days. Feasibility and acceptability of the device was assessed by patient reports of device tolerability (rated on a 100mm visual analog scale where 0 is not tolerable at all and 100 is the most tolerable) as well as qualitative reporting. Additional outcomes assessed included proportion of patients not using opioids in hospital, as well as pain at rest, pain with movement, and total opioid consumption in the hospital and for the first 5 days after surgery. There were 60 patients included in the final analysis. Device tolerability was rated highly, with an average daily score of >75 mm on the visual analog scale. The trial retention rate was 89.7% with most exclusions (42.9%) occurring due to unanticipated development of care complexity (e.g., hemorrhage and additional surgical procedures), with only 1 exclusion (14.3%) due to device discomfort. The active device group achieved the highest proportion of opioid-free hospitalizations (40%) compared to placebo (20%) and no device groups (30%). Pain at rest and with movement was similar between treatment groups. This trial protocol designed to test the efficacy of NSS2-Bridge device for post-cesarean pain management is feasible and acceptable. Larger proportions of patients not using opioids in the active device group justifies additional investigation on device effectiveness in pregnant and postpartum people at highest risk for pain.

Influence of Catheter–Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial

Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter–incision incongruent for cesarean delivery. Methods: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. Results: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). Conclusions: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.

A Quality Improvement Initiative to Reduce Postcesarean Opioid Consumption

The opioid epidemic is a public health emergency in the United States that stems in part from widespread misuse and the overprescription of opioids after surgery. Approximately 1 in 300 patients with no prior exposure to opioids develop an opioid-use disorder after a cesarean birth. Effective management of postcesarean pain requires providers to individualize treatment and balance a patient’s goals of optimal recovery with their ability to safely care for their newborn. Accordingly, the American College of Obstetricians and Gynecologists recommends a multimodal approach to pain management after cesarean birth.

Patient and Procedural Risk Factors for Increased Postoperative Pain After Cesarean Delivery Under Neuraxial Anesthesia: A Retrospective Study

(Int J Obstet Anesth. 2020;44:60–67) Satisfactory postcesarean pain management is important for many reasons, including allowing early mobility to decrease thromboembolic risk, improved newborn care, and decreased risk for postpartum depression. There is still room for improvement in the management of postoperative pain in cesarean patients and a need to better understand individual variability. This study aimed to identify risk factors associated with increased postoperative pain following cesarean delivery (CD).

A Quality Improvement Project to Reduce Postcesarean Opioid Consumption.

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. 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. 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. 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.

867 Standardized order sets do not eliminate racial/ethnic inequities in postpartum pain evaluation and management

To quantify the extent to which a standardized pain management order set reduced racial/ethnic inequities in post-Cesarean pain evaluation and treatment. A follow-up retrospective cohort study comparing previously reported racial/ethnic inequities in post-Cesarean pain management (baseline period: 07/01/14–06/30/16) to data after implementation of a standardized pain management order set (03/01/17–02/28/18). Medical records were queried for number of pain assessments; pain scores> 7; scheduled non-opiate doses, and as needed opiate doses (converted to 5mg oxycodone tablet equivalents, OTE). Outcomes were grouped into 0-< 24 and 24-48 hours postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black (NHB), non-Hispanic White (NHW), Asian, and other). Analyses included logistic regression for the categorical outcome of pain score> 7 (severe pain), and linear regression. Main effect and interaction terms were used to calculate the difference-in-difference from baseline to follow-up. Before order set implementation (N=1701), we demonstrated NHW women had lower pain scores, more frequent pain assessments, and received more opiates than NHB women (% pain scores> 7 NHW/NHB 0-< 24h: 20%/28%; 24-48h: 25%/37%). After implementation (N=888), severe pain remained more common among NHB women (% pain scores> 7 NHW/NHB 0-< 24h: 23%/31%; 24-48h: 26%/38%). Pain management processes changed after implementation (Table), with overall fewer assessments, less opiates and more non-opiate analgesics. However, racial/ethnic inequities in number of assessments and treatment were unchanged (Table, all p for interaction > 0.05), with the exception of an increase in NSAID doses 24-48 hours postpartum for Hispanic women. A standardized pain management order set reduced overall postpartum opiate use, but did not reduce racial/ethnic inequities in pain evaluation and treatment. Future work should investigate racial equity-focused education and interventions designed to eliminate inequities in pain management.View Large Image Figure ViewerDownload Hi-res image Download (PPT)