Objective To define the amount of opioid analgesics prescribed and consumed after discharge after cesarean delivery. Methods We conducted a survey at six academic medical centers in the United States from 9/2014 to 3/2016. Women who had undergone a cesarean delivery were contacted by phone two weeks after discharge and participated in a structured interview about the opioid prescription they received upon discharge and their oral opioid intake while at home. Results A total of 720 women were enrolled; of these, 615 (85.4%) filled an opioid prescription. The median number of dispensed opioid tablets was 40 (interquartile range (IQR) 30 to 40), the median number consumed was 20 (IQR 8 to 30), and leftover was 15 (IQR 3 to 26). Of those with leftover opioids, 95.3% had not disposed of the excess medication at the time of the interview. There was an association between a larger number of tablets dispensed and the number consumed independent of patient characteristics. The amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription. Conclusion The amount of opioid prescribed after cesarean delivery generally exceeds the amount consumed by a significant margin, leading to substantial amounts of leftover opioid medication. Lower opioid prescription correlates with lower consumption without a concomitant increase in pain scores or satisfaction.

OBJECTIVE: To identify and quantify risk factors for atonic postpartum hemorrhage. DATA SOURCES: PubMed, CINAHL, EMBASE, Web of Science, and and ClinicalTrials.gov databases were searched for English language studies with no restrictions on date or location. Studies included randomized trials, prospective or retrospective cohort studies, and case–control studies of pregnant patients who developed atonic postpartum hemorrhage and reported at least one risk factor. METHODS OF STUDY SELECTION: Title, abstract, and full-text screening were performed using the Raayan web application. Of 1,239 records screened, 27 studies were included in this review. Adjusted or unadjusted odds ratios (ORs), relative risks, or rate ratios were recorded or calculated. For each risk factor, a qualitative synthesis of low and moderate risk of bias studies classifies the risk factor as definite, likely, unclear, or not a risk factor. For risk factors with sufficiently homogeneous definitions and reference ranges, a quantitative meta-analysis of low and moderate risk of bias studies was implemented to estimate a combined OR. TABULATION, INTEGRATION, AND RESULTS: Forty-seven potential risk factors for atonic postpartum hemorrhage were identified in this review, of which 15 were judged definite or likely risk factors. The remaining 32 assessed risk factors showed no association with atonic postpartum hemorrhage or had conflicting or unclear evidence. CONCLUSION: A substantial proportion of postpartum hemorrhage occurs in the absence of recognized risk factors. Many risk factors for atonic hemorrhage included in current risk-assessment tools were confirmed, with the greatest risk conferred by prior postpartum hemorrhage of any etiology, placenta previa, placental abruption, uterine rupture, and multiple gestation. Novel risk factors not currently included in risk-assessment tools included hypertension, diabetes, and ethnicity. Obesity and magnesium were not associated with atonic postpartum hemorrhage in this review. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020157521.

In the United States, postpartum hemorrhage is a leading preventable cause of maternal mortality and morbidity. To reduce morbidity from postpartum hemorrhage, risk assessment is an important starting point for informing decisions about risk management and hemorrhage prevention. Current perinatal care guidelines from the Joint Commission recommend that all patients undergo postpartum hemorrhage risk assessment at admission and after delivery. Three maternal health organizations—the California Maternal Quality Care Collaborative, AWHONN, and the American College of Obstetricians and Gynecologists’ Safe Motherhood Initiative—have developed postpartum hemorrhage risk-assessment tools for clinical use. Based on the presence of risk factors, each organization categorizes patients as low-, medium-, or high-risk, and ties pretransfusion testing recommendations to these categorizations. However, the accuracy of these tools' risk categorizations has come under increasing scrutiny. Given their low positive predictive value, the value proposition of pretransfusion testing in all patients classified as medium- and high-risk is low. Further, 40% of all postpartum hemorrhage events occur in low-risk patients, emphasizing the need for early vigilance and treatment regardless of categorization. We recommend that maternal health organizations consider alternatives to category-based risk tools for evaluating postpartum hemorrhage risk before delivery.

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Oxytocin has known antinociceptive effects and is upregulated perinatally. This pilot study investigated the association of plasma oxytocin and postcesarean incisional pain. Plasma samples from 18 patients undergoing elective cesarean delivery were drawn at 1 hour preoperatively and 1 and 24 hours postoperatively and analyzed by using enzyme-linked immunosorbent assay. Pain was assessed at 1 day, 8 weeks, 3 months, and 6 months postoperatively. Incisional pain at 24 hours was inversely correlated with 1- and 24-hour oxytocin levels, with higher plasma oxytocin associated with lower pain (ρ, -0.52 and -0.66; P < .05).

Background Severe acute post-cesarean delivery (CD) pain has been associated with an increased risk for persistent pain and postpartum depression. Identification of women at increased risk for pain can be used to optimize post-cesarean analgesia. The impact of labor prior to CD (intrapartum CD) on acute post-operative pain and opioid use is unclear. We hypothesized that intrapartum CD, which has been associated with both increased inflammation and affective distress related to an unexpected surgical procedure, would result in higher postoperative pain scores and increased opioid intake. Methods This is a secondary analysis of a prospective cohort study examining opioid use up to 2 weeks following CD. Women undergoing CD at six academic medical centers in the United States 9/2014-3/2016 were contacted by phone two weeks following discharge. Participants completed a structured interview that included questions about postoperative pain scores and opioid utilization. They were asked to retrospectively estimate their maximal pain score on an 11-point numeric rating scale at multiple time points, including day of surgery, during hospitalization, immediately after discharge, 1st week, and 2nd week following discharge. Pain scores over time were assessed utilizing a generalized linear mixed-effects model with the patient identifier being a random effect, adjusting for an a priori defined set of confounders. A multivariate negative binomial model was utilized to assess the association between intrapartum CD and opioid utilization after discharge, also adjusting for the same confounders. In the context of non-random prescription distribution, this model was constructed with an offset for the number of tablets dispensed. Results A total of 720 women were enrolled, 392 with and 328 without labor prior to CD. Patients with intrapartum CD were younger, less likely to undergo repeat CD or additional surgical procedures, and more likely to experience a complication of CD. Women with intrapartum CD consumed more opioid tablets following discharge than women without labor (median 20, IQR 10–30 versus 17, IQR 6–30; p = 0.005). This association persisted after adjustment for confounders (incidence rate ratio 1.16, 95% CI 1.05–1.29; p = 0.004). Pain scores on the day of surgery were higher in women with intrapartum CD (difference 0.91, 95% CI 0.52–1.30; adj. p = <0.001) even after adjustment for confounders. Pain scores at other time points were not meaningfully different between the two groups. Conclusion Intrapartum CD is associated with worse pain on the day of surgery but not other time points. Opioid requirements following discharge were modestly increased following intrapartum CD.

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