Abstract
Objective Our objective was to evaluate the efficacy of perioperative multimodal pain management
in reducing opioid use after elective cesarean delivery (CD).
Study Design A single-center, double-blinded, placebo-controlled randomized trial of women undergoing
elective CD. Participants were allocated 1:1 to receive the multimodal protocol or
matching placebos. The multimodal protocol consisted of a preoperative dose of intravenous
acetaminophen, preincision injection of subcutaneous bupivacaine, and intraoperative
injection of intramuscular ketorolac. Primary outcome was total opioid intake at 48
hours postoperatively. Secondary outcomes were pain scores, time to first opioid intake,
neonatal outcomes, and total outpatient opioid intake on postoperative day (POD) 7.
Data were analyzed using parametric and nonparametric tests and quantile regression
as appropriate.
Results A total of 242 women were screened with 120 randomized, 60 to the multimodal group
and 60 to control group. There was no significant difference in the primary outcome
of opioid use nor in the secondary outcomes. Smokers and patients with a history of
drug use had higher median postoperative opiate use and earlier administration. On
POD 7, only 40% of prescribed opioids had been used, and there was no difference between
the groups.
Conclusion This perioperative multimodal pain regimen did not reduce opioid use in 48 hours
after CD. Patients who smoke or with a history of drug use required more opioids in
the postoperative period. Providers significantly overprescribed opioids after CD.
Keywords
multimodal - pain management - cesarean delivery - opioid use - postpartum
