Published online: 2020-12-02

SMFM Fellowship Series Article

Post-Cesarean Opioid Use after Implementation

of Enhanced Recovery after Surgery Protocol
Caitlin A. MacGregor, MD1,2 Mark Neerhof, DO1 Mary J. Sperling, RN3 David Alspach, MD4
Beth A. Plunkett, MD, MPH1 Alexandria Choi1 Rebecca Blumenthal, MD4

1 Department of Obstetrics and Gynecology, NorthShore University Address for correspondence Caitlin A. MacGregor, MD, University of
HealthSystem, Evanston, Illinois Chicago/NorthShore University HealthSystem, 2650 Ridge Ave,
2 Department of Obstetrics and Gynecology, University of Chicago Evanston, IL 60201 (e-mail: cmacgregor@northshore.org).
Pritzker School of Medicine, Chicago, Illinois
3 Care Transformation, NorthShore University HealthSystem,
Evanston, Illinois
4 Department of Anesthesiology, NorthShore University
HealthSystem, Evanston, Illinois

Am J Perinatol

Abstract Objective This study aimed to evaluate whether implementation of an enhanced recovery after

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Keywords
► cesarean delivery
► enhanced recovery
after surgery
► length of stay
► multidisciplinary
► obstetrics
► opioid use
► patient education
surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD).
Study Design We performed a pre- and postimplementation (PRE and POST,
respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal,
multidisciplinary perioperative approach. The four pillars of our protocol include
education, pain management, nutrition, and early ambulation. Patients were coun-
seled by their outpatient providers and given an educational booklet. Pain manage-
ment included gabapentin and acetaminophen immediately prior to spinal anesthesia.
Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxyco-
done was initiated as needed 24 hours after spinal analgesia. Preoperative diet
consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative
time with advancement as tolerated immediately postoperation. Women with a body
mass index (BMI) <40 kg/m2 and scheduled CD were eligible for ERAS. PRE patients
were randomly selected from repeat cesarean deliveries (RCDs) at a single site from
October 2017 to September 2018, BMI <40 kg/m2, without trial of labor. The POST
cohort included women who participated in ERAS from October 2018 to June 2019. PRE
and POST demographic and clinical characteristics were compared. Primary outcome
was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes
included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score.
Results All women in PRE (n ¼ 70) had RCD compared with 66.2% (49/74) in POST.
Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5–182.5) in
PRE compared with 0.0 (IQR: 0.0–72.5) in POST (p < 0.001). Median LOS in PRE was
4.02 days (IQR: 3.26–4.27) compared with 2.37 days (IQR: 2.21–3.26) in POST
(p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation
[SD] ¼ 1.86) in PRE compared with 4.67 (SD ¼ 1.63) in POST (p ¼ 0.04).
Conclusion ERAS protocol was associated with decreased postoperative opioid use,
shorter LOS, and decreased pain after CD.

received Copyright © by Thieme Medical DOI https://doi.org/

July 13, 2020 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0040-1721075.
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Post-Cesarean Opioid Use MacGregor et al.
Key Points
• ERAS protocol was associated with decreased postoperative opioid use after CD.
• ERAS protocol was associated with shorter length of stay after CD.
• ERAS protocol was associated with decreased postoperative pain after CD.
Cesarean delivery (CD) is the most commonly performed
surgery worldwide. In 2018, approximately 3.8 million births
were registered in the United States, of which 31.9% were
delivered via cesarean.1 Women recovering postpartum
from a CD must not only recuperate postoperatively, but
also care for their newborn. Surgical strategies designed to
facilitate early recovery, such as enhanced recovery after
surgery (ERAS) protocols, have the potential for an enormous
impact on new mothers and their families.
Recently, the American Journal of Obstetrics and Gynecology
(AJOG) published its last installment of a three-part guideline
of Enhanced Recovery after Surgery Society (ERASS) compo-
nents and recommendations for preoperative, intraoperative,
and postoperative care for CD.2–4 These guidelines are evi-
dence-based recommendations with a maternal focus. In
August 2019, AJOG published a call to action for obstetricians
to implement enhanced recovery after cesarean to address
many pressing needs in obstetrics, such as reducing maternal
morbidity and mortality, combatting the opioid epidemic
addressing costs, and optimizing peripartum care.5
Surgery induces a stress response that leads to a catabolic
state in which multiple organ systems are affected.6–8 This
stress response can lead to physiologic dysfunction and pro-
longed recovery.9–12 ERAS protocols were developed with the
aim of maintaining normal physiology to optimize periopera-
tive care.6,9 Although ERAS protocols were initially adopted by
colorectal surgeons, multiple surgical subspecialties have
implemented ERAS pathways after research demonstrated
shorter hospital stays and decreased complication rates among
colorectal patients.13–18 The American College of Obstetricians
and Gynecologists (ACOG) strongly encourages the use of ERAS
pathways in gynecologic surgery19 as ERAS protocols have
been shown to reduce length of stay (LOS), decrease postoper-
ative pain and opioid use, and increase patient satisfaction in
gynecologic and gynecologic oncology surgeries.20–22
Our institution developed an ERAS protocol for women
undergoing scheduled cesarean deliveries. The multidisci-
plinary team included anesthesia, obstetrics, pharmacy,
nursing, and care transformation (our institutional quality
improvement) representatives. We hypothesized that wom-
en undergoing a CD with an ERAS perioperative approach
would use less opioids in the postoperative period compared
with historic controls. The objective of our study was to
evaluate whether implementation of an ERAS protocol is
associated with lower maternal opioid use after CD.
Materials and Methods
We performed a pre- and post-implementation (PRE ad
POST, respectively) study of an ERAS protocol for cesarean
American Journal of Perinatology
deliveries conducted at a single site, Evanston Hospital
NorthShore University HealthSystem. PRE patients were
randomly selected from repeat cesarean deliveries (RCD)
from October 2017 to September 2018. Women who under-
went a trial of labor or who had a body mass index (BMI) 
40 kg/m2 were excluded. The POST cohort included women
who participated in ERAS from October 2018 to June 2019.
ERAS was initially piloted in women having scheduled RCD
whose BMI was <40 kg/m2 and then expanded to all sched-
uled cesarean deliveries whose BMI was <40 kg/m2. Women
with chronic opioid use were excluded from the study.
The ERAS protocol encompassed preoperative, intra-
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operative, and postoperative care. The four pillars of our
ERAS protocol include education, pain management, nutri-
tion, and early ambulation. Each of the four pillars contains
several additional evidence-based interventions that are
incorporated in the preoperative, intraoperative, and post-
operative phases of our ERAS CD protocol. During outpatient
preoperative counseling, nurses, midwives, or physicians
reviewed in detail the ERAS protocol prior to participating.
In addition to provider counseling, patients were provided
with an ERAS educational booklet to help prepare for their
CD and to describe how patients would play an active role in
their recovery, which included daily goals to achieve post-
operatively. The various components of ERAS were discussed
in the patient education booklet and expectations were set
forth for pain control after delivery and anticipated discharge
on postoperative day 2 (POD2).
Pain management consisted of multimodal nonopioid
analgesia and regional anesthesia. Preoperative analgesia
included 600-mg gabapentin and 1,000 mg acetaminophen
orally immediately prior to arriving in the operating room
(OR). Spinal anesthesia with a combination of morphine,
fentanyl, and local anesthetic was administered in the OR.
Patients received a single dose of intravenous (IV) ketorolac
immediately postoperation if the patient was deemed he-
mostatic by the obstetrician. Postoperative pain manage-
ment included scheduled ibuprofen 600 mg in every 6 hours
starting at 6 hours after IV ketorolac was given. Scheduled
acetaminophen 650 mg in every 6 hours was given starting at
6 hours after the preoperative dose. Oxycodone was given as
needed 5 mg in every 4 hours >24 hours after spinal admin-
istration as this was expected to provide pain relief for
24 hours.
Patients were instructed that they could consume food until
6 hours prior to the start of the surgery. In addition, they were
instructed to fast until 2 hours prior to their scheduled surgery.
At that time, they were given a clear carbohydrate drink and
then resumed fasting until their surgery was completed.
Patients received 1 to 2 L of lactated ringers prior to scheduled
 Post-Cesarean Opioid Use MacGregor et al.

start time and spinal, open fluid administration intraopera-
tively, followed by maintenance rate of 125 mL/hour upon
arrival in the postanesthesia care unit (PACU). Patients were
also instructed to void when called to the OR for their CD. A
Foley’s catheter was placed to dependent drainage. Standard
preoperative antibiotics were given. Postoperative manage-
ment included a clear liquid diet starting 30 minutes after
arrival in the PACU after surgery with advancement as tolerat-
ed to general diet starting 1 hour after arrival in PACU. In
addition, chewing gum was given in every 8 hours and IV fluids
were discontinued once oral intake was adequate (>1,000 mL
in the first 24 hours without emesis). The Foley catheter was
removed when the patient was in ambulatory.
Early ambulation was required and documented starting
6 hours postoperatively. Specific activity orders included
ambulating the length of the hallway at least four times
daily, taking all meals in the chair, and to be out of bed for at
least 8 hours total during the day.
Maternal sociodemographic and delivery data were
obtained from patients’ electronic medical record. BMI was
Categorical variables were compared by Chi-square or
Fisher’s exact test where appropriate. Continuous variables
were compared using Student’s t-test or nonparametric
Wilcoxon’s sum rank test where appropriate. All statistical
tests were two-tailed and a p-value <0.05 was considered
significant. Data analysis was performed with SPSS (IBM
Corp. Released 2013. IBM SPSS Statistics for Windows, Ver-
sion 22.0, Armonk, NY).
Results
A total of 144 women were included in the analysis, 70
women in PRE and 74 in POST. All women in PRE had a repeat
CD compared with 66.2% in POST. The mean patient age was
35 years and mean BMI was 30.3 kg/m2 at delivery. The mean
gestational age at delivery was 390/7 weeks and mean birth
weight was 3,391 g. There were no significant differences
between the women in PRE versus POST with regard to
insurance status, marital status, history of mental illness,
and tobacco use (►Table 1).

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calculated by self-reported height and recorded weight on
admission to labor and delivery. Race and ethnicity were
based on self-reported data captured in the medical record.
Estimated date of confinement (EDC) was based on provider
assessment using the last menstrual period and/or ultra-
sound as documented in the medical record. The EDC was
used to calculate gestational age at the time of delivery. PRE
and POST demographic and clinical characteristics were
compared. Primary outcome was total postoperative mor-
phine milligram equivalents (MMEs) during delivery admis-
sion. Secondary outcomes included LOS, maximum POD2
pain score (scale 1–10), and MMEs prescribed at discharge.
We specifically evaluated the POD2 pain score as a proxy for
level of pain at discharge.
Median total postoperative MMEs were 140.0 (interquar-
tile range [IQR]: 87.5–182.5) in PRE compared with 0.0 (IQR:
0.0–72.5) in POST (p < 0.001, ►Fig. 1). Median LOS was 4.02
days (IQR: 3.26–4.27) in PRE compared with 2.37 days (IQR:
2.21–3.26) in POST (p < 0.001, ►Fig. 2). Mean maximum
POD2 pain score was 5.28 (standard deviation [SD] ¼ 1.86)
in PRE compared with 4.67 (SD ¼ 1.63) in POST
(p ¼ 0.04, ►Fig. 3).
With regard to discharge opioid prescriptions, mean
MMEs prescribed at discharge were 145.9 (SD 64.7) in
PRE compared to 54.4 (SD 63.4) in POST
(p < 0.001; ►Fig. 4). After ERAS implementation, 56.8%
(42/74) received a prescription for opioids upon discharge,
compared with 97.1% (68/70) of women prior to ERAS. Of

Table 1 Maternal demographic and clinical characteristics

PRE POST p-Value

Maternal age (y) 34.5 (33.0, 38.0) 35.0 (32.0, 38.0) 0.689
Race 0.398
White 38 (54.3) 44 (62.0)
Black 6 (8.6) 2 (2.8)
Asian 6 (8.6) 8 (11.3)
Other 20 (28.6) 17 (23.9)
Hispanic 9 (13.0) 4 (5.7) 0.157
Public insurance 14 (20.0) 6 (8.1) 0.053
Married 56 (80.0) 67 (91.8) 0.054
BMI (kg/m2) 30.8 (5.2) 29.8 (3.9) 0.166
History of mental illness 14 (20.0) 10 (13.5) 0.372
Tobacco use 1 (1.4) 0 (0) 0.486
Gestational age (wk) 39.0 (38.0–39.3) 39.0 (38.1–39.3) 0.951
Birth weight (g) 3,358 (3,033–3,581) 3,423 (3,063–3,790) 0.315

Abbreviations: BMI, body mass index at delivery; POST, postimplementation; PRE, preimplementation.
Note: All data are displayed as n (%), mean  SD or median (Q1–Q3).

American Journal of Perinatology

Post-Cesarean Opioid Use MacGregor et al.
Fig. 1 Median total postoperative morphine milligram equivalents
(MMEs) during delivery admission. Box plots display median, inter-
quartile range, minimum and maximum values. POST, postimple-
mentation; PRE, preimplementation.
Fig. 2 Median length of stay (days). Box plots display median,
interquartile range, minimum and maximum values. POST, postim-
plementation; PRE, preimplementation.
Fig. 3 Mean postoperative day 2 maximum pain score (scale 1–10).
POST, postimplementation; PRE, preimplementation.
the 42 women in POST who received no postoperative
opioids during delivery admission, 47.6% (20/42) were given
a prescription for opioids upon discharge.
Discussion
In this study, we found that an ERAS protocol was associated
with decreased postoperative opioid use after CD. It was also
American Journal of Perinatology
Fig. 4 Mean morphine milligram equivalents (MMEs) prescribed at
discharge. POST, postimplementation; PRE, preimplementation.
associated with a shorter LOS, lower maximum POD2 pain
scores, and fewer MMEs prescribed at discharge. Our findings
are consistent with other retrospective and prospective
studies of ERAS at cesarean23–26 that demonstrated de-
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creased postoperative LOS. Our findings are also similar to
a recently published randomized controlled trial.27 This trial
included 118 women, 58 of whom were randomized to an
ERAS protocol and 60 of whom received standard perioper-
ative care. Similar to our findings, this study demonstrated
decreased LOS (although their primary outcome POD2 dis-
charges was not significantly increased). However unlike our
findings, there was no reduction in postoperative opioid use.
This may be explained by differences in our ERAS protocol
which include extensive preoperative patient education, use
of preoperative analgesia with gabapentin and acetamino-
phen, and intrathecal morphine. In a recently published
report, Kleiman et al demonstrated that implementation of
ERAS for cesarean resulted in decreased opioid consumption,
improved pain scores, and shortened LOS.28 These findings
are very consistent with ours. Thus decreased opioid con-
sumption has been demonstrated in several, but not all
studies.
The results of our study have important implications for
the rising opioid epidemic. In 2014, approximately 1.9
million people had opioid use disorder related to prescrip-
tion pain relievers.29 In 2012, providers wrote 259 million
opioid prescriptions.30 About 1 in 300 opioid naïve women
become persistent users following CD.31 The potential for
ERAS to limit opioid exposure in women recovering from CD
may have enormous implications for the opioid crisis. ACOG
endorses a multimodal approach to postpartum pain man-
agement in addition to shared decision making regarding
discharge opioid prescriptions to minimize the number of
unused opioid pills and to prevent the development of opioid
use disorder.32 One study evaluating whether shared deci-
sion-making intervention decreases the quantity of opioids
prescribed after CD found that median number of 5-mg
oxycodone tablets women chose for their prescription was
20.0 compared with their institution’s standard 40-tablet
prescription.33 In our study, although there were no ERAS
guidelines proscribing specific discharge opioid prescrip-
tions, there was a 40.3% reduction in the number of women

not receiving any opioid prescriptions upon discharge in the
POST cohort compared with PRE. We also found a significant
reduction in the number of MMEs prescribed to women in
ERAS compared with the historic control (90.5 MMEs
which is equivalent to 18 tablets of 5-mg hydrocodone or
12 tablets of 5-mg oxycodone). Although our ERAS protocol
had a positive impact in reducing both the number of opioid
prescriptions and MMEs prescribed, 47.6% of women who
received no postoperative opioids during delivery admission
were still given a prescription for opioids upon discharge.
This finding highlights the need for further provider educa-
tion and provides an opportunity to improve our ERAS
protocol to include discharge opioid proscribing recommen-
dations based on postoperative opioid use. Combining
shared decision making for postpartum discharge opioid
prescriptions with an ERAS protocol that maximizes non-
narcotic pain medications may further reduce opioid use and
maintain patient satisfaction.
Limitations and Strengths
Our study has several limitations. A limitation of this study is
that it is a PRE and POST study, which has the potential to
introduce selection bias into the study. Although patients
were randomly selected for PRE, ERAS was initially presented
as optional and women chose to participate in the ERAS
protocol. However, as improved outcomes were recognized,
ERAS became the standard of care at our institution. Another
limitation is that we did not collect patient satisfaction data
and as such are unable to speak to the acceptability of the
patient experience. Our study represents a single center’s
experience that predominantly cares for privately insured
patients, which may limit its generalizability. Although
sample size is not very large, the results are substantial for
9 months after the introduction of our ERAS protocol. As we
performed a quality improvement study with an observa-
tional design, like all observational studies, we are unable to
assess causality.
Despite these limitations, our study has several strengths
to be considered. A strength of our study is the multidisci-
plinary input from anesthesia, obstetrics, pharmacy, nurs-
ing, and care transformation (our institutional quality
improvement) representatives to create the ERAS protocol.
This approach ensured commitment and dedication to the
success of the program. Our protocol demonstrates that
engaging key stakeholders in different disciplines can lead
to the successful creation and implementation of an ERAS
protocol.
Conclusion
ERAS is associated with decreased postoperative opioid use,
shorter LOS, lower maximum POD2 pain scores, and reduc-
tion in discharge opioid prescriptions after CD. Health care
organizations should develop ERAS protocols for cesarean
deliveries that incorporate input from multiple disciplines to
optimize perioperative care. In future studies, it would be
informative to investigate how ERAS impacts postpartum
Post-Cesarean Opioid Use MacGregor et al.
issues, such as postpartum depression, maternal–infant
bonding, and breastfeeding.
Funding
None.
Conflict of Interest
None declared.
Acknowledgments
The authors are grateful to the entire ERAS C-section team
which includes anesthesia, obstetrics, pharmacy, nursing,
and care transformation representatives for their incredi-
ble support and for championing the ERAS protocol.
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