Why we are recommending this best practice
Strategies for implementation
- Establish a multidisciplinary team to implement a unit-wide ERAC protocol.
- Scheduled NSAIDs and acetaminophen are the first line agents for postpartum pain control. Ibuprofen 600 mg and Acetaminophen 650 mg PO Q 6 hours can be concurrent or staggered dosing. The oral route is preferred unless inappropriate.
- Offer oxycodone 5 mg PO Q6 hours PRN pain instead of the combination of APAP/oxycodone. Avoid codeine and tramadol in breastfeeding women.
- Consider a lidocaine patch for post-cesarean laparotomy pain. Consider transverse abdominus plane block immediately post-cesarean for post-incisional pain. See Best Practice #15.
- Evaluate the amount of opioids used by the patient in the 24 hours prior to discharge and use shared decision making to decide how many oxycodone tablets to give the patient, but limit the amount to a three-day supply or on average 15-20 tablets.
- Perineal pain requiring opioids should prompt a careful evaluation for hematoma, wound breakdown, or infection.
Proposed guidelines for uncomplicated normal spontaneous vaginal birth (Mills JR, et al, 2019)
- Guideline 1: Long-term opioid use often begins with the treatment of acute pain. When opioids are started, providers should order the lowest effective dosage and prescribe no greater quantity of opioids than needed for the expected duration of pain severe enough to require opioids.
- Guideline 2: When starting opioid therapy, providers should prescribe immediate-release opioids instead of extended-release or long-acting opioids. This is especially important on the day of discharge.
- Guideline 3: Providers should avoid prescribing opioid pain medications and benzodiazepines concurrently whenever possible.
- Guideline 4: Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for patients who had a normal, spontaneous vaginal delivery with no complications. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate.
- Guideline 5: When providers identify a patient with OUD, treatment discussions should be prioritized during hospitalization, on discharge, and at the postpartum appointment.
- Neuraxial long-acting opioids.
- Non-opioid analgesia started in the operating room unless contraindicated. These are ideally started prior to onset of pain (ketorolac 15-30 mg IV after peritoneum closed and/or acetaminophen IV after delivery or PO before/after delivery).
- Consider local wound pain control such as TAP block or lidocaine patch at incision site.
- Promote return of bowel function. Constipation can lead to increased unnecessary post-operative gas pain; limiting opioids, scheduled bowel regimen, and mobilization can mitigate this.
- Sample patient-oriented teaching regarding multimodal pain management after cesarean delivery: UNC School of Medicine, Center for Maternal and Infant Health.
- Sample discharge instructions regarding pain medication after delivery: UNC School of Medicine, Center for Maternal and Infant Health.
- Society of Obstetric Anesthesia and Perinatology (SOAP) Enhanced Recovery After Cesarean (ERAC) Consensus Statement.
- Bateman BT, Cole NM, Maeda A, et al. Patterns of Opioid Prescription and Use After Cesarean Delivery. Obstet Gynecol. 2017;130(1):29-35.
- Fahey JO. Best practices in management of postpartum ain. J Perinat Neonatal Nurs. 2017;31:126-36.
- Inciardi JA, Surratt HL, Cicero TJ, Beard RA. Prescription Opioid Abuse and Diversion in an Urban Community: The Results of an Ultrarapid Assessment. Pain Medicine. 2009;10(3):537-548. doi:10.1111/j.1526-4637.2009.00603.
- Smith AM, Young P, Blosser CC, Poole AT. Multimodal Stepwise Approach to Reducing In-Hospital Opioid Use After Cesarean Delivery: A Quality Improvement Initiative. Obstet Gynecol. 2019;133(4):700-706.
- Prabhu M, Dubois H, James K, et al. Implementation of a Quality Improvement Initiative to Decrease Opioid Prescribing After Cesarean Delivery. Obstetrics & Gynecology. 2018;132(3):631-636. doi:10.1097/aog.0000000000002789.
- Prabhu M1, Garry EM, Hernandez-Diaz S, MacDonald SC, Huybrechts KF, Bateman BT. Frequency of opioid dispensing after vaginal delivery. Obstet Gynecol. 2018;132(2):459-465.
- Osmundson SS, Schornack LA, Grasch JL, Zuckerwise LC, Young JL, Richardson MG. Postdischarge Opioid Use After Cesarean Delivery. Obstet Gynecol. 2017;130(1):36-41.
- Prabhu M, McQuaid-Hanson E, Hopp S, et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol. 2017;130:42-6.
- Komatsu R, Carvalho B, Flood PD. Recovery after Nulliparous Birth: A Detailed Analysis of Pain Analgesia and Recovery of Function. Anesthesiology. 2017;127(4):684-694.
- Mundkur ML, Franklin JM, Abdia Y, et al. Days' Supply of Initial Opioid Analgesic Prescriptions and Additional Fills for Acute Pain Conditions Treated in the Primary Care Setting - United States, 2014. MMWR Morbidity and mortality weekly report. 2019;68(6):140-143.
- Mills JR, Huizinga MM, Robinson SB, et al. Draft Opioid-Prescribing Guidelines for Uncomplicated Normal Spontaneous Vaginal Birth. Obstet Gynecol. 2019;133(1):81-90.
- Scully RE, Schoenfeld AJ, Jiang W, et al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA surgery. 2018;153(1):37-43.
- Peahl AF, Smith R, Johnson TRB, Morgan DM, Pearlman MD. Better late than never: why obstetricians must implement enhanced recovery after cesarean. Am J Obstet Gynecol. 2019;221(2):117.e1-117.e7.