Impact of Enhanced Recovery After Surgery Pathway for Cesarean Delivery on Postoperative Pain

Background: Enhanced Recovery After Surgery pathways provide evidence-based recommendations to optimize perioperative care.

Objective: This study aimed to holistically investigate the effect of implementing an Enhanced Recovery After Surgery pathway for all cesarean deliveries on postoperative pain experience.

Study Design: This was a prepost study comparing subjective and objective measures of postoperative pain before and after the implementation of an Enhanced Recovery After Surgery pathway for cesarean delivery. The Enhanced Recovery After Surgery pathway was developed by a multidisciplinary team and included preoperative, intraoperative, and postoperative components, with emphasis on preoperative preparation, hemodynamic optimization, early mobilization, and multimodal analgesia. All individuals undergoing cesarean delivery, whether scheduled, urgent, or emergent, were included. Demographic, delivery, and inpatient pain management data were obtained through medical record review. Of note, 2 weeks after discharge, patients were surveyed about their delivery experience, analgesic usage, and complications. The primary outcome was inpatient opioid use.

Results: The study included 128 individuals, 56 in the preimplementation cohort and 72 in the Enhanced Recovery After Surgery cohort. Baseline characteristics between the 2 groups were similar. The survey response rate was 73% (94/128). Opioid use in the first 48 hours postoperatively was significantly lower in the Enhanced Recovery After Surgery group than the preimplementation group (9.4 vs 21.4 morphine milligram equivalents 0-24 hours after delivery [<.001]; 14.1 vs 25.4 morphine milligram equivalents 24-48 hours after delivery [<.001]) with no increase in either average or maximum postoperative pain scores. Individuals in the Enhanced Recovery After Surgery group used fewer opioid pills after discharge (10 vs 20; <.001). Patient satisfaction and complication rates did not change after the implementation of an Enhanced Recovery After Surgery pathway.

Conclusion: The implementation of an Enhanced Recovery After Surgery pathway for all cesarean deliveries decreased both inpatient and outpatient postpartum opioid use without increasing pain scores or decreasing patient satisfaction.