Improving Pain Perceptions After Initiating a Delivery Application

A. Objective To compare perception of postpartum pain and patient satisfaction between women who receive routine obstetric care to those who receive routine obstetric care and complete a standardized counseling aid antepartum.

B. Background Enhanced Recovery After Surgery (ERAS) is a standardized, evidenced-based method for the perioperative management of surgical patients. ERAS protocols have been well studied in several surgical specialties, including gynecologic oncology and benign gynecology, and have been shown to reduce hospital length of stay and costs without increasing rates of complications or readmission.

The use of ERAS in obstetrics is also growing. Recent studies have shown that an enhanced recovery pathway after cesarean delivery can decrease hospital stay and cost and reduce opioid use. Guidelines have been developed for evidence-based recommendations for preoperative, intraoperative and postoperative phases of care.

An important component of any ERAS protocol is pre-operative counseling. Postoperative pain management starts with counseling prior to surgery. Guidelines suggest that preoperative counseling should include patient-centered education on the options for management of pain. This process also allows an opportunity to engage patients in the decision making process. Previous studies have shown that counseling on pain expectations can improve patient outcomes.

The aim of our study is to develop a standardized antepartum counseling aid and improve postpartum pain perceptions and patient experience.

C. Study Methodology

• Study Design The study is a randomized control trial. Patients will be assigned 1:1 to the study group and control group.
• Comparison Groups:

1: Group 1:

• Study Group: Women will watch an educational video regarding expectations for delivery and postpartum care in addition to receiving standard care and counseling.

2: Group 2:

• Control Group: Women will receive standard care and counseling.

• Procedures:

Identification of Potentially Eligible Patients

• Potentially eligible patients will be identified through screening of clinic patients at time of routine prenatal visit at the Prisma Health OBGYN Center between 35 to 41 weeks gestation.

Study Enrollment

• Investigators will review charts of women scheduled for routine obstetric appointments and screen for eligibility. Eligible women will be contacted at the time of their prenatal appointment.
• Study fliers advertising the study will also be posted in OB clinics at the OBGYN Center.
• Women who are interested in enrollment will be counseled and consented by study personnel at their scheduled appointment.
• The enrollment process involves a face-to-face interview with one of the study investigators for verification of study eligibility and counseling regarding study procedures as well as potential benefits and risks prior to obtaining written consent.

Treatment Allocation

• On day of enrollment, patients will be randomized into the treatment group or the control group using a computer-generated randomization scheme.
• Randomization will be stratified by plan for delivery with plan for vaginal delivery versus plan for cesarean delivery, as content of the educational videos will be geared towards mode of delivery.
• Randomization assignment will not be blinded.
• All participants will complete an initial demographic questionnaire immediately following randomization via self- administered assessments within the test application using a mobile tablet.
• Subjects allocated to Group 1: will:

A. Complete the demographic questionnaire, the survey questions, and then complete the counseling aid.

B. Prior to discharge after delivery, study personnel will administer the postpartum questionnaire via a mobile tablet. The questionnaire is programmed into the study application.

• Subjects allocated to Group 2: will:

A. Complete the demographic questionnaire and survey questions without watching the educational video.

B. Prior to discharge after delivery, study personnel will administer the postpartum questionnaire via a mobile tablet. The questionnaire is programmed into the study application.

• Research staff will complete chart reviews to confirm delivery information and other study related data.

• Outcomes:

• Primary: What is the impact of a standardized antepartum counseling aid on patient satisfaction with pain expectations during hospital admission for labor and delivery compared to women who do not use the counseling aid and receive routine counseling only? Satisfaction will be measured using the Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R). The APS-POQ-R is designed for use in adult hospital pain management QI activities and measures 6 aspects of quality including: (1) pain severity and relief; (2) impact of pain on activity, sleep, and negative emotions; (3) side effects of treatment; (4) helpfulness of information about pain treatment; (5) ability to participate in pain treatment decisions; and (6) use of nonpharmocological strategies.
• Secondary outcomes: Perception of pain control intrapartum and postpartum based on postpartum questionnaires, expectations of what type and how much pain medication at time of discharge, use of narcotics postpartum as determined by chart review, pain perceptions in patients with history of mood disorder as determined by questionnaire, pain perceptions in patients with history of substance abuse as determined by questionnaire.

Inclusion criteria

• Pregnant women > 18 years of age
• Gestational age 35 weeks to 41 weeks
• English or Spanish speaking
• Plan for vaginal delivery or cesarean delivery at Greenville Memorial Hospital
• Singleton or twin gestation

Exclusion criteria

• Non-English or Non-Spanish speaking patients
• Inability to read English, inability to read Spanish
• Pregnancy diagnosed with fetal anomalies
• Intrauterine fetal demise