OBJECTIVE: To evaluate the association of a standardized, structured approach to in-hospital postcesarean delivery pain management with maternal opioid use after cesarean delivery. METHODS: We conducted a retrospective cohort study of women who underwent cesarean delivery before and after a quality improvement intervention at a single tertiary care center. A multidisciplinary task force revised electronic order sets for all patients who underwent cesarean delivery with neuraxial anesthesia. The revised order set separated acetaminophen from opioids, scheduled acetaminophen and nonsteroidal antiinflammatory drug administration, and limited opioid use to breakthrough pain. Data were collected by electronic chart review. The primary outcome was median morphine milligram equivalents per hospital stay. Secondary outcomes included median morphine milligram equivalents per day, median pain scores, time to discharge, and opioid–nonopioid pain medication use. Descriptive and bivariable analyses were performed. RESULTS: There were no significant differences in baseline characteristics in the preintervention (n=283) and postintervention (n=286) groups. There was a 75% reduction in median morphine milligram equivalents per stay from 120 (90–176 interquartile range) preintervention to 30 (5–68) postintervention (P<.001) and a 77% reduction in median morphine milligram equivalents per day (51 [41–60] vs 12 [2–25], P<.001). There was no difference between groups in time to discharge or median pain scores. There was no difference in ketorolac use (80% preintervention vs 75% postintervention, P=.14) or in median ibuprofen mg per day (1,391 preintervention vs 1,347 postintervention, P=.22). There was an increase in median acetaminophen mg per day (753 preintervention vs 2,340 postintervention, P<.001). There was a significant increase in patients who used no opioids during their hospital stay (6% preintervention vs 19% postintervention, P<.001). CONCLUSION: A multimodal stepwise approach to postcesarean delivery pain control was associated with markedly reduced opioid consumption without increasing hospital stay or median pain scores. By separating acetaminophen from opioids and limiting opioids to breakthrough pain, we were able to operationalize a tier-based approach to pain management.

Open Access Original Article

Objective To evaluate the ability of estimated blood loss (EBL) and quantitative blood loss (QBL) to predict the need for blood transfusion in postpartum patients. Methods This is a retrospective observational study involving all deliveries one year before and after the change from EBL to QBL assessment in June 2017. Blood loss, need for blood transfusion, admission hematocrit, and postpartum nadir hematocrit were collected. Descriptive and bivariable analyses were performed. Receiver operator curves were compared. Results Overall, the baseline characteristics between the EBL (n=2743) and QBL (n=2,712) groups were similar. Although there was a higher rate of blood loss ≥ 1,000 mL in QBL vs EBL (6.5% vs 2.1%, P<0.001), there was no difference in the rate of blood transfusions (2.0% vs 2.0%, P=1). Among cesarean deliveries, QBL outperformed EBL for predicting blood transfusion and/or ≥10 point drop in hematocrit (AUC 0.75 vs 0.66, P=0.02). QBL also outperformed EBL for predicting transfusion after vaginal delivery (AUC 0.93 vs 0.81, P=0.03). Conclusion QBL is a more sensitive test for detecting clinically significant blood loss, which could lead to earlier recognition of hemorrhage and interventions.

Introduction In-situ interprofessional emergency team training improves participants’ with confidence and knowledge and identifies latent safety threats. This study examined the impact of a structured debrief on an interprofessional perinatal team’s ability to identify latent safety threats and assess competency in managing perinatal emergencies. It was hypothesized that latent safety threats would be reduced and checklist compliance would increase during subsequent in-situ perinatal team training. Methods Two in-situ training sessions were held six months apart. The perinatal emergency response team provided care for a standardized patient with preterm twin gestation. Each session included off-ward delivery and resuscitation of the first infant, transportation to appropriate inpatient units, cesarean delivery, and resuscitation of the second twin. Postpartum hemorrhage ensued, requiring massive transfusion protocol activation. Medical experts assessed team performance with critical action checklists. A structured debrief identified latent safety threats, developed action plans, and reviewed checklist compliance. Checklist compliance rates were analyzed using a z-ratio test. Results The first training session: seven teams (75 staff) completed 75% (292/391) critical action checklist items and identified 34 latent safety threats. Second training session: four teams (45 staff) completed 89% (94/106) critical action checklist items. Ten latent safety threats were mitigated during the second session. Utilizing a z-ratio, a significant difference was detected between the overall checklist compliance rates of the two sessions, z = -3.069, p = .002. Post-hoc power calculation was <10%. Conclusions In-situ interprofessional perinatal emergency team training is feasible, identifies latent patient safety threats, and may improve team competency.

INTRODUCTION: We evaluate the effect of a selective early postpartum magnesium cessation protocol in patients diagnosed with preeclampsia with severe features. METHODS: A standardized protocol was implemented in March 2017 identifying patients at lower risk of postpartum eclampsia, and thus eligible for early discontinuation of magnesium sulfate at 12 hours postpartum. An IRB approved, retrospective cohort study was performed of all patients with preeclampsia with severe features 25 months before and after protocol implementation. The primary outcome assessed was the incidence of postpartum readministration of magnesium sulfate after completion of the initial course. RESULTS: Preeclampsia with severe features was identified in 737 patients with exclusion of 58 patients due to postpartum preeclampsia diagnosis or eclampsia prior to initial magnesium cessation. While the rate of preeclampsia with severe features increased (3.9% vs 7.0%, p<.001) in the pre and post-implementation groups, there was no difference in the rate of eclampsia (0.03% vs 0.05%, P=.59). Analysis included 272 patients pre and 407 patients post protocol implementation. Rates of early magnesium cessation, less than 23 hours of postpartum magnesium, were 11.1% vs 55.5% pre and post protocol implementation. In patients who underwent early magnesium cessation (n=226), there was no significant difference in postpartum readministration of magnesium (1.5% vs 3%, P=.25). There was no difference in readmission for hypertensive disorders of pregnancy (1.1% vs 2.5%, P=.20). CONCLUSION: In patients with preeclampsia with severe features who underwent selective early magnesium cessation there was no difference in postpartum readministration of magnesium sulfate or readmission for hypertensive disorders of pregnancy.

OBJECTIVE:To determine the median use of opioid analgesic in the last 24 hours prior to discharge following cesarean delivery and the feasibility of an automated inpatient report to facilitate quantity of opioids indicated for discharge. STUDY DESIGN: Previously, all cesarean deliveries received a set number of opioids at the time of discharge regardless of use while inpatient. In an effort to minimize opioid use while inpatient, a multimodal approach was taken which included the separation of acetaminophen from opioids and scheduling of acetaminophen and non-steroidal anti-inflammatory drugs with opioid use reserved for breakthrough pain. An inpatient report was created which calculated total quantity of 5mg tabs of Roxicodone used in last 24 hours prior to discharge. A 5-day supply of opioids was then prescribed which was individualized based on the last 24-hour intake with a maximum of 40 tabs given. The median, interquartile range, 90 th percentile, and percent of patients requiring zero opioids was determined. RESULTS: There were 129 patients included in this review who underwent a cesarean delivery with a median time from delivery to discharge of 57.7 hours. The median number Roxicodone 5mg tabs given in the last 24 hours prior to discharge was 2 (interquartile range 0 to 4). The 90th percentile was 7 tabs with a maximum of 14. Prior to institution of this quality improvement project, all patients were discharged with 32 tabs of 5mg Roxicodone. After implementation, the median amount was 10 tabs given at discharge with an interquartile range of 0 to 20. Fifty patients (38.8%) required no opioids for last 24 hours prior to discharge. The report was printed daily and made available for obstetric providers to aid in personalizing discharge quantity of opioids. CONCLUSION: With the use of the electronic medical record and automated inpatient narcotic use report, the quantity of opioids at the time of discharge following cesarean delivery can be easily customized with an overall reduction in the amount of opioids dispensed for home use.241 Maternal perception of birth trauma and its association with postpartum mood and parenting stress