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

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)