Guidelines for Postoperative Care in Cesarean Delivery: Enhanced Recovery After Surgery (ERAS) Society Recommendations (Part 3)

TL;DR: This special report focused on the period beginning 30 to 60 minutes before the start of the procedure (decision to operate) and ending at hospital discharge, and created recommendations based on clinical evidence that allow physicians to learn, modify, and improve their care processes, leading to improved patient health outcomes.

Abstract: T his is the second document in a series of 3 focused on the Enhanced Recovery After Surgery (ERAS) care program, specifically in regards to cesarean delivery (CD) and its intraoperative care. ERAS has both clinical benefits (decreased length of stay, complications, and readmissions) and decreased cost of care. This special report focused on the period beginning 30 to 60 minutes before the start of the procedure (decision to operate) and ending at hospital discharge. The ERAS CD program provides audit and feedback cycles for both scheduled and unscheduled CD, and creates recommendations based on clinical evidence that allow physicians to learn, modify, and improve their care processes, leading to improved patient health outcomes. The ERAS Society author group was assembled in May 2017, topics were allocated to specific authors depending on expertise, and a literature search was conducted (1966-2017). Embase and Pubmed were searched for meta-analyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series. Search terms included cesarean section, CD, cesarean section delivery, and all intraoperative ERAS items. Articles were screened by individual authors and then graded for quality via the Grading of Recommendations, Assessment, Development and Evaluation system (high, moderate, low, and very low quality). Final recommendations were then created and any discrepancies were resolved by lead and senior authors (A.B.C. and R.D.W.). The recommendations focused on preoperative antimicrobial prophylaxis and skin preparation (wound preparation, vaginal preparation), preoperative and intraoperative anesthetic management, prevention of intraoperative hypothermia, CD surgical techniques and considerations (surgical incision, repair of incision), perioperative fluid management, and immediate care of the newborn infant. Routine intravenous antibiotics, such as a first-generation cephalosporin, are administered within 60 minutes before CD skin incision. Cochrane reviews have reported significant reduction in composite maternal infectious morbidity with this practice (risk ratio, 0.57; 95% confidence interval, 0.45-0.72). Women in labor or with ruptured membranes may also receive azithromycin, as there is strong evidence that azithromycin significantly reduces postoperative infections (P<0.001). For wound preparation, chlorhexidine-alcohol is preferred over an aqueous povidone-iodine solution (strong evidence). For vaginal preparations, a povidone-iodine solution can be considered to reduce infection, but the evidence supporting this practice is only moderate (recommendation grade: weak). Recommendations for surgical technique include blunt expansion of the transverse uterine hysterotomy, closure of the hysterotomy in 2 layers, nonclosure of the peritoneum, reapproximation of the tissue layer in women with ≥2 cm subcutaneous tissue, and use of a subcuticular suture to reduce wound separation. However, it is of note that the evidence levels are moderate and the recommendation grades are weak for all of these interventions. Regional anesthesia is the preferred method for CD over general anesthesia. Regional anesthesia improves pain control, organ function, mobility, and postoperative nausea and vomiting and also lowers risks of blood loss and postoperative sedation (recommendation grade: strong). Perioperative hypothermia occurs in 50% to 80% of patients undergoing spinal anesthesia for CD. In addition to monitoring patient temperature, forced air warming, intravenous fluid warming, and increasing operating room temperature can help to prevent hypothermia during CD (recommendation grade: strong). Euvolemia preoperatively and intraoperatively are associated with improved maternal and neonatal outcomes. Neonatal care should consist of delayed cord clamping by at least 1 minute for term delivery and at least 30 seconds for a preterm delivery, maintenance of neonate body temperature between 36.5°C and 37.5°C after birth, avoidance of routine airway suctioning (suctioning should be used only in cases of obstructed airway) and supplementation of room air as inspired air with oxygen may be associated with harm, and availability of immediate neonatal resuscitation procedures. The grades of all the neonatal recommendations are strong. The frequency of CD in the United States increased from 4.5% in 1970 to 31.9% in 2015, and is the most common surgery performed in the country. Multiple repeat CDs carry increasing risks for complications such as wound and uterine hematoma, placenta previa, blood transfusion, etc. Therefore, it is essential that CD pathways are well understood, evaluated, and optimized by maternity care teams. In this special report, a focused ERAS CD pathway clinical audit tool has been created composed of 5 preoperative, 4 intraoperative, and 9 postoperative focused elements. Clinicians should adopt and incorporate these into best practices, with the ultimate goal of reducing costs and risks while improving resources and maternal and neonatal outcomes.