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

Disclosures

Anesth Analg. 2021;132(5):1362-1377.

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.

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Table 1. Preoperative ERAC Pathway Elements
Recommendation	Action	Comments	Strength of recommendation	Level of evidence
(1) Limit fasting interval	• Solids up to 8 h before cesarean delivery • Clear fluids up to 2 h before cesarean delivery	Reduces aspiration risk while limiting hypovolemia, metabolic stress, and ketosis. • Data extrapolated from colorectal ERAS programs ASA guidelines state 6–8 h based on the type of food ingested: • A light meal or milk may be ingested for up to 6 h before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia • Additional fasting time (8 or more hours) may be needed in cases of patient intake of fried foods, fatty foods, or meat	Class IIb	Level C-EO
(2) Nonparticulate liquid carbohydrate loading	• Nonparticulate carbohydrate drink up to 2 h before cesarean delivery (nondiabetic women only) • 45 g carbohydrate is recommended • Examples: Gatorade 32 oz (54 g carbohydrate) clear apple juice 16 oz (56 g carbohydrate)	• Reduces maternal hypoglycemia and metabolic stress • The benefit of complex carbohydrate (eg, maltodextrin) drinks for cesarean delivery is currently undefined, and fetal effects unknown • Can omit if mother is diabetic; follow institutional protocols for maternal diabetes/neonatal monitoring • Most data are extrapolated from colorectal ERAS programs • More data in cesarean population is needed specifically with respect to ideal type of carbohydrate, dose, and fetal-neonatal effects	Class IIb	Level C-EO
(3) Patient education	• Minimum: Handout or other standardized educational tool or interaction that includes precesarean delivery instructions, what to expect during cesarean delivery, and enhanced recovery information, provided at least 1 d before surgery • Example: SOAP videos available on https://soap.org/education/information-for-mothers/videos/ • Ideal: Direct contact with patients with phone call/reminder or meeting before cesarean, to remind patient of ERAC goals	• The goal of ERAC patient education is to set expectations, and to engage/empower the patient to participate more completely in their care plan and recovery • Ideally, patient education takes place before the day of surgery • Preoperative discussion should include ERAC goals in addition to the routine preoperative evaluation • Patient education in general improves patient compliance with care pathways and improves outcomes in certain clinical settings; reduces patient anxiety and postoperative pain; supports patient empowerment	Class IIb	Level C-NR
(4) Lactation/breastfeeding preparation and education	• Minimum: Handout or other standardized tool or interaction that includes information on normal breastfeeding physiology, management of common lactation complications, and resources for breastfeeding support after discharge • Ideal: Structured prenatal classes with books, videos, and in-person lactation support in the hospital; referrals to breastfeeding support groups and/or lactation consultant after discharge	• Early breastfeeding improves newborn and maternal outcomes, including promoting emotional attachment, reducing infant infectious complications, and decreasing the risk for sudden infant death syndrome • Breastfeeding is a public health priority because it is protective for downstream adverse health outcomes such as breast cancer and hypertension • Every woman should be supported in her informed decision on infant feeding	Class IIa	Level B-R
(5) Hemoglobin optimization	All pregnant women should be screened for anemia per ACOG guidelines²¹ • Women with iron-deficiency anemia should be treated with supplemental orally, per os (or if refractory anemia with IV) iron in addition to prenatal vitamins • Anemia other than iron-deficiency should be further evaluated	• Goal: Work with obstetric provider team during prenatal visits, to engage patient in understanding the importance of hemoglobin optimization; treat prenatal anemia appropriately • Antepartum anemia is a significant predictor of postpartum anemia, which is linked to depression and fatigue • Iron-deficiency anemia in pregnancy is linked to increased risk for low birth weight, preterm delivery, and perinatal mortality	Class IIa	Level B-R

The included 5 preoperative elements aim to reduce fasting periods, engage patients and providers in the care plan, and promote physical health optimization. The 2016 ACC and AHA Clinical Practice Guideline Recommendation Classification Systems were used to evaluate each of the elements, based on the best available evidence.²⁶
Abbreviations: ACC, American College of Cardiology; ACOG, American College of Obstetricians and Gynecologists; AHA, American Heart Association; ASA, American Society of Anesthesiologists; ERAC, Enhanced Recovery After Cesarean Delivery; ERAS, Enhanced Recovery After Surgery; IV, intravenous; SOAP, Society for Obstetric Anesthesia and Perinatology.

Table 2. Intraoperative ERAC Pathway Elements
Recommendation	Action	Comments	Strength of recommendation	Level of evidence
(1) Prevent spinal anesthesia–induced hypotension	• Maintain blood pressure at baseline • Optimally managed with prophylactic vasopressor infusion, for example, phenylephrine (or norepinephrine) infusion	• Spinal anesthesia–associated hypotension is primarily an afterload-driven problem • Goal is to prevent intraoperative nausea/vomiting after spinal anesthesia and maintain uteroplacental perfusion • Vasopressor regimen may need to be modified in women with preeclampsia as the degree of hypotension with spinal anesthesia may be less than that in nonpreeclamptics • Data are well supported in literature from the obstetric population	Class I	Level A
(2) Maintain normothermia	• Active warming: Example: • In-line IV fluid warmer • Forced air warming • Keep the OR temperature ideally >72°F or 23.0°C (Joint Commission guidance)	• Consider active warming starting preoperatively	Class I	Level C
(3) Optimal uterotonic administration	• Use lowest effective dose of uterotonic necessary to achieve adequate uterine tone and minimize side effects Example: -Elective cesarean delivery: Bolus 1 IU oxytocin; start oxytocin infusion at 2.5–7.5 IU·h⁻¹ (0.04–0.125 IU·min⁻¹) -Intrapartum cesarean delivery: 3 IU oxytocin over ≥30 s; start oxytocin infusion at 7.5–15 IU·h⁻¹ (0.125–0.25 IU·min⁻¹)²⁷	• In the case of hemorrhage caused by uterine atony, transition from ERAC to institutional hemorrhage resuscitation protocol	Class II	Level A
(4) Antibiotic prophylaxis	• Antibiotic prophylaxis dosed before skin incision (do not wait until after cord clamping)	Follow ACOG guidelines²⁴	Class I	Level A
(5) IONV/PONV prophylaxis	• Prophylactic vasopressor infusion (see above) to decrease hypotension-associated IONV • Address uterine exteriorization and abdominal saline irrigation with surgeon • Combination of at least 2 prophylactic IV antiemetics with different mechanisms of action. Examples: • 5HT₃ antagonist (eg, ondansetron 4 mg) • Glucocorticoid (eg, dexamethasone 4 mg) • D2 receptors antagonist (eg, metoclopramide 10 mg)	• IONV/PONV is a major stressor for the mother and should be avoided, bearing in mind the different etiologies • Limiting/avoiding uterine exteriorization which is associated with IONV and delayed bowel function recovery • Abdominal saline irrigation may worsen IONV and PONV • Dexamethasone is effective for PONV and not IONV due to delayed onset of action • Metoclopramide is effective for IONV but not PONV	Class I IONV/PONV prophylaxis Class IIa uterine exteriorization	Level B Level C-LD
(6) Initiate multimodal analgesia	Neuraxial long-acting opioid Example: • IT morphine 50–150 μg or • Epidural morphine 1–3 mg Nonopioid analgesia started in OR unless contraindicated: 1. Ketorolac 15–30 mg IV after peritoneum closed 2. APAP IV after delivery or orally, per os before or after delivery Consider local anesthetic wound infiltration or regional blocks such as TAP or QLB if neuraxial morphine is not administered	• Use neuraxial doses consistent with SOAP Center of Excellence criteria Link: https://soap.org/grants/center-of-excellence/ • Nonopioid analgesia is ideally started before the onset of pain • Rectal APAP may be an alternative but has lower bioavailability • The role of wound infiltration and other regional blocks for postcesarean pain should be considered in select cases, for example, in women who could not receive neuraxial morphine, or other multimodal analgesia regimen components, or patients at risk for severe pain	Class I Data to support preemptive analgesia in caesarean delivery are limited	Level A
(7) Promote breastfeeding and maternal-linfant bonding	• Skin-to-skin contact should occur as soon as possible in the operating room as appropriate based on maternal/neonatal condition	• Skin-to-skin contact intraoperatively supports the "golden hour" of breastfeeding initiation within 1 h of birth • Supports a safe transition of the infant from intrauterine life to extrauterine life • Facilitates mother-infant bonding • May require additional nurse support intraoperatively (follow hospital guideline for safe positioning for the newborn during skin-to-skin contact) • Ideally the responsibility of a nonanesthesia care team member • Ways to facilitate skin-to-skin contact intraoperatively include moving electrocardiogram leads and electrodes to the patients back to clear space on the chest; moving equipment to allow nursing personnel space to safely accomplish skin-to-skin contact; maintain efforts to keep maternal/neonatal temperature (eg, forced air warmer, warmed blankets)	Class IIa	Level C
(8) Intravenous fluid optimization	• Limit intravenous fluids to <3 L for routine cases	• In the case of hemorrhage, transition from ERAC to institutional hemorrhage resuscitation protocol • Spinal anesthesia–associated hypotension in cesarean delivery should be primarily managed with vasopressors, instead of fluids • Ideal intravenous fluid parameters/goals in cesarean delivery are not well established	Class IIa	Level C
(9) Delayed umbilical cord clamping	ACOG recommends delay in umbilical cord clamping in vigorous term and preterm infants for at least 30–60 s after birth²⁸	• Benefits: Term: improved iron stores, developmental benefits; preterm: improved transitional circulation, reduced need for transfusion, lower risk of necrotizing enterocolitis and intraventricular hemorrhage • Does not increase maternal risk for blood loss or transfusion • The ability to provide delayed cord clamping may vary among institutions and settings Delayed cord clamping should be deferred in certain situations (eg, maternal instability, fetal/neonatal need for immediate resuscitation)²⁸	Class I	Level A

The included 9 intraoperative elements aim to prevent spinal anesthesia–induced hypotension and IONV, initiate multimodal analgesia, support breastfeeding and maternal-infant bonding, and optimize fluid management and fetal outcomes. The 2016 ACC and AHA Clinical Practice Guideline Recommendation Classification Systems were used to evaluate each of the elements, based on the best available evidence.²⁶
Abbreviations: 5HT3, 5 hydroxytryptamine receptor; ACC, American College of Cardiology; ACOG, American College of Obstetricians and Gynecologists; AHA, American Heart Association; APAP, acetaminophen; D2, dopamine receptor; ERAC, Enhanced Recovery After Cesarean Delivery; IONV, intraoperative nausea and vomiting; IT, intrathecal; IV, intravenous; OR, operation room; PONV, postoperative nausea and vomiting; QLB, quadratus lumborum block; SOAP, Society for Obstetric Anesthesia and Perinatology; TAP, transversus abdominis plane block.

Table 3. Postoperative ERAC Pathway Elements
Recommendation	Action	Comments	Strength of Recommendation	Level of Evidence
(1) Early oral intake	• Ice chips and/or water within 60 min postcesarean admission to PACU • Heparin/saline lock the IV early once oxytocin infusion complete, tolerating fluids, and urine output adequate • Advance to regular diet ideally within 4 h postcesarean, as tolerated	Early oral intake leads to: • Accelerated return of bowel function • Reduced hospital length of stay • No increased rates of complication • No increased risk of postoperative nausea or vomiting • Reduced postoperative catabolism • Improved insulin sensitivity • Reduced surgical stress response	Class IIb For caesarean delivery	Level C-EO
(2) Early mobilization	• Ambulate only after adequate return of motor function Examples: 0–8 h postoperatively: • Sit on edge of bed • Out of bed to chair • Ambulation as tolerated 8–24 h postoperatively: • Ambulation as tolerated • Walk: 1–2 times (or more) in hall 24–48 h postoperatively: • Walk: 3–4 times (or more) in hall • Out of bed for 8 h	Early mobilization decreases: • Insulin resistance • Muscle atrophy • Hypoxia • Venous thromboembolism • Length of stay Remove barriers to early mobilization: • IV poles • Urinary catheters • Poor pain control • Sedation • PONV • Dizziness • Slow block regression	Class I	Level B-NR
(3) Promotion of resting periods	• Optimize sleep and rest • Encourage clustered interventions (eg, vital signs assessments in coordination with analgesic administration; timing of oral analgesics contemporaneously) Appropriate use of postoperative monitoring (see SOAP neuraxial morphine monitoring consensus statement²⁹)	• Fatigue potentially impacts cognitive function, depression, pain, maternal-infant bonding, and risk of respiratory depression	Class IIb	Level C-EO
(4) Early urinary catheter removal	• Urinary catheter removed by 6–12 h postpartum • Construct protocols to establish criteria for appropriate removal and to manage postcatheter removal urinary retention	Benefits include: • Improved ambulation • Reduced length of stay • Lower rates of symptomatic UTI Earlier catheter removal may be associated with higher rates of urinary retention and need for recatheterization Dose of neuraxial local anesthetic and opioid can impact catheter removal time	Class IIb	Level C-EO
(5) Venous thromboembolism prophylaxis	Follow institutional practices as per ACOG and ACCP guidelines^30–33	• Cesarean delivery approximately doubles the risk of venous thromboembolism compared to vaginal delivery, but in otherwise healthy patients the absolute risk is low • ACOG recommends mechanical thromboembolism prophylaxis for all women not already receiving pharmacologic thromboprophylaxis³³	Class I	Level A
(6) Facilitate early discharge	• Standardize discharge planning and coordinate care starting preoperatively • Establish patient-oriented goals early • Personalize/patient-centered opioid prescribing at discharge • Use metrics to monitor patient progress in meeting early discharge criteria	• Discharge planning on POD 1 should ideally include pediatric, lactation, and contraceptive planning	Class IIb	Level C-EO
(7) Anemia remediation	• Screen and treat anemia	• Hb check on POD 1 or 2 should be considered in patients with severe intraoperative bleeding	Class I	Level A
(8) Breastfeeding support	• Robust lactation support per institutional guideline	• Should start immediately after birth by offering skin-to-skin care and continued throughout hospitalization • Support of the "golden hour" to help women initiate breastfeeding within 1 h of birth • Initial skin-to-skin contact should continue uninterrupted until the completion of the first breastfeeding • In the case of formula fed infants, initial skin-to-skin contact should continue as uninterrupted as possible for at least 1 h • After the initial period of skin-to-skin contact, mothers should be encouraged to continue this type of care as much as possible during the hospital stay • Provide lactation consulting and educational material (10 steps to successful breastfeeding as documented in the Joint Statement by UNICEF and WHO: Baby Friendly Hospital Initiative³⁴)	Class I	Level A
(9) Multimodal analgesia	Multimodal analgesia protocols include: • Low-dose long-acting neuraxial opioid such as morphine (see above) • Scheduled NSAID • Scheduled APAP • Local anesthetic techniques as indicated Example: • APAP 650–1000 mg orally, per os q6h scheduled • Ibuprofen 600 mg orally, per os q6h scheduled after IV ketorolac 15–30 mg that is given after delivery in OR, or naproxen 500 mg orally, per os twice a day or other NSAID • Oxycodone 2.5–5 mg orally, per os q4h PRN pain • Preemptive or rescue supplemental regional blocks as indicated	Multimodal analgesia should be used to: • Reduce pain • Improve mobilization • Limit IV opioids in PACU • Limit opioids in hospital • Limit opioids at discharge Opioids are associated with nausea/vomiting, sedation, fatigue, ileus, constipation, misuse/addiction risk • Multimodal analgesia (including NSAID + APAP) decrease opioid use/side effects by 30% • See SOAP Center of Excellence criteria Link: https://soap.org/grants/center-of-excellence/ • Expectation management²⁵ • Truncal blocks (TAP, QLB) or continuous wound infiltration available when neuraxial morphine cannot be given, or as a rescue technique when severe breakthrough pain despite the use of neuraxial morphine • TAP blocks does not provide significant improvement when given in addition to neuraxial morphine and scheduled NSAID/APAP • Gabapentinoids have not been shown to have significant benefit in routine cesarean; may be appropriate in select patients; use caution in patients on methadone or other QTc prolonging medications	Class I	Level B-NR
(10) Glycemic control	• Patient with diabetes ideally first case of day • Maintain normoglycemia (<180–200 mg/dL); check maternal/neonatal glucose per hospital protocol	• Hyperglycemia (>180–200 mg/dL) is associated with poor outcomes including infection and delayed wound healing • Data based on nonobstetric population	Class I	Level A
(11) Promotion of return of bowel function	• Minimization of opioid consumption • Consider chewing gum • Remove barriers to recovery • Encourage mobilization	• Availability of multiple PRN bowel medications, eg, Docusate (Colace, Purdue Pharma LP, Stamford, CT), Polyethylene glycol 3350 (Miralax, Bayer HealthCare LLC, Tarrytown, NY), Simethicone (Gas Relief, Equate TM, Perrigo Company PLC, Allegan, MI)	Class IIb	Level C-EO

The included 11 postoperative elements aim to minimize postcesarean metabolic stress by early feeding, promote early mobilization, remove physical early mobilization barriers, facilitate hospital discharge, control glycemic levels, promote early return of bowel function and utilize multimodal analgesia. The 2016 ACC and AHA Clinical Practice Guideline Recommendation Classification Systems were used to evaluate each of the elements, based on the best available evidence.²⁶
Abbreviations: ACC, American College of Cardiology; ACCP, American College of Clinical Pharmacy; ACOG, American College of Obstetricians and Gynecologists; AHA, American Heart Association; ERAC, Enhanced Recovery After Cesarean Delivery; Hb, hemoglobin; IV, intravenous; POD, postoperative day; PONV, postoperative nausea and vomiting; SOAP, Society for Obstetric Anesthesia and Perinatology; UNICEF, United Nations International Children's Emergency Fund; UTI, urinary tract infection; WHO, World Health Organization.

Authors and Disclosures

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** and Brendan Carvalho, MBBCh, FRCA, MDCH‡

*Department of Anesthesiology & Pain Medicine, University of Washington School of Medicine, Seattle, Washington; †Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania; ‡Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, California; §Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina; ||Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York; ¶Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California; #Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia; and **Department of Anesthesiology, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania.

Address correspondence to
Laurent Bollag, MD, Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA 98195. Address e-mail to bollag@uw.edu.

The authors declare no conflicts of interest.

Disclosures
Name: Laurent Bollag, MD.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Grace Lim, MD, MS.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Pervez Sultan, MBChB, FRCA, MD (Res).
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Ashraf S. Habib, MBBCh, MSc, FRCA.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Ruth Landau, MD.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Mark Zakowski, MD.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Mohamed Tiouririne, MD.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Sumita Bhambhani, MD.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: Brendan Carvalho, MBBCh, FRCA, MDCH.
Contribution: This author helped write the manuscript and approve the final manuscript.
This manuscript was handled by: Jill M. Mhyre, MD.