Reducing opioid prescriptions after C-sections

But there's a better way to take care of patients after C-sections to help them heal faster and manage pain without increasing their risk of long-term opioid use, Michigan Medicine researchers say in a new publication in the American Journal of Obstetrics & Gynecology.

Standardized, evidence-based pain management protocols that lessen opioid use have been used successfully at a handful of institutions around the country, including at University of Michigan's Von Voigtlander Women's Hospital. U-M has seen opioid prescription levels for caesarean deliveries drop to nearly the same as vaginal births.

But these care bundles, which involve a set of interventions to improve patient outcomes, need to be more widespread to benefit more birthing moms no matter where they give birth, U-M authors say.

"Cesarean delivery is the most common abdominal surgery in the world. Despite persistent concerns about high cesarean delivery rates internationally, there has been less attention on improving perioperative outcomes for birthing moms," says lead author Alex Peahl, M.D., a U-M obstetrician gynecologist.

"We need to make sure moms are safe in the postpartum period and are receiving the highest quality care possible," she says. "This includes helping patients achieve greater pain control with less opioids."

More effective birth pain management is crucial at a time when there are increasing concerns for higher caesarean rates, maternal mortality and morbidity and risk for persistent opioid use among birthing moms, the authors say.

Research suggests that women are at greater risk of persistent opioid user after the postoperative period if an opioid is prescribed.

Pain control starts early

Authors highlight a pain management protocol called Enhanced Recovery After Surgery, which has more commonly been implemented for other types of surgeries, including hysterectomies, but has been slower to be used broadly for cesarean deliveries. While intended for planned surgeries, authors say there the strategy is effective for unplanned C-sections as well.

ERAS involves a combination of long-acting opioids that last for 18 hours after delivery -- reducing the patient's pain immediately after cesarean -- and alternating non-narcotic medications around the clock to limit inpatient morphine.

Timing is key

"The goal is to get on top of the pain before the surgery even starts," Peahl says. "Pain is like a mountain. It's much harder to come down once you're at the top."

"We are offering a longer, more even level of pain control to keep patients comfortable through the day. This helps avoid those high peaks of pain that are much harder to come down from quickly and when the most potent painkillers are often used for immediate relief."

Ensuring high quality care after all c-sections

ERAS could also potentially lower health costs by lessening length of hospital stay. Authors note that ERAS protocols have facilitated next day discharge without increase in readmission rates for up to 25 percent of patients leaving the hospital the day after a c-section.

"This is a promising intervention to standardize care for millions of women who undergo a caesarean delivery every year," Peahl says. "We wanted to share evidence for the potential of these strategies improving the quality of care and patient satisfaction, while reducing overall healthcare costs."

While proven to be effective, several barriers may deter wide implementation of opioid-sparing pain methods like ERAS -- which may require shifting some elements of care from hospitals to clinics and developing more robust connections between care settings. U-M, for example, is employing new strategies to further improve patients' pain management through educational materials and shared decision making at the time of discharge.

But once implemented, the protocol is simple to follow and has potential to make care teams' jobs managing pain control much easier, Peahl says.

"Not only have these patients just had surgery but they are also new moms," she says. "Helping them recover from surgery and improving their time with their new infants is crucial.

"Standardizing the process and care provided after c-sections is one step to helping ensure that every woman, regardless of demographics or where she lives, receives the same high quality level of care throughout the birth experience."