Cesarean Delivery Best Practices & Guidelines – The ERAS Committee Recommendations

SUMMARY:

The Enhanced Recovery After Surgery (ERAS) Committee has produced evidenced-based guidance on perioperative care for cesarean delivery.  The guidance covers practices from the time of decision making to hospital discharge. These recommendations are based on a thorough review of the literature and includes a ‘maternal focused pathway’ for both scheduled and unscheduled surgeries. Key elements of ERAS protocols include preoperative patient optimization and perioperative procedures. (Part 3 considers postpartum best practices and that summary can be found in ‘Related ObG Topics’ below)

Optimize Antenatal Pathway

Preadmission information, education and counseling 

  • Inform patients about procedures related to the surgery (adapted for scheduled vs unscheduled)  
    • Evidence Quality Level: Very low to low
    • Recommendation: Strong
  • Cesarean delivery without medical indication: Not recommended without “solid preadmission evaluation of harms and benefits” for both mother and baby  
    • Evidence Quality Level: Very Low to Low  
    • Recommendation: Strong  

Preoperative Pathway

Preanesthetic medications 

  • Administer antacid and histamine H2 receptor antagonists  
    • Evidence Quality Level: Low 
    • Recommendation: Strong  
  • Do not administer preoperative sedation  
    • Evidence Quality Level: Low 
    • Recommendation: Strong  

Preoperative bowel preparation 

  • Do not administer oral or mechanical bowel prep  
    • Evidence Quality Level: High 
    • Recommendation: Strong  

Preoperative fasting 

  • Encourage clear fluids (pulp free juice, coffee, tea without milk) up to 2 hours before surgery 
    • Evidence Quality Level: High 
    • Recommendation: Strong  
  • Light meal up until 6 hours before surgery  
    • Evidence Quality Level: High 
    • Recommendation: Strong  

Preoperative carbohydrate supplementation 

  • May offer to nondiabetic patients oral carbohydrate fluid supplementation up to 2 hours before surgery  
    • Evidence Quality Level: Low 
    • Recommendation: Weak

Intraoperative Pathway

Preoperative antimicrobial prophylaxis and skin preparation 

  • Administer IV antibiotics within 60 minutes before skin incision  
  • Use first generation cephalosporin 
  • In labor or ROM: add azithromycin  
    • Evidence Quality Level: High 
    • Recommendation: Strong  

Skin prep 

  • Chlorhexidine-alcohol preferred to aqueous providone-iodine  
    • Evidence Quality Level: Low 
    • Recommendation: Strong  

Vaginal prep 

  • Consider providone-iodine 
    • Evidence Quality Level: Moderate
    • Recommendation: Weak 

Anesthetic management 

  • Regional anesthesia preferred  
    • Evidence Quality Level: Low 
    • Recommendation: Strong  

Hypothermia prevention 

  • Use appropriate patient monitoring to apply warming devices  
    • Evidence Quality Level: Low 
    • Recommendation: Strong  
  • Use forced air warming, IV fluid warming and increased OR temperature  
    • Evidence Quality Level: High  
    • Recommendation: Strong  

Operative techniques  

  • Blunt expansion of transverse uterine hysterotomy may reduce blood loss  
    • Evidence Quality Level: Moderate  
    • Recommendation: Weak  
  • 2-layer closure of uterine incision may be associated with reduced risk of uterine rupture  
    • Evidence Quality Level: Low  
    • Recommendation: Weak  
  • Peritoneum does not need to be closed  
    • Evidence Quality Level: Low  
    • Recommendation: Weak  
  • Reapproximate if subcutaneous layer is ≥2 cm 
    • Evidence Quality Level: Moderate  
    • Recommendation: Weak  
  • Use subcuticular closure to prevent wound separation (vs staple removal ≤4 days)  
    • Evidence Quality Level: Moderate  
    • Recommendation: Weak 

Fluid management 

  • Maintain perioperative and intraoperative euvolemia  
    • Evidence Quality Level: Low to Moderate  
    • Recommendation: Strong  

Neonatal Pathway

  • Term: Delay cord clamping for at least 1 minute  
    • Evidence Quality Level: Moderate  
    • Recommendation: Strong 
  • Preterm: Delay cord clamping for at least 30 seconds  
    • Evidence Quality Level: Low to Moderate  
    • Recommendation: Strong 
  • Newborn body temperature: Maintain 36.5°C – 37.5°C after birth through admission and stabilization 
    • Evidence Quality Level: Low to Moderate  
    • Recommendation: Strong 
  • Avoid airway suctioning or gastric aspiration unless obstruction present  
    • Evidence Quality Level: Low  
    • Recommendation: Strong 
  • Recommended use of room air supplementation rather than inspired air with oxygen  
    • Evidence Quality Level: Low to Moderate  
    • Recommendation: Strong 
  • Availability of immediate neonatal resuscitation mandatory  
    • Evidence Quality Level: High  
    • Recommendation: Strong 

KEY POINTS:

Optimize and Manage Maternal Comorbidities

  • The following maternal comorbidities if not managed are associated with increased maternal and fetal complications (High level evidence; Strong recommendation) 
    • Obesity, especially BMI >40 
    • Chronic Hypertension 
    • Gestational Diabetes with following targets for both preexisting and GDM 
      • Fasting: <95 mg/dL (<5.3 mmol/L)
      • 1-hour postprandial: <140 mg/dL (<7.8 mmol/L)  
      • 2 postprandial: <120 mg/dL (<6.7 mmol/L) 
    • Maternal smoking   
  • Maternal anemia (Moderate level evidence; Strong recommendation)
    • WHO definition: Hemoglobin levels <11.0 g%
    • Is associated with
      • Preterm birth | Low birthweight | Increased perioperative morbidity | Increased mortality rates 
    • Identify cause and correct anemia

Quality and Recommendation Grading System

Evidence level

  • High quality
    • Further research unlikely to change confidence in effect estimate
  • Moderate quality
    • Further research is likely to have important impact on confidence of effect estimate
    • Effect estimate may change
  • Low quality
    • Further research is very likely to have important impact on confidence effect estimate
    • Effect estimate likely to change
  • Very low quality
    • Any effect estimate is very uncertain

Recommendation strength

  • Strong
    • Desirable effects of intervention clearly outweigh the undesirable effects or
    • Desirable effects of intervention clearly do not outweigh the undesirable effects
  • Weak
    • Trade-offs are less certain due to
      • Low quality evidence or
      • Evidence suggests desirable and undesirable effects are closely balanced

Learn More – Primary Sources:

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2)