Vaginal Birth After Cesarean

Recorded on May 26th, 2021 at 7:00PM EDT

FREE for ObGFirst™ Members!

Includes CME

Faculty: Sara Petruska, MD, University of Louisville

Moderators: Rebecca Dunsmoor-Su, MD

Disclosures

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:

Faculty: Sara Petruska, MD has nothing to disclose.

Rebecca Dunsmoor-Su, MD receives a salary from Gennev, and consulting fees from ObG Connect. Dr. Dunsmoor-Su has a financial ownership Interest in Gennev and ObBest Practice LLC

The PIM planners and others have nothing to disclose.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education 

Postgraduate Institute for Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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)

FIGO: Good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery