Care Bundles: Enhanced Recovery After Delivery : Maternal-Fetal Medicine

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Care Bundles: Enhanced Recovery After Delivery

Hu, Ling-Qun1; Lysandrou, Plato J.1; Minehart, Rebecca2; Wang, Jing-Ping3; Xia, Yun1; Hu, Yiling4; Worly, Brett5,∗

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Maternal-Fetal Medicine ():10.1097/FM9.0000000000000178, January 5, 2023. | DOI: 10.1097/FM9.0000000000000178
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Optimizing patient safety and satisfaction throughout the obstetric care experience is an essential aspect of improving birth outcomes. We hope to provide clinical guidance to obstetrics, anesthesia, and pediatrician healthcare providers and staff in the outpatient and inpatient settings to optimize the delivery experience with a clinical review that includes recommendations for the prenatal, intrapartum, and postpartum care. Through shared clinical experience, best practices, counseling, guidance, evidence-based healthcare decisions, and participation in the shared decision-making model of care, we aim to help obstetrics and anesthesia providers and healthcare team members improve their knowledge and understanding and improve the overall pregnancy experience. Specific goals include improved patient/provider communication, improved patient satisfaction, improved outpatient and inpatient pregnancy healthcare, decreased cesarean section on maternal demand, decreased postoperative pain, improved breastfeeding rates, and reduced hospital stay. We have divided the birth experience into prenatal, intrapartum, and postpartum sections.

Prenatal care


Pregnancy is an opportunity to provide impactful healthcare and a positive experience with patients who are often young and healthy and may not otherwise regularly access the healthcare system for healthcare screening visits. This is an opportunity to screen for mental health problems, interpersonal violence, sexually transmitted infections, and cervical cancer screening, in addition to providing high-quality pregnancy care. The professional relationship between the healthcare provider and the patient can be valuable as it pertains to the pregnancy itself and also after the pregnancy. One of the most important decisions for patients is the mode of delivery, cesarean section, or vaginal delivery. While the ultimate decision regarding the mode of delivery occurs during the intrapartum phase, many aspects of prenatal care influence the decision regarding mode of delivery, which, in turn, influences the patient outcome and overall satisfaction with the pregnancy experience.1

Prenatal clinical care pearls

  • (1) Schedule first-trimester ultrasound to confirm gestational age. Start prenatal vitamins with 400 to 800 μg of folic acid daily. Inform the patient of the recommended weight gain in pregnancy per the Institute of Medicine guidelines.1
  • (2) All pregnant women should be screened for anemia in accordance with the American College of Obstetricians and Gynecologists guidelines.1

Women with iron-deficiency anemia should take oral iron supplements, in addition to prenatal vitamins, or be treated with iron intravenously if refractory anemia persists, or if the parturient cannot take oral medication.1 Prenatal anemia must be addressed as it is an important predictor of postpartum anemia and the possible need for peripartum blood transfusions.2 Antenatal assessment for anemia in the third trimester and subsequent treatment may decrease the incidence of postpartum anemia. Perinatal anemia is associated with maternal postpartum depression, cognitive impairment, and fatigue.2 Iron-deficiency anemia during pregnancy is associated with low birth weight, premature delivery, and increased perinatal mortality.3,4 In addition to iron deficiency, other causes of anemia should be investigated and treated accordingly.1

  • 3. To optimize fetal growth, prevent/manage excess weight gain, hypertension, polypharmacy, and gestational diabetes mellitus. Maternal nutritional management and weight control should be a priority. Screen for gestational diabetes at 24 to 28 weeks of gestation with glucose tolerance testing.1,5
  • 4. Schedule prenatal visits and manage obstetric and medical issues in a timely fashion, especially when taking care of high-risk pregnant women. Screen for hypertension at each visit with a blood pressure check. Screen for mental health issues in the first and the third trimesters. Screen for sexually transmitted infections. Vaccinate patients with the influenza vaccine, as appropriate. Check for group B Streptococcus with a rectovaginal swab at 36 weeks.1
  • 5. Designate and strengthen existing education programs for the general public regarding the risks versus benefits of different modes of delivery. This may decrease the anxiety of prospective parturients, increase their compliance with their medical management, and empower them to participate in all aspects of the medical decision-making process, to better grant their needs, wishes, and rights.1,6–8 In doing so, an attempt should be made to:
  • (1) Prioritize vaginal delivery for the appropriate patient as cesarean deliveries generally have higher maternal risks than other modes of delivery. This counseling is intended to reduce cesarean deliveries that are not medically indicated.1
  • (2) Allow the parturients to choose between the different modes of delivery, after educating them regarding the risks versus benefits of each option.1,6–8
  • (3) If cesarean delivery is planned, enact enhanced recovery after cesarean delivery (ERAD) protocols, ensuring clear communication among all the specialties the day before the cesarean delivery. Collaboration and good communication are key to successful ERAD.9–11
  • 6. Consider contraception counseling in the third trimester to aid with appropriate birth spacing. The optimal spacing from the delivery of one baby until the conception of the next is a minimum of 1 to 1.5 years.1 We use a website to help us counsel patients:
  • 7. Promote breastfeeding through education and preparation, make counseling services easily available, and provide resources, training, and assistance.
  • (1) Early breastfeeding can improve the outcome of newborns and pregnant women, resulting in increased emotional bonding and decreased infant infection rates, neonatal jaundice, and sudden infant death syndrome.
  • (2) Breastfeeding is a public health issue as it can decrease long-term adverse health outcomes for mothers, such as breast cancer and hypertension.
  • (3) After ensuring mothers are educated, their decision on whether to breastfeed should be respected.1,13 We use a website to help educate our patients:


Intrapartum clinical care—delivery modality decision process

The mode of delivery depends heavily on individual clinical situations and should be decided by obstetric indications, the incidence of complications, and the quality of postpartum recovery (transition and rate of recovery). Current clinical practice is to facilitate vaginal delivery, when possible, including enrolling low- or moderate-risk women in the trial of labor after cesarean delivery (TOLAC), external cephalic version for fetal malpresentation in the third trimester, and twin vaginal delivery with cephalic presentation of the presenting twin, when appropriate.1,8

Because of continuous improvements in anesthesia care and surgical techniques, differences in outcomes between the different modes of delivery continue to decrease. However, the risk of complications from cesarean delivery is still significantly higher than that in vaginal delivery, and recovery is still considerably slower.8,15 The emergence of ERAD is another effort to narrow this difference further.9–11,15–18 Our current practice considers the risk-to-benefit ratio of all the delivery modalities. Predicting vaginal birth after cesarean delivery (VBAC) or TOLAC success is an excellent example of evaluating these risks. (See for an externally validated VBAC calculator tool that we commonly use for counseling patients.19)

If successful vaginal delivery is unlikely, elective cesarean delivery is recommended, with solid evidence that most delivery complications occur in parturients who failed VBAC.6 Any clinical plan may not be fully executed because of the many uncertainties of every individual childbirth, such as the natural course of childbirth, coexisting medical conditions, complications from pregnancy, or adverse effects/complications of medical interventions, or even other unexpected events. Being prepared for the unexpected will help with the physical and mental recovery after childbirth.1

Previous studies mostly focused on the risks versus benefits of different modes of delivery by evaluating different factors individually and independently, such as maternal and fetal mortality, short- and long-term morbidity, overall patient satisfaction, and cost-effectiveness.6–11,15–18,20–22 Although cesarean delivery may be the best option for some patients, there exists a threefold increased risk of hemorrhage requiring blood transfusion or hysterectomy, anesthetic complications, shock, cardiac arrest, acute renal failure, assisted ventilation, venous thromboembolism (VTE), wound disruption, and hematoma.20–22

Although there are some absolute contraindications to vaginal delivery attempt, including fetal intolerance of labor, a new outbreak of genital herpes, cephalopelvic disproportion, arrest of dilation, and arrest of descent, it would be helpful to have a counseling tool to help healthcare providers and patients better communicate regarding this decision. Delivery modality not only has a social and an emotional impact but also has an obstetric impact because it may affect future pregnancy delivery modality. This is particularly important when discussing cesarean delivery on maternal demand and TOLAC.1

Cesarean delivery is one of the most common surgeries in the United States, with 1.3 million cesarean deliveries performed annually, making up one-third of all births.16 These increasing rates of cesarean delivery are also seen in Central America and Europe, whereas the rates have not changed much in sub-Saharan Africa.16 Increased cesarean delivery rates are seen in China as well.23 Cesarean delivery may be associated with increased pain, prolonged recovery time, and longer hospital stay when compared with vaginal delivery.15,17 ERAD aims to maximize the mother's comfort, optimize recovery after delivery, and improve clinical outcomes for both the mother and the newborn. In addition, ERAD is conducive to earlier discharge from the hospital by improving the postpartum recovery process.9–11,17

A universal scoring system that assigns a score to the overall childbirth experience would be valuable. Explicitly stating all of the different complications and the risks of each complication occurring depending on which mode of delivery is selected would help both the healthcare providers and the public understand the risk-to-benefit ratio of all the different modes. Ideally, this information would be presented in the outpatient prenatal setting prior to labor pains or the stressful hospital experience.1 This, in turn, would facilitate evidence-based decision-making conversations between patients and clinicians, which is needed for informed consent to take place. Through better assessment of the childbirth experience, such a score could potentially blunt the rising incidence rates of elective cesarean deliveries worldwide, specifically cesarean delivery on maternal request (or “on-demand cesarean delivery”).8 The current clinical discussion regarding the method of delivery is more reflective of the negative aspects of childbirth (risks) than of the positive experiences (benefits). Other childbirth experiences are worthy of study as well, such as self-care ability after childbirth, quality of life, pelvic floor function, mental state, and pain control.24–33 A more holistic scoring system to evaluate postpartum recovery is needed.

In recent years, protocols for enhanced recovery after surgery have given us examples of a series of objective, comprehensive scoring tools for judging the pros and cons of different perioperative measures. In 2000, Quality of Recovery-40 (QoR-40) became available as one such tool.34 In 2013, it was modified to QoR-15 having 15 items, instead of 40 items.35 In 2019, the Obstetric Quality of Recovery-11 (ObsQoR-11) score emerged for elective cesarean delivery, the most common surgery in the world.36 Further refinements produced the ObsQoR-10, which appeared in 2020.37 A near-comprehensive review published in JAMA in 2020 summarized these scoring systems on objectivity, repeatability, and scientific characteristics.25 However, one additional tool developed by No Pain Labor & Delivery—Global Health Initiative (NPLD-GHI), not included in this review, was the Quality of Recovery after Delivery-9 (QoRaD-9), developed in 2011 and published in 2016.38 This tool was based on a combination of QoR-40 and commonly used postpartum parameters, utilizing objective measurements for the quality of postpartum recovery from different modes of delivery. This was partly due to the high percentage of parturients requesting cesarean delivery.38

Both ObsQoR-10 and QoRaD-9 appear to be superior tools providing a more objective and comprehensive understanding of the overall quality of recovery from various delivery modes.36,37 Most important is that healthcare providers select one of these tools and use it in a value-based and risk/benefit–based discussion with pregnant patients and families to start discussions regarding priorities throughout the delivery experience. We are anxiously awaiting upcoming clinical research publications that will evaluate their utility.

A very important issue is altering the expectations of the mother, which directly affects patient satisfaction. From QoR-10 for vaginal delivery to QoR-11 for cesarean delivery, it can be found that the difference between QoR-11 and QoR-10 are items related to postoperative complications such as nausea, vomiting, dizziness, and shivering. QoR-10 and QoR-11 help to clarify those aspects that may be most important to patients and families throughout their maternal and infant care experience. Labor and delivery units should expect sudden emergencies and be ready with rapid responses. ERAD is not exempt.36–38

Although there are no specific data on ObsQoR-10 other than its validation based on tracked parameters for postdelivery day 1, exemplary results that include faster recovery with fewer complications are associated with straightforward vaginal deliveries.38 Thus, the consensus is to avoid cesarean deliveries, whenever possible, and preventing cesarean delivery has become the primary focus of enhanced antenatal and intrapartum care efforts.8 The following approaches would help avoid cesarean deliveries:

  • (1) Shared decision-making with the patient, weighing risks and benefits in an objective fashion
  • (2) Predicting the possibility of successful vaginal delivery in patients with previous uterine surgeries for TOLAC
  • (3) The external cephalic version in late pregnancy for malpresentation of the fetus, with the hope of successful vaginal delivery
  • (4) Vaginal delivery should also be considered first in many high-risk patients including those with morbid obesity, preeclampsia, coronavirus disease 2019 infection, and even uncertainty from cephalic pelvic disproportion

Maternal and fetal morbidity and mortality, cost-effectiveness, and patient satisfaction are the main variables assessed in evidence-based medicine.20–22 The emergence of these aforementioned scoring systems is meant to elevate the maternal and fetal healthcare quality by objectively measuring birth outcomes and clarifying what is best for the mother and the baby.25 In addition, these include patient self-reported scoring systems, which could be extrapolated to patient satisfaction scores, but with itemized aspects.25 Patient satisfaction scores may be different from these measures and note aspects such as “doctor-nurse communication” and how well the healthcare team “listened to me” and are separate from these scoring systems.

According to a comprehensive review of the existing medical literature, quality measures include maternal postpartum recovery time, short- and long-term postpartum complications, breastfeeding rates, short- and long-term neonatal complications, and maternal and infant mortality rates.1,13 The different modes of delivery are ranked in the following order on the patient transition experience and rate of recovery:

  • (1) Vaginal delivery (this includes both TOLAC success and spontaneous vaginal delivery)
  • (2) Operative vaginal delivery
  • (3) Elective cesarean delivery
  • (4) Intrapartum cesarean delivery after attempted vaginal delivery
  • (5) Emergent cesarean delivery1,6–8,15,20–22,24–33

Intrapartum clinical care optimization—clinical pearls for vaginal delivery attempt

Induce labor only when indicated and at the appropriate fetal age. Keep the patient in the same room and the same bed throughout the progression of the three stages of labor as much as possible. Disturb the parturient as little as possible, allowing her to set the room temperature, bring her own pillows and blankets, and have to her favorite music and scent.1

  • (1) Oral restriction and hydration: fasting after the start of labor and sips of clear oral liquids are permissible for parturients, despite risk for having cesarean delivery.
  • (2) Allow patients to adjust the room temperature to their comfort (usually 68°F–74°F or 20°C–23°C).9–11,39,40
  • (3) Prioritize education of parturients, especially parturients with high risk of having cesarean delivery (TOLAC, preeclampsia, twins, morbid obesity, cardiovascular and cerebrovascular diseases, history of difficult airway, coagulopathy, nonreassuring fetal heart rate pattern, etc).
  • (4) Offer neuraxial labor analgesia as soon as induction of labor is initiated or when spontaneous labor starts, whenever clinically feasible.9–11,39,40
  • (5) After the parturients are well educated about the risks versus benefits of labor analgesia, they should be allowed to choose options of analgesia better suited to them. This includes the parturient in the decision-making process, empowering them and leading to better patient satisfaction.9–11,39,40
  • (6) Preventing and managing hypotension during neuraxial labor analgesia are essential, especially right after spinal placement. Maintain adequate analgesia throughout labor, ensuring the epidural analgesia is fully functioning because it might be needed for an emergency cesarean delivery. A well-functioning epidural analgesia will also lead to better patient satisfaction and to a lower risk of postpartum depression.9–11,39–41
  • (7) Define and document amniotic membrane rupture time and rational use of antibiotics and oxytocin.1
  • (8) Carefully manage the following issues for high-risk women1:
  • (1) Use of antibiotics for GBS-positive parturiens.1
  • (2) Blood glucose levels in diabetic patients should be well monitored and controlled.
  • (3) Start a magnesium sulfate infusion for neonatal neuroprotection against seizures in patients delivering at <34 weeks and patients with preeclampsia with severe features, thus preventing eclampsia in parturients with preeclampsia. Also, glucocorticoids should be used to promote fetal lung maturity if premature birth is unavoidable.1
  • (4) Monitor the blood pressure closely and control it well and within certain individualized patient-specific parameters.1

Mode of delivery altered

Pregnant women are often encouraged to have their childbirth plan. Parturients who have a childbirth plan need to be cognizant that the plan may have to change, emergently sometimes, because of a variety of reasons including the following:

  • (1) Nonreassuring fetal heart rate and failure to recover on their own or through immediate intrauterine resuscitation
  • (2) Obstetric emergencies including amniotic fluid embolism, placental abruption, umbilical cord prolapse after the rupture of membranes, and uterine rupture during TOLAC
  • (3) Rapid changes of circumstances occurring in laboring women with preeclampsia to the point where the delivery needs to proceed to save the mother and/or baby
  • (4) Elective cesarean delivery becomes nonelective because of the onset of spontaneous labor
  • (5) A simple vaginal delivery could be converted to operative vaginal delivery with or without episiotomy
  • (6) Intrapartum cesarean delivery due to failure to progress or failure to TOLAC1

Intrapartum care to optimize the cesarean delivery childbirth experience: ERAD

The process of enhanced postpartum recovery involves a multifaceted approach with interdisciplinary and interprofessional collaboration and communication, utilizing a set of proactive enhanced recovery protocols. The personnel involved in the patient's medical management process involve all healthcare providers participating in the parturient's care, such as obstetricians, subspecialists in maternal and fetal medicine, anesthesiologists, obstetric anesthesiologists, pediatricians, neonatologists, midwives, labor and delivery nurses, lactation advisors, nutritionists, pharmacists, hospital managers, and, of course, parturients and their support network.

Postpartum pain control is one of the most important and influential factors of enhanced recovery after childbirth in both QoR-11 and QoR-10. Pain control is directly related to the content of 2/11 in QoR-11.36 Acute pain plays the most important role, given the evidence of its close association with altered emotions, its effect on activity and ability to self-care, loss of sleep, and its importance on the restoration of bowel function, even though some causal-effect relationships are still not certain.32,42 The inability to get out of bed resulting from severe pain not only prolongs hospital stay but also increases the risk of postpartum venous thrombosis, which currently is the highest cause of postpartum mortality in the United States.1,9–11,16–18,39,40,42–45 Recently, it has also been found that postpartum pain from cesarean delivery is associated with chronic pain and long-term use of opioids; thus, postpartum pain control is important in this regard.39,42–44

When cesarean delivery is unavoidable, a comprehensive team approach should be utilized to minimize recovery disadvantages and achieve the ERAD goals of enhancing recovery and improving maternal and neonatal clinical outcomes. Protocols for cesarean delivery need to be evidence-based, team-based, and patient-centered. Care bundles that undergo continuous improvement through interprofessional collaboration and research should be provided.9–11,16–18,39,42–44

ERAD is a team-based continuous care plan that starts with prenatal education and optimization of medical conditions and nutritional status, along with surgical and anesthetic intraoperative management optimization. It ends with postnatal care and follow-up visits with a multidisciplinary involvement. The most important goals include attempts to:

  • (1) Minimize disturbances to the gastrointestinal system by decreasing NPO times for parturients, avoiding solid foods 6 to 8 hours preoperatively, and continue to give a moderate amount of clear liquids for up to 2 hours prior to anesthesia. This may include intake of carbohydrates, with either 945 mL of Gatorade (54 g carbohydrates) or 475 mL of pulpless apple juice (56 g carbohydrates).9–11,39,40 In the postoperative setting, establish regular feeding as soon as possible and improve nutrition and hydration.
  • (2) Preoperative treatment for postpartum pain control and postoperative nausea/vomiting.9–11,39,40 This includes use of neuraxial anesthesia as the first choice for anesthesia.9–11,39,40 A phenylephrine infusion should be routinely initiated after neuraxial anesthesia to control hypotension by counteracting the sympathetic blockade caused by the spinal anesthesia, starting it at 50 μg/min and titrating it, as needed.9–11,39,40 Intravenous fluids should be given right before and after spinal anesthesia is initiated, preferably <3 L.9–11,39,40 If there is excessive bleeding, switch to postpartum hemorrhage fluid management and blood transfusion protocol.1 Prevention of nausea and vomiting is essential and will require at least two medications with different mechanisms of action among the following five types:
  • (1) 5-HT3 receptor antagonists (eg, ondansetron 4 mg)
  • (2) Glucocorticoids (eg, dexamethasone 4 mg)
  • (c) (3) D2 receptor antagonists (eg, metoclopramide 10 mg)
  • (4) H2-receptor antagonists (eg, famotidine 20 mg)
  • (5) Scopolamine9–11,39,40

It is also beneficial to avoid uterine externalization of the uterus for surgical suturing and abdominal saline irrigation.1

  • (1) Maintain normal body temperature (36.2°C–37.5°C) by actively warming the patient by applying a forced-air warming blanket or other heating devices or regular warm blankets, and/or using an intravenous fluid warmer.9–11,39,40
  • (2) Antibiotic prophylaxis should be given 15 to 60 minutes before skin incision, including azithromycin for ruptured amniotic membranes, in both intrapartum and elective scheduled cesarean delivery.1
  • (3) Restore daily activities as soon as possible to prevent VTE, establish good rest, remove urinary catheters or any other surgical drains as soon as possible, aggressively treat anemia, promote breastfeeding, and facilitate early discharge, when possible.
  • (4) When epidural anesthesia is used, a single dose of water-soluble long-acting opioid such as morphine 1 to 3 mg should be given right after the delivery via the epidural catheter during the operation, and an intravenous nonsteroidal anti-inflammatory drug (NSAID) should be given, followed by oral NSAIDs, if not contraindicated:
  • (1) If spinal anesthesia is chosen for cesarean delivery and preservative-free morphine 50 to 150 μg is mixed with local anesthetics intrathecally, followed by the same NSAID regimen intravenously/orally
  • (2) Intravenous patient-controlled analgesia for parturients who have a contraindication to neuraxial morphine, combined with an NSAID regimen intravenously/orally
  • (3) For chronic opioid users, patient-controlled epidural analgesia may be a good choice, giving good pain relief while avoiding IV opioids
  • (4) For patients who cannot use neuraxial morphine, or multimodal analgesia, or after cesarean under general anesthesia, or if their pain is severe and difficult to manage, wound local anesthetic infiltration or a local nerve block should be considered, such as transversus abdominis plane block, or quadratus lumborum block, to minimize pain after cesarean delivery9–11,16–18,39,42–44


Postpartum clinical pearls

Although the mode of delivery may be different, the goals of postpartum recovery for all of them are very similar. The Society of Obstetric Anesthesia and Perinatology guidelines about ERAD are very insightful:

  • (1) Minimize gastrointestinal and metabolic disturbance by encouraging early eating, including ice and/or water within 60 minutes after delivery. If possible, resume a regular diet within 4 hours after cesarean delivery. The benefits of early eating include the following:
  • (1) Promotes the recovery of intestinal function
  • (2) Shortens the length of hospital stay
  • (c) (3) Does not increase the incidence of complications
  • (d) (4) Reduces the risk of postoperative nausea or vomiting
  • (5) Improves postoperative catabolism
  • (f) (6) Maintains insulin sensitivity
  • (g) (7) Reduces surgical stress to the body
  • 2. Pain control:
  • (1) NSAID: ketorolac 15 to 30 mg, IV after delivery, ibuprofen 600 mg/6 h, or naproxen 500 mg/12 hours orally after
  • (2) Acetaminophen 650 to 1000 mg/6 h
  • (3) Gabapentin limited evidence of analgesic effect for elective surgery
  • 3. It is important to facilitate the recovery of intestinal function with:
  • (1) Decreased use of opioids
  • (b) (2) Encourage gum chewing
  • (3) Use enteral drugs, such as docusate sodium, polyethylene glycol, and simethicone
  • (d) (4) Eliminate factors that prevent early mobility and recovery
  • 4. Once the infusion of oxytocin is completed, intravenous access should be Hep-Locked to avoid excessive fluid intake and frequent urination.
  • 5. Control blood glucose:
  • (1) Ideally, diabetic patients should have their cesarean delivery scheduled as the first case of the day
  • (2) Control blood glucose <180 to 200 mg/dL; check maternal/newborn blood glucose in diabetic patients every hour
  • (3) Hyperglycemia (>180–200 mg/dL) should be promptly treated as it is associated with poor outcomes, including infection and delayed wound healing
  • 6. Encourage return to normal physical activity and sleep
  • 7. VTE prevention1,45
  • (1) Cesarean delivery doubles the risk of VTE. VTE prophylaxis should be considered in a risk-adjusted fashion at 12 to 24 hours after surgery, in compliance with the American College of Obstetricians and Gynecologists and American College of Chest Physicians updated clinical guidelines
  • (2) The American College of Obstetricians and Gynecologists recommends the use of thromboembolism physical prevention devices for postoperative cesarean delivery parturients who decline pharmacologic VTE prophylaxis
  • 8. Screening and correction of anemia: routinely check for hemoglobin on the first or the second day after surgery, especially with a history of bleeding
  • 9. Restarting home medications as needed
  • 10. Screening for perinatal depression.1,41 If there are any unexpected events during labor, maternal mental health has to be addressed to avoid mental health issues causing a negative impact on the mother's outcome and well-being.41 If planned labor analgesia failed, or labor epidural analgesia that was not planned became necessary, postpartum maternal mental health issues may increase the possibility of depression41

Back to home: early discharge

  • (1) A discharge and postoperative care plan should be developed before the operation1,9–12,17,18
  • (2) Establish a patient-centric goal as soon as possible. Use of care team signage in patient rooms with quantitative indicators to monitor the recovery process will help meet the early discharge goals and improve communication between the patient, family, and the healthcare team. Ideally, the discharge plan for the first day after surgery should include pediatrics, breastfeeding, and birth control planning1
  • (3) Personalized and patient-centered opioid prescriptions when discharged from hospital
  • (4) Advocate and support breastfeeding1,13:
  • (1) Provide strong lactation support according to professional guidelines
  • (2) Start skin-to-skin contact immediately after birth and throughout the hospital stay
  • (3) Skin-to-skin contact should be initiated and uninterrupted until the first breastfeeding is completed
  • (4) For formula-feeding infants, the initial skin contact should continue uninterrupted for at least 1 hour
  • (5) Mothers should be encouraged to continue breastfeeding as much as possible after the first skin contact during hospitalization
  • (f) (6) Provide lactation counseling and educational materials, including the 10 steps to successful breastfeeding described in the joint statement of UNICEF and the Baby-Friendly Hospital Initiative13

With more evidence on the quality of recovery based on assessments via QoR-10, QoR-11, or QoRaD-9, it would help to know which one is the best tool for assessment of the childbirth experience. Quality of recovery has become increasingly more important because insurers and healthcare systems shifted from a fee-for-service model to a value-based reimbursement model. Value-based reimbursement models compensate providers based on both the quantity and the quality of the care they provide. Assessment of the quality of care is essential not only to the value-based reimbursement model but also to the goal-orientated improvement for quality of care. Patient health outcomes are also important and include objective measurement of mental health and pain, perioperative complications, and clinical management responses to complications. With the increased demand for information on the quality of care parturients received, it is expected that related research will surge, including objectively evaluating the pros and cons of various modes of delivery, which caused the most complications, and validations of the assessment tools themselves on the quality of care parturients received.25

Short-term postpartum recovery is discussed in this section. Medium- to long-term postpartum recovery, which is also important, is beyond this discussion. Other indications for postpartum care that occur with decreased frequency including removal of surgical scars, regression of pregnancy-induced abdominal stretch marks, healing of perineal incision or scars, pelvic floor rehabilitation, restoring separated rectus abdominis, and fading skin pigmentation were not addressed here. Issues such as the prevention of uterine prolapse and chronic pain caused by the surgical incision are also not within the scope of this article.

The strengths of this article include the multispecialty and multi-institutional approach to the pregnant patient, the strength of consensus statements to drive care, and the decades of clinical experience from senior physicians in their respective fields. The limitations include the lack of systemic medical literature review, the focus on patient care in the United States when the healthcare systems of other countries may have better outcomes, and the reliance on expert opinion inherent in consensus statements when data may be lacking. The authors hope to provide a unique set of organized ideas from distinct healthcare provider specialties that may be helpful in improving education, understanding, patient counseling, and patient outcomes for pregnant and postpartum patients.


Pregnancy is a very exciting and stressful time in the lives of patients and their families. Using clinical best practices in each step of the pregnancy can be very helpful in optimizing the healthcare experience. The decision on whether to proceed with a cesarean delivery or attempt a vaginal delivery can be quite challenging, but by allocating enough time to the decision-making process, utilizing appropriate resources, and providing counseling to the patient, the trust and respect of the parturient may be earned by the healthcare providers. Enhanced recovery in the intrapartum and postpartum periods will improve the birthing experience.



Conflicts of interest



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Delivery, obstetric; Prenatal care; Cesarean delivery; Vaginal delivery; Intrapartum care; Postpartum care; Enhanced recovery after delivery

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