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

Preoperative ERAC Recommendations

A total of 5 preoperative ERAC elements were identified (Table 1): (1) limited fasting intervals; (2) nonparticulate liquid carbohydrate loading; (3) patient education; (4) lactation/breastfeeding education; (5) hemoglobin optimization.

Limit Fasting Interval (Class IIb, Level C-EO, Low-grade Level of Evidence)

Oral intake up to the limits of the ASA guidelines is encouraged.[35] Limiting preoperative fasting interval is a key component of all ERAS pathways, because it limits metabolic stress and ketosis.[36] Curtailing these metabolic demands enables improved recovery quality and reduced length of stay after colorectal surgery.[37] The data supporting the recommendations for limiting preoperative fasting period was derived from nonobstetric populations (Table 1).

Nonparticulate Liquid Carbohydrate Loading (Class IIb, Level C-EO, Low-grade Level of Evidence)

In the obstetric population, a balance needs to be struck between the desire to limit preoperative fasting and selecting appropriate oral intake parameters to prevent aspiration in this high-risk population.[20,35] For example, particulate carbohydrate loading is not advisable, given the historical context of lethal aspiration pneumonitis/pneumonia hazards that are well described in this patient cohort.[38] Studies in nonlaboring women scheduled to undergo a cesarean delivery suggest that gastric emptying is not decreased compared to their nonpregnant counterparts.[39] Therefore, carbohydrate loading with nonparticulate liquids (eg, clear apple juice) up to 2 hours before scheduled cesarean delivery is recommended.

Patient Education (Class IIb, Level C-NR, Moderate-grade Level of Evidence)

Patient education, information material, and clear communication are essential to enhanced recovery pathways, as patient empowerment for active participation in their health care is vital to improving health outcomes.[37,40–43] Malpractice claims, a potential surrogate for care quality, are lower among physicians who emphasize a positive communication style and orientate toward patient education in clinical encounters.[42] For obstetric patients, patient activation and prenatal engagement, both of which emphasize patient counseling and education, are associated with positive patient experience and improved obstetric outcomes.[44]

Lactation/Breastfeeding Education (Class IIa, Level B-R, Moderate-grade Level of Evidence)

Lactation/breastfeeding education is an important element of postpartum recovery for breastfeeding mothers and their infants.[22,23,45–49] Numerous professional organizations, including the World Health Organization (WHO) and American Academy of Pediatrics (AAP), recognize the many medical and neurodevelopmental advantages of breastfeeding, and consider infant nutrition to be a public health issue rather than a lifestyle choice.[45] The AAP recommends exclusive breastfeeding for 6 months and continued breastfeeding alongside solid food for 1 year or longer as desired by both mother and infant. Hospitals should therefore encourage and support the initiation and maintenance of breastfeeding.[45] The US Surgeon General, Centers for Disease Control and Prevention (CDC), and The Joint Commission have issued strategies to facilitate breastfeeding in the hospital and community settings, and highlight the potential for improved breastfeeding end points with the implementation of breastfeeding-friendly practices.[50–52]

Hemoglobin Optimization (Class IIa, Level B-R, Moderate-grade Level of Evidence)

Many health benefits are associated with perinatal anemia prevention and treatment, including transfusion avoidance, improved cognition and mood, and quicker postpartum recovery.[21,53–57] One randomized controlled trial suggested that early prenatal iron supplementation improved postpartum depression screening scores,[56] although its effect on clinical diagnosis of depression was not assessed. For other surgeries, preoperative anemia optimization is recommended as part of a multimodal patient blood management approach.[54] Preoperative anemia optimization for cesarean delivery is particularly important given that: (1) pregnancy is associated with increased blood volume and dilutional anemia; (2) cesarean delivery is associated with blood loss that is higher than most abdominal surgeries; (3) prenatal anemia is a strong predictor of severe postpartum anemia;[55] (4) ACOG and CDC recommend screening, prevention, and treatment of anemia in pregnancy.[21,53]

In summary, preoperative ERAC element recommendations include patient education, minimizing preoperative fasting periods, and nonparticulate carbohydrate loading up to 2 hours before scheduled delivery, lactation/breastfeeding education, and hemoglobin optimization.