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Chapter 51: Enhanced Recovery After Cesarean

Lindsay K. Sween; Liberty G. Reforma; Philip E. Hess

BACKGROUND

Enhanced recovery after surgery (ERAS) care pathways were originally developed in the 1990s to 2000s for colorectal surgery. They have since been developed for many other surgical subspecialties. ERAS protocols standardize patient care throughout the perioperative period, thus improving outcomes (e.g., postoperative pain and hospital length of stay) and patient satisfaction.1 Enhanced recovery after cesarean delivery (ERAC) care pathways provide evidence-based recommendations for preoperative, intraoperative, and postoperative maternal care.1-4

GOALS

  • Improve patient satisfaction and outcomes.

  • Reduce postoperative pain, nausea/vomiting, time to void, and time to ambulation by minimizing opioids and maximizing alternative medications and techniques.

CLINICAL PRACTICE

Table 51-1 demonstrates a sample ERAC protocol utilized at a single tertiary care academic medical center.

TABLE 51-1Enhanced Recovery After Cesarean Delivery at BIDMC5
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TABLE 51-1 Enhanced Recovery After Cesarean Delivery at BIDMC5

Scheduled Cesarean

Unscheduled Cesarean

To Whom It Applies

Patients with scheduled cesarean delivery.

Patients with unscheduled cesarean delivery (e.g., intrapartum).

NPO Guidelines

Patients should eat their last large presurgery meal prior to midnight on the night before surgery. They may have a light, low-fat snack (e.g., crackers or one slice of dry toast) up to 6 hours prior to surgery. They may have clear liquids up until 2 hours before surgery. Patients will be instructed to drink a noncarbonated, nonparticulate 45-g carbohydrate beverage (e.g., Gatorade or apple juice) up to 2 hours prior to surgery for nondiabetic patients.

Patients should be NPO (nothing by mouth) as soon as the decision for cesarean section is made.

Depending on the urgency of delivery, the anesthesia and obstetric team will discuss appropriate timing based on last intake.

If patients have neuraxial anesthesia during labor, their diet should be changed to clear liquids at the time of placement.

Preoperative (Anesthesia)

Anesthesia assessment

Intraoperative (Anesthesia)

  • Antibiotics within 60 minutes of skin incision. (Cephalosporin preferred. Add azithromycin if patient in labor or membranes ruptured.)

  • Neuraxial anesthesia is the preferred method.

  • Aspiration prophylaxis with nonparticulate antacid.

  • Appropriate patient monitoring.

  • IV fluid warming and increased OR temperature to at least 68°F are recommended to prevent hypothermia in patients under neuraxial anesthesia; forced air warming can be added for patient comfort, neonatal skin to skin, or during general anesthesia.

  • Prophylactic IV ondansetron 4 mg at the end of surgery.

  • Treat shivering PRN (e.g., dexmedetomidine 10 µg, IV, may repeat up to 30 µg).

  • First dose of ketorolac 30 mg after fascia is closed.

Postoperative Orders

Standard medication order sets by obstetricians and anesthesia teams

Labor & Delivery Recovery (Anesthesia)

Pain medications:

  • IV ketorolac 30 mg every 6 hours for 24 hours, then transition to PO ibuprofen 600 mg every 6 hours and acetaminophen 1 g every 8 hours.

  • Oxycodone 5 mg every 4 hours PRN (as needed) for severe pain (avoid opioids in first 24 hours in ...

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