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 (‘Related ObG Topics’)

KEY POINTS:

Chewing Gum to Prevent Ileus and Promote Flatus

• Different regimens
  • Initiation: immediate up to 12 hours postpartum
  • Duration: 15 to 60 minutes
  • Number of sessions: 3 to >6
• Note: While “appears to be effective and low risk”, may not be as effective if early oral intake policy is in place (see below) | Should be considered if delayed oral intake policy is in place
  • Evidence Quality Level: Low | Recommendation: Weak

Nausea and Vomiting Prevention

• Procedures to limit hypotension may also reduce nausea and vomiting and include
  • Fluid preloading | Ephedrine or phenylephrine (both IV) and | Lower limb compression
    • Evidence Quality Level: Moderate | Recommendation: Strong
• Antiemetic agents: Use Multimodal approach “becoming standard of care”, for example
  • 5-HT3 antagonists combined with droperidol or dexamethasone
  • Tropisetron 2 mg and metoclopramide 20 mg
    • Evidence Quality Level: Moderate (multiple interventions) | Recommendation: Strong

Post-Operative Analgesia

• Use multimodal approach
  • Long acting intrathecal opioids (side effects include nausea and pruritis)
  • Transversus abdominis plane (TAP) field block
  • Perioperative oral analgesia
    • NSAIDs reduces post-op cesarean pain
    • NSAIDS together with paracetamol (acetaminophen) are synergistic
  • Evidence Quality Level: Moderate | Recommendation: Strong

Early Oral Intake

• Begin regular diet within 2 hours after cesarean delivery
  • Evidence Quality Level: High | Recommendation: Strong

Peri-Operative Glucose Control for Diabetes

• Maintain tight control of capillary blood glucose (CBG) postoperatively
  • Patient on Insulin: Check CBG after delivery due to rapid fall in insulin requirements and risk of hypoglycemia
  • GDM: discontinue insulin
  • Type 2 diabetes: Continue metformin and glyburide (glibenclamide)
• Evidence Quality Level (maintaining tight control): Low | Recommendation: Strong

VTE Prophylaxis

• Use pneumatic compression stockings
  • Evidence Quality Level: Low | Recommendation: Strong
• Heparin should not be routinely used (target use based on clinical circumstances)
  • Evidence Quality Level: Low | Recommendation: Weak

Early Mobilization

• Limited evidence in women undergoing cesarean section, but early mobilization is recommended
  • Evidence Quality Level: Very Low | Recommendation: Weak

Urinary Drainage

• If no additional monitoring required, remove catheter immediately
  • Evidence Quality Level: Low | Recommendation: Strong

Discharge Counseling

• Limited evidence in women undergoing cesarean section, but standardized written discharge instructions are recommended
  • Evidence Quality Level: Low | Recommendation: Weak

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 (ERAS) Society Recommendations (Part 3)