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


Considerations for enhanced recovery pathways for cesarean deliveries differ significantly from those proposed after other surgical procedures, in that unique and essential elements for both maternal and fetal/neonatal care goals, standards and outcomes are necessary. Importantly, ensuring women's ability to care for their newborn is crucial, which requires optimization of pain management and achievement of specific milestones by the time of hospital discharge. The overarching goal is to improve maternal outcomes without compromising measures of patient safety including maternal readmission and complication rates. While it is desirable to reduce postpartum depression, improve neonatal safety, reduce chronic pain, and decrease maternal morbidity (eg, surgical site infection, acute kidney injury, and wound dehiscence), future research needs to evaluate ERAC effects on these rarer outcomes.

Implementation of ERAC pathways for obstetric patients requires highly functional relationships between hospital systems and local cultural factors to support each element. ERAC pathways improve maternal and infant outcomes, enhance the patient experience, and support a local culture of growth orientation and commitment to continuous improvement and high quality of clinical care. Inherent to enhanced recovery pathways is ongoing interdisciplinary quality improvement and auditing of processes and outcomes to continuously adapt and improve individual ERAC protocols.

Due to relatively limited, high-quality evidence supporting enhanced recovery elements specific to obstetric populations, several recommendations presented here are based on low or very low-quality evidence or expert consensus. Strongest evidence (level 1 A) exists for intraoperative and postoperative recommendations, such as avoidance of spinal-induced hypotension to prevent IONV, implementation of multimodal analgesia and delayed cord clamping. Postoperative recommendations with strong evidence (level 1 A) are early mobilization, glycemic control, and use of multimodal analgesia.

There is minimal evidence of specific effects of individual elements of ERAC protocols; however, recommended elements proposed here have been evaluated together in different bundles and resulted in improved maternal and neonatal outcomes.[123]

A limitation of this consensus statement is that no obstetricians or nurses were invited to participate, yet several recommendations primarily apply to obstetric providers and nurses. However, as perioperative specialists, it is the responsibility of obstetric anesthesiologists to promote and facilitate these important elements of an enhanced recovery program to all, rather than on a case-by-case basis, and ensure they are built into ERAC pathways. There is no international consensus regarding which specific outcomes should be monitored in perioperative enhanced recovery pathway studies. Future research should therefore focus on providing high-quality data clarifying which pathway elements, or combinations thereof, best enhance recovery. More study is required to facilitate consensus among the various ERAC protocols that are utilized while considering the impact of local practices. Other areas of knowledge gaps include how to best initiate, support, and maintain ERAC system changes, and how to optimally involve and motivate patients to be part of and comply with enhanced recovery care pathways.