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Evaluation of a Quality Improvement Intervention That Eliminated Routine Use of Opioids After Cesarean Delivery

Holland, Erica MD; Bateman, Brian T. MD, MSc; Cole, Naida MD; Taggart, Ashley MD; Robinson, Laura A. BS; Sugrue, Ronan MBBCH, BAO; Xu, Xinling PhD; Robinson, Julian N. MD

doi: 10.1097/AOG.0000000000003010
Contents: Obstetrics: Clinical Practice and Quality

OBJECTIVE: To evaluate the effects of eliminating the routine use of oral opioids for postcesarean delivery analgesia on postcesarean opioid consumption.

METHODS: At a tertiary care center, we implemented a quality improvement intervention among faculty practice patients undergoing cesarean delivery, which consisted of 1) eliminating routine ordering of oral opioids after cesarean delivery, 2) implementing guidelines for ordering a short course of opioids when deemed necessary, and 3) coupling opioid prescribing at discharge to patterns of opioid use in-hospital combined with shared decision-making. All patients, both before and after the intervention, were administered neuraxial opioids and scheduled acetaminophen and nonsteroidal antiinflammatory medications in the absence of contraindications. The primary outcome was the percentage of women who used any opioids postoperatively in-hospital. Secondary outcomes included the percentage of women discharged with a prescription for opioids, the quantity of opioids used in-hospital, pain scores, satisfaction, opioid-related side effects, and opioid prescriptions ordered in the 6 weeks after delivery. The effects of this intervention were assessed based on a chart review of patient data and a survey of patients in the 12 weeks before and 12 weeks after the intervention.

RESULTS: We evaluated the records of 191 postcesarean delivery patients before and 181 after the intervention. Less than half of women used oral opioids in-hospital after the intervention, 82 (45%) compared with 130 (68%) before (P<.001). However, there was no change in pain scores or overall satisfaction with pain relief. Postintervention, only 40% of patients were discharged with prescriptions for opioids compared with 91% of patients before the intervention (P<.001).

CONCLUSION: Eliminating routine ordering of oral opioids after cesarean delivery is associated with a significant decrease in opioid consumption while maintaining the same levels of pain control and patient satisfaction. Oral opioids are not needed by a large proportion of women after cesarean delivery.

It is possible to eliminate routine ordering of oral opioids after cesarean delivery and reduce postoperative opioid consumption without increasing patients' pain scores.

Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, and the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, and the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Corresponding author: Erica Holland, MD, Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215; email:

Financial Disclosure Brian T. Bateman is an investigator on grants to Brigham and Women's Hospital from the National Institutes of Health, U.S. Food and Drug Administration, Lily, Pfizer, GSK, Baxalta, and Pacira outside of the submitted work. Dr. Bateman is also a consultant to Aetion, Inc. The other authors did not report any potential conflicts of interest.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

© 2018 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.