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

Intraoperative ERAC Recommendations

A total of 9 intraoperative ERAC elements were identified (Table 2): (1) prevention of spinal-induced hypotension; (2) maintenance of normothermia; (3) optimized uterotonic administration; (4) antibiotic prophylaxis; (5) IONV and postoperative nausea and vomiting (PONV) prophylaxis; (6) multimodal analgesia initiation; (7) promotion of breastfeeding and maternal-infant bonding; (8) intravenous fluid optimization, and (9) delayed umbilical cord clamping.

Spinal Anesthesia–Induced Hypotension Prevention (Class I, Level A, High-grade Level of Evidence)

Preventing spinal-induced hypotension is an important strategy to enhance maternal and neonatal outcomes in cesarean delivery.[38] Fetal perfusion is dependent on uteroplacental blood flow, which lacks autoregulation, making it directly dependent on uterine perfusion pressure and inversely proportional to uterine vascular resistance. Current evidence supports the routine use of prophylactic phenylephrine infusion started immediately after injection of spinal anesthesia medications.[38,58] A crystalloid fluid coload (1 L administered immediately and rapidly after spinal injection) is preferable to a preload, and in combination with vasopressors significantly reduces the incidence of spinal-induced hypotension.[58] Spinal-induced hypotension during cesarean delivery should be managed with vasopressor agents having primarily direct alpha activity (eg, phenylephrine or norepinephrine), while fluids should remain a complementary intervention. Since IONV during cesarean delivery is commonly the result of spinal-induced hypotension, the above-recommended management techniques can be effective at reducing the incidence of IONV during cesarean delivery. Among women randomized to receive a prophylactic phenylephrine infusion compared to intermittent bolus regimens, umbilical artery pH and base excess were improved and the incidence of maternal IONV was lower.[58]

Normothermia Maintenance (Class I, Level C, Low-grade Level of Evidence)

Maintaining normothermia confers multiple perioperative maternal-neonatal benefits including reduced surgical site infection risk, shorter hospital length of stay (as shown in nonobstetric surgical settings), and improved neonatal umbilical artery pH and Apgar scores.[59–64] One meta-analysis found that active warming for elective cesarean delivery significantly decreased the incidence of hypothermia and perioperative shivering.[63] Preferred methods of facilitating maternal-neonatal warming in cesarean delivery include preoperative patient warming, and intraoperative fluid and forced air warming. A higher ambient operating room temperature set at 72°F (23.0 °C) is also recommended.[65]

Uterotonic Administration (Class II, Level A, High-grade Level of Evidence)

Optimal uterotonic administration during cesarean delivery is important to prevent and treat uterine atony and associated postpartum hemorrhage (PPH).[66,67] However, appropriate dosing of these medications is important to avoid drug-related side effects. It is advisable to use the lowest effective dose of uterotonics needed to achieve adequate uterine tone to minimize side effects. Undesirable effects of uterotonic agents include flushing, nausea and vomiting, tachycardia, hypotension, delayed water retention, hyponatremia and seizures (oxytocin), bronchospasm (prostaglandins), hypertension (ergot alkaloids), and drug errors (a risk associated with any unnecessarily administered drug).[27,66] A suggested uterotonic dosing regimen can be found in Table 2. Large and rapidly administered oxytocin boluses should be avoided to minimize side effects. Intrapartum cesarean delivery oxytocin dosing requirements are several fold higher than for elective cases without prior oxytocin exposure.[68]

Antibiotic Prophylaxis (Class I, Level A, High-grade Level of Evidence)

Appropriate antibiotic prophylaxis is critical for prevention of surgical site infection. ACOG guidelines consider cefazolin 2 g as a first-line antibiotic, with the addition of azithromycin in appropriate cesarean deliveries (such as in the presence of ruptured membranes).[24,69] Prophylactic antibiotics should be administered before incision, rather than after cord clamping. Preincision administration improves prophylaxis effectiveness without increasing risks to the fetus.[24]

IONV/PONV Prophylaxis (Class I, Level B, Moderate-grade Level of Evidence)

Adding lipophilic opioids such as fentanyl or sufentanil to spinal anesthesia with local anesthetics enhances intraoperative anesthesia,[70] reduces the total required dose of local anesthetic and thereby decreases spinal hypotension, reduces intraoperative pain and need for rescue analgesics, and decreases IONV.[38,71] PONV prophylaxis elements for cesarean delivery include the use of at least 2 antiemetic agents, for example, ondansetron and dexamethasone.[72–74] Metoclopramide is effective for IONV prevention, while dexamethasone's pharmacological profile make it a better option for PONV prophylaxis.[75] Evidence supports the avoidance of intraabdominal saline irrigation, which does not reduce the incidence of infectious complications but does increase the incidence of IONV and PONV.[76,77]

Avoiding uterine exteriorization has also been suggested as a strategy to reduce IONV,[78] intra- and postoperative pain, and time-to-return of bowel function following cesarean delivery; however, evidence regarding its effectiveness in preventing IONV is conflicting. The committee favored avoiding uterine exteriorization because studies with IONV as the primary outcome after uterine exteriorization suggested benefits with not externalizing the uterus.[78–84]

Multimodal Analgesia (Class I, Level A, High-grade Level of Evidence)

Initiating multimodal analgesia includes administration of intrathecal morphine (50–150 μg) or epidural morphine (1–3 mg); nonopioid analgesia, for example, nonsteroidal anti-inflammatory drugs and acetaminophen (started in the operating room unless contraindicated); and supplemental local anesthetic wound infiltration or truncal blocks in select cases (eg, if unable to receive the above-recommended drugs).[20,38,85,86] An emphasis on regular scheduled nonopioid analgesia commencing before the onset of pain (ie, immediately after delivery of fetus and not upon first pain request) should be central in these multimodal analgesic regimens.

Breastfeeding and Maternal-infant Bonding (Class IIa, Level C, Low-grade Level of Evidence)

Skin-to-skin contact immediately after delivery improves breastfeeding success and promotes maternal-infant bonding.[47–49] The Association of Women's Health, Obstetric and Neonatal Nurses support skin-to-skin contact to promote lactation and breastfeeding.[49] One quality improvement project found that early skin-to-skin contact in the operating room during cesarean delivery was feasible and increased breastfeeding initiation behaviors.[47] These infants had lower rates of formula supplementation in the hospital. A meta-analysis, including 38 randomized controlled studies, showed that skin-to-skin contact promoted breastfeeding among healthy infants, and found potential physiologic benefits for infants in transitioning to extrauterine life.[48] Although a randomized trial did not find this physiologic benefit for infants, it did not report elevated risks associated with early skin-to-skin contact.[87]

Intravenous Fluid Optimization (Class IIa, Level C, Low-grade Level of Evidence)

Goal-directed intraoperative fluid management is a mainstay of many ERAS pathways (Table 2). In colorectal surgery, the avoidance of both volume overload (that may affect anastomotic integrity) and under-resuscitation (that may cause end-organ hypoperfusion) are important.[37] As previously stated, prevention and treatment of spinal anesthesia–induced hypotension should focus on the use of vasopressors in conjunction with judicious coadministration of fluids. Ideal fluid management parameters or goals in cesarean delivery have not been established. Expert consensus suggests limiting intravenous fluids to <3 L for routine cases. Avoidance of excessive volumes is important given the ubiquitous coadministration of oxytocin for active management of the third stage of labor, which increases postoperative intravascular fluid shifts and the risk of hyponatremia.[66,88] Early recognition and preparedness for PPH, a commonly preventable cause of serious maternal morbidity,[11] is of critical importance. In the setting of PPH, fluid and blood administration as part of hemorrhage protocols supersede ERAC fluid guidelines. Data supporting the recommendations for intraoperative fluid management were derived from nonobstetric surgical populations (Table 2).

Delayed Cord Clamping (Class I, Level A, High-grade Level of Evidence)

Delayed umbilical cord clamping improves neonatal hemoglobin levels at birth and improves iron stores in term infants, which may have neurodevelopmental benefits.[89] Preterm infants benefit from delayed cord clamping by improved circulation, greater red cell volume, reduced transfusion risk, and decreased risk for necrotizing enterocolitis and cerebral hemorrhage. There may be a small increased risk for neonatal jaundice associated with this technique, and therefore systems should be set up for monitoring and treating jaundice in these infants. Delayed cord clamping does not significantly increase perioperative blood loss or the incidence of maternal postoperative anemia.[28] ACOG currently recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30–60 seconds after birth.[89] Patient-physician judgments should determine whether delayed cord clamping is performed in setting of PPH or high-risk deliveries.

In summary, intraoperative ERAC element recommendations include (1) prevention of spinal-induced hypotension, (2) maintenance of normothermia, (3) optimization of uterotonic administration, (4) antibiotic prophylaxis, (5) IONV and PONV prophylaxis, (6) multimodal analgesia initiation, (7) promotion of breastfeeding and maternal-infant bonding, (8) intravenous fluid optimization, and (9) delayed cord clamping.