Stopping Opioid Overuse in Obstetrics to Halt Exposure Trial

Nearly 1 in 3 women in the US deliver by cesarean delivery. After cesarean delivery, approximately 75-87% percent of women are discharged from the hospital with an opioid prescription. Most women fill that prescription and 1% continue to use those opioids 90 days after delivery despite no longer requiring them for pain control, predisposing them to opioid dependence. This study aims to determine if transverse abdominis plane (TAP) block using bupivacaine liposome suspension injection (EXPAREL®) significantly reduces the use of opioid medications after discharge in women undergoing scheduled cesarean delivery. The study is a proposed double-blinded, randomized controlled trial. Pregnant women who have completed 37 weeks gestation and are scheduled for cesarean delivery will be randomized to receive a TAP block with 80 ml of mixed liposomal bupivacaine or saline. Based on its use in other surgical settings, the investigators hypothesize that women who receive a liposomal bupivacaine TAP block will use significantly less opioids by postoperative day 7 as calculated in morphine milligram equivalents. In addition to overall consumption of opioids after discharge, other aims to be studied include inpatient opioid use, effect on pain scores, rates of postpartum depression, patient-perceived quality of breastfeeding, patient quality of recovery, and composite adverse outcomes.

With better overall pain control and less dependence on opioids postpartum, liposomal bupivacaine TAP blocks at the time of scheduled cesarean delivery may offer a highly effective analgesic alternative that can help shift the tide in the ongoing opioid epidemic among reproductive females.

Inclusion criteria

• Unlabored, scheduled primary or repeat cesarean delivery
• Cesarean performed by obstetrician or surgically-trained family medicine physician
• Ability to complete numeric pain scale assessment and surveys
• Patients who do not speak English but are able to converse via an interpreter both in person and by phone

Exclusion criteria

• Complications requiring return to the operating room
• Unscheduled deliveries
• <18 years old, >45 years old
• Twin deliveries
• Preterm deliveries (<37 wks)
• Current or previous history of opioid-substance use disorder according to patient report or medical chart
• Prescription of opioid medication filled in previous 30 days prior to delivery according to patient report, documentation in electronic medical record, or documentation in the prescription drug monitoring program
• Allergy to local anesthetics or NSAIDs
• Cardiovascular disease, eg arrhythmia, or ASA (American Society of Anesthesiologists) Class III or higher
• Diagnosis of liver disorder or dysfunction including fatty liver of pregnancy, preeclampsia with severe features including liver or kidney involvement
• Known significant renal disease, oliguria, or Cr >1.1.
• Platelet count less than or equal to 90k or rapid decline in third trimester or other coagulopathy
• Infection overlying the regional anesthesia site
• Hypovolemia prohibiting regional anesthesia
• General anesthesia