ERAS Part 3: Cesarean Delivery Best Practices & Guidelines – Post-Op Care

SUMMARY:

The Enhanced Recovery After Surgery (ERAS) Committee reviewed available data to provide evidence-based guidance on perioperative care for cesarean delivery with a maternal focus. Part 3 covers the immediate post-op period until patient discharge. The summary of ERAS recommendations for perioperative patient optimization and intraoperative procedures can be found below. Further information can be found in ‘Related ObG Topics’.

KEY POINTS:

Early Drinking and Feeding

• Resume oral diet in PACU
• Consider ice chips or water before light diet
• Evidence Quality Level: Low | Recommendation: Strong

Early Discontinuation of IV Fluid

• Discontinue when
  • Hemodynamically stable | Tolerating fluids | With adequate urine output
  • Uterotonic infusion is complete
  • IV fluids can either be removed or saline and heparin locked
• Decisions based on physician judgement
• Evidence Quality Level: Very low | Recommendation: Strong

Early Mobilization and Ambulation

• Attempt ambulation under supervision 6 hours postop
• Motor function targets include
  •   0 to 8 hr: sit on the edge of bed | Transfer from bed to chair | Ambulate with wheelchair
  •   8 to 24 hr: Ambulate as tolerated | Walk at least 1 to 2 times in the hall
  •   24 to 48 hr: Walk  at least 3 to 4 times in the hall | Out of bed for ≥8 hr
• Evidence Quality Level: Low | Recommendation: Strong

Early Removal of Urinary Catheter

• Aim to remove catheter 6 to 12 hrs postop
  • After patient is walking
• Exclusions: Bleeding | Magnesium infusions | Unsteadiness on feet
• Evidence Quality Level: Low | Recommendation: Strong

Scheduled Acetaminophen and NSAIDs

• Schedule regular oral drug if
  • Tolerated during hospital stay
  • No contraindications
• Evidence Quality Level: Moderate (acetaminophen), High (NSAIDs)| Recommendation: Strong

Rescue Opioids

• Only if acetaminophen or NSAIDs not sufficient for pain control  
• Oral preferable to IV
• Use oral opioids for breakthrough pain as required
• Limit dose per day: e.g., 30 mg oxycodone per day
• Evidence Quality Level: Low | Recommendation: Strong

Standardized Rescue Medication Protocol for Side Effects

• As required IV postop
  • Antiemetic: e.g., ondansetron
  • Shivering: e.g., meperidine
  • Pruritis: e.g., nalbuphine
  • Respiratory depression: e.g., naloxone
• Evidence Quality Level: Low – moderate | Recommendation: Strong

VTE Prophylaxis

• Mechanical: e.g., compression stockings, pneumatic bed
  • Until fully ambulatory
• Pharmacotherapy: Assess need if high risk
• Evidence Quality Level: Low | Recommendation: Strong

Anemia

• Consider transfusion if no cardiac disease
  • Hb level is <7 g/dL or
  • Symptomatic
• Iron deficiency anemia: Treat with iron supplementation
• Evidence Quality Level: Moderate | Recommendation: Strong

Breastfeeding

• Encourage
  • Early skin-to-skin contact
  • Lactation nurse or specialist for counseling and evaluation
• Evidence Quality Level: Low | Recommendation: Strong

Maternal Rest

• Group interventions to be performed at one time such as
  • Maternal examination
  • Infant checks
  • Scheduled drug administration
  • Blood draws
  • Patient-appropriate postop monitoring
• Evidence Quality Level: Low | Recommendation: Strong

Transition to Discharge

• Patient-centered approach
  • Use maternal and neonatal discharge checklists
  • Coordinate: Administrative tasks | Referrals |Tests | Paperwork | Education | Counseling
  • Provide standardized discharge instructions in patient’s preferred language
• Evidence Quality Level: Low | Recommendation: Strong

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 postoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 3) – 2025 update