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Am J Perinatol 2024; 41(03): 229-240
DOI: 10.1055/s-0043-1775560
SMFM Fellowship Series Article

A Prospective Longitudinal Quality Initiative toward Improved Enhanced Recovery after Cesarean Pathways

Liviu Cojocaru 
1   Department of Obstetrics, Gynecology and Reproductive Science, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, Maryland
,
Suzanne Alton
2   Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland Medical Center, Baltimore, Maryland
,
Autusa Pahlavan
3   Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
,
Martha Coghlan
4   Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
,
Hyunuk Seung
5   Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland
,
Ariel Trilling
6   Department of Obstetrics, Gynecology and Reproductive Science, University of Pittsburg School of Medicine, Pittsburg, Pennsylvania
,
Bhavani S. Kodali
7   Department of Anesthesiology, Division of Obstetric Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
,
Sarah Crimmins 
1   Department of Obstetrics, Gynecology and Reproductive Science, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, Maryland
,
Katherine R. Goetzinger
1   Department of Obstetrics, Gynecology and Reproductive Science, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Abstract

Objective This study aimed to evaluate whether enhanced recovery after cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery.

Study Design This is a prospective, longitudinal, quality improvement study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English- and non-Spanish-speaking patients. Our study compared patient outcomes before (pre-ERAC) and after (post-ERAC) implementation of ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores. Secondary outcomes were outpatient MME prescriptions and indicators of postoperative recovery (time to feeding, ambulation, and hospital discharge).

Results Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30 [20–49] vs. 16.8 MME [11.2–33.9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of MMEs prescribed (150 [150–225] vs. 150 MME [112–150], p < 0.001; different shape of distribution). Furthermore, the patients in the pre-ERAC cohort had higher delta pain scores (3.3 [2.3–4.7] vs. 2.2 [1.3–3.7], p < 0.001).

Conclusion Our study has illustrated that our ERAC pathways were associated with reduced inpatient opioid use, outpatient opioid use, patient-reported pain scores, and improved indicators of postoperative recovery.

Key Points

  • Implementation of ERAC pathways is associated with a higher percentage of no postpartum opioid use.

  • Implementation of ERAC pathways is associated with lower delta (reported − expected) pain scores.

  • The results of ERAC pathways implementation are increased by adopting a patient-centered approach.

Keywords

cesarean section - obstetrics - quality of care - maternal health - enhanced recovery after surgery

Authors' Contributions

L.C. drafted the first manuscript. H.S. performed the statistical analysis and ensured its correct interpretation. All authors contributed to the writing, editing, and approval of the final version.


Supplementary Material



Publication History

Received: 04 November 2021

Accepted: 18 August 2023

Article published online:
25 September 2023

© 2023. Thieme. All rights reserved.

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