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Vol 2 No.

2 October 2022 E-ISSN : 2797-0035


Solo Journal of Anesthesi, Pain and Critical Care P- ISSN : 2776-1770

CASE REPORT
Implementation of Enhanced Recovery After Caesarean Section
(ERACS) in Elective Procedure : A Case Report
Sardimon*, Yusmalinda*, Zafrullah Khany Jasa*, Rahmi*, Fauzan Bachtiar Amin*

Article Info : ABSTRACT


Submitted : Background: Enhanced Recovery After Cesarean
27-01-2022 Section (ERACS) protocol includes every component of
Accepted : the pre-operative, intra-operative and post-operative
15-08-2022 pathway. In the pre-operative phase, the protocol applied
Published : to this patient included the shortest possible fasting
30-10-2022
interval, oral intake of liquid carbohydrate and patient
counselling. For intra-operative pathway, the
https://doi.org/10.20961/
components applied are prevention of hypotension,
soja.V2i2.58950
maintenance of normothermia, optimal uterotonic
administration, IONV (intra-operative nausea and
vomiting)/PONV (post-operative nausea and vomiting)
Authors’ affiliations : prophylaxis, multi-modal analgesia and optimization of
*
Department of fluid administration. Post-operatively, the patient was
Anesthesiology, Faculty given early nutritional intake, early mobilization, urinary
of Medicine, Universitas catheter removal, venous thrombo-embolism
Syiah Kuala, Banda Aceh, prophylaxis, multi-modal analgesia and glycemic
Indonesia control. ERACS prove useful for early discharge,

Correspondence: improving outcomes such as breastfeeding or reducing
sardimon1@gmail.com post-discharge opioid use.
Case Illustration: A 31-year-old woman came with the
chief complaint of fluid discharge since ± 3 hours prior
to admission to the hospital. Based on the medical
history, physical examination, and laboratory findings,
the patient was diagnosed with premature rupture of
membranes in a gestational age of 37-38 weeks and had
a live, single-headed presentation of the fetus. Patient’s
physical status is ASA II and scheduled for elective C-
section procedure with spinal anesthesia.
Conclusion: The implementation of the ERACS
protocol in this case has been shown to reduce the rate of
infection and post operative complications as well as
reducing length of stay for the mother.

Keywords: ERACS; ERAS; sectio caesaria; spinal


anesthesia

Copyright @ 2021 Authors. This is an open access article distributed under the terms of the Creative Commons
Attribution- 4.0 International License (https://creativecommons.org/licenses/by/4.0/)
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo.
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

INTRODUCTION bariatrics (2016), hepatology (2016),


Enhanced recovery after surgery head and neck cancer (2017), breast
or ERAS is a multi-disciplinary reconstruction (2017) to section
perioperative care protocol standard in cesarian (SC) procedure3,4.
surgical patients that aims to prevent ERAS guidelines on cesarean
stress and attempt to modify the stress delivery or Enhanced Recovery After
response resulting in better outcomes1. Cesarean Section (ERACS) were
Differ from current conventional introduced in 2018, long after
perioperative care, ERAS emphasizes a recommendations on other
process consisting of a variety of subspecialties were published. Thus, the
interventions that may reduce surgical ERACS protocol is still very limited, and
stress, maintain balance physiological more studies are required following the
function, and speed up the recovery different circumstances of the patient4.
process to its previous state1. In the UK, Most of SC patients are healthy patients
approximately 40% of women go home without severe comorbid, so the
the day after their planned Caesarean probability of successful ERAS is
section with many being enrolled on greater than in other surgeries where the
ERACS pathways2. patient's condition already has a severe
The Enhanced Recovery After comorbid. The ERACS protocol on
Surgery (ERAS) protocol was developed cesarean delivery aims to improve the
in 2001 by a group of surgeons in quality and safety of cesarean delivery,
Europe. The protocol was pioneered by maternal and fetal outcomes. Immediate
Henrik Kehlet with the objective to post-operative recovery as early as
improve post-operative clinical possible will enable a newly mother take
outcomes. ERAS protocols were care of her baby more quickly5.
originally developed for colorectal Several studies have been
surgery, but over time, the ERAS conducted on patients indicating
protocol was developed for many other cesarean delivery procedures with the
surgical subspecialties. To date, ERAS ERACS protocol showed a good
Society has published various guidelines prognosis in the short and long term.
and recommendations including for Based on Liang Li in 2017, patients with
colorectal (2005), gastrointestinal 80-100% ERAS compliance had a 6.9%
(2012), gynecologic oncology (2016), risk of infection and 16.7% in

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 48
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

complications, compared to patients with solution may lie in adjusting the ERACS
0-60% ERAS compliance who had a protocol to better suit the conditions of
24.2% risk of infection of and 41.3% in poor and developing countries. This has
complications. Another study revealed been suggested by Nelson in 2021, who
that 38.5% of women who had a C- proposes focusing on the basic
section went home the next day. These components of ERACS in advance (e.g.,
findings suggest that ERAS protocol pre-operative optimization, multi-modal
compliance had a role in the low pain management, early post-operative
incidence of secondary infections due to mobilization) and assure to provide
surgical procedure, lower post-operative affordable drugs available to patients.
complications rates and shorter Hospitals in developing countries may
hospitalization periods 6.7. not able to adopt all ERACS
In low- and middle-income recommendations at once, but rather start
countries, including Indonesia, small and then establish their own
implementation of the ERACS protocol protocols when improvements in clinical
is still less than optimal. Though outcomes achieved and more resources
cesarean delivery rates continue to are available8,9.
increase significantly from year to year. This case report describes
The results of Basic Health Research implementation of ERACS and its
(RISKESDAS) 2018 showed the birth outcome in patient who underwent
rate with caesarean delivery in Indonesia elective C-section procedure.
was 17.6% with the highest prevalence CASE ILLUSTRATION
in DKI Jakarta at 31.1% and the lowest A 31-year-old woman came to
prevalence in Papua at 6.7%. In Aceh, RSUD Zainoel Abidin Banda Aceh with
the proportion of cesarean delivery is the main complain of fluid discharge
above the national average of 22% 7. since ± 3 hours before admitted to the
The lack of optimal hospital. There is no contraction or
implementation of ERACS in Indonesia mucous discharge. The patient suggested
occurs due to lack of resources and costs that she is 9-months pregnant and had
needed5. Despite the obstacles, the active fetal movement. The First Day of
ERACS protocol must still be the Last Menstruation (Hari Pertama
implemented and prioritized. The Haid Terakhir/HPHT) is on January 4th,

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 49
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

2021. Estimated of due date was October anesthetic regimen administered were
11th, 2021. The estimated gestational age bupivacaine 6.5 mg plus fentanyl 25 mcg
was 37-38 weeks. Routine antenatal care and morphine 100 mcg, with a total
to obstetricians was 12 visits and to volume of 1.9 cc diluted with
midwives was 2 visits. History of cerebrospinal fluid (CSF) up to a total
previous diseases and family history of volume of 2.1 cc. The anesthesia
asthma, heart disease, diabetes mellitus regimen was injected at a speed of
and hypertension were denied. The 0.4cc/second. Post-spinal anesthesia,
history of allergies was denied. The patient was given oxygen via nasal
previous labor was 6 years ago, and this cannula 3 l/m and administered 10 mg of
is the second pregnancy. Physical ephedrine and 8 mg intravenous
examination and laboratory results dexamethasone. The location of spinal
within normal limits. anesthesia was obtained as high as T4.
Based on anamnesis, physical Aseptic and antiseptic precautions were
examination, and laboratory performed, and draping was one to limit
examination, concluded that the patient the area of surgery. Incision began 15
had an early rupture of membrane with minutes after spinal anesthesia
gestational age of 37-38 weeks and performed. The baby was safely born 15
single, alive, head-presentation fetus. minutes after the onset of incision and
Patient was ASA II physical status and cried spontaneously. Umbilical cord
had already scheduled for elective SC clamping was delayed for 1 minute.
procedure with spinal anesthesia. During the procedure, there were
Pre-operative treatment no hypotension and IONV (intra-
consisted of 6-hours fasting prior to operative nausea and vomiting). Patient
procedure (solid food), patient was was administered oxytocin 20 IU drip in
allowed to drink sweet tea up to 2 hours 500 cc Ringer Lactate after the baby was
before the delivery. Intra-operative born. Thirty minutes before the
treatment included ondansetron injection procedure was completed, the patient
of 4 mg before spinal anesthesia was was given analgetic (paracetamol drip
performed. Patient was arranged with 1gr and ketorolac IV 30 mg). The
spinal anesthesia in a sitting position, procedure lasted for 1 hour and 45
performed puncture on the intervertebral minutes, with amount of intra-operative
space L4-L5 using spinocain 27G. The hemorrhage was 400 cc, urine output of

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 50
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

1.3 cc/kg/hour. During surgery the able to immediately recovered as well as


patient got 1000 ml of crystalloids. success in breast feeding and taking care
After the procedure was the babies11. The satisfaction rate of
completed, the patient then transferred to ERACS was very high compared to
the PACU room and took into a warmer. patients with routine care. The majority
The patient was then given sweet tea and of mothers undergoing SC surgery are
biscuits and observed for 30 minutes. young and healthy patients, thus
The patient was transferred to the allowing for a rapid post-delivery
inpatient room when achieved a bromage recovery and return to regular
score of 0. (Figure 3) Analgesics activities12. Comparative study
(ketorolac 30 mg) continued for every 8 conducted by Pravina in 2020 showed
hours. The catheter removal was that SC groups implemented the ERAS
performed 6 hours post-spinal protocol experienced faster early
anesthesia. Within 24 hours, there was recovery time and higher satisfaction
no sign of post-operative complications. levels than the group with standard
Patients already mobilized and tried to operative care. Therefore, this approach
independently take care for her newborn is expected to be applied to more
baby, then the patient was discharged pregnant women who will undergo SC
with outpatient treatment education. procedure in the future13.
DISCUSSION The implementation of ERACS
Enhanced Recovery After requires the support of stakeholder and
Cesarean Section (ERACS) is a multi- policy maker, due to its multi-
disciplinary, multi-modal perioperative disciplinary and multi-modality
management designed to decrease stress measures. The key to ERACS success
response during a section caesarean depends on the collaboration of
surgery, reduce complications, length of physicians, nurses, hospitals, and
stay, and speed recovery time10. patients. Anesthesiologists are the center
Various studies in United of this process and often take a leading
Kingdom and other European countries role. The ERACS Society has published
has reported the advantages of ERACS, guidelines with evidence-level
including improving the quality of assessments and recommendation
services, and patient satisfaction that strength for each component of the pre-

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 51
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

operative, perioperative and post- side effects of prolonged fasting. As a


operative pathways7. ERACS guidelines result, ERACS recommends the shortest
were created for both scheduled and possible fasting period and the use of
unscheduled SC procedures. ERACS liquid carbohydrate to minimize the
procedures range from 30-60 minutes effects of fasting15.
before skin incisions to patient Solid food allowed up to 6-8
discharged13. hours prior the surgery. Patients should
Pre-operative be encouraged to consume non-
Pre-operative treatments focused particulate carbohydrate drink 2 hours
on 5 elements include shortest possible before SC. Several studies showed that
fasting-interval, administration of liquid the drink may reduce the risk of
carbohydrates, patient education, aspiration, preventing hypovolemia,
lactation/breastfeeding education and metabolic stress and ketosis when
preparation, and hemoglobin administered before a C-section7.15.
optimization14. In this case, the patient Furthermore, non-particulate
was restricted from solid foods 6 hours carbohydrate drink is only given to non-
prior the surgery and allowed to drink diabetic women. The recommended
sweet tea for up to 2 hours pre-operative. amount is 45 grams of carbohydrates.
The clinical consideration for this For example, Gatorade 32 oz contains 54
measure was because pregnancy will grams of carbohydrates or apple juice
increase the risk of pulmonary aspiration contains 56 grams of carbohydrate. The
from the stomach contents under prescription formulation of ERACS pre-
anesthesia effect. Thus, pre-operative operative high-carbohydrate beverages
fasting has been recommended to limit requires agreement with nutritionists at
this risk. As a result, pregnant women the hospital. In Indonesia patient may be
who undergo SC procedure will fast and given beverages such as tea, coffee
starve for up to 20 hours until the actual without milk or pulp-free fruit juice up to
surgery. It may increase catabolic 2 hours before the procedure 7,15.
markers and urinary ketosis. Therefore, a Prior the surgery procedure,
careful balance must be reached between patients will undergo counselling session
these two conflicting directions, which is in accordance with ERACS protocol.
to ensure that the stomach is empty at the Counselling and education are very
time of operation while preventing the important elements in the success of

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 52
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

ERACS implementation. The goal of required, gastrointestinal intake plans


ERACS counselling is to motivate and during the period of time before and after
engage patients to better participate in surgery, as well as location and post-
treatment plans. It shall improve patient operative treatments on the mother and
adherence during treatment, improve newborn baby13. The patient permitted to
clinical outcomes and reduce patient be transferred to the surgical preparation
anxiety. Ideally, this session is room prior to the SC procedure13.
conducted one day before the day of Intra-operative
procedure 14. Intra-operative protocol carried
The ERACS counselling out since the patient is in the operating
includes the reasons/indications of room. Intra-operative protocols include
cesarean delivery, the location and type preventing hypotension due to spinal
of abdominal laparotomy incision as anesthesia, maintaining normothermia,
well as the techniques of abdominal skin optimal uterotonic administration,
incision closure will perform, preventive antibiotic prophylaxis, IONV/PONV
measures used to minimize the morbidity prophylaxis, multi-modal analgesia,
of post-operative maternal infections, the breastfeeding support and maternal-
patient's estimated post-operative infant bonding, optimization of fluid
risk for thromboembolism and additional administration and delayed umbilical
medical prophylaxis that may be cord clamping 14.

Intra Operative Monitoring


150

100

50

0
09:30 10:00 10:30 11:00 11:30

Sistolik Diastolik MAP


Heart Rate SpO2 ET CO2
Figure 1. Intraoperative Vital Sign

In this patient, the anesthetic administered 4 mg of ondansetron and


regimen was bupivacaine 6.5 mg plus post-spinal anesthesia, the patient
fentanyl 25 mcg and morphine 100 mcg. accepted 10 mg ephedrine and 8 mg of
Before spinal anesthesia, the patient was dexamethasone intravenously. During

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 53
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

the surgery procedure, the patient was with fluid, but with vasopressor. This is
observed and no hypotension and IONV because the root cause of hypotension is
(intraoperative nausea and vomiting) vasodilatation, not due to hypovolemic
were found. state. Blood pressure is maintained
Intra-operative nausea and according to the patient's daily baseline.
vomiting (IONV) or post-operative The regimens includes
nausea and vomiting (PONV) is phenylepinephrine, ephedrine or
common in women undergoing regional norepinephrine.16,18 Ephedrine is the
anesthesia during SC procedure and it first drug of choice to maintain maternal
has become an important clinical blood pressure. Its sympathomimetic
problem because this technique is widely stimulant activity on α- and β-adrenergic
used. A study showed the incidence of receptors causes positive inotropic and
IONV and PONV accounted for 80% chronotropic effects. Norepinephrine
and 30% of all patients undergoing may be used as an alternative
regional anesthesia during cesarean vasopressor to stabilize the maternal
section, respectively. The underlying blood pressure during spinal anesthesia
mechanisms of IONV and PONV in at SC procedure without causing side
cesarean delivery mainly include effects to the neonatal outcomes18.
hypotension due to sympathy colysis Furthermore, hypotensive
during neuraxial anesthesia, bradycardia prevention may achieved by use of low-
due to increased vagal tone, and dose local anesthesia, the addition of
intravenous administration of opioids16. intra-thecal opioids, the use of local
Based on current guidelines and solutions of hyperbaric anesthesia for
literature, the first step to reducing IONV adequate control of neuraxial
and PONV incidence is comprehensive distribution such as Bupivacaine 6.5mg,
management of circulation parameters. Fentanyl 25 mcg, and Morphine 100
This management includes the mcg16,17.
administration of perioperative fluids In addition, administration of
and the use of vasopressors in antiemetic agent as a prophylaxis of
accordance with the necessary IONV or PONV. Some of regimens may
circumstances17. Hypotension due to be used are 5HT3 antagonists (e.g.
spinal anesthesia in SC is not treated ondansetron 4 mg before spinal

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 54
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

anesthesia), D2 receptors antagonist (e.g. approximately 400 cc. Post-partum


metoclopramide 10 mg before spinal hemorrhage (PPH) is the leading cause
anesthesia), or dexamethasone (after of maternal death worldwide. The
spinal anesthesia). A minimum of 2 uterotonic drug is routinely
modalities with different mechanisms recommended as a prophylaxis of PPH.
for IONV and PONV prophylaxis are Optimal uterotonic administration starts
administered to the patient 14. from the lowest dose in order to achieve
During the delivery procedure, sufficient uterine tone and minimal side
the maternal temperature should be effects. In elective SC, a bolus of
monitored as well. Proper patient oxytocin 1 IU is given and continued
temperature monitoring is needed to with oxytocin infusion dose according to
consider the time to apply the warmer clinical state of uterus. Excessive
device and avoid hypothermia. Intra- oxytocin will cause hypotension and
operative hypothermia, defined as a nausea-vomiting14.
condition when core body temperature of In this patient, analgetic given
<360C. It might happen when patient were paracetamol drip 1 gr and 30 mg
loose high volume of blood during ketorolac IV prior to the surgery. Multi-
surgery. Maternal hypothermia might be modal analgesia that administered
a barrier to having skin-to-skin contact starting from durante surgery was
with the baby, as this will lead to neuraxial long-acting opioids such as
neonatal hypothermia. Active warming intrathecal morphine 50-150 mcg (100
has begun since the pre-operative mcg) or epidural morphine 1-3 mg. If
protocol in the operating-preparation there is no contraindications, non-opioid
room in the form of in-line IV fluid analgesia such as paracetamol and
warmer, forced air warming, and set the NSAIDs IV may be given
operating room temperature of 230C intraoperatively after the baby is born.
during cesarean delivery5.7. The purpose of this administration is
After the baby is born, this when the duration of the local drug
patient is given an oxytocin drip 20 IU in anesthetic has been diminished, the
500 cc Ringer Lactate. The operation drugs are already working, if neuraxial
lasted for 1 hour 45 minutes and the morphine is not given, consider local
intra-operative hemorrhage volume was infiltration anesthesia on the incision

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 55
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

wound, such as Transversus Abdominis


Plane (TAP) block, or Quadratus
Lumborum (QL) block14.
Post-operative
Post-operative protocols include
several elements, including nutrition
intake, immediate mobilization, rest,
urine catheter removal, venous thrombo-
embolism prophylaxis, early discharge,
anemia recovery, lactation consultation,
multi-modal analgesia, glycemic control, Figure 2. Patient was able to walk 6
and restoring gastrointestinal function14. hours post C-section procedure
In this case, the patient was given
sweet tea and biscuits and then observed
for 30 minutes in the recovery room.
Post-operative feeding in women who
give birth by caesarean section has been
reported to have quite an effect on the
morbidity associated with cesarean
delivery. Early intake after surgery
suggests to reduce the risk of post-
operative nausea and vomiting. Nausea
and vomiting may increase the potential
risk of aspiration, which becomes one of
many causes of the maternal death.
In addition, early intake after surgery Figure 3. Patient’s Bromage score 0 after
30-minutes observation at PACU
can stimulate the restoration of
gastrointestinal function, improve length of stay and improve patient
insulin sensitivity, reduce stress response satisfaction16. ERACS recommends
due to surgery, reduce hospitalization mothers to receive immediate oral
intake, such as sweet tea and biscuits
within 60 minutes of cesarean delivery.

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 56
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

Furthermore, regular diet allowed to be Mobilization in the recovery


given 4 hours post-SC procedures14. room is carried out gradually after the
Furthermore, in less than 24 administration of oral intake. If the
hours, patients recommended to patient feels comfortable, the bed
mobilize. In this case, the patient may allowed to be raised to 30 degrees. If
lift the leg within 2 hours after spinal there is no complaint, 10-15 minutes
anesthesia and walk to the bathroom later the bed can be raised again. If there
without the help of 6 hours post spinal is no complaint, encourage the patient to
anesthesia. In line with general ERAS sit without a backrest from the bed. If the
guidelines, it is recommended for early patient is able and no complain, 15-30
mobilization after surgery. SC causes minutes later encourage the patient to
post-operative changes in the autonomic dangle his legs. Next, help the patient to
nervous system, which lead to a decrease stand up and walk14.
in bowel movements. Decreased motility After 6 hours post-delivery, a
might cause several problems including urinary catheter in patient is removed.
constipation, paralytic ileus, atelectasis, This is because patients didn’t equire a
wound infections, urinary retention and strict assessment of urine production.
urinary tract infections. Post SC patients The timing of the catheter removal
need intensive supervision to reduce should also consider the absence of
complications from surgery by early residual anesthesia. Urinary catheters are
mobilization17. released to reduce the risk of urinary
Early mobilization theoretically tract infections, urinary retention and
expected to restore bowel function reduce length of hospitalization16,18.
quickly, decrease the risk of thrombosis, Post-operative pain control needs
and decrease the length of to be performed carefully because it
hospitalization. Spinal anesthesia for a affects the length of recovery time. A
C-section takes about 6 hours to high pain score will potentially prevent a
disappear completely, but the range mother's efforts to be independent and
variation is wide. Therefore, it is take care for her newborn. Multi-modal
important to ensure the absence of analgesia is a key in the management of
residual anesthesia before the first step of post-operative pain as part of recovery
post-operative protocol7,18. protocols. Analgesia begins to be given

Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 57
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report

since intra-operative protocol. Avoid results in shorter maternal length of


using opioids for post-operative hospitalization.
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