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. 

In This Article

Postoperative ERAC Recommendations

A total of 11 postoperative ERAC elements were identified (Table 3): (1) early oral intake, (2) early mobilization, (3) resting periods promotion, (4) early urinary catheter removal, (5) venous thromboembolism (VTE) prophylaxis, (6) early discharge facilitation, (7) anemia remediation, (8) breastfeeding support, (9) multimodal analgesia, (10) glycemic control, and (11) return of bowel function promotion.

Early Oral Intake (Class IIb, Level C-EO, Low-grade Level of Evidence)

The goals of early oral intake are to accelerate return of bowel function and reduce postoperative catabolism. Early oral intake improves insulin sensitivity and mitigates the surgical stress response.[37,90–95] Early oral intake is not associated with increased rates of gastrointestinal complications or risk for PONV in the nonobstetric and obstetric population. A meta-analysis, including 11 studies found that early oral intake after cesarean delivery enhances the return of bowel function and does not increase the risk of postoperative complications.[90,92]

Early Mobilization (Class I, Level B-NR, Moderate-grade Level of Evidence)

Early mobilization reduces insulin resistance, venous thromboembolic risk, and hospital length of stay.[96–99] Table 3 provides examples of time-based goals for ambulation postcesarean delivery.[100] For example, getting out of bed to a chair or ambulating within 8 hours as tolerated is a recommended goal. Barriers to early mobilization such as intravenous poles, urinary catheters, and poor pain control should be removed. Data supporting these recommendations were derived from nonobstetric populations (Table 3).

Resting Periods (Class IIb, Level C-EO, Low-grade Level of Evidence)

Minimizing interruptions from visitors and health care providers encourage maternal resting periods. Maternal fatigue may negatively impact cognitive function, depression, mood, maternal-infant bonding, and increase the risk of respiratory depression.[101] Practices that support these goals include clustering interventions such as assessment of vital signs, scheduled analgesic administration, and patient-appropriate postoperative monitoring. The 2019 SOAP respiratory monitoring consensus statement outlines patient-centered monitoring options in more detail.[29]

Early Urinary Catheter Removal (Class IIb, Level C-EO, Low-grade Level of Evidence)

Early urinary catheter removal is important to support early mobilization goals. Other benefits include facilitating ambulation, shortening length of hospital stay, and lowering rates of symptomatic urinary tract infections.[102–105] Neuraxial local anesthetic dose and particularly long-acting neuraxial opioids can increase the duration of detrusor muscle dysfunction and delay catheter removal times.[103] Early urinary catheter removal must be balanced against increased risk of recatheterization. Data supporting these recommendations were derived from nonobstetric surgical populations (Table 3).

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

Modern VTE prophylaxis goals in cesarean delivery[96,106] include mechanical thromboprophylaxis for all women not already receiving pharmacologic thromboprophylaxis with low-molecular-weight heparin or unfractionated heparin (ACOG and American College of Chest Physicians, ACCP guidelines) unless contraindicated.[30–33,96,106]

Early Discharge (Class IIb, Level C-EO, Low-grade Level of Evidence)

Facilitating early discharge ideally starts with establishing patient-oriented goals preoperatively, and encompasses elements such as neonatal care planning, lactation education, and contraception planning. Patient and support person education strategies in addition to patient self-empowerment for active participation in their health care are emphasized.[107]

Anemia Remediation (Class I, Level A, High-grade Level of Evidence)

Anemia remediation includes early recognition and treatment of peripartum hemorrhage and management of postpartum anemia. Routinely checking postpartum laboratory tests in low-risk cohorts is not necessary, and routine hemoglobin checks on postoperative day 1 or 2 should be reserved for patients with significant (eg, >1 L) intraoperative bleeding or preexisting anemia.[21,53–57] Although oral or intravenous formulations are acceptable for treatment of iron-deficiency anemia, 1 meta-analysis suggests intravenous formulations may offer increased efficacy (higher hemoglobin levels at 6 weeks postpartum) compared to oral administration, without increased risk of side effects.[57] Recent reports describe the association between postpartum iron-deficiency anemia and postpartum anxiety and depression, emphasizing the importance of anemia remediation in preventing postpartum morbidity.[108–110] Of note, there is no evidence that liberal transfusion policies improves maternal outcomes and transfusion reactions are more common in pregnant and postpartum women compared to their nonpregnant peers.[111]

Breastfeeding Support (Class I, Level A, High-grade Level of Evidence)

Lactation education and counseling should continue throughout the hospital stay in accordance with the Joint Statement by United Nations International Children's Emergency Fund (UNICEF) and WHO.[34]

Multimodal Analgesia (Class I, Level B-NR, Moderate-grade Level of Evidence)

Multimodal analgesia in the postpartum period facilitates a reduction of pain, improves mobility, limits intravenous opioid requirement, and reduces in-hospital and discharge opioid use.[112–115] These goals are accomplished by low-dose long-acting neuraxial opioids such as morphine (see "Intraoperative" section), scheduled nonsteroidal anti-inflammatory drugs, and scheduled acetaminophen.[85,86,116–119] Local anesthetic techniques, including wound infiltration, transversus abdominis plane (TAP), and quadratus lumborum blocks (QLB) should also be leveraged when indicated (Table 2).

Glycemic Control (Class I, Level A, High-grade Level of Evidence)

Avoidance of hyperglycemia (>180–200 mg/dL) is desirable because perioperative hyperglycemia increases risk of surgical site infection and delayed wound healing.[120–122] Strategies to maintain normoglycemia include scheduling patients with insulin-dependent diabetes early in the day and checking maternal-neonatal glucose parameters per institutional protocol. These recommendations were derived from nonobstetric populations (Table 3).

Return of Bowel Function (Class IIb, Level C-EO, Low-grade Level of Evidence)

Promoting return of bowel function emphasizes the use of multiple pro re nata bowel medications such as docusate and simethicone, minimizing opioid use, providing adequate hydration and encouraging mobilization.[37,90] These recommendations were derived from nonobstetric populations (Table 3).

In summary, postoperative ERAC element recommendations include promotion of (1) early oral intake, (2) early mobilization, (3) resting periods, (4) early urinary catheter removal, (5) VTE prophylaxis, (6) facilitation of early discharge, (7) anemia remediation, (8) breastfeeding support, (9) multimodal analgesia, (10) glycemic control, and (11) early return of bowel function.

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