OPIOID UTILIZATION WITH ENHANCED RECOVERY AFTER CESAREAN DELIVERY PROTOCOL VERSUS STANDARD OF CARE Authors: Trace Easterling, Amanda Williams, Allison Daneault, Catherine Childre, Anna Bulman, Brianna Wheeler, Megan Missanelli, Brittney Bicksler, Francie Ruzic.
Objective: Compare opioid utilization in patients undergoing cesarean delivery with and without use of the enhanced recovery after cesarean delivery protocol.
Background/Purpose – Cesarean delivery is the most common surgical procedure in the United States and accounts for many women’s first exposure to opioids. The Enhanced Recovery After Surgery (ERAS) Society has published guidelines for many surgical procedures, including cesarean delivery, with the goal of expediting post-surgical recovery, minimizing exposure to opioids, and improving maternal and neonatal outcomes. Until recently, only one facility within Infirmary Health System utilized a standardized Enhanced Recovery and Cesarean (ERAC) protocol. The primary aim of this study is to compare opioid utilization in patients undergoing cesarean delivery with and without use of the ERAC protocol.
Methods – A retrospective chart review of patients at least 18 years of age undergoing cesarean delivery with ERAC protocol and without ERAC protocol across the three labor and delivery units encompassed in Infirmary Health System was conducted starting July 31, 2025 and working back in time until 150 patients in each category had been reviewed. Data collected through the electronic health record (EHR) included patient demographics, primary or repeat cesarean, scheduled or unscheduled cesarean, intraoperative and post-operative pain management modality, total morphine milligram equivalents (MMEs) post-operatively, length of hospitalization, average daily pain scores for post-operative days 1-3, and post-operative duration epidural and urinary catheterization. Discharge prescriptions were also reviewed and total MMEs of all outpatient prescriptions were recorded. Patient were excluded if they were less then 18 years old, had a complication that may have resulted in increased opioid requirements or length of stay, or had grossly incomplete chart data.
Results – A total of 303 patients were included in the results of the study. 145 patients received the non-ERAC protocol and 158 received the ERAC protocol. The median total postoperative MMEs were lower in the ERAC arm compared to the non-ERAC study arm (22.5 vs. 86.3 p < 0.01). Median length of stay and time to first as needed analgesic was also lower in the ERAC group compared to the non-ERAC group (Length of stay (h): 63 vs 75 p < 0.01; Time to first as needed analgesic (h): 15.8 vs. 24.6 p < 0.01). Median postoperative pain scores at day one, two, and three were also decreased in the ERAC arm (Day 1: 1 vs. 2 p < 0.01; Day 2: 2 vs. 3 p < 0.01; Day 3: 2 vs. 3 p < 0.01). For the median MMEs prescribed at discharge, patients in the ERAC group had a lower MME prescribed at discharge compared to those in the non-ERAC group. (MMEs at discharge: 112.5 vs 225 p < 0.01)
Conclusions – Patient receiving cesarean sections in the ERAC protocol had reduced inpatient opioid requirements, a shorter length of stay, improved pain control and accelerated recovery timelines compared to those in the non-ERAC group. Mothers in the ERAC group also went longer without requesting additional analgesics and received less opioids at discharge on average. These results continue to prove positive outcomes for ERAC protocols mothers receiving cesarean sections.
