Cesarean Delivery: Original Research
Enhanced Recovery After Surgery to Change
Process Measures and Reduce Opioid Use
After Cesarean Delivery
A Quality Improvement Initiative
Monique Hedderson, PhD, Derrick Lee, MD, Eric Hunt, MD, PhD, Kimberly Lee, MD, Fei Xu,
Alex Mustille, PhD, Jessica Galin, MPH, Cynthia Campbell, PhD, Charles Quesenberry, PhD,
Vivian Reyes, MD, Mengfei Huang, PhD, Barbara Nicol, MD, Shirley Paulson, DNP, MPA, RN,
and Vincent Liu, MD, MS
OBJECTIVE: To evaluate implementation of an enhanced
recovery after surgery (ERAS) program for patients under-
going elective cesarean delivery by comparing opioid
exposure, multimodal analgesia use, and other process
and outcome measures before and after implementation.
METHODS: An ERAS program was implemented
among patients undergoing elective cesarean delivery
in a large integrated health care delivery system. We
conducted a pre–post study of ERAS implementation to
compare changes in process and outcome measures
during the 12 months before and 12 months after im-
plementation.
RESULTS: The study included 4,689 patients who under-
went an elective cesarean delivery in the 12 months
From the Kaiser Permanente Division of Research and the Permanente Medical
Group, Oakland, and the Department of Psychiatry, Weill Institute for
Neurosciences, University of California, San Francisco, San Francisco
California.
Supported by a grant from The Permanente Medical Group. Vincent Liu’s time
for this work was also covered by the NIGMS R35GM128672 grant.
The authors thank the ERAS Executive Sponsors, Steering Committee, Regional
Mentors, Local Champion Committees, KP HealthConnect, and Regional Health
Education teams for their dedication to improving surgical care, and the thou-
sands of clinicians and staff who each contributed to make this work a reality.
Each author has confirmed compliance with the journal’s requirements for
authorship.
Corresponding author: Monique Hedderson, Kaiser Permanente Division of
Research, Oakland, CA, email: Monique.M.Hedderson@kp.org.
Financial Disclosure
Cynthia Campbell received money paid to her institution from the Campbell
Consortium. Barbara Nicol disclosed receiving funds from The Permanente
Medical Group, which is her employer. The other authors did not report any
potential conflicts of interest.
© 2019 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/19
VOL. 134, NO. 3, SEPTEMBER 2019
© 2019 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MS,
before (pilot sites: March 1, 2015–February 29, 2016, all
other sites: October 1, 2015–September 30, 2016), and
4,624 patients in the 12 months after (pilot sites: April 1,
2016–March 31, 2017, all other sites: November 1, 2016–
October 31, 2017) ERAS program implementation. After
ERAS implementation mean inpatient opioid exposure
(average daily morphine equivalents) decreased from
10.7 equivalents (95% CI 10.2–11.3) to 5.4 equivalents
(95% CI 4.8–5.9) controlling for age, race–ethnicity, pre-
pregnancy body mass index, patient reported pain score,
and medical center. The use of multimodal analgesia (ie,
acetaminophen and neuraxial anesthesia) increased from
9.7% to 88.8%, the adjusted risk ratio (RR) for meeting
multimodal analgesic goals was 9.13 (RR comparing post-
ERAS with pre-ERAS; 95% CI 8.35–10.0) and the propor-
tion of time patients reported acceptable pain scores
increased from 82.1% to 86.4% (P,.001). Outpatient
opioids dispensed at hospital discharge decreased from
85.9% to 82.2% post-ERAS (P,.001) and the average
number of dispensed pills decreased from 38 to 26
(P,.001). The hours to first postsurgical ambulation
decreased by 2.7 hours (95% CI 23.1 to 22.4) and the
hours to first postsurgical solid intake decreased by 11.1
hours (95% CI 211.5 to 210.7). There were no significant
changes in hospital length of stay, surgical site infections,
hospital readmissions, or breastfeeding rates.
CONCLUSIONS: Implementation of an ERAS program
in patients undergoing elective cesarean delivery was
associated with a reduction in opioid inpatient and
outpatient exposure and with changes in surgical pro-
cess measures of care without worsened surgical out-
comes.
(Obstet Gynecol 2019;134:511–9)
DOI: 10.1097/AOG.0000000000003406
OBSTETRICS & GYNECOLOGY 511
E nhanced recovery after surgery (ERAS) programs
are evidence-based care pathways designed to
decrease the surgical stress response and maximize
the potential for recovery.1 These pathways include
the use of multimodal analgesia to reduce opioid
exposure, avoidance of prolonged fasting, encourage-
ment of early mobility, and education of patients
regarding goals and expectations of surgery.2–5
Enhanced recovery after surgery programs have been
implemented and evaluated in a variety of surgical
populations, including colorectal, thoracic, complex
urologic, joint replacement, and gynecologic surgical
populations,3–12 but less is known about ERAS pro-
grams among patients undergoing elective cesarean
delivery.
Kaiser Permanente Northern California, a large
integrated health care delivery system, developed and
implemented an ERAS pathway protocol for cesarean
delivery, with implementation taking place between
March and October 2016 across 15 medical centers.
We designed this pre–post study to assess changes in
process measures (defined as clinical care actions
clinicians perform to maintain or improve the health
of their patients)13 and outcomes among patients
undergoing elective cesarean deliveries during the
12 months before and 12 months after implementa-
tion of the ERAS program.
METHODS
This study was approved by the Kaiser Permanente
Northern California Institutional Review Board. A
multidisciplinary team of obstetricians, anesthesiolo-
gists, perinatologists, neonatologists, nursing leaders,
and medical research consultants in Kaiser Perma-
nente Northern California developed an ERAS care
pathway for patients undergoing cesarean delivery
based on prior ERAS efforts targeting other surgical
populations; these methods have been previously
described.6,14 The Kaiser Permanente Northern Cal-
ifornia ERAS Program aimed to standardize surgical
care with an emphasis on four interventions: 1) mul-
timodal pain management and decreased opioid use,
2) early mobility, 3) optimal nutrition, and 4) patient
engagement (Table 1).
For pain management, post-ERAS patients rou-
tinely received intrathecal opioids followed by acet-
aminophen and nonsteroidal antiinflammatory drugs
(NSAIDs) every 6 hours, or four times daily. Patients
received scheduled 24 hours of intravenous (IV)
acetaminophen followed by oral acetaminophen. Oral
oxycodone was available for breakthrough pain.
Inpatient pain management was directed toward
decoupling opioid administration from that of other
512 Hedderson et al Enhanced Recovery After Surgery and Elective Cesarean Deliveries
© 2019 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
pain medications (eg, NSAIDs and acetaminophen).
A similar practice was implemented for default
discharge decoupled pain medication prescriptions
(defined as separate prescriptions for opioids, acet-
aminophen, and NSAIDS as opposed to combination
products). Pre-ERAS cohort, the order sets, which
consisted of predefined bundles of physician orders
with standardized options, included the option for
hydrocodone or oxycodone with a default quantity of
30 tablets. Post-ERAS, we decoupled the medications
(acetaminophen and oxycodone). There was still the
option for hydrocodone, but most providers elected to
use decoupled combinations, so patients could max-
imize their acetaminophen dose before adding an
opioid (oxycodone). The number of tablets in the
opioid prescription was reduced to 20 tablets. Pre-
ERAS patients were encouraged to ambulate as
tolerated and the removal of the Foley occurred after
ambulation was established. Post-ERAS patients were
encouraged to begin ambulation within 12 hours of
surgery completion. Pre-ERAS patients were advised
to fast after midnight, but this was not standardized;
post-ERAS patients were provided 8 oz (237 mL) of
carbohydrate drink to be consumed 2 hours before
hospital arrival, with diabetic patients instructed to
drink water instead, given gum to chew, and offered
a regular diet within 12 hours after surgery. Pre-
operative surgical site infection prophylaxis during
the Pre-ERAS period included preoperative antibiot-
ics and a chlorhexidine gluconate abdominal prep.
For post-ERAS implementation, chlorhexidine wipes
were added to this regimen to use at home.
In the ERAS epoch, patient education was pro-
vided during a preoperative visit where patients
received an ERAS kit that included a brochure
explaining ERAS and what to expect before, during,
and after their surgery, the carbohydrate drink with
instructions on when to consume it, and instructions
on the use of the chlorhexidine wipes. Patients were
educated regarding what to expect during their
surgery and the benefits of the ERAS pathways by
their providers, the cesarean delivery scheduling staff
and nurses in the hospitals. At each hospital, a staff
member reviewed with patients a brochure explaining
ERAS, the principles of ERAS, and answered any
questions. Implementation of ERAS care processes
were supported by the development of standardized
electronic health record (EHR)–based order sets.
The ERAS program was implemented in a stag-
gered nonrandomized fashion across 15 medical
centers throughout 2016. Two pilot sites were chosen
based on leadership interest, performance improve-
ment expertise, and clinician engagement with
OBSTETRICS & GYNECOLOGY
Table 1. Care Processes Included in the Enhanced Recovery After Surgery Program

Care Process Description

Preoperative
Patient education
No prolonged fasting
Carbohydrate loading
Surgical site infection prophylaxis
Intraoperative
Standard anesthetic protocol
Antimicrobial prophylaxis
Postoperative nausea and
vomiting prophylaxis
Multimodal analgesia
Perioperative fluid management
Prevention of hypothermia
Postoperative
Multimodal analgesia
Early oral nutrition
Early ambulation
Early urinary catheter removal
Restoration of gut function
NSAID, nonsteroidal antiinflammatory drugs.
Verbal counseling and written brochures provided preoperatively
Clear liquids allowed up to 2 h and solids up to 8 h before scheduled hospital arrival
Apple juice 2 h before scheduled hospital arrival
Chlorhexidine wipes were given to patients to use at home
Optimal dose neuraxial opioids
Chlorhexidine skin preparation and antibiotics with weight-based dosing 15–60 min before
incision
Fluid administration, correction of hypotension, ondansetron, and optional scopolamine;
avoidance of uterine exteriorization
Acetaminophen and neuraxial anesthesia
Euvolemia targeted
Active warming devices
Scheduled acetaminophen and NSAID
Regular diet within 12 h after surgery
Ambulation accomplished within 12 h after surgery
Removal of urinary catheter within 12 h after surgery
Chewing gum

implementation occurring in March 2016. Full
regional implementation was completed at the re-
maining 13 centers in October 2016. Nursing and
physician leads at each site were supported by local
quality and multidisciplinary clinical teams that led
ERAS pathway implementation. Thus, existing staff
was used to implement the ERAS program. These
local teams also oversaw education of physicians,
nurses, and other staff, and provided regular feedback
on local ERAS process metrics and outcomes.
Regional performance dashboards were created to
provide a performance report to review the process
measures and outcomes at each of the 15 medical
centers and for the Kaiser Permanente Northern
California region overall were developed to display
and track process and outcome measures based on the
EHR data and were provided on a weekly basis to
local teams. Regional support was also provided
through biweekly teleconferencing and frequent com-
munication with nurse consultant mentors,14 who
were experts in performance improvement deployed
to each medical facility to facilitate ERAS implemen-
tation and to identify and provide solutions for any
barriers. A regional Kaiser Permanente Northern Cal-
ifornia leadership team monitored implementation
working in conjunction with three clinical regional
nursing coordinators.
We used a pre–post study design to compare
changes in processes and outcomes among patients
undergoing elective cesarean delivery before and after
implementation of the ERAS program. Starting with
the ERAS implementation month, standardized as
“time zero” for each medical center, we collected pro-
cess and outcomes data from the preceding (pre) 12
months and subsequent (post) 12 months using EHR
data, excluding the month of implementation, “time
zero.” Kaiser Permanente Northern California’s EHR
system is designed by Epic Corporation and custom-
ized for the needs of Kaiser Permanente and has been
renamed KP HealthConnect. All medical centers and
hospitals in Kaiser Permanente Northern California
use the same KP HealthConnect system.
We identified elective cesarean delivery ERAS
patients based on International Classification of Dis-
eases, 10th Revision, Clinical Modification hospital
diagnosis and procedure codes, including diagnosis
codes 082.1, 082.2, 082.8, 082.9 and procedure code
59510. We restricted our analysis to elective cesarean
deliveries to ensure that there was adequate time for
the ERAS process measures to be implemented pre-
operatively. We identified elective procedures based
on an EHR operating room scheduling database. A
validation of 100 randomly selected cesarean deliver-
ies study found that 95% of cases were correctly
identified as elective or urgent when comparing
clinical documentation with EHR data.
We selected process of care measures within each
ERAS perioperative care element, excluding patient
education and engagement, in our analysis. For pain
management and sedation, we evaluated: 1) the daily

VOL. 134, NO. 3, SEPTEMBER 2019 Hedderson et al Enhanced Recovery After Surgery and Elective Cesarean Deliveries 513

© 2019 by the American College of Obstetricians

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Unauthorized reproduction of this article is prohibited.
IV morphine-equivalent dosage of opioid medication
administered from 4 hours before the operating room
through the third postoperative day (“opioid usage”);
2) the use of multimodal analgesia, defined multi-
modal as the administration of two or more doses of
NSAIDs from 4 hours preoperatively through the first
postoperative day, and the administration of two or
more doses of IV acetaminophen during the same
time period; and 3) delta pain scores, defined as the
difference between a patient’s acceptable level of pain
(based on a visual analogue scale from 0 to 10) and the
amount of pain they reported feeling at a specific
moment in time to assess how well pain was being
managed. A score of 0 or less suggests that a patient’s
pain was being adequately managed. We quantified
these metrics using standardized methods based on
medication administration records, preoperative
checklists, and nursing shift assessments recorded in
the EHR6,14
We also identified outpatient opioid dispensa-
tions at discharge from the Kaiser Permanente
Northern California pharmacy database including
generic name, strength, date dispensed, quantity
dispensed, and days-supply. More than 90% of
Kaiser Permanente Northern California members
obtain all or almost all of their prescription medi-
cations through Kaiser Permanente Northern Cal-
ifornia pharmacies.15 We focused on formulations
with higher likelihood of abuse, and those used pri-
marily to treat pain based in prior studies,16,17
excluding non–pain related opioid formulations (ie,
antitussives, anesthetics, antihistamines, antidiar-
rheals) and medications to treat opioid use disorder
(eg, buprenorphine). We determined the percentage
of opioid prescriptions for opioid tablets, for which
the opioid was decoupled from a second medication
such as acetaminophen. Dispensations were con-
verted into mean morphine milligram equivalents
per day using a standard conversion table.18 We also
determined the number of tablets per prescription
filled at hospital discharge.
For mobility, we evaluated 1) ambulation within
12 hours of surgery (“early ambulation”) and 2) the
elapsed hours from surgery to first ambulation (“hours
to ambulation”). Time to first ambulation was docu-
mented by nurses and recorded in flowsheets in the
EHR both pre-ERAS and post-ERAS implementa-
tion. For nutrition, we evaluated 1) the provision of
last meal or liquids in the preoperative period (no
prolonged fast), 2) the provision of postoperative oral
nutrition within 12 hours of surgery (“early nutri-
tion”), and 3) the elapsed hours from surgery to first
nutrition (“hours to nutrition”).
514 Hedderson et al Enhanced Recovery After Surgery and Elective Cesarean Deliveries
© 2019 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Study outcome metrics included hospital length
of stay, discharge to home, 30-day readmission, and
30-day intensive care unit (ICU) admission extracted
from EHR data. We identified surgical site infections
based on manually abstracted data compiled in the
National Healthcare Safety Network. We also ex-
tracted EHR data on breastfeeding from inpatient
flowsheets and based on data from the first well-child
visit typically at 7 days postdelivery.
To assess for potential secular changes in our
elective cesarean cohort, we extracted data on mater-
nal age at delivery, race–ethnicity, parity, and gesta-
tional age at delivery. We identified neonatal birth
weights using EHR data including categories such as
large for gestational age (birth weight greater than
90th percentile) and small for gestational age (birth
weight less than 10th percentile) according to the
Kaiser Permanente Northern California race–
ethnicity and gestational age-specific birth weight
distribution.19
Descriptive statistics are reported separately for
the pre-ERAS and post-ERAS implementation peri-
ods. Medians and interquartile range are used to
describe continuous variables. Frequencies and per-
centages are used to describe categorical variables.
Unadjusted comparisons between groups are based
on t-tests, Wilcoxon rank-sum, or chi-squared tests,
respectively. Our pre–post analyses adjusted for cal-
endar month and demographic variables to account
for seasonal changes in cesarean delivery rates, which
may affect outcomes and the characteristics of the
underlying population including demographics and
reproductive risk factors (ie, age at delivery, race–
ethnicity, prepregnancy body mass index [BMI, cal-
culated as weight in kilograms divided by height in
meters squared], parity, and preterm birth). We used
generalized linear regression to estimate the effect of
exposure to the ERAS program (post compared with
pre) on continuous outcomes of interest. The regres-
sion model form (ie, link) and distributional assump-
tions varied, as appropriate to each outcome of
interest. Poisson regression with robust standard er-
rors were used to provide crude and adjusted esti-
mates of relative risks (RR) to estimate the effect of
exposure to the ERAS program (post compared with
pre) on dichotomous outcomes of interest.20
RESULTS
A total of 4,689 patients underwent an elective
cesarean delivery in the 12 months before, and
4,624 patients in the 12 months after ERAS pro-
gram implementation. Patient demographic and
reproductive characteristics were similar in the
OBSTETRICS & GYNECOLOGY
preimplementation and postimplementation periods,
except that patients delivering during the post-ERAS
implementation period were slightly more likely to be
black or Hispanic and to be overweight or obese
compared with patients delivering during the pre-
ERAS implementation period (Table 2).
The daily inpatient morphine equivalents
decreased significantly from 10.7 to 5.4 equivalents in
the multivariable adjusted model (Table 3). The use of
multimodal analgesia increased significantly from 9.7%
to 88.8%, with a 9-fold increased adjusted RR for meet-
ing multimodal analgesic goals, driven by an 8-fold
increase in IV acetaminophen use. The percent of time
patients reported acceptable pain scores increased sig-
nificantly from 82.1% before ERAS to 86.4% after
ERAS implementation. The patient reported accept-
able pain scores were significantly higher in the post-
ERAS implementation period for all postoperative
days (0–3) (data not shown). The percent of patients
that did not use any postoperative inpatient opioids
increased significantly (Table 2). The average number
of tablets per prescription of outpatient opioid prescrip-
tion at hospital discharge also decreased significantly
from 37 to 26; with the average morphine milligram
equivalents per day of the outpatient prescription at
hospital discharge decreasing from 53.3 to 50.4.

Table 2. Characteristics of Patients in the 1-Year Periods Before (Pre) and After (Post) Enhanced Recovery
After Surgery Implementation

ERAS Elective Cesarean Delivery Patients

Characteristic Pre (n54,689) Post (n54,624) P

Age (y) 33.365.1 33.465.0 .73

Younger than 30 1,029 (21.9) 981 (21.2) .81
30–34 1,691 (36.1) 1,704 (36.9)
35–39 1,466 (31.3) 1,441 (31.2)
40 and older 503 (10.7) 498 (10.8)
Prepregnancy BMI (kg/m2)
Underweight (less than 18.5) 74 (1.6) 63 (1.4) .005
Normal weight (18.5–24.9) 1,565 (33.4) 1,446 (31.3)
Overweight (25.0–29.9) 1,239 (26.4) 1,260 (27.3)
Obese (30.0 or higher) 1,379 (29.4) 1,488 (32.2)
Unknown or missing 432 (9.2) 367 (7.9)
Race–ethnicity
White 1,890 (40.3) 1,716 (37.1) .002
Black 304 (6.5) 364 (7.9)
Asian or Pacific Islander 1,061 (22.6) 1,028 (22.2)
Hispanic 1,191 (25.4) 1,263 (27.3)
Other 234 (5.0) 236 (5.1)
Unknown or missing 9 (0.2) 17 (0.4)
Language interpreter required
Yes 195 (4.2) 183 (4.0) .66
Parity
0 1,218 (26.0) 1,107 (24.0) .12
1 2,177 (46.4) 2,240 (48.4)
2 or more 1,292 (27.6) 1,275 (27.6)
Unknown or missing 2 (0.0) 2 (0.0)
Neonatal size*
Small for gestational age 359 (8.0) 356 (8.1) .54
Appropriate for gestational age 3,482 (77.8) 3,386 (76.9)
Large for gestational age 634 (14.2) 659 (15.0)
Singleton gestation 4,475 (95.4) 4,401 (95.2) .91
Twin gestation 202 (4.3) 211 (4.6)
Triplet gestation 4 (0.1) 5 (0.1)
Unknown or missing 8 (0.2) 7 (0.2)
Gestational age (wk) 38.561.3 38.561.5 .03
Preterm (less than 37 wk of gestation) 306 (6.5) 344 (7.5) .08
ERAS, enhanced recovery after surgery; BMI, body mass index.
Data are mean6SD or n (%) unless otherwise specified.
* Only among singleton deliveries. Small for gestational age defined as birth weight less than the 10th percentile of the underlying
population. Large for gestational age defined as birth weight greater than the 90th percentile of the underlying population.

VOL. 134, NO. 3, SEPTEMBER 2019 Hedderson et al Enhanced Recovery After Surgery and Elective Cesarean Deliveries 515

© 2019 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 3. Multivariate Adjusted* Associations of Post-ERAS Implementation Changes With Process
Measures

Pre-ERAS (n54,689) Post-ERAS (n54,624)

Unadjusted Mean Adjusted Mean
Mean Difference‡ or Difference‡ or
n† (95% CI) n Mean (95% CI) RR (95% CI) RR (95% CI) P
Pain management
§
Morphine equivalents, 4,689 10.7 4,624 5.4 25.8 25.4 ,.001
average rate/d (mg) (10.2–11.3) (4.8–5.9) (26.2 to 25.4) (25.7 to 25.0)
Met multimodal analgesic 4,689 9.7 4,624 88.8 9.19 9.13 ,.001
(8.8–10.5) (87.9–89.7) (8.42–10.0) (8.35–9.99)
Met NSAID 4,689 94.2 4,624 94.8 1.01 1.01 .057
(93.5–94.8) (94.2–95.5) (1.00–1.02) (1.00–1.02)
Met IV acetaminophen 4,689 11.4 4,624 93.4 8.23 8.17 ,.001
(10.4–12.3) (92.7–94.1) (7.60–8.92) (7.53–8.87)
║
Average delta pain score 4,689 21.32 4,624 21.57 20.27 20.25 ,.001
(21.42 to 21.21) (21.68 to 21.46) (20.35 to 20.20) (20.32 to 20.18)
Average delta pain score 4,689 82.1 4,624 86.4 1.05 1.05 ,.001
at or below patient (81.0–83.2) (85.4–87.4) (1.03–1.07) (1.03–1.07)
pain tolerance
Did not use any 4,689 8.3 4,624 21.4 2.59 2.69 ,.001
postoperative opioids (7.5–9.1) (20.2–22.6) (2.32–2.89) (2.39–3.02)
Prescriptions at hospital
discharge
Filled opioid prescription 4,689 85.9 4,624 82.2 0.96 0.96 ,.001
at discharge (84.9–86.9) (81.1–83.3) (0.94–0.97) (0.94–0.98)
¶
% decoupled opioids 4,029 1.6 3,801 87.4 ,.001
(1.2–2.0) (86.4–88.5)
Total no. of tablets 4,029 37 3,801 26 211 211 ,.001
(37–38) (25–27) (212 to 211) (212 to 211)
Average morphine 4,029 53.8 3,801 51.3 22.9 22.5 ,.001
equivalents/d of opioid (52.1–55.6) (49.5–53.1) (24.0 to 21.8) (23.7 to 21.4)
prescription (mg)
Refilled opioid prescription 4,029 17.1 3,801 15.3 0.86 0.87 .011
within 6 mo of (15.9–18.2) (14.2–16.5) (0.77–0.95) (0.78–0.97)
hospital discharge
Mobility
Earlier ambulation within 12 h 4,689 43.6 4,622 60.9 1.40 1.39 ,.001
(42.2–45.0) (59.5–62.3) (1.34–1.45) (1.34–1.45)
Time to first ambulation (h) 4,659 16.4 4,602 13.7 22.7 22.7 ,.001
(15.9–16.9) (13.2–14.2) (23.0 to 22.3) (23.1 to 22.4)
Nutrition
Last liquids (no prolonged fast) 4,689 13.2 4,624 51.5 3.91 3.99 ,.001
(12.2–14.1) (50.0–52.9) (3.61–4.23) (3.68–4.33)
Early nutrition within 12 h 4,447 16.2 4,515 71.9 4.56 4.50 (4.19–4.84) ,.001
(15.2–17.3) (70.6–73.2) (4.25–4.89)
Hours to first nutrition 4,447 21.8 4,515 10.7 211.14 211.12 ,.001
(21.2–22.4) (10.1–11.3) (211.5 to 210.8) (211.5 to 210.7)
ERAS, enhanced recovery after surgery; RR, risk ratio; NSAIDs, nonsteroidal antiinflammatory drugs.
* Adjusted for age at delivery, medical center, race–ethnicity, prepregnancy body mass index, parity, preterm birth, calendar month, and
medical center.
†
Numbers that do not add up to the total number are the result of missing values.
‡
Adjusted b-estimate for continuous variables and RRs for dichotomous outcomes.
§
Further adjusted for patient pain score.
║
Change in patient-reported pain score before and after analgesia.
¶
Defined as separate prescriptions for opioids, acetaminophen, and NSAIDS as opposed to combination products.

Most process measures of surgical care among
patients undergoing elective cesarean delivery
changed significantly between the pre-ERAS and
post-ERAS implementation phases in multivariable
models adjusting for patient age, race–ethnicity,
BMI, parity, preterm birth, medical center, and
calendar month (Table 3). After ERAS im-
plementation, the adjusted mean hours to first
ambulation decreased by 2.7 hours (95% CI 23.1 to
22.4) with a concomitant increase in the percent-
age of patients who walked within 12 hours of
surgery from 43.6% to 60.9% (RR 1.4; 95% CI 1.3–
1.5). The percent of patients that had last liquids,
instead of a prolonged fast, before surgery
increased four-fold after ERAS implementation
(RR 3.99; 95% CI 3.68–4.33). There was a four-
fold increase in patients that received early nutri-
tion (RR 4.50; 95% CI 4.19–4.84) and the mean

516 Hedderson et al Enhanced Recovery After Surgery and Elective Cesarean Deliveries OBSTETRICS & GYNECOLOGY

© 2019 by the American College of Obstetricians

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Unauthorized reproduction of this article is prohibited.
time to first nutrition decreased by 11.1 hours (95%
CI 211.5 to 210.7).
The changes in process measures after ERAS
implementation appeared to be sustained through the
1-year period after implementation (Fig. 1).
There were no statistically significant changes in
any of the outcome metrics during the post-ERAS
period. For example, surgical site infection rates after
ERAS were not significantly different compared with
before ERAS implementation (RR; 1.26; 95% CI
0.94–1.70) (Table 4).
DISCUSSION
Multi-center implementation of an ERAS program in
a large integrated health care delivery system was
associated with significant practice changes among
patients undergoing elective cesarean delivery. The
most significant finding after ERAS program imple-
mentation was an almost 50% decrease in the average
inpatient opioid exposure per day which was accom-
panied by stable, or increased, rates of patient-
reported acceptable pain thresholds. There was also
more than 85% adoption of multimodal analgesia for
managing perioperative pain among patients under-
going elective cesarean deliveries post-ERAS imple-
mentation. Enhanced recovery after surgery
implementation was also associated with improved
early mobilization and nutrition targets. There were
no significant increases in adverse outcomes after
program implementation.
Implementation of the ERAS program was asso-
ciated with changes in process measures without
negatively affecting outcomes, including surgical site
infections, length of stay, hospital readmissions, or
breastfeeding rates. Although we did not observe
a significant decrease in hospital length of stay or
surgical site infections, as has been observed in other
ERAS patient populations in Kaiser Permanente
Northern California,6 this may be a result of the fact
that the length of stay is already short (less than 3
days) and surgical site infections were rare among
the elective cesarean delivery patient population,
making it more difficult to affect those outcomes.
We also did not anticipate a significant decrease in
length of stay, given clear regulatory guidelines on
maternal length of stay of 96 hours after cesarean
delivery. Therefore, a length of stay reduction was
specifically excluded as a goal of the ERAS program.

Fig. 1. Monthly process measure attainment before and after enhanced recovery after surgery implementation. Im-
plementation is standardized to the go-live month within each facility. Each point represents averaged values over a 1-month
period; data from the implementation month (month zero) are not included. Early ambulation (%) (A); early nutrition (%) (B);
average morphine equivalents rate per day (mg), median (C); met multimodal analgesic (%) (D).
Hedderson. Enhanced Recovery After Surgery and Elective Cesarean Deliveries. Obstet Gynecol 2019.

VOL. 134, NO. 3, SEPTEMBER 2019 Hedderson et al Enhanced Recovery After Surgery and Elective Cesarean Deliveries 517

© 2019 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 4. Multivariable Adjusted* Associations of Post-ERAS Implementation Changes With Outcome
Metrics

Pre-ERAS Post-ERAS Unadjusted Mean Adjusted Mean

Difference† or RR Difference† or RR‡
n Mean (95% CI) n Mean (95% CI) (95% CI) (95% CI) P

Outcome metrics
Hospital length 4,689 4.72 (4.57–4.88) 4,624 4.71 (4.56–4.87) 0.01 (20.09 to 0.11) 20.01 (20.11 to 0.09)† .856
of stay (d)
Surgical site 4,689 1.8 (1.4–2.1) 4,624 2.2 (1.8–2.7) 1.26 (0.95–1.68) 1.26 (0.94–1.70)‡ .122
infection
30-d 4,689 1.5 (1.2–1.9) 4,624 1.9 (1.5–2.3) 1.27 (0.93–1.73) 1.27 (0.93–1.73)‡§ .128
readmission
30-d ICU 4,689 0.3 (0.1–0.4) 4,624 0.2 (0.1–0.3) 0.76 (0.32–1.80) 0.76 (0.32–1.80)‡§ .533
admission
Discharge to 4,689 99.7 (99.6–99.9) 4,624 99.8 (99.7–99.9) 1.00 (1.00–1.00) 1.00 (1.00–1.00)‡ .946
home
Breastfed in 4,665 97.0 (96.5–97.5) 4,599 96.7 (96.2–97.2) 1.00 (0.99–1.00) 1.00 (0.99–1.01)‡ .691
the hospital
Breastfed 1st 4,524 90.6 (89.8–91.5) 4,530 91.3 (90.5–92.1) 1.01 (0.99–1.02) 1.01 (1.00–1.02)‡ .168
well-child
visit
ERAS, enhanced recovery after surgery; RR, risk ratio; ICU, intensive care unit.
* Adjusted for age at delivery, race–ethnicity, prepregnancy BMI, parity, preterm birth, calendar month, and medical facility.
†
Adjusted b-estimate.
‡
Adjusted RR estimate and 95% CIs.
§
Crude model because multivariable model did not converge.

Consistent with past studies of acute pain manage-
ment following both obstetrics and gynecology proce-
dures and non–obstetrics and gynecology procedures
that have demonstrated multimodal analgesia is asso-
ciated with superior pain relief and decreased opioid
use,6,21 we found a significant, almost 50%, reduction in
inpatient morphine milligram equivalents of opioid
exposure associated with the adoption of multimodal
analgesia use post-ERAS. These changes in pain man-
agement were associated with improved patient-
reported acceptable pain scores. A recent quality
improvement intervention designed to eliminate rou-
tine use of oral opioids for analgesia postcesarean deliv-
ery was also associated with a reduced use of oral
opioids in-hospital from 68% to 40%, with no associated
change in patient satisfaction or pain relief and also
decreased opioid prescriptions at hospital discharge.22
Our findings contribute to a growing body of evidence
that is possible to implement quality improvement pro-
grams to reduce inpatient and outpatient opioid expo-
sure without negatively affecting pain relief.
Enhanced recovery after surgery implementation
was associated with a shift to prescribing outpatient
decoupled opioids.23 This is consistent with The Amer-
ican Pain Society published guidelines for the manage-
ment of acute pain,24 recommending that nonopioid
analgesics, such as NSAIDs and acetaminophen,
should be used as first-line therapy, with the use of
supplemental opioid medications only if needed.
The study has important limitations. First, a pre–
post study design is unable to distinguish association
from causation. Thus, the results may be affected by
residual confounding and baseline differences in the
pre and post patient populations as well as other insti-
tutional or practice changes occurring during the
study period other than the ERAS implementation.
The finding of a decrease in outpatient postdischarge
opioid dispensations may have been affected by Cen-
ter for Disease Control and Prevention guidelines25
and a recent opioid safety initiative implemented by
the health system. The initiative implemented local
guidelines and provider training around screening
for opioid misuse, implementing signed opioid agree-
ments, increasing urine drug screening, and reducing
high-dose prescribing as appropriate.26 Kaiser Perma-
nente Northern California is an integrated health care
delivery system, thus it may not be representative of
other health care systems in the United States.
Enhanced recovery after surgery implementation
and results may vary in other settings depending on
the model of surgical practice and performance
improvement methodology. We did not collect infor-
mation on patient-reported outcomes so we were
unable to assess whether the ERAS program affected
patient satisfaction.
Implementation of the program was associated
with positive process-of-care metrics for patients
undergoing elective cesarean delivery in 15 hospitals.

518 Hedderson et al Enhanced Recovery After Surgery and Elective Cesarean Deliveries OBSTETRICS & GYNECOLOGY

© 2019 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
In this study, ERAS implementation was associated
with significantly reduced inpatient opioid exposure
with improvement in the proportion of time patients
reported their pain as acceptable and had no associ-
ation with postoperative complication rates.
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PEER REVIEW HISTORY
Received March 8, 2019. Received in revised form May 9, 2019.
Accepted May 23, 2019. Peer reviews and author correspondence
are available at http://links.lww.com/AOG/B478.