Enhanced Recovery After Surgery (ERAS)

Cesarean section
Prepared By

Mohammed Salem
ERAS
This Enhanced Recovery After Surgery (ERAS) Guideline for
perioperative care in cesarean delivery will provide best practice,
evidenced-based, recommendations for preoperative, intraoperative,
and postoperative phases with, primarily, a maternal focus

The focused pathway process for scheduled and unscheduled cesarean

delivery for this ERAS Cesarean Delivery Guideline will consider from
the time from decision to operate (starting with the 30-60 minutes
.before skin incision) to hospital discharge
ERAS Purpose
quality improvement is the science of process management; if you
cannot measure it, you cannot improve it; managed care means
managing the processes of care (not the human resources of care);
getting the right data in the right format at the right time in the right
hands; and engaging the human healthcare resources (physicians,
nurses, and other allied health professionals)
Antenatal preadmission information, education, and counselling
-Pre operative pathway 1
Intra operative pathway -2
Post operatove pathway -3
:List of ERAS cesarean delivery elements
Preoperative
Anesthetic medications -1
Fasting -2
Carbohydrate supplementation -3
Antimicrobial prophylaxis -4
Skin wash/vaginal preparation to minimize infectious risk -5
Procedures for prevention of intraoperative hypothermia -6
:List of ERAS cesarean delivery elements

Intraoperative
Pre and intraoperative anesthetic management -1
Abdominal/vaginal antimicrobial cleansing -2
Cesarean delivery surgical techniques (opening-delivery-closure) -3
Perioperative fluid management -4
Neonatal immediate care/delayed cord clamping -5
:List of ERAS cesarean delivery elements

Postoperative
ERAS sham feeding/chewing gum -1
Nausea and vomiting management -2
Analgesia -3
Perioperative nutritional care/early feeding -4
Glucose control -5
Thromboembolism prevention -6
Early mobilization -7
Urinary drainage management -8
Preoperative anesthetic medications
Aspiration pneumonitis is still a cause of maternal death during anesthesia for CS delivery, even in well – -
.resourced countries
Although the quality of evidence was poor, it was found that the pre operative administration of a combination -
of antacids and histamine H2 receptor antagonists was more effective than no intervention and was superior to
antacids alone in the prevention of low gastric PH

The pre operative administration of gabapentin has been found to improve post CS delivery pain but with -
increased incidence of serious adverse events

IT has been suggested that maternal sedation may delay skin to skin contact between mother and baby -

administration of benzodiazepines in pregnancy have been associated with -

floppy baby syndrome ," disturbed neonatal thermogenesis, and lower“
.Apgar scores
Preoperative anesthetic medications
Antacids and histamine H2 receptor antagonists should be
administered as pre – medication to reduce the risk from aspiration
pneumonitis
( Evidence level : Low. Recommendation Grade : strong )

Preoperative sedation should not be used for scheduled CS because of

the potential for detrimental effects on the mother and neonate
( Evidence Level: LOW Recommendation Grade : Strong )
Bowel preparation

Preoperative oral and/or mechanical bowel preparation has been used

primarily in colorectal surgery to prevent postoperative infection and
.anastomotic Leak

before There is only small clinical trial on mechanical bowel preparation

CS delivery that did not document any benefits small clinical trial of
Bowel preparation
Oral or mechanical bowel preparation should not be used before
cesarean delivery

( Evidence Level : High. Recommendation Grade : Strong )

Preoperative fasting
Preoperative fasting was first described as a measure to prevent vomiting
.after the use of anesthesia

After a syndrome of post operative aspiration pneumonia was described, it

hours became more common to recommend fasting periods increased from 6
“ to the standard “ NPO after midnight
The European Society of Anesthesiology Guidelines recommended that adult
and children should be encouraged to drink clear fluids up to 2 hours before
elective surgery. Solid food should be prohibited for 6 hours before elective
.surgery

There have been no fasting trials in CS delivery patients

Preoperative fasting
Women Should be encouraged to drink clear fluids until 2 hours before
.surgery
( Evidence Level High. Recommendation Grade : Strong )

A light meal may be eaten up to 6 hours before surgery

( Evidence Level : High. Recommendation Grade : Strong )
Preoperative carbohydrate supplementation

.There have been multiple trials of oral carbohydrate supplement use up to 2 hours before surgery
Most trials had
.High risk of bias -1
The treatment was associated with only a small reduction in the length of stay ( 0.3 day ) -2
Decreased time of passage of flatus ( 0.39 day ) -3
.Post operative complications were not changed -4

Pre operative carbohydrate loading was found to be non inferior to fasting and neither group showed
.superiority for pre operative blood glucose concentration, hyperglycemia or length of stay

There are no trials of oral carbohydrates supplements before CS delivery either diabetic or non
diabetic women
Preoperative carbohydrate supplementation
Oral carbohydrate fluid supplements 2 hours before CS delivery may be
offered to non diabetic pregnant women

( Evidence Level: Low. Recommendation Grade : Strong )

Preoperative antimicrobial prophylaxis and
skin preparation
A cesarean delivery performed before rupture of the membranes and
without chorioamnionitis usually will be considered a clean (class I)
incision
a cesarean delivery in the setting of ruptured membranes, particularly
in active phase of labor or second stage of labor or with
chorioamnionitis
usually is classified as a clean contaminated (class II) incision
Preoperative antimicrobial prophylaxis
and skin preparation
the class I incisions will be predominantly at-risk from abdominal skin
flora, the class II or class III incisions both carry the risk of skin flora plus
the risk of exposure from vaginal flora
it is now recommended to give The antibiotics 30 – 60 minutes before
.CS delivery
the addition of azithromycin to the routine cephalosporins further
% reduced infectious complications from 6.1 % to 12
Preoperative antimicrobial prophylaxis and skin
preparation
There are special concerns for obese women because of their increased risk of
wound complications and the potential of higher blood volume for the antibiotic
.distribution

?? Increase dose of antibiotic from 1-2 gm to 3 gram

s, there were no differences in infectious morbidity between 2-g and 3-g dosing of
.cephazolin
.further evidence must be collected
In a recent prospective, randomized trial, the risk of surgical site infection was
reduced from 15.4 to 6.4% from the use of cephalosporin and metronidazole versus
.placebo after cesarean delivery

.further study
Intraoperative cesarean delivery pathway

Intravenous antibiotics should be administered routinely within 60 minutes before CS delivery. In all
women in labor or with ruptured membranes, The addition of azithromycin confers additional
reduction in post operative infections
(Evidence Level: High. Recommendation Grade : Strong )

Chlorhexidine-alcohol is preferred to aqueous povidone-iodine solution for abdominal skin cleansing

before cesarean delivery
(Evidence Level: LOW. Recommendation Grade : Strong )

infections Vaginal preparation with povidone iodine solution should be considered for the reduction of
after cesarean delivery
(Evidence Level: Moderate. Recommendation Grade : Weak )
Intraoperative cesarean delivery pathway

Regional Anesthesia has been found to have a positive impact for

enhanced recovery outcomes in terms of pain control, organ function,
mobility, postoperative nausea and vomiting, number of days spent in
.hospital and adverse events

However, a metanalysis of mode of anesthesia for CS delivery, other

than higher blood loss with General anesthesia, there was no evidence
that regional anesthesia was superior to general one in terms of major
maternal or neonatal outcomes
Pre- and intraoperative anesthetic
management
Regional anesthesia is the preferred method of anesthesia for
caesarean delivery as part of an enhanced recovery protocol
( Evidence Level : Low. Recommendation Grade : Strong )
Cesarean delivery surgical techniques
considerations
Blunt expansion of a transverse uterine hysterotomy at time of cesarean delivery is recommended to
.reduce surgical blood loss
(Evidence Level: Moderate. Recommendation Grade : Weak )

.Closure of the hysterotmy in two layers may be associated with a lower rate of uterine rupture
(Evidence Level: Low. Recommendation Grade: Weak )

The peritoneum does not need to be closed because closure is not associated with improved
outcomes and increases operative times
.(evidence level: low / recommendation grade: weak)

.Reapproximation of subcutaneous tissue should be performed in women with more than 2 cm

(Evidenve Level: Moderate. Recommendation Grade: Weak )
Perioperative fluid management

Perioperative euvolemia is an important factor to obtain optimal -

outcomes after cesarean delivery
Maintaining adequate uterine perfusion cannot only optimize fetal -
oxygenation and prevent acidosis but also deliver nutrients and
.eliminate waste products from the uterine myometrium
Perioperative fluid overload has higher risks of increased -
.cardiovascular work and pulmonary edema in pregnant Women
Perioperative fluid management

The incidence of hypotension is high after spinal anesthesia and can cause severe effects on
the mother and fetus

Perioperative fluid management is always a controversial topic in anesthesia practice -

the intravenous fluids alone have limited efficacy and that many clinicians now administer -
prophylactic phenylephrine infusions, which not only prevent hypertension but also reduce
.the risk of fetal acidosis

Metanalysis and systematic review indicated that goal-directed fluid therapy significantly -
reduced the incidence of surgical site infections and length of hospital stay after abdominal
surgery However, the number of high-quality research trials that have evaluated the effects
of goal directed fluid therapy during cesarean delivery is too few to provide consistent
.evidence of benefit
Perioperative fluid management

Preoperative and intraoperative euvolemia are important factors in

patient perioperative care and appear to lead to improved maternal
and neonatal outcomes after cesarean delivery
.(evidence level: low to moderate/recommendation grade: strong)
Immediate care of the newborn infant
Delayed cord clamping for at least 1 minutes in full term delivery is recommended
( Evidence Level : Moderate. Recommendation Grade : Strong )

Delayed cord clamping for at least 30 seconds in pre term delivery is recommended
( Evidence Level : Moderate. Recommendation Grade : Strong )

Routine suctioning of the airway or gastric aspiration should be avoided and used
;only for symptoms of an obstructive airway by secretions or meconium
(Evidence Level: Low, Recommendation Grade: Strong )
Sham feeding ( chewing gum ) after CS
.In a separate review of gum chewing after CS , 15 clinical trials were identified
The regimens for gum chewing varied widely in studies
initiation from immediately after the operation to up to 12 hours after the operation

duration of each session of 15-60 minutes

.number of sessions per day from 3 to >6

In 10 of these studies, the comparator group was traditional delayed feeding until return of intestinal function
.(bowel sounds or flatus)

.In 2 studies, the comparator group had an early feeding policy

Sham feeding ( chewing gum ) after CS
With gum chewing (using a variety of gum types and duration of
chewing), there was a
hour improvement in time to flatus compared with those who did -7
.not chew gum
Only 4 studies reported postoperative ileus that was reduced with gum
chewing
Hospital stay was not changed
Sham feeding ( chewing gum ) after CS
.Gum chewing appears to be effective and is low risk

It may be a redundant treatment if a policy for early oral intake is being used

.It should be considered if delayed oral intake is planned

(.Evidence level: low/ recommendation grade: weak)

Nausea & Vomiting after CS
Nausea and vomiting are common symptoms that are experienced
during CS and that happen during the surgery if the patient is awake or
.after the procedure in the recovery room
% The Overall incidence after CS is between 21 – 79
There are multiple causes of like symptoms and hypotension after
regional anesthesia is a common one
Nausea & Vomiting after CS
We can reduced the incidence of spinal anesthesia related
hypotension by

Colloid or crystalloid preloading

The intravenous administration of ephedrine or phenylephrine

Lower limb compression (by bandages, stockings, or inflatable boots)

Nausea & Vomiting after CS
:A Cochrane review study (41 studies and 5046 patients) demonstrated that

intraoperative
HT3 antagonists (eg, ondansetron)-5
dopamine antagonists (eg, metoclopramide)
sedatives (eg, midazolam)
Corticosteroids (such as dexamethasone)

Postoperative
Anticholinergic agents (eg, scopolamine)

NB: Other interventions (opioids, supplemental oxygen, supplemental intravenous

fluid, acupressure/ acupuncture) did not reduce intraoperative nausea or
postoperative nausea and vomiting
Nausea & Vomiting after CS
Fluid preloading, the intravenous administration of ephedrine or (1)
phenylephrine, and lower limb compression are effective in the
reduction of hypotension and the incidence of intraoperative and
.postoperative nausea and vomiting
(Evidence level: moderate; recommendation grade: strong)

Antiemetic agents are effective for the prevention of postoperative (2)

nausea and vomiting during cesarean delivery. Multimodal approach
should be applied to treat postoperative nausea and vomiting
(.Evidence level: moderate; recommendation grade: strong)
Post Operative analgesia
Poor postoperative pain control may be detrimental to recovery for surgery of any
kind. Pain may prolong recovery and delay discharge
For cesarean delivery, high pain scores have the potential to prevent early
mobilization and the mother’s efforts to be independent and to care for her
newborn baby
Multimodal analgesia is a key component in the management of postoperative pain
as part of an enhanced recovery protocol, which results in fewer side-effects and
faster postoperative recovery
Post Operative analgesia
:A review of oral analgesia for post-cesarean delivery pain relief concluded that
There was insufficient evidence to make recommendations regarding the safest and most
.effective form
Nevertheless, the perioperative administration of NSAIDs is known to diminish postoperative pain for
cesarean delivery

Evidence in the obstetric population is less clear for paracetamol, although a systematic review of
studies that included studies in which patients underwent cesarean delivery found that the
.combination of NSAIDs and paracetamol was synergistic for postoperative pain

This combination is cheap, effective, easy to administer, and opioid-sparing, which leads to fewer
.opioid-related side-effects, and is compatible with ERAS regimens
Post Operative analgesia
Multimodal postoperative analgesia that includes regular NSAIDs and
paracetamol is recommended for enhanced recovery for cesarean
delivery

A review of oral analgesia for post-cesarean delivery pain relief

:concluded that
There was insufficient evidence to make recommendations
.regarding the safest and most effective form
Prophylaxis against thromboembolism
Pregnant and postpartum women are at an increased risk of venous thromboembolism

A variety of modalities are available to reduce the risk of post-cesarean delivery thromboembolic
:disease that include

Mechanical methods
graduated compression stockings
(intermittent pneumatic compression

Pharmacologic methods
unfractionated heparin
low molecular weight heparin
Prophylaxis against thromboembolism
,In the comparison of heparin (either low molecular weight heparin or unfractionated heparin) with placebo/ no treatment

.there were no differences in symptomatic thromboembolic events ,symptomatic pulmonary embolism ,or symptomatic deep vein thrombosis

One recent study from a large health system compared rates of post-cesarean delivery pulmonary embolism deaths in the time

period before a universal policy for pneumatic compression stockings to the time period after implementation

There was a significant reduction in death from post-cesarean delivery pulmonary embolism between these 2 time periods
Prophylaxis against thromboembolism
undergo Pneumatic compression stockings should be used to prevent thromboembolic disease in patients who (1)

.cesarean delivery

(.Evidence level: low; recommendation grade: strong)

Heparin should not be used routinely for venous thromboembolism prophylaxis in patients after cesarean (2)

.delivery

(.Evidence level: low; recommendation grade: weak)

Early mobilization after cesarean delivery
Early mobilization theoretically can improve a number of short-term
outcomes after surgery, which include rapid return of bowel function,
reduced risk of thrombosis, and decreased length of stay

Early mobilization is often part of a surgical bundle or “enhanced

”recovery after surgery

This bundle of care has not been evaluated in patients after cesarean
delivery
Early mobilization after cesarean delivery

.Early mobilization after cesarean delivery is recommended

(.Evidence level: very low; recommendation grade: weak)

Urinary drainage after cesarean delivery

Urinary catheter placement during cesarean delivery is a widely accepted

.practice
It is believed generally that bladder drainage can measure urinary output,
.retention reduce urinary system injuries, and decrease postoperative urinary
However, urinary tract infection is 1 of the most common complications after
.cesarean delivery
Indwelling urinary catheters can increase the incidence of urinary tract
.infection, urethral pain, and difficult voiding
These complications result in delayed ambulation, prolonged hospital stay,
and increased costs
Urinary drainage after cesarean delivery
In a prospective study, 420 patients who underwent elective cesarean delivery were assigned

randomly into an non-catheterized group or a catheterized group (the catheter was removed 12 hours

postoperatively). The study reported that mean time to patient ambulation, first postoperative

voiding, oral rehydration, bowel movement, and length of hospital stay were significantly less in the

noncatheterized group

Even though the urinary catheter was removed 12 hours after surgery, the incidence of urinary tract

infection was significantly higher

Urinary drainage after cesarean delivery
A systemic review (2 randomized controlled trials and 1 nonrandomized controlled trial) concluded
that
.urinary catheter usage is associated with higher rates of urinary tract infections
Urinary catheter does not reduce postoperative urinary retention or decrease intraoperative surgical difficulties

In another prospective randomized clinical trial of immediate (n¼150) vs 12-hour (n¼150) removal of
postoperative the urinary catheter in women who undergo elective cesarean delivery, the incidence of
bacteriuria, dysuria, burning on the micturition, urinary frequency and urgency, the time till the first
voiding, mean postoperative ambulation time, and length of hospital stay were significantly lower in
the immediate urinary catheter removal group
Urinary drainage after cesarean delivery
In women who do not need ongoing strict assessment of urine output,
the urinary catheter should be removed immediately after cesarean
.delivery, if placed during surgery

(.Evidence level: low; recommendation grade: strong)