Multimodal pain management after cesarean reduces opioid use and early breast-feeding initiation

As a strategy to combat the ongoing opioid epidemic, physicians have tried to reduce opioid exposure and use in patients. With this goal, postoperative pain management strategies have evolved and physicians have moved away from the traditional strategies that relied heavily on opioids toward opioid-sparing protocols using multiple classes of nonnarcotic analgesics, with opioid administration prescribed only as needed. These newer protocols are often referred to as multimodal pain management regimens.

Other surgical fields including gynecology and gynecologic oncology have adopted the use of multimodal pain management strategies. These multimodal pathways have resulted in a decreased length of hospital stays, readmission rates, and postoperative complications; they have also decreased hospital costs. However, there are mixed results with regard to decreasing the opioid consumption.

This study by Macias DA et al determined if a multimodal pain management regimen after cesarean delivery reduces the number of morphine milligram equivalents compared with traditional morphine PCA while adequately controlling postoperative pain.Authors found that a transition from a traditional morphine PCA to a multimodal pain management regimen significantly reduced opioid use in the postpartum period, without a detrimental effect on the pain scores as published in American Journal of Obstetrics and Gynecology.

This was a prospective cohort study of postoperative pain management for women undergoing cesarean delivery at a large county hospital. It was conducted during a transition from a traditional morphine patient-controlled analgesia regimen to a multimodal regimen that included scheduled nonsteroidal anti-inflammatory drugs and acetaminophen, with opioids used as needed. The data were collected for a 6- week period before and after the transition. The primary outcome was postoperative opioid use defined as morphine milligram equivalents in the first 48 hours. The secondary outcomes included serial pain scores, time to discharge, and exclusive breastfeeding rates. Women who required general anesthesia or had a history of substance abuse disorder were excluded.

During the study period, 877 women underwent cesarean delivery and 778 met the inclusion criteria—378 received the traditional morphine patient-controlled analgesia and 400 received the multimodal regimen. The implementation of a multimodal regimen resulted in a significant reduction in the morphine milligram equivalent use in the first 48 hours (P<.001). Compared with the traditional group, more women in the multimodal group reported a pain score
4 by 48 hours (88% vs 77%; P><.001). There was no difference in the time to discharge (P¼.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P><.001). Compared with the traditional group, more women in the multimodal group reported a pain score ≤4 by 48 hours (88% vs 77%; P<.001). There was no difference in the time to discharge (P¼.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P><.001). There was no difference in the time to discharge (P=.32). Of the women who exclusively planned to breastfeed, fewer used formula before discharge in the multimodal group than in the traditional group (9% vs 12%; P<.001).

In this prospective observational study, there were 4 findings.

• First, there was a reduction in the opioid use with the implementation of a multimodal pain management regimen when compared with a traditional morphine PCA.

• Second, this reduction persisted over time as the patients transitioned to oral pain medications.

• Third, postoperative pain remained adequately controlled regardless of the regimen, with lower pain scores at 48 hours in the multimodal group despite a lower opioid requirement.

• Fourth, even though the time to discharge was not different between the 2 groups as the protocols and practices did not change during the study period, the continuation of exclusive breastfeeding at discharge was significantly higher in the multimodal group among those women with plans to exclusively breastfeed on arrival. Put another way, more women in the multimodal group who entered the delivery experience intending to exclusively breastfeed were successful than the traditional PCA group.

The use of a multimodal postoperative pain management regimen alone, without other ERAS measures, can provide a meaningful change to current practice even in facilities with limited resources. The regimen used in this study included scheduled acetaminophen and ibuprofen with other medications as needed. Primarily, this study showed that a multimodal regimen can decrease opioid consumption. In this way, a multimodal regimen has the potential to decrease postoperative sedation and the risk of developing substance use disorder.

"We found that a transition from a traditional morphine PCA to a multimodal pain management regimen significantly reduced opioid use in the postpartum period, without a detrimental effect on the pain scores. These findings support the adoption of such regimens moving forward, with or without other ERAS protocol measures. Future efforts to further explore pain management strategies should incorporate the use of a multimodal pain regimen as secondary benefits such as improved breastfeeding may be identified."

Source: Macias DA, Adhikari EH, Eddins M, et al. A comparison of acute pain management strategies after cesarean delivery. Am J Obstet Gynecol 2022;226:407.e1-7.

https://doi.org/10.1016/j.ajog.2021.09.003