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 with a focus on RCTs and large observational studies. (Part 3 considers postpartum best practices and that summary can be found in ‘Related ObG Topics’ below)

• Optimize Antenatal Pathway
• Preoperative Pathway
• Intraoperative Pathway
• Neonatal Pathway
• Optimize and Manage Maternal Comorbidities

Optimize Antenatal Pathway

Preadmission Information, Education and Counseling

• Inform patients about clinical care opportunities, antenatal screening or diagnosis and procedures related to the surgery (adapted for scheduled vs unscheduled) 
• Requires organizational, administrative and fiscal support to optimize quality improvement
  • Evidence Quality: Low
  • Recommendation: Strong

Preoperative Pathway

Antiemetic Prophylaxis

• Dual antiemetic therapy: Combination of intraoperative 5HT-3 antagonist/dexamethasone or 5HT-3 antagonist/dopamine antagonist (e.g., metoclopramide) 
• Most effective with neuraxial anesthesia with long-acting intrathecal opioids
  • Evidence Quality: Low
  • Recommendation: Strong 

Intraoperative Pathway

Support Person in the OR

• Applies if there is no general anesthesia
• Support person should be available on request
  • Evidence Quality: Very Low
  • Recommendation: Strong

Preoperative Antimicrobial Prophylaxis

• Administer IV antibiotics within 60 minutes before skin incision (see ‘Related ObG Topics’ below for recommended antibiotic prophylaxis including dosing)
  • Use single dose first generation cephalosporin with weight-based dosing
  • Evidence Quality: High
  • Recommendation: Strong
• Add azithromycin for unscheduled cesarean
  • Evidence Quality: High
  • Recommendation: Strong
• Obesity: Prophylaxis can include preoperative azithromycin or postoperative oral cephalexin plus metronidazole (48 hours)
  • Evidence Quality: Moderate
  • Recommendation: Strong

Abdominal Skin Prep

• Chlorhexidine-alcohol
  • Evidence Quality: Moderate
  • Recommendation: Strong 

Vaginal prep 

• Chlorhexidine or povidone-iodine: Recommended for intrapartum cesarean delivery or ruptured membranes | Consider for scheduled cesarean with membrane rupture
  • Evidence Quality: Low
  • Recommendation: Strong

Management of Spinal Anesthesia Induced Hypotension

• To prevent and treat maternal hypotension related to anesthesia: Phenylephrine infusion with IV fluid coloading
  • Evidence Quality: Moderate
  • Strength of Recommendation: Strong
• Left lateral tilt or other uterine displacement techniques
  • Evidence Quality: Low.
  • Recommendation: Strong

Hypothermia Prevention 

• To maintain normothermia during surgery: If surgery expected to last beyond 60 minutes, provide warmed IV fluids and forced air warming
• Preop, patients should wear warm clothing, mobilize and remain in a warm environment | Consider forced air warming if above not possible
• Temperature: Measure prior to anesthesia and every 30 minutes during surgery
  • Evidence Quality Level: Moderate
  • Recommendation: Strong 

Fluid Management

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

Prophylactic Uterotonic Agents

• Routine use of postdelivery oxytocin or carbetocin: Initiation bolus 1 IU for antepartum cesarean and 3 IU for intrapartum cesarean (bolus of these drugs should not be faster than 1 IU over 10 sec)
  • Evidence Quality: Moderate
  • Recommendation: Strong  

Note: Suggested rescue algorithm if tone inadequate after 2 min

• Antepartum cesarean: 3 IU bolus | Maintenance infusion: 2.5 to 7.5 IU/h
• Intrapartum cesarean: 3 IU bolus | Maintenance infusion: 7.5 to 15 IU/h

Mutimodal Analgesia

• Intrathecal morphine for postop analgesia
  • Evidence Quality: High
  • Recommendation: Strong  

Note: If intrathecal morphine not used, supplemental local blocks are recommended

• Preop or intraop acetaminophen
  • Evidence Quality: Moderate
  • Recommendation: Strong  
• Intraop NSAIDs
  • Evidence Quality: High
  • Recommendation: Strong  
• Intraop dexamethasone can be considered to enhance effects of analgesia
  • Evidence Quality: Low
  • Recommendation: Weak

Neonatal Pathway

Skin-to-Skin Care Recommended

• Early initiation improves breast feeding success
  • Evidence Quality: Moderate 
  • Recommendation: Strong
• Early initiation facilitates smoother postnatal adaptation
  •   Evidence Quality: Very Low 
  • Recommendation: Weak

KEY POINTS:

Optimize and Manage Maternal Comorbidities

• The following maternal comorbidities if not managed are associated with increased maternal and fetal complications (Moderate level evidence; Strong recommendation)
  • Obesity: Preoperative planning
    • Appropriate operating room table size with life with a lift device and adequately sized wheelchair or gurney
    • Plan incision site based on clinical data such as location of uterus and fetal lie with preference for transverse skin incision if possible
    • Preop chlorhexidine wash | No shaving
    • Intraoperative: Pannus retraction | Appropriate antibiotic prophylaxis | Minimize placental extraction
    • Close subcutaneous layer and careful postop wound monitoring
    • Thromboprophylaxis
  • 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
    • Associated with: Preterm birth | Low birthweight | Increased perioperative morbidity | Increased mortality rates
    • Identify cause and correct anemia
    • Studies suggest IV iron superior to oral iron for reduction of adverse outcomes
  • Epilepsy
    • Team-based care for maternal management and fetal teratogenic risk counseling
    • Epilepsy and antiseizure medication are associated with increased risk for adverse pregnancy outcomes
    • Regular care with ObGyn and epilepsy specialist
  • Autoimmune disease
    • Increased risk for maternal complications such as preeclampsia
    • Risks to fetus and newborn: Miscarriage | FGR | LBW | SGA | Preterm birth | Stillbirth
  • Asthma
    • Comorbidities generally more prevalent
    • Risk for exacerbations

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) – 2025 update

Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 2) – 2025 update

Expert Review (AJOG): Neuraxial anesthesia and pain management for cesarean delivery