Adherence to an intraoperative and post-cesarean analgesia protocol: a before-and-after implementation study in a...

Optimized pain management after cesarean delivery is essential for adequate maternal recovery. Multimodal analgesia protocols are recommended by all societies as part of enhanced recovery strategies, but their implementation in clinical practice remains challenging due to inconsistent adoption.

This single-center prospective before-and-after cohort study evaluated the adherence to an intraoperative anesthesia protocol and a postoperative nursing protocol after implementation of these two protocols for women undergoing term cesarean delivery, between May 2024 and July 2025. Secondary outcomes included the incidence of pain greater than 3 on a 10-point visual analogue pain scale. Protocol adherence was assessed through investigator-led audits using anesthetic records and electronic medical records to evaluate compliance with individual protocol components.

A total of 202 cases were included, 101 patients in the pre-implementation group and 101 patients in the post-implementation group. Intraoperative adherence improved rapidly, exceeding 90% within three months and reaching 96% by 10 months. This was associated with a reduction the incidence of pain (VAS > 3) in the post-anesthesia care unit decreasing from 33.6% to 4%. In contrast, postoperative adherence remained poor across postoperative days 1-3 (71.3%, 13.9%, and 3%, respectively), with persistently high rates of postoperative pain (VAS >3) of 52.5%, 60.4%, and 24.8%, respectively.

After implementation of protocols intended to improve post-cesarean analgesia, quasi-universal adherence to the intraoperative multimodal analgesia protocol was achieved within the first three months and was associated with significantly improved pain scores in the post-anesthesia care unit. Targeted multidisciplinary strategies are required to improve implementation across all phases of care.