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MATERNAL FETAL MEDICINE: Edited by Deirdre Lyell, Mark Boddy, and Martha Rode

Enhanced recovery after surgery for cesarean delivery

Suharwardy, Sanaaa; Carvalho, Brendanb

Author Information
Current Opinion in Obstetrics and Gynecology: April 2020 - Volume 32 - Issue 2 - p 113-120
doi: 10.1097/GCO.0000000000000616
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Abstract

INTRODUCTION

Enhanced recovery after surgery (ERAS) is a multidisciplinary approach to improving the care of surgical patients, from the preoperative planning through the surgery and postoperative period. Surgery is a known physiological stressor, and ERAS pathways optimize care to accelerate the return to normal function. Although the composition of ERAS pathways differs by specialty and institution, many contain these key elements: patient education, limiting preoperative fasting, maintenance of normothermia, limiting fluid administration, standardizing multimodal analgesia, minimizing opioid analgesia, prompt oral intake, early ambulation, early urinary catheter removal and streamlining hospital discharge [1▪▪,2].

Although the concept of ERAS began in the 1990s, it took over a decade to develop the ideas into an evidence-based consensus protocol tailored for colonic surgery. Since then, nearly all surgical subspecialties have published ERAS consensus documents in conjunction with the international ERAS Society, including gynecology and gynecologic oncology [3]. These documents typically outline evidence-based best practices in perioperative care. More and more institutions are implementing standard ERAS pathways; however, there remains a paucity of protocols and data for ERAS after cesarean delivery. 

Box 1
Box 1:
no caption available

Enhanced recovery after surgery in obstetrics

Implementation of ERAS principles through standardized care protocols has been shown to reduce length of stay, decrease cost, reduce postoperative complications and improve patient satisfaction in a variety of settings [4]. There are approximately 18.5 million cesarean deliveries performed worldwide annually with more than 2.1 million performed annually in the United States, making cesarean delivery the most common major surgery [5,6]. Therefore, the application of ERAS more broadly to the obstetric populations would have widespread impact.

A call to action was recently published encouraging obstetricians to implement ERAS especially given the current setting of persistently high cesarean delivery rates, emphasis on high quality, lower cost care that reduces maternal morbidity and mortality, and increased focus on preventing unnecessary opioid prescribing [7▪]. The focus on reducing the rate of unnecessary cesarean delivery should not detract from improving the quality of care and outcomes through widespread adoption of ERAS. The benefit of ERAS goes beyond improved clinical outcomes and has the potential to aid in recovery for an obstetric patient who is transitioning to motherhood and caring for a newborn [2]. Cesarean delivery is different from all other surgeries in that patients need to care for their newborn while they recover from surgery.

An important component of quality improvement is to reduce variation in healthcare processes, particularly for common clinical situations [8]. With the volume of cesarean deliveries and the variation in practice by individual providers, ERAS implementation would also help to standardize care and reduce healthcare disparities by promoting equality across a broad obstetric population [9▪].

Enhanced recovery after surgery implementation after cesarean delivery

Initial studies of ERAS implementation after cesarean delivery were largely out of Europe and performed mostly in patients who underwent scheduled cesarean delivery. A 2010 review of published clinical protocols identified 25 individual care components within five clinical protocols. Of these components, three (early oral feeding, early mobilization and timely removal of the urinary catheter) were present in all five protocols [10]. It is difficult to study the effects of individual components of ERAS as components are typically implemented as part of an ERAS bundle.

An early study of women discharged after uncomplicated, scheduled cesarean delivery in the UK demonstrated an increase in day 1 discharges from 1.6 to 25.2% with a comparable rate of 30-day readmissions [11]. In France, one institution found decreased length of stay (3.9 vs. 4.3 days, P < 0.01) with improved mobility and independent toileting. Urinary catheter removal was decreased from 17 to 4 h; however, an increase in acute urinary retention was noted without long-term consequences (11 vs. 2%, P = 0.01) [12]. A second French cohort had similar results after ERAS implementation for scheduled cesarean delivery, with a decrease in length of stay (4.0 vs. 5.5 days, P < 0.05) [13].

A single center study more recently evaluated clinical outcomes before and after local ERAS implementation for scheduled cesarean delivery and reported a decrease in length of stay (2.5 ± 0.5 vs. 2.9 ± 1.2 days, P < 0.001) and reduction in opioid consumption (28.4 ± 24.1 vs. 46.1 ± 37.0 MMEQ, P < 0.001) and lower peak pain scores (7 [5,6,7▪,8,9▪] vs. 8 [7▪,8,9▪], P < 0.01), without a difference in hospital readmissions or complications [14▪].

A retrospective cohort study at a single institution found a notable decrease in total (preoperative and postoperative) length of stay for those who underwent planned cesarean delivery after ERAS implementation (3.9 vs. 3.1 days; P = .005) as well as a decrease in postoperative direct costs by $642.85 per patient (P < .001), without a difference in readmission rates [15▪].

Elements of enhanced recovery after surgery after cesarean delivery

In 2017, the ERAS Society Guideline Committee selected a group of experts to review and compile Guidelines for Perioperative Care in Cesarean Delivery. The recommendations (based on available evidence through 2017) were published in 2018–2019 in three parts: antenatal and preoperative care, intraoperative care and postoperative care [16▪▪,17▪▪,18▪▪]. In 2019, the Society for Obstetric Anesthesia and Perinatology (SOAP) compiled a consensus document regarding Enhanced Recovery after Cesarean (ERAC) [19▪]. The SOAP recommendations outlined core and desired elements that are required to fulfill ERAC (Table 1). Elements of the specific protocols and guidance publications for ERAS after cesarean delivery are reviewed below.

Table 1
Table 1:
Key elements and recommendations for enhanced recovery after cesarean delivery

PREOPERATIVE PREPARATION

General ERAS principles in the preoperative period include optimization of medical comorbidities, patient education with detailed preoperative counseling and setting of postoperative expectations, and minimizing preoperative fasting and offering a carbohydrate drink (to prevent catabolic state, maintain normoglycemia and minimize dehydration).

Medical optimization

  • (1) It is important to treat and optimize any concurrent comorbidities, for example treat hypertension, strict glucose control in diabetic patients and correction of preoperative anemia. As obesity is known to increase risks of intraoperative and postoperative complications, all women, particularly obese women, are recommended to actively manage weight to limit excess maternal weight gain in pregnancy [17▪▪].

Patient education

  • (1) Although the quality of the evidence was low, strong recommendations were made by the ERAS Society for preoperative counseling of patients on the expected procedures before, during and after delivery; with emphasis on extensive counseling of risks and benefits of cesarean delivery on maternal request. Simplified infographics can be used to visually describe the ERAS process (Fig. 1). SOAP similarly emphasized the importance of patient education and breastfeeding preparation. Setting maternal expectations (e.g. postoperative pain levels) may impact reported satisfaction. Antenatal counseling should also include smoking cessation and avoidance of illicit drugs, as well as importance of minimizing prescribed opioids after discharge [17▪▪,19▪].
FIGURE 1
FIGURE 1:
Enhanced recovery after surgery (ERAS) for cesarean delivery. Sample infographic to visually describe the ERAS process to patients.

Preoperative nutrition and fasting period

  • (1) A light meal may be consumed up to 6 h before surgery and patients should be encouraged to consume clear liquids until 2 h before surgery. Oral or mechanical bowel preparation is discouraged. Premedication with antacids or histamine receptor blockers in the case of general anesthesia (not routinely required for neuraxial anesthesia) and avoidance of preoperative sedation can reduce the risk of aspiration [17▪▪,19▪].
  • (2) American Society of Anesthesiologists recommendations are consistent with ERAS, but recommend adjustment of the fasting interval to 8 h after heavy meals (e.g. meats and fatty foods) [19▪,20].
  • (3) Supplementation of a carbohydrate-containing drink to nondiabetic mothers is a common element of ERAS pathways, although the evidence regarding carbohydrate supplementation prior to cesarean delivery is limited [17▪▪,19▪].

INTRAOPERATIVE CONSIDERATIONS

ERAS guidelines regarding intraoperative care include many practices familiar to both obstetric and nonobstetric surgeons: preoperative skin cleansing, prophylactic antibiotics and appropriate surgical technique. However, uterotonic administration, uterine externalization and initiation of breastfeeding are unique to cesarean delivery. Prevention of intraoperative and postoperative nausea and vomiting, initiation of analgesia and maintenance of normothermia are core elements to ERAC (Table 1).

Surgical site infection prophylaxis

  • (1) Prophylactic antibiotics to reduce infections are well studied and evidence based.
  • (2) Administration of prophylactic antibiotics should ideally be prior to skin incision, rather than after cord-clamping. In cases of emergent cesarean delivery, antibiotics should be administered as soon as possible [21].
  • (3) The first-line antibiotic of choice for routine cesarean delivery is a cephalosporin, such as cefazolin. Adjustment of regimen for patients already on antibiotics or with allergies should follow ACOG Practice Bulletin: Use of Prophylactic Antibiotics on Labor and Delivery recommendations [21].
  • (4) Use of an antiseptic, generally chlorhexidine-alcohol solution, for skin cleansing prior to cesarean delivery is a common practice. ACOG notes that vaginal cleansing before cesarean delivery may reduce the rate of endometritis and postoperative fever; however, it has not been found to reduce the wound infection rate. Vaginal preparation can be performed using povidine-iodine or chlorhexidine gluconate with a low concentration of alcohol [17▪▪,21].

Maintenance of euvolemia and normothermia

  • (1) Limiting intravenous fluids to less than 3 liter for routine cases and managing spinal anesthesia-associated hypotension primarily with vasopressors instead of fluid administration is recommended. However, in the setting of hemorrhage, ERAS fluid minimization principles should be abandoned in preference to volume resuscitation [19▪].
  • (2) Prevention of hypothermia during the case can be achieved by routine utilization of forced air warming during surgery and warming of intravenous fluids, as well as increasing the temperature of the operating room (>72 degrees Fahrenheit). Normothermia may reduce postoperative complications and hasten recovery [17▪▪,19▪].

Multimodal analgesia

  • (1) Neuraxial anesthesia (spinal or combined-spinal epidural) is the preferred cesarean delivery anesthetic [17▪▪,19▪].
  • (2) SOAP recommends a neuraxial morphine and nonopioid analgesia started in the operating room (e.g. acetaminophen IV or PO and ketorolac 15–30 mg IV after closure of peritoneum), as well as consideration of continuous local anesthetic wound infiltration or regional blocks in select cases [19▪].

Intraoperative and postoperative nausea and vomiting prophylaxis

  • (1) Prevention of nausea and vomiting are essential to improve recovery of mothers.
  • (2) Prophylactic vasopressor (e.g. phenylephrine infusion) and coadministration of fluids can prevent or minimize spinal anesthesia-induced hypotension [17▪▪,19▪].
  • (3) Two different classes of antiemetics (such as a 5-HT3 receptor blocker and a corticosteroid) should be routinely administered to prevent nausea and vomiting. Avoiding uterine exteriorization and abdominal irrigation by surgeon when appropriate is also beneficial. Using the lowest effective dose of oxytocin and appropriate secondary uterotonics will decrease drug-related nausea and vomiting [17▪▪,19▪].

Surgical approach

  • (1) Although a cesarean delivery must use an open surgical approach, there are ways to minimize the invasiveness of the procedure. Blunt expansion of transverse uterine hysterotomy, nonclosure of the peritoneum layer, reapproximation of subcutaneous tissue measuring more than 2 cm in depth and closure of skin with subcuticular suture are suggested methods to reduce blood loss and complications [1▪▪,17▪▪].
  • (2) A Cochrane review found that Joel–Cohen transverse incisions are associated with shorter operating times and less morbidity; however, many providers are comfortable with the more common Pfannensteil incisions, which may in part be due to the more cosmetic location on the abdomen [22,23].
  • (3) A Cochrane review evaluating placental delivery methods found that spontaneous delivery of the placenta, facilitated by gentle cord traction or uterine massage, was associated with a lower risk of endometritis and blood loss as well as shorter hospital stay compared to manual extraction of the placenta [24].

Breastfeeding and infant considerations

  • (1) Skin-to-skin contact should be facilitated soon after delivery in the operating room. If appropriately implemented, mother–infant bonding can actually be enhanced by ERAS, with ERAS participants responding with more positive feelings toward their newborn, greater maternal satisfaction and more comfortable caring for their newborn, specifically cradling and breastfeeding [25].

POSTOPERATIVE CARE

Postoperative care must take the patient's postpartum state into account as well as the care of the newborn. Key ERAS elements include early oral feeding, early mobilization, standardizing multimodal analgesia, minimizing opioid analgesia and streamlining hospital discharge.

Early oral intake and promotion of bowel function

  • (1) Minimizing postoperative opioid use decreases ileus and promotes return of bowel function.
  • (2) Resumption of a regular diet within 2 h after surgery is a strong recommendation from the ERAS Society guidelines and is based on high to moderate quality evidence. SOAP recommends ice chips/water within 1 h and regular diet ideally within 4 h. Intravenous line should be clamped early once oxytocin infusion is complete and oral fluids are tolerated [18▪▪,19▪].
  • (3) A randomized control trial on gum chewing after cesarean delivery found that women who chewed gum 2 h postoperatively and continued every 2 h while awake had shorter time to first bowel movement than those who consumed oral fluids 6 h postoperatively or a control group on intravenous fluids (20.1 ± 0.3 vs. 33.7 ± 0.8 vs. 33.9 ± 0.9 h, P < 0.001) [26]. The ERAS Society made a weak recommendation for gum chewing in the immediate postoperative period [18▪▪].

Glycemic control

  • (1) Capillary blood glucose of more than 200 mg/dl has been associated with poor wound healing and increased wound infection [27,28].
  • (2) Blood glucose control of less than 180–200 is recommended as well as scheduling diabetic patients as the first case of the day [19▪].

Early ambulation

  • (1) Early mobilization decreases muscle atrophy, hypoxia, postoperative venous thromboembolism (VTE) and insulin resistance [29–31]. Although all ERAS pathways contain some element of early mobilization and/or frequent ambulation, there is very limited guidance on specific timing, type and amount of ambulation.
  • (2) Mobilization and ambulation should occur soon after return of motor function. An example of a mobilization schedule from SOAP includes dangling feet on the edge of the bed and sitting in the chair within the first 8 h postoperatively, followed by walking at least 1–2 times within 24 h postoperatively, followed by walking 3–4 times daily on the subsequent postoperative day [19▪].

Prevention of venous thromboembolism and anemia screening/treatment

  • (1) Patients undergoing cesarean delivery have an increased risk of VTE [29].
  • (2) ACOG recommends the placement of pneumatic compression devices before cesarean delivery for all women, and institutional consideration and implementation of risk assessment protocols to reduce the incidence of VTE in the postpartum period. Women at higher risk of VTE should be given chemoprophylaxis, such as heparin or low molecular weight heparin [29,32].
  • (3) Postpartum anemia may delay recovery and can be associated with postpartum depression [33]. Postoperative hemoglobin checks should be considered in patients with excessive intraoperative or postoperative bleeding.

Multimodal analgesia

  • (1) Ideal postoperative pain management involves setting expectations (e.g. no pain is unrealistic and treatment should aim at reducing moderate to severe pain), utilizing scheduled nonopioid multimodal analgesics and minimizing opioid use.
  • (2) All women should be prescribed scheduled/regular administration of nonopioid analgesics (acetaminophen and NSAIDs) to reduce pain and reliance on opioids. Multimodal analgesia can decrease opioid use and related side-effects by 30–50%. Peripheral nerve blocks and gabapentin may be considered in select patients or for severe refractory pain [34,35].
  • (3) Opioids have several immediate and short-term harms associated with use, including increased nausea/vomiting, pruritus, respiratory depression, sedation, fatigue, suppression of bowel function and ileus, as well as persistent use and opioid dependence [36].

Timely removal of urinary catheter

  • (1) Nearly all ERAS pathways include early removal of urinary catheter to encourage mobilization, reduce the risk of catheter-associated urinary tract infections and improve patient's satisfaction through independent toileting. Removal of urinary catheters should be performed after return of motor function with emphasis on monitoring and identifying acute urinary retention, which may be a side-effect of early catheter removal [12,37–39].
  • (2) The timing of catheter removal is not well studied and ERAS pathways differ in the recommended time of removal, ranging from immediately after surgery to within 24 h postoperatively. A reasonable approach after cesarean delivery is removal within 6–12 h postoperatively [18▪▪,19▪].

Breastfeeding support and facilitation of mother–infant bonding

  • (1) Breastfeeding should start immediately after birth with skin-to-skin care and should be continued throughout the hospitalization. Robust lactation support per institutional guideline is a core element of ERAS. Mother–infant bonding can be enhanced by ERAS [19▪,25].
  • (2) Continuation of breastfeeding can be achieved with ERAS protocols, even those enabling a day 1 discharge. A fast-track pathway for uncomplicated, scheduled cesarean delivery patients revealed high maternal satisfaction, good pain control and continuation of breastfeeding after discharge, without increased readmissions [40▪].
  • (3) Minimizing excess opioids is important as use may impact the breastfeeding newborn as well as impair the mother and her ability to care for her infant [19▪].
  • (4) Maternal fatigue may impact maternal–infant bonding, cognitive function, depression, reported pain and risk of respiratory depression. Limiting unnecessary postpartum interruptions (e.g. with clustered interventions) is an important element of ERAS after cesarean delivery [19▪,41].

Successful implementation

  • (1) A multidisciplinary team is necessary for a successful ERAS implementation. ERAS protocols for cesarean delivery have the added complexity of having two patients simultaneously being cared for. An obstetric ERAS team should include obstetricians, obstetric anesthesiologists, midwives, maternal–fetal–medicine specialists, pediatricians, neonatal specialists and lactation specialists, in addition to nurses familiar with prenatal and postnatal care.
  • (2) Many ERAS principles and protocols for scheduled cesarean delivery can be applied to unscheduled cases [1▪▪]. Many pregnant patients ultimately undergo unanticipated cesarean delivery, and providers should anticipate the possibility of this and include special provisions for patients undergoing unscheduled cesarean delivery to participate in an ERAS pathway. Furthermore, the possibility of urgent or emergent cesarean delivery should prompt providers to incorporate alternatives to the standard ERAS elements when constructing their bundles, such as alternatives to conventional skin preparations and more concise patient counseling.
  • (3) Timely discharge may be significantly impacted by poorly coordinated discharge practices. Streamlined, standardized discharge planning and coordinated care should start preoperatively, and the patient progress should be monitored postpartum with interventions for women failing to meet expected recovery metrics. Length-of-stay considerations must include neonatal and newborn providers to allow for infants and mothers to be discharged together.

CONCLUSION

All institutions that provide obstetric care should consider implementing ERAS for cesarean delivery, with the aim of providing women with evidence-based and patient-centered care, in a standardized approach that optimizes maternal recovery and improves both maternal and neonatal outcomes. Successful implementation of ERAS pathways for cesarean delivery requires a multidisciplinary team, careful understanding and consideration of local care protocols, and assessment of both maternal and neonatal factors that may impact ERAS at an individual institution. Implementing key protocol elements, addressing barriers to implementation and providing ongoing success metric assessments are essential, so that the full benefit of ERAS after cesarean delivery can be achieved.

Acknowledgements

We would like to thank Araseli Hernandez for her assistance with this piece.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

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Keywords:

cesarean delivery; cesarean section; enhanced recovery after surgery; enhanced recovery pathway; length-of-stay

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