Determining the Effect of an "Alternate Recovery Protocol" Versus Current Standard of Care After Cesarean Section

"Enhanced recovery" is a multi-modal, evidence based approach to peri-operative care, with
the goal of accelerating recovery and return to normal activity after surgery. Initially
introduced in colorectal surgery, some of the key changes in management include: preoperative
patient education, reduction in preoperative fasting, peri-operative euvolemia, early removal
of urinary catheters, multimodal and standing analgesia, early postoperative mobilization,
and earlier return to a regular diet. Results have shown stable pain control with a decrease
in narcotic consumption, a quicker return of bowel function, and decreased length of hospital
stay and cost with no change in level of patient satisfaction, morbidity, or readmission
rate. The thought is that these interventions speed recuperation by attenuating the stress
response associated with surgery, subsequently decreasing time spent in the hospital and
improving quality of life.

The largest retrospective cohort study demonstrating the successful implementation of the
"enhanced recovery" protocol in gynecology was conducted at the Mayo Clinic, published in
2013. This protocol was created by general gynecologists, gynecology oncologists,
urogynecologists, anesthesiologists, pharmacists, and nursing, and was initiated as a quality
improvement project. This "enhanced recovery" protocol was used as the template for our
alternate management order set. The results showed an 80% reduction in opioid consumption,
stable pain scores and patient satisfaction, a 1 day earlier return of bowel function, and 4
day reduction in hospital stay with subsequent significant cost savings. An obstetric
alternate management protocol was created at Lankenau, trying to incorporate the most current
recommendations in "enhanced recovery" while accounting for issues unique to obstetric
patients. This protocol is currently being used by certain obstetricians.

The only literature published on "enhanced recovery" being implemented in the field of
obstetrics was an observational study conducted with 708 C-sections at the Jessop Wing
Obstetric Unit, in Sheffield, England, published in 2015. See below for the protocol used.
The development of an obstetric "enhanced recovery" plan resulted from a desire for earlier
discharge following cesarean section, due to pressure on national health service budgets to
cut costs. There was an increase in day 1 discharges following uncomplicated cesarean
sections from 1.6% to 25 % with the above mentioned protocol, and a stable 30 day readmission
rate. Their conclusion was that "an enhanced recovery program was successfully implemented…
Many of the interventions were straightforward and could be adopted easily elsewhere."

A somewhat controversial element of the "enhanced recovery" protocol is the use of gabapentin
in pregnancy. Gabapentin is a Category C drug, meaning that risk cannot be ruled out in
pregnancy and that the drug should be given if potential benefits outweigh potential risks.
Our alternate management order set includes giving 1 dose of 600mg of pre-operative
gabapentin. There have been many papers documenting its safety when given as a single dose
pre-operatively. A randomized controlled trial published in 2011 in the Society of Obstetric
Anesthesia and Perinatology, evaluated the peri-operative use of gabapentin for cesarean
sections. Neonatal outcomes were evaluated for the gabapentin group, involving 600mg
pre-operatively, as well as the placebo group. There was no significant difference in
neonatal outcomes. A second study published in 2015 in the American Society of
Anesthesiologists also showed no difference in neonatal outcomes with a single pre-operative
dose of 600mg gabapentin. Lactmed, a database that lists drugs and dietary supplements that
may affect breastfeeding, endorsed by the American Academy of Pediatrics, states that
"maternal doses of gabapentin up to 2.1 grams daily produce relatively low levels in infant
serum," and that " a single PO dose of 600 mg prior to cesarean section appeared to have no
effect on breastfeeding initiation."

Given that the national cesarean section rate in the United States is 32.2%, implementing an
"enhanced recovery" protocol in obstetrics could have a huge impact on care for women in the
post-partum period. The widespread adoption of "enhanced recovery" stems from evidence
showing reduced narcotic consumption, earlier return to normal activities, and even reduced
morbidity in some studies. From a post-partum standpoint, given the increased risk of DVT
until 6 weeks post-partum, and the additional increased risk after cesarean section,
encouraging ambulation and return to normal activity seems beneficial. Also, the potential to
decrease narcotic use has great implications in both the post- partum and post- operative
period. The CDC has recently published guidelines on prescribing opioids, given that opioid
abuse is a growing epidemic in this country. The American Congress of Obstetricians and
Gynecologist had responded saying that physicians would try to combat the use of prescription
opioids across the country and that they should be using current best prescribing practices
and all possible options for multimodal pain relief. Additionally, the American Academy of
Pediatrics published an update to their Transfer of Drugs and Therapeutics in Human Breast
Milk Series in 2013. The AAP states that acetaminophen and ibuprofen should be used as first
line therapy for post-partum pain management, and discourages the use of codeine,
hydrocodone, and oxycodone when breast feeding. One study found that as high as 20% of
infants exposed to oxycodone through breast milk had central nervous system depression. Also,
the state of Pennsylvania has started a breast feeding quality improvement project, called
the Keystone 10 Initiative, developed by the department of health. The goal is to promote and
support breastfeeding to "improve the health of mothers and babies," through changes such as
more skin to skin contact and less time infants spend in the nursery. Given that the most
common side effect of narcotic use is somnolence, seen up to 42% of the time, this may
interfere with the mother's ability to care for her newborn. Therefore, it is clear that an
"enhanced recovery" protocol after cesarean sections has potential to improve care
post-operatively and post-partum on multiple levels.

Methods:

A randomized control pilot study will be performed with the primary outcome of narcotic
utilization in the post-operative period. After IRB approval, patients will be recruited for
the study in the outpatient setting or upon their arrival to the labor and delivery floor,
for their scheduled cesarean section. They will be consented by the principal investigator,
or his designee. Consent for the study will include a series of questions related to the
exclusion criteria listed below in addition to the risks and benefits of the study. The
patient will be randomized to either the alternate management group, or the standard cesarean
section group, via computer randomization.

The regular Lankenau cesarean section order set includes routine vital signs, labs, IV
fluids, and fetal heart monitoring. Post standard cesarean section orders include IV fluids
running at 125 cc/ hour, along with routine post-partum care. In terms of pain control, most
patients receive 9 doses of 30mg of IV ketorolac every 6 hours, along with hydromorphone,
oxycodone/acetaminophen, or a hydromorphone PCA, per patient or attending request.

With the alternate management protocol, the pre-operative order set is the same, with the
addition of a single preoperative dose of acetaminophen 1 g IV x1, gabapentin 600 mg PO x1,
and ondansetron 8 mg IV x1. Post-operatively, patients receive the same ketorolac 30mg x 9
doses every 6 hours, as well as acetaminophen 975 mg every 6 hours, both given standing.
These two are timed so the patient is receiving one of the two medications every 3 hours
during their inpatient stay. After 9 doses of ketorolac, the patient receives 600mg of
ibuprofen PO, also given standing, instead of the ketorolac. If the patient requires
narcotics, they may receive them on an as needed basis. IV fluids are running at 80 cc/ hour.
Patients are encouraged to ambulate, including the evening of the surgery, have their foley
catheter removed 12 hours post-operatively, and can have a regular diet immediately.

The morphine equivalent score will be used to calculate total narcotic use while the patient
remains as an inpatient. Secondary outcomes will include presence of flatus, assessed at 8
hour intervals, and pain via the visual analogue scale. Patient satisfaction will be assessed
using the validated survey used in the Mayo Clinic Trial, to be filled out prior to
discharge. Post-operative complications and readmissions will be noted during the inpatient
stay. Information regarding patient satisfaction, pain score, and presence of flatus will be
gathered by nursing, and will be self-reported by the patient. Total narcotic use will be
calculated.

Sample Size: 65 standard recovery patients, 65 alternate management patients Using the
Vanderbilt power calculator, and an alpha value of 0.5, and a beta of 20%, to achieve a 50%
reduction in narcotic use, approximately 65 patients will be required in each group. The
investigators will perform an interim analysis on our data, after 65 subjects have been
recruited, both for efficacy and assessment of any adverse outcomes. This will help the
investigators determine fewer or more patients are needed in order to achieve a statistically
significant difference in narcotic consumption.

Inclusion Criteria:

- Scheduled to undergo a cesarean section

Exclusion Criteria:

- Existing diagnosis of chronic pain

- Need to undergo a vertical skin incision

- AST > 50; ALT > 70

- Platelets below 80,000 on admission

- Need to undergo general anesthesia

- Tubal ligation at time of Cesarean section

- Prior or known allergy to any of the medications being utilized in this study