Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery.

OBJECTIVE: Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. STUDY DESIGN: An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. RESULTS: A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10-181.6) MME to 15.8 (IQR: 0-75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18-3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48-1.02). CONCLUSION: Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. KEY POINTS: · ERAS after cesarean reduces inpatient opioid consumption.. · ERAS after cesarean increases the proportion of women not consuming any opioids.. · This pathway can be feasibly adopted elsewhere..

The role of litigation in midwifery practice in the United States: results from a nationwide survey of certified nurse-midwives/certified midwives.

Professional liability litigation is playing an increasing role in the practice of women's health care in this country. Although the impact of litigation on obstetricians' practices has been widely documented, data on the effect of litigation on midwifery practice are scant. The authors conducted a nationwide Web-based survey of American College of Nurse-Midwives (ACNM) members about the experience of being involved in litigation. The survey was completed by 600 midwives (17.5% response rate). Of those midwives completing the survey, 152 (25.3%) had been named in a lawsuit at least once during their midwifery careers. The litigation cases had been resolved for 114 (75%) of these respondents at the time of the survey. Forty-one (36%) reported being dropped from the case, even though the litigation continued without their involvement. Another 54 individuals (47.4%) were involved in cases that were settled before going to court, and an additional 10 cases (8.8%) were dropped without a settlement. Of the nine lawsuits (7.9%) that went to court, four favored the plaintiff (3.5%) and five (4.4%) favored the defendant. Future surveys are needed to better define the relationship between the practices of midwives and medical malpractice litigation.