Society of Obstetric Anesthesia and Perinatology (SOAP)

Enhanced Recovery After Cesarean (ERAC)

Consensus Statement

5/23/19

Committee:

Dr. Laurent Bollag (Co-Chair) Dr. Mohammed Tiouririne (Co-Chair) Dr. Grace Lim (Member) – on behalf of SOAP Education Committee Dr. Brendan Carvalho (Member) Dr. Mark Zakowski (Member) Dr. Sumita Bhambhani (Member) – on behalf of SOAP Patient Safety Committee Dr. Eric Hunt (Consultant) Dr. Ruth Landau (Consultant) Dr. Ashraf Habib (Consultant) Background of Enhanced Recovery after Cesarean (ERAC)

An ERAC protocol aims to standardize the perioperative care of the pregnant patient. By reducing variabilities in care and creating a specific evidence-based care pathway, maternal and fetal outcomes can be improved1-4. In this document, we present the core values and elements that a cesarean delivery-specific enhanced recovery after surgery program should include and present outcome metrics that will allow one to measure the success of the program. Many elements have been adapted from other successful enhanced recovery after surgery (ERAS) programs, predominantly enhanced recovery after colorectal surgery. The level of evidence is provided for each element, based on American College of Cardiology (ACC) and American Heart Association (AHA) Grading Criteria (Appendix), and is subject to change as further evidence is published. Inherent to any enhanced recovery program is the interdisciplinary approach and the inclusion of all parties involved in the care of patients including anesthesiology, obstetricians, perinatologists, pediatricians, neonatologists, nursing, lactation specialists, pharmacy, hospital administration, the patient and patients’ support systems. Implementing change is always challenging and buy-in from stakeholders varies, but individual practices should still be evidence-based in your subspecialty. Importantly, successful implementation of ERAC may not necessarily lead to a reduction in length of stay for mother and/or newborn or be a cost reduction intervention, rather the mission of ERAC is to improve the global quality of care and optimize quality of recovery after cesarean delivery. Goal of Enhanced Recovery after Cesarean (ERAC)

The goal of ERAC is to help provide all women with evidence-based, patient-centered care using a standardized, multidisciplinary approach that optimizes recovery from cesarean delivery and improves maternal and newborn outcomes. Central to this goal is a culture of critically examining and applying current knowledge through continual process improvements and collaborations.

Care Pathway

ERAC should be considered a continuum of care from preconception outreach, antepartum optimization, intrapartum care including the anesthetic, and concluding with postpartum inpatient care and outpatient support. In this guideline, we will focus on elements of the care pathway for the preoperative, intraoperative and postoperative periods,

presented in table format below. Some elements may not be implemented at your clinical site, while others are likely already part of your patient workflow and care models. Success of the ERAC program lies in interdisciplinary collaborations. The committee has identified a few core elements that are required for a program to be called ERAC. These core elements are identified by bolded text with asterisks** within each table. ERAC pathways have been developed for scheduled cesarean delivery. However, many elements of the pathway can be applied to non-scheduled cesarean delivery. Examples of various ERAC-related documents, including patient education materials, can be found in the Appendix to help with successful implementation.

Class of Recommendations and Level of Evidence A review of the literature was conducted for each recommendation. Existing evidence was evaluated for each of the core elements as they relate to enhanced maternal and neonatal recovery after cesarean delivery. The 2016 American College of Cardiology (ACC) and American Heart Association (ACC/AHA) Clinical Practice Guideline Recommendation Classification System1 have been applied to each of the Core Elements, based on the best available evidence. The classification system is available in the Appendix.

Preoperative ERAC Elements

Table 1 lists both core and recommended preoperative elements for ERAC. The aim of these preoperative elements is to reduce fasting periods, engage patients and providers in the care plan, and promote physical health optimization. Table 1: Pre-Operative Elements

ERAC Recommendation Action Comments Level of Evidence

Limit fasting interval** • Solids up to 6-8 hrs. prior to cesarean delivery

• Clear fluids up to 2 hrs prior to cesarean delivery

Reduces aspiration risk while limiting thirst and starvation ASA guidelines state 6-8 hrs based on the type of food ingested: • A light meal (e.g. toast

and a clear liquid) or milk may be ingested for up to 6 hrs before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.

• Additional fasting time (8 or more hrs) may be needed in cases of patient intake of fried foods, fatty foods or meat. Both the amount and type of foods ingested must be considered when determining an appropriate fasting period.

Class IIb, Level C-EO Low, data extrapolated from colorectal ERAS programs

Non-particulate liquid

carbohydrate loading** • Non-particulate

carbohydrate drink up to 2 hrs prior to cesarean delivery (non-diabetic women only)

• 45 grams carbohydrate is recommended

• Examples: Gatorade 945 ml (54 g carbohydrate) Apple juice 475 ml (56 g carbohydrate), no pulp

• Reduces maternal hypoglycemia and metabolic stress

• The benefit of complex carbohydrate (e.g. maltodextrin) drinks for cesarean delivery is currently undefined, and fetal effects unknown

• Can omit if mother is diabetic; follow institutional protocols for maternal diabetes/neonatal monitoring

Class IIb, Level C-EO Low, specifically in respect to quantity and quality of evidence; most data are extrapolated from colorectal ERAS programs. More data in cesarean population is needed specifically with respect to ideal type of carbohydrate, dose and fetal-neonatal effects

Patient education** • Minimum: Handout or other standardized educational tool or interaction that

• The goal of ERAC patient education is to set expectations, and to

Class IIb, Level C-NR

includes pre-cesarean delivery instructions, what to expect during cesarean delivery, and enhanced recovery information provided at least one day before surgery. Examples: Patient Handout 1 and 2; SOAP videos available on www.SOAP.org

• Ideal: Direct contact with patients with phone call/reminder or meeting before their cesarean delivery to remind patient of ERAC goals

engage/empower the patient to participate more completely in their care plan and recovery

• Ideally, patient education takes place before the day of surgery

• Pre-operative discussion must include ERAC goals, and these goals must be provided in addition to the routine pre-operative evaluation

Patient education in general improves patient compliance with care pathways and improves outcomes in certain clinical settings. Reported benefits include reduced patient anxiety and postoperative pain. Supports principal of patient engagement and empowerment

Lactation/Breastfeeding preparation and support

• Minimum: Handout or other standardized tool or interaction that includes information on normal breastfeeding physiology, management of common lactation complications, and resources for breastfeeding support after discharge

• Ideal: Structured prenatal classes with books, videos, and in-person lactation support in the hospital. Support of the “golden hour” to help women initiate breastfeeding within one hour of birth; referrals to breastfeeding support groups and/or lactation consultant after discharge

• Early breastfeeding improves newborn and maternal outcomes, including promoting emotional attachment, reducing infant infectious complications, and decreasing risk for sudden infant death syndrome

• Breastfeeding is a public health priority because it is risk protective for downstream adverse health outcomes such as breast cancer and hypertension

• Every woman should be supported in her informed decision on infant feeding

Class IIa, Level B-R

Hemoglobin optimization • All pregnant women should be screened for anemia per ACOG guidelines. Women with iron deficiency anemia should be treated with supplemental PO (or if refractory anemia with IV) iron in addition to prenatal vitamins

• Anemia other than iron deficiency should be further evaluated

• Goal: Work with obstetric provider team during prenatal visits to engage patient in understanding the importance of hemoglobin optimization; treat prenatal anemia appropriately

• Antepartum anemia is a significant predictor of postpartum anemia, which is linked to depression, cognitive impairment and fatigue

Class IIa, Level B-R

• Iron deficiency anemia in pregnancy is linked to increased risk for low birth weight, preterm delivery, and perinatal mortality

Legend: **= Core ERAC Element ERAC= Enhanced Recovery After Cesarean, SOAP= The Society for Obstetric Anesthesia and Perinatology, ASA= The American Society of Anesthesiologist, ACOG= The American College of Obstetricians and Gynecologists, ACCP= American College of Clinical Pharmacy, ACC= American College of Cardiology, AHA= American Heart Association, WHO= World Health Organization, UNICEF= United Nations International Children's Emergency Fund, TAP= Transversus Abdominal Plane Block, QLB= Quadratus Lumborum Block, NSAID= Nonsteroidal Anti-Inflammatory Drugs, PACU= Post-Anesthesia Care Unit, IONV= Intra-Operative Nausea and Vomiting, PONV= Post-Operative Nausea and Vomiting, post-OP= Postoperative, IV= Intravenous, PO= By Mouth, e.g.= For Example, PRN= When Necessary, g= Gram, mg=Milligram, mcg= Microgram, mL=Milliliter, dL= Deciliter, L= Liter, oF= Degree Fahrenheit, sec=Seconds, min= Minutes, hrs= Hours

Intraoperative ERAC Elements

Table 2 lists both core and recommended intraoperative elements for ERAC. The aim of these elements is to optimize fluid management, prevent spinal anesthesia induced hypotension, minimize intraoperative nausea and vomiting, initiate multi-modal analgesia, and support early breastfeeding and maternal-infant bonding. Table 2: Intra-Operative Elements

Recommendation Action Comments Level of Evidence

Intravenous fluid optimization

• Limit intravenous fluids to <3L for routine cases (suggested)

• In the case of hemorrhage, transition from ERAC to institutional hemorrhage resuscitation protocol

• In contrast to fluid management in non-obstetric abdominal surgery, spinal anesthesia-associated hypotension in cesarean delivery should be primarily managed with vasopressors, instead of fluid administration

Class IIa; Level C-EO Ideal intravenous fluid parameters in cesarean delivery are not well established

Prevent and treat

spinal anesthesia

induced

hypotension**

• Goal is to prevent intraoperative nausea/vomiting after spinal anesthesia and maintain uteroplacental perfusion

• Optimally managed with prophylactic vasopressor infusion: for example phenylephrine (or norepinephrine) infusion

• Spinal anesthesia-associated hypotension is primarily an afterload-driven physiological phenomenon

• Vasopressor regimen may need to be modified in women with pre-eclampsia as the degree of hypotension with spinal anesthesia may be less than that in non-pre eclamptic women

Class I, Level A Preventative and treatment strategies for spinal hypotension are well studied and highly evidence-based

Maintain

normothermia**

• Active warming: Example: • In-line IV fluid warmer • Forced air warming

• Consider active warming starting pre-operatively

• Keep the operating room temperature ideally >72oF/22oC (Joint Commission guidance)

Class IIa, Level C-LD

Optimal uterotonic

administration**

• Use the lowest effective dose of uterotonic necessary to achieve adequate uterine tone and minimize side effects

• Consider evidence-based uterotonic administration

• In the case of hemorrhage, transition from ERAC to institutional hemorrhage resuscitation protocol

Class IIa, Level B-R

Antibiotic

prophylaxis** • Antibiotic prophylaxis dosed

prior to skin incision (do not wait until after cord clamping)

• Follow ACOG guidelines Class I, Level A

Intra- and Post-

operative nausea

and vomiting

(IONV/PONV)

prophylaxis and

treatment**

• Prophylactic vasopressor infusion (see above) to decrease hypotension-associated IONV

• The committee agrees that IONV /PONV is a major stressor for the mother and should be avoided. The different etiologies and prevention/treatments for IONV and PONV need to be considered.

Class I, Level B-R for IONV/PONV prophylaxis Class IIb, Level C-LD for uterine exteriorization

• Limit/avoid uterine exteriorization and abdominal saline irrigation by surgeon

• Combination of at least 2 prophylactic IV antiemetics with different mechanisms of action. Examples: • 5HT3 antagonist (e.g.

ondansetron 4 mg) • Glucocorticoid (e.g.

dexamethasone 4 mg) • D2 receptors antagonist (e.g.

metoclopramide 10 mg)

• Limiting/avoid uterine exteriorization which is associated with IONV and delayed bowel function recovery

• Abdominal saline irrigation may worsen IONV and PONV

• Dexamethasone is effective for PONV not IONV due to delayed onset of action

• Metoclopramide is effective for IONV but not PONV

Initiate multimodal

analgesia**

Neuraxial long-acting opioid Example: • IT morphine 50-150 mcg or • Epidural morphine 1-3 mg

Non-opioid analgesia started in the operating room unless contraindicated:

1. Ketorolac 15-30 mg IV after peritoneum closed

2. Acetaminophen IV after delivery or PO before or after delivery

Consider local anesthetic (continuous) wound infiltration or regional blocks (e.g. transversus abdominis plane block (TAP), quadratus lumborum block (QLB))

• Use neuraxial doses consistent with SOAP Center of Excellence criteria Link: https://soap.org/grants/center-of-excellence/

• Non-opioid analgesia ideally started prior to the onset of pain

• Rectal acetaminophen may be an alternative but has lower/less reliable bioavailability

• The role of wound infiltrations and other regional blocks for post- cesarean pain should be considered in select cases, for example in women who could not receive neuraxial morphine or other multimodal analgesia regimen components, or patients at risk for severe pain.

Class I; Level A High level of evidence for neuraxial morphine, NSAIDs and acetaminophen. Data to support pre-emptive analgesia in cesarean delivery are limited

Promote

breastfeeding and

maternal-infant

bonding**

• Skin-to-skin contact should occur as soon as possible in the operating room as appropriate based on maternal/neonatal condition

• May require additional nurse support intraoperatively.

• Follow your institutions guideline for safe positioning for the newborn while skin-to-skin)

• Must be primary responsibility of non-anesthesia care team member

• Skin-to-skin intraoperatively supports the “golden hour” of breastfeeding initiation within one hour of birth

• Facilitates mother-infant bonding • Suggested techniques to facilitate

skin-to-skin intraoperatively include moving electrocardiogram leads and electrodes to the patients back to clear space on the chest; moving equipment to allow nursing personnel space to safely

Class IIa, Level B-R

accomplish skin-to-skin; maintain efforts to keep maternal/neonatal temperature (e.g. forced air warmer, warmed blanket)

Delayed cord clamping

• ACOG recommends delay in umbilical cord clamping in vigorous term and preterm infants for at least 30-60 seconds after birth

• Benefits: Term: Improved iron stores, developmental benefits; Preterm: Improved transitional circulation, reduced need for transfusion, lower risk of necrotizing enterocolitis and intraventricular hemorrhage

• Does not increase maternal risk for blood loss or transfusion

• The administration of oxytocin should be started after the delivery of the baby

• The ability to provide delayed cord clamping may vary among institutions and settings

• Delayed cord clamping should be deferred in certain situations (e.g. maternal instability, fetal/neonatal need for immediate resuscitation; see ACOG opinion 684)

Class I, Level B-R

Legend: **= Core ERAC Element ERAC= Enhanced Recovery After Cesarean, SOAP= The Society for Obstetric Anesthesia and Perinatology, ASA= The American Society of Anesthesiologist, ACOG= The American College of Obstetricians and Gynecologists, ACCP= American College of Clinical Pharmacy, ACC= American College of Cardiology, AHA= American Heart Association, WHO= World Health Organization, UNICEF= United Nations International Children's Emergency Fund, TAP= Transversus Abdominal Plane Block, QLB= Quadratus Lumborum Block, NSAID= Nonsteroidal Anti-Inflammatory Drugs, PACU= Post-Anesthesia Care Unit, IONV= Intra-Operative Nausea and Vomiting, PONV= Post-Operative Nausea and Vomiting, post-OP= Postoperative, IV= Intravenous, PO= By Mouth, e.g.= For Example, PRN= When Necessary, g= Gram, mg=Milligram, mcg= Microgram, mL=Milliliter, dL= Deciliter, L= Liter, oF= Degree Fahrenheit, sec=Seconds, min= Minutes, hrs= Hours

Postoperative ERAC Elements

Table 3 lists both core and recommended postoperative elements for ERAC. The aims of these postoperative elements include minimizing post-cesarean metabolic stress by early feeding, promoting early mobilization by providing multimodal analgesia, removing physical early mobilization barriers, and facilitating hospital discharge. Table 3: Post-Operative Elements

Recommendation

Action

Comments

Level of Evidence

Early oral intake** • Ice chips and/or water within 60 min of admission to PACU

• Heparin/saline lock the IV early once oxytocin infusion complete, tolerating fluids and urine output adequate

• Advance to regular diet ideally within 4 hrs post cesarean, as tolerated

Early oral intake leads to: • Accelerated return of bowel function • Reduced hospital length of stay • No increased rates of complication • No increased risk of postoperative nausea

or vomiting • Reduced postoperative catabolism • Improved insulin sensitivity • Reduced surgical stress response

Class IIb, Level C-EO Low level of evidence in the cesarean delivery setting

Glycemic Control • Patient with diabetes should ideally be scheduled as the first case of day

• Maintain normoglycemia (<180-200 mg/dL); check maternal/neonatal glucose as per hospital protocol

• Hyperglycemia (>180-200 mg/dL) is associated with poor outcomes including infection and delayed wound healing

Class I, Level B-R

Early mobilization** • Ambulation should occur soon after return of motor function

Examples: 0-8hrs Post-op:

• Sit on edge of bed • Out of bed to chair • Ambulation as tolerated

8-24hrs Post-op: • Ambulation as tolerated • Walk: 1-2 times (or

more) in hall 24-48hrs Post-op:

• Walk: 3-4 times (or more) in hall

• Out of bed for 8 hrs

Early mobilization decreases: • Insulin resistance • Muscle atrophy • Hypoxia • Venous thromboembolism • Length of stay

Ambulate only after adequate return of motor function Remove barriers to early mobilization: • Intravenous lines and poles • Urinary catheters • Poor pain control • Sedation • PONV • Dizziness • Slow block regression

Class I, Level B-NR

Promotion of resting

periods**

• Optimize sleep and rest • Limit unnecessary

interruptions Example: clustered interventions (e.g. vital signs assessments in coordination

• Fatigue potentially negatively impacts cognitive function, increase depression, worsen pain, impair maternal-infant bonding, and may increase risk of respiratory depression

Class IIb, Level C-LD

with analgesic administration; time scheduled oral analgesics (e.g., NSAIDs and acetaminophen) together

• Follow appropriate postoperative monitoring

• See SOAP neuraxial morphine monitoring consensus statement: Link: https://soap.org/neuraxial-morphine-consensus-statement.php

Promotion of return of bowel function

• Minimize opioid consumption

• Consider chewing gum

• Availability of multiple PRN bowel medications for example: Docusate (Colace®), Polyethylene glycol 3350 (Miralax®), Simethicone (Gas Relief®)

• Remove barriers to recovery and mobilization

Class IIb, Level C-EO Low level of evidence in the cesarean delivery setting

Early urinary

catheter removal**

• Urinary catheter should be removed by 6-12 hrs postpartum

• Construct protocols to establish criteria for appropriate removal, and to manage post-catheter removal urinary retention

Benefits include: • Improved ambulation • Shorter length of stay • Lower rates of symptomatic urinary

tract infections Earlier catheter removal may be associated with higher rates of urinary retention and need for re-catheterization The dose of neuraxial local anesthetic and opioid can prolong catheter removal time

Class IIb, Level C-EO Limited evidence in the or cesarean delivery setting

Venous

thromboembolism

prophylaxis**

Follow institutional practices as per ACOG and ACCP guidelines

• Cesarean delivery approximately doubles the risk of venous thromboembolism, but in otherwise healthy patients the absolute risk is low

• ACOG recommends mechanical thromboembolism prophylaxis for all women not already receiving pharmacologic thromboprophylaxis

•

Class IIa, Level B-NR

Multimodal

analgesia**

Multimodal analgesia protocols include: • Low dose long-acting

neuraxial opioid such as morphine (see above)

• Scheduled non-steroidal anti-inflammatory drugs (NSAID)

• Scheduled acetaminophen • Local anesthetic techniques

as indicated

Example: • Acetaminophen 650 mg-

1000 mg every 6 hrs scheduled

• Ibuprofen 600 mg every 6 hrs scheduled after IV Ketorolac

Multimodal analgesia should be used to: • Reduce pain • Improve mobilization • Limit IV opioids in recovery • Reduce in-hospital opioid use • Decrease opioid use after discharge Opioids are associated with nausea/vomiting, sedation, fatigue, ileus, constipation, misuse/addiction risk • Multimodal analgesia (including NSAIDs

+ acetaminophen) decrease opioid use/side effects by 30-50%

• See SOAP Center of Excellence criteria Link: https://soap.org/grants/center-of-excellence/

• Expectation Management (see Patient Handout 1 and 2 for an example)

Class I; Level A High level of evidence for neuraxial morphine, NSAIDs and acetaminophen.

15-30 mg given after delivery in operating room (see above), or other NSAIDs (e.g. naproxen 500 mg PO every 12 hrs)

• Oxycodone 2.5 -5 mg PO every 4 hrs PRN pain

• Pre-emptive or rescue supplemental regional blocks as indicated (see comments)

• Peripheral nerve blocks (e.g. TAP or QLB), and continuous wound infiltration if available when neuraxial morphine cannot be given, or as a rescue technique when severe breakthrough postoperative pain

• TAP block does not provide significant improvement when given in addition to neuraxial morphine and scheduled NSAID plus acetaminophen

• Gabapentinoids have limited benefit as routine analgesic after cesarean but may be appropriate in select patients; use caution in patients on methadone or other QT interval prolonging medications in the electrocardiogram

Facilitate early

discharge**

• Standardize discharge planning and coordinate care should start pre-operatively

• Use metrics to monitor patient progress in meeting early discharge criteria

• Establish patient-oriented goals early • Discharge planning on postoperative

day 1 should ideally include pediatric, lactation and contraceptive planning

• Consider personalize and patient-centered opioid prescribing at discharge

Class IIb, Level C-EO

Anemia

remediation**

• Screen and treat anemia • Routine hemoglobin check on post-operative day 1 or 2 should be considered in patients experiencing any significant intra operative bleeding

Class IIa, Level B-R

Breastfeeding

support**

• Robust lactation support per institutional guideline

Should start immediately after birth by offering skin-to-skin care and continued throughout hospitalization • Initial skin-to-skin contact should

continue uninterrupted until the completion of the first breastfeeding

• For formula feed infants, initial skin-to-skin contact should continue uninterrupted for at least one hour

• After the initial period of skin-to-skin contact, mothers should be encouraged to continue this type of care as much as possible during their hospital stay

Provide lactation consulting and educational material (Ten steps to successful breastfeeding as documented in the Joint Statement by UNICEF and WHO’s Baby Friendly Hospital Initiative)

Class IIa, Level B-R

Legend: **= Core ERAC Element ERAC= Enhanced Recovery After Cesarean, SOAP= The Society for Obstetric Anesthesia and Perinatology, ASA= The American Society of Anesthesiologist, ACOG= The American College of Obstetricians and Gynecologists, ACCP= American College of Clinical Pharmacy,

ACC= American College of Cardiology, AHA= American Heart Association, WHO= World Health Organization, UNICEF= United Nations International Children's Emergency Fund, TAP= Transversus Abdominal Plane Block, QLB= Quadratus Lumborum Block, NSAID= Nonsteroidal Anti-Inflammatory Drugs, PACU= Post-Anesthesia Care Unit, IONV= Intra-Operative Nausea and Vomiting, PONV= Post-Operative Nausea and Vomiting, post-OP= Postoperative, IV= Intravenous, PO= By Mouth, e.g.= For Example, PRN= When Necessary, g= Gram, mg=Milligram, mcg= Microgram, mL=Milliliter, dL= Deciliter, L= Liter, oF= Degree Fahrenheit, sec=Seconds, min= Minutes, hrs= Hours

REFERENCES

Background: 1. Mann S, Pratt S, Gluck P, Nielsen P, Risser D, Greenberg P, Marcus R, Goldman M, Shapiro D, Pearlman M,

Sachs B: Assessing quality obstetrical care: development of standardized measures. Jt Comm J Qual Patient Saf 2006 Sep;32(9):497-505

2. Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, Gorlin JB, Lagrew DC, Levy BS; National Parternship for Maternal Safety; Council for Patient Safety in Women's Health Care: National Partnership for Maternal Safety: consensus bundle on obstetric hemorrhage. Anesth Analg 2015 Jul;121(1):142-8

3. Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, Gorlin JB, Lagrew DC, Levy BS; National Partnership for Maternal Safety; Council on Patient Safety in Women's Health Care: National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. Obstet Gynecol 2015 Jul;126(1):155-62

Class of Recommendations and Level of Evidence: 1. Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA,

Gentile F, Gidding S, Hlatky MA, Ikonomidis J, Joglar J, Pressler SJ, Wijeysundera DN.: Further Evolution of the ACC/AHA Clinical Practice Guideline Recommendation Classification System: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2016 Apr 5;133(14):1426-8.

Preoperative ERAC: 1. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk

of Pulmonary Aspiration: Application to Healthy Patients Undergoing ElectiveProcedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017 Mar;126(3):376-393.

2. Thiele RH, Raghumathan K, Brudney CS, et al. for the Perioperative Quality Initiative (POQI) Workgroup: American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Periop Medicine 2016; 5:24

3. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology 2016;124:270-300.

4. American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures, An updated report. Anesthesiology 2017; 126:376–93.

5. Recommendations to prevent and control iron deficiency anemia in the United States. Center for Disease Control and Prevention. MMWR Recom. Rep 1998; 47:1-29.

6. ACOG Practice Bulletin No. 95: anemia in pregnancy. Obstet Gynecol 2008;112:201 7. Butwick AJ, Walsh EM, Euzniewicz M, et al: Patterns and predictors of severe postpartum anemia after

cesarean section. Transfusion 2017;57:36-44. 8. Althoff FC, Neb H, Herrmann E, et al: Multimodal patient blood management program based on a three-

pillar strategy: a systematic review and meta-analysis. Ann Surg 2018. PMID 30418206

9. Sheikh M, Hantoushzadeh S, Shariat M, et al: The efficacy of early iron supplementation on postpartum depression, a randomized double-blind placebo-controlled trial. Eur J Nutr 2017;56:901-908

10. Sultan P, Bampoe S, Shah R, et al: Oral versus intravenous iron therapy for postpartum anemia: A systematic review and meta-analysis. Am J Obstet Gynecol 2019 [epub ahead of print] doi: 10.1016/j.ajog.2018.12.016

11. Chang CW, Shih SC, Wang HY, et al: Meta-analysis: The effect of patient education on bowel preparation for colonoscopy. Endosc Int Open 2015;3: 646-52

12. Claus D, Coudeyre E, Chazal J, et al: An evidence-based information booklet helps reduce fear-avoidance beliefs after first-time discectomy for disc prolapse. Ann Phys Rehabil Med 2017;60(2):68-73

13. Levinson W, Roter DL, et al: Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277:553-9.

14. Love EM, Manalo IF, Chen SC, Chen KH, Stoff BK: A video-based educational pilot for basal cell carcinoma (BCC) treatment: A randomized controlled trial. J Am Acad Dermatol 2016;74(3):477-83e7

15. ACOG Committee Opinion No. 756: Optimizing Support for Breastfeeding as Part of Obstetric Practice. Obstet Gynecol 2018; 132:e187-e196

16. Breastfeeding and the use of human milk. Section on breastfeeding. Pediatrics 2012;129:e827–41 17. Association of Women’s Health, Obstetric and Neonatal Nurses: Breastfeeding support: preconception care

through the first year. 3rd ed. Washington, DC: AWHONN; 2015 18. American College of Obstetricians and Gynecologists: Breastfeeding in underserved women: increasing

initiation and continuation of breastfeeding. Committee Opinion No. 570. Obstet Gynecol 2013;122:423–8 19. Moore ER, Bergman N, Anderson GC, Medley N: Early skin-to-skin contact for mothers and their healthy

newborn infants. The Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub4

20. DiGirolamo AM, Grummer-Strawn LM, Fein SB: Effect of maternity-care practices on breastfeeding. Pediatrics 2008;122(suppl 2):43

21. Hung KJ, Berg O: Early skin-to-skin after cesarean to improve breastfeeding. MCN Am J Matern Child Nurs 2011;36:6

Intraoperative ERAC References: 1. Sultan P, Habib AS, Cho Y, Carvalho B: The Effect of patient warming during Caesarean delivery on maternal

and neonatal outcomes: a meta-analysis. Br J Anaesth 2015;115(4):500-10 2. Kollmann M, Aldrian L, Scheuchenegger A, et al.: Early skin-to-skin contact after cesarean section: A

randomized clinical pilot study. PLoS ONE 2017;12(2):e0168783 3. Gode F, Okyay RE, Saatli B, et al: Comparison of uterine exteriorization and in situ repair during cesarean

sections. Arch Gynecol Obstet 2012;285(6):1541-5 4. Kovacheva VP, Soens MA, Tsen LC: A Randomized, Double-blinded Trial of a "Rule of Threes" Algorithm

versus Continuous Infusion of Oxytocin during Elective Cesarean Delivery. Anesthesiology. 2015 Jul;123(1):92-100.

5. Dyer RA, van Dyk D, Dresner A.: The use of uterotonic drugs during caesarean section. Int J Obstet Anesth. 2010 Jul;19(3):313-9.

6. Tita AT, Szychowski JM, Boggess K, Saade G, Longo S, Clark E, Esplin S, Cleary K, Wapner R, Letson K, Owens M, Abramovici A, Ambalavanan N, Cutter G, Andrews W; C/SOAP Trial Consortium: Azithro for labor to cesarean-Adjunctive Azithromycin Prophylaxis for Cesarean Delivery. N Engl J Med 2016;375(13):1231-41

7. El-Khayat W, Elsharkawi M, Hassan A: A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery. Int J Gynaecol Obstet 2014;127(2):163-6

8. Coutinho IC, Ramos de Amorim MM, Katz L, Bandeira de Ferraz AA: Uterine exteriorization compared with in situ repair at cesarean delivery: a randomized controlled trial. Obstet Gynecol 2008;111(3):639-47

9. Nafisi S: Influence of uterine exteriorization versus in situ repair on post-Cesarean maternal pain: a randomized trial. Int J Obstet Anesth 2007;16(2):135-8

10. Zaphiratos V, George RB, Boyd JC, Habib AS: Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis. Can J Anaesth 2015;62(11):1209-20

11. Siddiqui M, Goldszmidt E, Fallah S, Kingdom J, Windrim R, Carvalho JC.: Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial. Obstet Gynecol. 2007 Sep;110(3):570-5.

12. Habib AS, George RB, McKeen DM, White WD, Ituk US, Megalla SA, Allen TK.: Antiemetics added to phenylephrine infusion during cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2013 Mar;121(3):615-23.

13. ACOG Practice Bulletin No. 199: Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol 2018;132(3):e103-e119

14. Viney R, Isaacs C, Chelmow D.: Intra-abdominal irrigation at cesarean delivery: a randomized controlled trial. Obstet Gynecol. 2012 Jun;119(6):1106-11.

15. Eke AC, Shukr GH, Chaalan TT, Nashif SK, Eleje GU.: Intra-abdominal saline irrigation at cesarean section: a systematic review and meta-analysis. J Matern Fetal Neonatal Med. 2016;29(10):1588-94.

16. ACOG Committee Opinion No. 684: Delayed Umbilical Cord Clamping After Birth. Obstet Gynecol 2017;129(1):e5-e10

17. Carvalho B, Butwick AJ.: Postcesarean delivery analgesia. Best Pract Res Clin Anaesthesiol. 2017 Mar;31(1):69-79

18. Eandi M, Viano I, Ricci Gamalero S.: Absolute bioavailability of paracetamol after oral or rectal administration in healthy volunteers. Arzneimittelforschung. 1984;34(8):903-7.

Postoperative ERAC References: Postoperative Oral Intake: 1. Huang H, Wang H, He M.: Early oral feeding compared with delayed oral feeding after cesarean section: a

meta-analysis. J Matern Fetal Neonatal Med. 2016;29(3):423-9. 2. Charoenkwan K, Phillipson G, Vutyavanich T: Early versus delayed (traditional) oral fluids and food for

reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev 2007;(4):CD004508

3. Minig L, Biffi R, et al: Reduction of postoperative complication rate with the use of early oral feeding in gyecnologic oncologic patients undergoing a major surgery: a randomized controlled trial. Ann Surg Oncol 2009;16:3101-3110

4. Minig L, Biffi R, et al: Early oral versus “Traditional” postoperative feeding in gynecologic oncology patients undergoing intestinal resection: a randomized controlled trial. Ann Surg Oncol 2009;16:1660-68

5. Schilder JM, Hurteau JA, et al: A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecol Oncol 1997; 67:235-40

6. Gillis C, Carli F: Promoting Perioperative Metabolic and Nutritional Care. Anesthesiology 2015;123(6):1455-72

7. Thiele RH, Raghunathan K, Brudney CS, et al: American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med (Lond) 2016;5:24

Perioperative Glycemia Management: 8. Kiram RP, Turina M et al: The clinical significant of an elevated postoperative glucose value in nondiabetic

patients after colorectal surgery: evidence for the need for tight glucose control? Ann Surg 2013;258:599-604

9. Ramos M, Khalpey Z et al: Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg 2008;248:585-591

10. Qaseem A, Humphrey LL, et al: Clinical Guidelines Committee of the American College of Physicians. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2011;154:260-267

Postoperative Mobilization: 11. Kehlet H, Wilmore DW, et al: Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-

641 12. Van der Leeden M, Hufjsmans R, et al: Early enforced mobilisation following surgery for gastrointestinal

cancer: feasibility and outcomes. Physiotherapy 2016;102(1):103-10 13. Liebermann M, Awad M, et al: Ambulation of hospitalized gynecologic surgical patients: a randomized

controlled trial. Obstet Gynecol 2013;121:533-37 14. D'Alton ME, Friedman AM, Smiley RM, Montgomery DM, Paidas MJ, D'Oria R, Frost JL, Hameed AB, Karsnitz

D, Levy BS, Clark SL: National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. Anesth Analg 2016;123(4):942-9

Limiting Interruptions/Interventions: 15. ACOG Committee Opinion No. 766 Summary: Approaches to Limit Intervention During Labor and Birth.

Obstet Gynecol 2019;133(2):406-408 Urinary Decatheterization: 16. Ahmed MR, Sayed Ahmed WA, et al: Timing of urinary catheter removal after uncomplicated total abdominal

hysterectomy: a prospective randomized trial. Eur J Obstet Gynecol Reprod Biol 2014;176:60-63 17. Ind TEJ, Brown R, et al: Midnight removal of urinary catheters- improved outcome following gynaecological

surgery. Int Urogynecol J 1993;4:342-5 18. Phipps S, Lim YN, et al: Short term urinary catheter policies following urogenital surgery in adults. Cochrane

Database Syst Rev 2006;(2):CD004374 19. Kuipers PW, Kamphuis ET, van Venrooij GE, et al: Intrathecal opioids and lower urinary tract function: a

urodynamic evaluation. Anesthesiology 2004;100(6):1497-503 Postpartum Analgesia: 20. Niruthisard S, Werawataganon T, et al: Improving the analgesic efficacy of intrathecal morphine with

parecoxib after total abdominal hysterectomy. Anesth Analg 2007;105:822-824 21. Blackburn A, Stevens JD, et al: Balanced alangesia with intravenous ketorolac and patient-controlled

morphine following lower abdominal surgery. J Clinc Anesth 1995;7:103-108 22. Ong CK, Seymour RA, Lirk P, Merry AF: Combining paracetamol (acetaminophen) with nonsteroidal anti-

inflammatory drugs: a qualitative systemic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010;110:1170-79

23. Berger JS, Gonzalez A, Hopkins A, et al: Dose-response of intrathecal morphine with intravenous ketorolac for post-cesarean analgesia: a two-center, prospective, randomized, blinded trial. Int J Obstet Anesth 2016;28:3-11

Discharge Planning: 24. Stergiopoulou A, Birbas K, Katostaras T, Mantas J: The Effect of Interactive Multimedia on Preoperative

Knowledge and Postoperative Recovery of Patients Undergoing Laparoscopic Cholecystectomy. Methods Inf Med 2007;46(4): 406-409

Breastfeeding support: 25. Dumas L, Lepage M, Bystrova K, et al: Influence of skin-to-skin contact and rooming-in on early mother-

infant interaction: A randomised controlled trial. Clin Nurs Res. 2013 Aug;22(3):310-36. 26. Emery JS: Associations of drugs routinely given in labour with breastfeeding at 48 hours: analysis of the

Cardiff Births Survey. BJOG. 2009 Nov;116(12):1622-9 27. Feldman-Winter L, Goldsmith JP: Task force on sudden infant death syndrome. Safe sleep and skin-to-skin

care in the neonatal period for healthy term newborns. Pediatrics. 2016 Sep;138(3) 28. Moore ER, Anderson GC, Bergman N, Dowswell T: Early skin-to-skin contact for mothers and their healthy

newborn infants. Cochrane Database Syst Rev. 2016 Nov 25;11:CD003519 29. Mori R, Khanna R, Pledge D, Nakayama T: Meta-analysis of physiological effects of skin-to-skin contact for

newborns and mothers. Pediatr Int. 2010 Apr;52(2):161-70 30. Ransjö-Arvidson AB, Matthiesen AS, Lilja G, et al: Maternal analgesia during labor disturbs newborn

behavior: effects on breastfeeding, temperature, and crying. Birth. 2001 Mar;28(1):5-12. 31. Righard L, Alade MO: Effect of delivery room routines on success of first breast-feed. Lancet. 1990 Nov

3;336(8723):1105-7 32. https://www.who.int/nutrition/publications/evidence_ten_step_eng.pdf

APPENDICES

For Providers

1. Clinical Guideline Classification System of the American College of Cardiology/ American Heart Association (ACC/AHA)

For Patients (Please Modify Templates Before Use)

2. Enhanced Recovery After Cesarean (ERAC) Infographic 3. Patient Handout 1: Enhanced Recovery After Cesarean (ERAC) Flyer 4. Patient Handout 2: Enhanced Recovery After Cesarean (ERAC) Steps for Faster Recovery After Cesarean

Delivery Table 5. Patient Facing Enhanced Recovery After Cesarean (ERAC) Poster

Welcome to Name of your Hospital

Patient Name:

Room:

Nurse Today:

Admission Date:

Target Discharge Date:

Target Discharge Time:

MOMFirst 24 hours after your surgery:

q Eat and drink within 4 hours after your surgeryq Sit up in bed within 4 hours after your surgeryq Walk within 8 hours after your surgery q Breastfeeding teaching with nurseq Needed blood testsq Talk about birth control with your obstetricianq Walk 4 times a day ! ! ! !

Next days after your surgery:q Obstetric team visit on the day of dischargeq Review home care instructions with nurseq Make sure your prescriptions are ready q Walk 4 times a day ! ! ! !q Talk to your team if you have questions ( for

example contraception questions)

Things To Be Done Before You Go HomeBABY

First 24 hours after your surgery:q Pick a doctor for your babyq Hepatitis B vaccineq Hearing check q Routine blood checksq Oxygen level check

Next days after your surgery:q Complete birth certificate form/social securityq Bring car seat before day of dischargeq Pediatric team visit on day of discharge

Courtesy Lucile Packard Children’s Hospital-Stanford University, Palo Alto, CA

Available Classes and ResourcesBreastfeeding Classes:Time:Place:Car Seat Classes:Time:Place:

What is Enhanced Recovery after Cesarean Section (ERAC)?

ERAC is a step by step plan to help you feel better faster after your Cesarean Section. Research has shown this plan helps you to manage your pain better, and help you start eating and moving soon after your surgery.

Spinal Anesthesia

Most scheduled Cesarean Sections are done with a spinal or combined spinal-epidural anesthetic.

The spinal medicine will make your body go numb from your chest down through your legs. The surgery will not start until you are numb. It is normal to feel some pressure and tugging during your Cesarean Section, but you will feel minimal to no pain. Let you anesthesia provider know if you fell any pain or discomfort.

How is a Spinal Anesthesia given?

A numbing medicine will be placed on your back where the anesthetic will be placed. If you feel discomfort, more numbing will be given. You may feel pressure when the medicine is given, but it should not be painful. After a few minutes your legs will start to feel numb.

Frequently asked questions

How long will I be in the Hospital?If you have Cesarean Section, you will be in the hospital for around 3 days. Women with complications might need to stay longer.

I am very nervous about my Cesarean Section, can I be asleep for it?Spinal anesthesia is safer. General anesthesia, or being asleep for your Cesarean Section, has risks for mom and baby and is usually reserved for emergencies.

Can my partner stay with me during my Cesarean Section?Yes, your partner can stay with you during your Cesarean Section. If there is an emergency your partner will be escorted out of the operation room, so the anesthesia team can focus on taking care of you.

Can I still hold my baby to my chest if I am having a Cesarean Section?Yes. Doctors will check your baby right after birth and if s/he is doing well, and it is a safe time during surgery, the baby will be brought to you for skin-to-skin.

Recovery After your Cesarean Section

Patient HandoutEnhanced Recovery after Cesarean Section (ERAC)

Resources

Labor and Delivery

Add Phone Number

Breastfeeding Class

Add Details

Car Seat Class Add DetailsCourtesy Lucile Packard Children’s Hospital-Stanford University, Palo Alto, CA

Enhance Recovery After Cesarean (ERAC) Patient Handout 2

Steps for Faster Recovery After Cesarean Delivery

Before Delivery Just before and during your Cesarean Delivery

First 24 hours after your surgery

24 hours before your hospital discharge

Pain control

Take medicines as instructed by your anesthesia and obstetric providers

You will receive spinal or epidural anesthesia for your Cesarean delivery

Take pain medicines as directed If needed, ask for medicines for itching, nausea and shivering

Take pain medicines as directed Continue skin-to-skin contact with your baby

Skin care Don’t shave pubic hair the day before or day of your Cesarean Shower or bathe and wait until you are completely dry before using the disinfectant wipes night before surgery

Do not touch your incision site

Bandage over incision is removed You may shower or bathe Follow wound care instructions

Eating and drinking

You may eat until 6-8 hours before your Cesarean delivery You may drink clear liquid (water) or a carbohydrate-containing drink up to 2 hours before surgery

You may start chewing gum while in recovery You may eat and drink as soon as you feel you are ready

Eat healthy foods, that are easy to digest Drink 8-10 large glasses of water each day

Activity Normal

With the assistance of your nurse: Sit up in bed within 4 hours after surgery Walk within 8 hours after surgery Walk at least 4 times every day

Walk at least 4 times every day Don’t lift anything heavier than your baby

Breastfeeding

Discuss breastfeeding with your care team If you plan to pump at home plan for it

Communicate your breastfeeding preference with your care team Ask for lactation support and inform yourself how to hand express to help stimulate your milk supply

Start breastfeeding as soon as possible after birth Breastfeed at least every 3 hours or more often if baby is hungry Your nurse and lactation services can address any question you have Try attend a breastfeeding class

Breastfeed at least every 3 hours or more often if baby is hungry

Other Steps

Don’t smoke as smoking may delay your recovery from surgery Talk to your doctor about programs to stop smoking

Review discharge instructions Schedule follow-up appointments with your obstetric provider and pediatrician

•ERAC CORE ELEMENTS•Limit fasting interval•Non-particulate liquid-carbohydrate loading

•Patient education•ERAC RECOMMENDED ELEMENTS•Lactation/ breastfeeding preparation and support

•Hemoglobin optimization

Pre-op

•ERAC CORE ELEMENT•Prevent spinal anesthesia induced hypotension

•Maintain normothermia•Antibiotic prophylaxis•Intra and postoperative nausea and vomiting prophylaxis

•Initiate multimodal analgesia•Promote breastfeeding and maternal -newborn bonding

•Optimal uteroronic adminstration•ERAC RECOMMENDED ELEMENTS•Intravenous fluid optimization•Delayed cord clamping

Intra-op •ERAC CORE ELEMENTS•Early oral intake•Early mobilization•Promotion of resting period•Early urinary catheter removal

•Multimodal analgesia•Facilitate early discharge•Venous thromboembolism prophylaxis

•Anemia remediation •Breastfeeding support

•ERAC RECOMMENDED ELEMENTS•Glycemic control•Promotion of return of bowel function

Post-opOAP