The implementation of intrathecal morphine for caesarean delivery into clinical practice, and assessment of its impact on patient-reported quality of recovery using the ObsQoR-10-Dutch scale: A single-centre cohort study

Abstract

BACKGROUNDOptimising a mother's quality of recovery following caesarean delivery is of paramount importance as it facilitates maternal care of the newborn and affects physical, psychological and emotional well being. Intrathecal morphine (ITM) reduces postoperative pain and may improve quality of recovery: however its widespread use is limited.OBJECTIVETo assess the effects of implementing ITM for caesarean delivery on postoperative quality of recovery.STUDY DESIGNSingle-centre observational before-after study.SETTINGTertiary university hospital, the Netherlands, January 2023 until April 2024.STUDY POPULATIONPatients who underwent caesarean delivery under spinal anaesthesia.INTERVENTIONPatients recruited before implementation of ITM (n = 55) received patient-controlled intravenous analgesia with morphine or continuation of epidural analgesia previously used for labour ('pre-ITM group'). Patients recruited after implementation of ITM (n = 47) received ITM 100 μg and oral morphine tablets 10 mg as needed ('ITM group').OUTCOMESPrimary outcome was the score on the Obstetric Quality of Recovery (ObsQoR-10-Dutch) questionnaire (0 to 100). Secondary outcomes included ObsQoR-10 subscores, length of stay, opioid consumption and self-reported general health score (0 to 100).RESULTSProtocol adherence for ITM was 98%. Quality of recovery improved significantly [ObsQoR-10 scores pre-ITM 65 ± 16 vs. ITM 74 ± 13 points, mean difference 9.0 (95% CI, 3.1 to 15] points, P = 0.002], with improvement in pain scores, physical comfort, independence and psychological wellbeing. In multivariate analysis, the improvement was 6.3 (95% CI, 0.37 to 12.2] points, which was statistically significant but did not reach the predefined threshold for clinical relevance. There was, however, an improvement in self-reported general health score (57 ± 18 vs. 68 ± 17, P = 0.002), median [IQR] length of hospital stay (41 [36 to 51] vs. 37 [32 to 49] h, P = 0.032) and median [IQR] opioid consumption (52 [35 to 73] vs. 0 [0 to 0] mg, P < 0.001).CONCLUSIONSImplementing ITM for caesarean delivery resulted in moderate improvements in obstetric recovery and reduced opioid consumption. Cautious interpretation is warranted given the nonrandomised design of this implementation study. Our findings support the use of ITM in a multimodal analgesia strategy for patients undergoing caesarean delivery.