A Prospective Cohort Study Towards Improving Enhanced Recovery After Cesarean (ERAC) Pathways.

Background: Enhanced Recovery After Surgery (ERAS) or, more specifically for obstetrics, Enhanced Recovery after Cesarean (ERAC) pathways have emerged as a multidisciplinary standardized bundled care approach to improve maternal outcomes. Despite this, ERAS pathways have not been fully embraced in obstetrics, leaving significant space for improvement. Moreover, most of the studies have not extended ERAC pathways to specific populations such as opioid-naive patients, patients with postpartum depression, or patients receiving Magnesium Sulfate, allowing aforementioned confounders to affect the magnitude of the measured outcome. Objectives: To evaluate whether an Enhanced Recovery After Cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery. Furthermore, the specifics of our protocol are intended to decrease the knowledge gaps in ERAC pathways. Study design: This is a prospective cohort study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded CD done under general anesthesia, those complicated by massive transfusion events, bowel injury, requiring recovery in the intensive care unit, and skin incision other than Pfannenstiel. Additionally, we excluded 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 the outcomes in patients before (pre-ERAC) and after (post-ERAC) implementation of an ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient9s delta pain scores (patient9s reported goal subtracted from patient9s pain score). Secondary outcomes were outpatient MME prescriptions as well as indicators of postoperative recovery (e.g., fasting time, time to feeding, time to indwelling urinary catheter removal, time to ambulation, and time to hospital discharge). Baseline demographics and outcomes were compared between pre-ERAC and post-ERAC cohorts. Multivariate logistic regression models were used to control for potential confounders. 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 post-ERAC cohort were less likely to require opioids in the postoperative period compared to the pre-ERAC cohort (35.7% vs. 18.4%, p<0.001). In addition, there was a significant reduction in the MME per stay in this cohort [16.8 MME (11.2-33.9) vs. 30 MME (20-49), p<0.001]. In the post-ERAC cohort, there was also a reduction in the number of patients who required prescribed opioids at the time of discharge (86.6 vs. 98%, p<0.001) as well as in the amount of MMEs prescribed [150 MME (112-150) vs. 150 MME (150-225), p<0.001; different shape of distribution]. Patients in the post-ERAC cohort had lower delta pain scores on postoperative days 1 to 4 as well as lower overall delta pain scores [2.2 (1.3-3.7) vs. 3.3 (2.3-4.7), p<0.001]. Conclusion: Our study has illustrated that our ERAC pathways reduced inpatient and outpatient opioid use as well as patient-reported pain scores while improving indicators of postoperative recovery.