Abstract
Objective: To evaluate if post cesarean section opioid usage is greater for mothers with neonates in the Neonatal Intensive Care Unit (NICU) versus in mothers with neonates in the well born nursery who were encouraged to “room in” with their mothers (WBN).
Methods: This was a retrospective chart review that analyzed 8136 records of women delivering at an urban academic institution. The study period was from January 1, 2013, through December 12, 2018. Daily post-operative opioid usage was assessed. Chi-square analysis was used to evaluate for differences between the groups.
Conclusions: Post-operative mothers with neonates in the NICU did not have greater opioid usage versus those with neonates in the WBN. However, post cesarean section mothers with neonates who required major surgery for life threatening diagnoses had significantly greater opioid usage.
Clinical Trial Registration: “Opioid use by Postpartum Mothers” (s19-01134).
Keywords
Opioid, Postpartum, Neonates, NICU
Introduction
The prevalence of opioid abuse disorder has markedly increased over the past years, having doubled in occurrence between 1988 to 2011 [11]. It has now become a national emergency [2,20] leading to multiple organizations and institutions focusing on with how to prevent, diagnose and treat this crisis [12,20].
Post-operative opioid use presents pain management dilemmas for mothers as it affects their ability to be alert and engaged in order to nurture their newborns. Mothers with neonates in the NICU may have additional stresses and thus desire “round the clock” pain management as opposed to “as needed” as a means to avoid the distractor of postpartum pain.
Although other areas of opioid use have been extensively studied including those at greater risk for substance abuse [1,2,4,7,8,10,11,14,20,30] and provider prescription patterns [14-16,19,22], no research to date has focused on whether there is a difference in postoperative opioid use in women with neonates in the NICU versus the WBN.
The aim of our study is to determine whether neonatal NICU admission poses an additional stressor for post-operative mothers and results in increased use of opioids during this vulnerable period.
Methods
After receiving IRB approval, a retrospective chart review of 8136 women who delivered at an urban academic institution from January 2013-December 2018 was performed. Information regarding daily post-operative opioid use as well as the location of the neonate (NICU versus WBN) was collected. Post-operative opioid usage for mothers with neonates in WBN (Group A) was compared to usage in mothers with neonates in the NICU (Group B). Opioid usage was stratified into 24-hour blocks. Substance abusers and chronic opioid users were excluded.
A subgroup analysis was performed for the indication of the NICU admission. Chi-square was used to analyze the data.
Results
All post-operative patients (n =8136, comprised of 6509 patients in group A [WBN] and 1627 patients in group B [NICU]) were prescribed both opioids and non-narcotic analgesics. Both agents were used by 84% of mothers while 16% used only non-narcotic analgesics. No patients exclusively used opioids alone.
During each 24 hour block, there were no statistically significant differences in opioid usage between the mothers with babies in the NICU versus the WBN (43% vs 45%, Post-Operative Day (POD) 1, 81% vs 80%, POD2, 72% vs 70%, POD3, 20% vs 23%, POD4) (Table 1).
Table 1: Opioid usage between Groups A and B.
|
Hospital days |
Group A (n=6509) | Group B (n=1627) |
P-value |
| POD1 |
43% (n=2799) |
45% (n=732) |
0.184 |
| POD2 |
81% (n=5272) |
80% (n=1302) |
0.144 |
| POD3 |
72% (n=4686) |
70% (n=1139) |
0.112 |
| POD4 |
20% (n=1302) |
23% (n=372) |
0.142 |
Group A: mothers with neonates in the regular nursery.
Group B: Mothers of infants in NICU.
The most common indications for NICU admissions included prematurity (12%), sepsis (4%), and neonates requiring major surgery for life threatening anomalies (3%) while other diagnoses included hypoglycemia, transient tachypnea of newborn, meconium aspiration and observation for other benign conditions represented smaller proportions (Table 2).
Table 2: Indications for admission and Opioid usage in Group B.
|
POD1 |
POD2 | POD3 |
POD4 |
|
| Prematurity |
39%(n=76) |
79%(n=154) | 65%(n=127) |
19%(n=37) |
| 12%(n=195) | ||||
| Sepsis |
41%(n=27) |
74%(n=48) | 67%(n=44) |
22%(n=14) |
| 4%(n=65) | ||||
| Serious problems |
58% (n=28) |
89%(n=44) | 81%(n=40) |
32%(n=16) |
| 3%(n=49) | ||||
| Other |
43% (567) |
78%(n=1028) | 68%(n=896) |
21%(n=277) |
| 81%(n=1318) |
Other: Hypoglycemia, meconium aspiration, mild respiratory distress, r/o infection
Mothers of NICU neonates (Group B) with life-threatening anomalies and who required corrective surgery (Group B1) had increased opioid usage on POD 1 and 4 when compared to those in Group A; this trend was also seen when compared to mothers whose babies were in the NICU but who did not have life threatening conditions on POD 1-4. (Group B2) (Tables 3 and 4).
Table 3: Opioid usage between Groups A and B1.
|
Hospital days |
Group A (n=6509) | Group B1 (n=49) |
P-value |
| POD1 |
43% (n=2799) |
58% (n=21) |
0.004 |
| POD2 |
81% (n=5272) |
89% (n=44) |
0.113 |
| POD3 |
72% (n=4686) |
81% (n=40) |
0.134 |
| POD4 |
20% (n=1302) |
32% (n=16) |
0.027 |
Group A: mothers with neonates in Well Born Nursery.
Group B1: Mothers of Infants with Serious problems.
Table 4: Opioid usage between Groups B1 and B2.
|
Hospital days |
Group B1 (n=49) | Group B2 (n=195) |
P-value |
| POD1 |
58% (n=21) |
39% (n=76) |
0.0215 |
| POD2 |
89% (n=44) |
79% (n=154) |
0.0833 |
| POD3 |
81% (n=40) |
65% (n=127) |
0.026 |
| POD4 |
32% (n=16) |
19% (n=37) |
0.0379 |
Group B1: Mothers of Infants with Serious problems.
Group B2: Mothers of infant’s prematurity.
At the time of discharge, all mothers received a prescription for narcotics, regardless of their choice of analgesics during the hospitalization, i.e. combinations of narcotics and non-narcotics, or only non-narcotics.
Discussion
Opioid use often starts with the treatment of acute pain [6,10,12] and it has been well documented that a single exposure can lead to persistent dependence [19]. For many women, their first exposure to opioids follows childbirth. Approximately 1 in 10 women suffer severe postpartum pain within the first 36 hours after delivery. Opioids are generally the mainstay of treatment at this time [14]. Multiple studies have documented inpatient use of opioids rates up to 58% for vaginal deliveries and 100% for cesarean sections [22] with 24% of patients continuing to use opioids even in the last 24 hours of hospitalization [2].
As many patients’ first exposure to opioids likely occurs during the post-operative period, our study sought to better understand opioid use in mothers who would be expected to undergo additional stresses due to their neonates being separated from their babies while admitted to the NICU. Interestingly, we did not find that these mothers had increased post-operative narcotic usage unless they were in the small subgroup of women whose babies were undergoing surgery for life threatening conditions.
Strengths of our study included the large sample size from a single academic institution with an existing standardized postpartum order set. Limitations of our study include lack of analysis of opioid use for women whose babies were briefly in the NICU but were transferred to the well-baby nursery or roomed in prior to mother’s discharge as well as an overall small sample size of mothers with neonates with “life threating” issues.
Conclusion
To our knowledge, this is the first study focusing on comparison of opioid use in mothers with neonates in the NICU versus in the newborn nursery or rooming in. This study illustrates that despite the perceived greater stresses of being separated from their neonates, only those mothers whose neonates had severe life-threatening conditions needing corrective surgery used more opioids on a “round the clock” basis. Given the findings that all patients received a narcotic prescription at discharge, even though 16 % had never used a narcotic during the hospitalization, further attention should be paid towards avoiding arbitrary prescribing narcotics in these circumstances. These findings should inform post-operative pain management plans in that mother whose babies are in the NICU may not require additional narcotics unless the neonates are undergoing corrective surgery for life threatening conditions. In addition, if mothers of neonates admitted to the NICU have not utilized narcotic prescriptions during the post-operative period they should not receive such prescriptions at discharge, as this will help to avoid the occurrence of chronic substance abuse.
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