Society for Obstetric Anesthesia and Perinatology

Consensus Statement and Recommendations for Enhanced Recovery After Cesarean

Laurent Bollag, MD; Grace Lim, MD, MS; Pervez Sultan, MBChB, FRCA, MD (Res); Ashraf S. Habib, MBBCh, MSc, MHSc, FRCA; Ruth Landau, MD; Mark Zakowski, MD; Mohamed Tiouririne, MD; Sumita Bhambhani, MD; Brendan Carvalho, MBBCh, FRCA, MDCH


Anesth Analg. 2021;132(5):1362-1377. 

In This Article

Abstract and Introduction


The purpose of this article is to provide a summary of the Enhanced Recovery After Cesarean delivery (ERAC) protocol written by a Society for Obstetric Anesthesia and Perinatology (SOAP) committee and approved by the SOAP Board of Directors in May 2019. The goal of the consensus statement is to provide both practical and where available, evidence-based recommendations regarding ERAC. These recommendations focus on optimizing maternal recovery, maternal-infant bonding, and perioperative outcomes after cesarean delivery. They also incorporate management strategies for this patient cohort, including recommendations from existing guidelines issued by professional organizations such as the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists. This consensus statement focuses on anesthesia-related and perioperative components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.


The first Enhanced Recovery after Surgery (ERAS) pathways were developed in the 1990s–2000s and focused on recovery after colorectal surgery.[1,2] Today, numerous ERAS protocols exist for multiple surgery types.[3–6] Since 2012, the National Institute for Health and Care Excellence (NICE) guidelines from the United Kingdom encouraged institutions to implement ERAS protocols in their obstetric units.[7] The widespread adoption of ERAS lies in successful standardization of perioperative patient management. Care pathways have the potential to limit the variability in patient care and therefore improve outcomes such as postoperative pain and hospital length of stay, without compromising patient outcomes or satisfaction.[8–10] Currently, evidence exists supporting benefits of standardizing protocols on improving maternal and fetal outcomes.[11,12] The ERAS Society published 3 distinct guidelines for antenatal, intraoperative, and postoperative care for women undergoing cesarean delivery.[13–15] They provide a solid foundation from which clinicians can base their perioperative management of the patient undergoing elective cesarean delivery; however, they lack details regarding important peri- and intraoperative anesthesia-related areas of patient care.

This consensus statement focuses on anesthesia-related components of an enhanced recovery pathway for cesarean delivery and provides the level of evidence for each recommendation.

Improving Quality of Care

The Institute of Medicine defines health care quality as, "[t]he degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."[16] Intuitively, the value of enhanced recovery protocols in obstetrics may be different from other surgical models. Women undergoing cesarean delivery are generally young and healthy, and therefore less likely to require preoperative optimization or have surgical complications. They are also expected to take care of their neonate and are therefore motivated to recover quickly. The traditional markers of successful implementation of ERAS may be different with Enhanced Recovery After Cesarean delivery (ERAC). For instance, reduction in maternal length of stay is influenced by multiple factors including neonatal health state and breastfeeding success, and this metric should therefore be taken in context with other measures when evaluating ERAC success. ERAC can increase the value of health care provided, by improving the global quality of care and optimizing quality of recovery after cesarean delivery.

The goal of this consensus statement is to improve maternal and neonatal outcomes with evidence-based, patient-centered care using a standardized approach that optimizes recovery from cesarean delivery. Central to this goal is a culture of critically examining and applying current knowledge through quality improvement and collaboration.

The Society for Obstetric Anesthesia and Perinatology ERAC Consensus Statement

The Society for Obstetric Anesthesia and Perinatology (SOAP) is a US- based, international professional society exclusively dedicated to optimizing maternal and perinatal health outcomes. In October 2018, SOAP Board of Directors convened a committee to review best practices and existing literature on enhanced recovery after cesarean. A consensus committee was selected, with 6 members from 6 different academic centers across the United States. Weekly phone calls were performed for 10 months between January and October 2019. Assigned members collated information regarding potential pre-, intra-, and postoperative ERAC elements that were further evaluated and subsequently discussed. Additional interventions were added/amended based on committee feedback. Of note, when there was a paucity in obstetric-specific data, elements of the consensus statement were adapted from other successful enhanced recovery programs, such as colorectal or gynecological-oncological surgical specialties.[1,7–10,17–19]

Three additional consultants (A.S.H., R.L., P.S.) were invited to participate in the consensus decisions and to provide further input, and a draft consensus statement was presented and approved by the SOAP Board of Directors in May 2019. The consensus statement incorporates the best available evidence on each element, with focus on the obstetric patients, and maternal and neonatal outcomes. These ERAC elements are consistent with current practice guidelines for obstetrics and obstetric anesthesia, including those issued by the American Society of Anesthesiologists (ASA) Committee on Obstetric Anesthesia and SOAP as well as the American College of Obstetricians and Gynecologists (ACOG).[20–24]

We present the elements that a perioperative scheduled cesarean delivery–specific enhanced recovery program should include. Specific outcomes that these recommendations are designed to improve are often interrelated (eg, the prevention of intraoperative nausea and vomiting [IONV], multimodal analgesia, and shivering control are all expected to improve mothers comfort during the cesarean delivery and their birthing experience) and include postoperative duration of hospital stay, postoperative opioid requirement, breastfeeding success rate, maternal-neonatal bonding, patient satisfaction, and care experience.

The complete consensus statement is available online (, along with resources to assist with implementation, including sample patient handouts.[25]

What is an ERAC Pathway?

ERAC is best conceptualized as a continuum of care, from preconception outreach, antepartum optimization, intrapartum care which includes the anesthetic management, and concluding with postpartum in-patient care and out-patient support. ERAC protocols aim to optimize patient outcomes by modifying the inflammation and metabolic changes associated with surgery by organizing multimodal evidence-based interventions into a specific care pathway. This consensus statement presents 25 specific recommendations that the committee believes define an ERAC pathway (Table 1, Table 2 and Table 3). Although the consensus statement was developed for scheduled cesarean deliveries, many of the elements of the pathway can be successfully applied to nonscheduled cesarean deliveries.

Class of Recommendations and Level of Evidence

Table 1, Table 2 and Table 3 present specific recommendations on ERAC elements for preoperative, intraoperative, and postoperative time frames. A focused literature review related to enhanced maternal and neonatal recovery after cesarean delivery was conducted for each recommendation by 2 committee members (preoperative period: S.B., M.T.; intraoperative period: G.L., M.Z.; postoperative period: L.B., B.C.) and then reviewed by the full committee. The existing evidence and strength of recommendations were evaluated for each of the elements by assigned committee members and subsequently discussed by the entire committee, in cases of disagreement, the level was up or downgraded until consensus was achieved. The 2016 American College of Cardiology (ACC) and American Heart Association (AHA) Clinical Practice Guideline Recommendation Classification Systems[26] were used to evaluate each of the element's level of evidence.