ERAS releases its guidelines for Antenatal and Peri-operative care in Cesarean Delivery

The Enhanced Recovery After Surgery (ERAS®) Society recently released its evidence-based, based practice recommendations to accelerate recovery after cesarean delivery (CD).

The recommendations published online ahead of print in the American Journal of Obstetrics and Gynecology involve interventions that start 30-60 minutes before skin incision and extends till the patient is discharged from hospital spanning the pre-operative, intra-operative, and post-operative phases of the CD.

The ERAS protocols were first introduced 15 years ago by Wilmore and Kehlet for colorectal surgery and are now successfully applied in other surgical disciplines like breast, urological, pancreatectomy, liver resection, and gynecologic surgery.

The ERAS team used Embase and PubMed to look at studies spanning 51 years (1966-2017) to gather evidence for developing the protocols and recommendations. The team created maternal FOCUSED pathways that involve protocols for the preoperative, intraoperative, and postoperative phase of the CD. GRADE system was used to assess the quality of studies.

The preoperative recommendations start 30-60 minutes before the skin incision for both elective and emergency cesarean sections and include a one on one communication with the patient about oral intake before surgery, what to expect during the surgery, postoperative pain, initiation of lactation, and recovery.  The Antenatal recommendations mainly focus on patient education about nutrition, supplements, delivery, what to expect during a CD and breastfeeding. 

Antenatal and Preoperative recommendations include:

Patient education

Six- to eight-hour fasting for solids and clear oral fluid intake up to two hours before the induction of anesthesia

Use of antacids and histamine H2 receptor antagonists

Hemoglobin optimization

Contact with patient 24 hours before elective CD

Intraoperative recommendations include:

A single dose of broad-spectrum antibiotics before the skin incision

skin preparation with chlorhexidine-alcohol

Fluid balance with 2L crystalloid and prophylactic phenylephrine infusion initiated at 50 mcg/minute

Maintaining perioperative normothermia (forced warm air, warmed IV fluids, room temperature),

Use of neuraxial anesthesia with neuraxial opioids

Prophylaxis against postoperative nausea and vomiting (PONV)

Delayed cord clamping for 30-60 sec

Initializing early skin to skin contact

Preventing PPH by low dose oxytocin infusion

Postoperative recommendations include :

Encouraging early oral intake within 2 hours

Early mobilization

Early removal of urinary catheter

Regular use of multimodal pain reliever

No VTE prophylaxis with heparin

Pneumatic compression stocking for VTE prophylaxis

Consultation with a lactational expert

Complete neonatal evaluation by the neonatal team

Abstract

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