Guidelines for Antenatal and Pre-operative care in Cesarean Delivery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations (Part 1).
Am J Obstet Gynecol. 2018 Sep 18;:
Authors: Wilson RD, Caughey AB, Wood SL, Macones GA, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G
OBJECTIVE: This ERAS Guideline for perioperative care in Cesarean Delivery (CD) will provide best practice, evidenced-based, recommendations for pre-operative, intra-operative, and post-operative phases with primarily, a maternal focus. The 'focused' pathway process for scheduled and unscheduled CD, for this ERAS CD guideline will consider, from 'decision to operate (starting with the 30 - 60 minutes prior to skin incision) to hospital discharge'.
METHODS: The literature search (1966-2017) used Embase and PubMed to search medical subject headings including "Cesarean Section", "Cesarean Section", "Cesarean Section Delivery" and all pre- and intra-operative ERAS® items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Meta-analyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence and recommendations were evaluated according to the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) as used and described in previous ERAS® Guidelines.
RESULTS: The ERAS Cesarean Delivery guideline / pathway has created a maternal FOCUSED Pathway (for scheduled and unscheduled surgery starting from 30-60 minutes prior to skin incision to maternal discharge) with ERAS CD consensus recommendations pre-operative elements (anesthetic medications, fasting
, carbohydrate supplementation, prophylactic antibiotics /skin preparation, ); intra-operative elements (anesthetic management, maternal hypothermia prevention, surgical technique (hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), peri-operative fluid management) and post-operative elements (chewing gum
, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, timing of maternal and neonate discharge). Limited topics for optimized care are discussed for antenatal education and counselling and the immediate neonatal needs at delivery. Strong recommendations for element use were given for pre-operative (antenatal education and counselling, use of antacids and histamine H2 receptor antagonists, 2 hour fasting
and small meal within 6 hours surgery ; antimicrobial prophylaxis and skin preparation / chlorhexidine-alcohol); intra-operative (regional anesthesia, prevention of maternal hypothermia (forced warm air, warmed IV fluids, room temperature), peri-operative fluid management for euvolemia, neonatal immediate care needs including delayed cord clamping), and post-operative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with NSAIDs/ Paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for VTE prophylaxis, immediate removal of urinary catheter). Recommendations against the element use was made for pre-operative (maternal sedation, bowel preparation), intra-operative (neonatal oral suctioning or increased inspired oxygen), and post-operative (heparin should not be used routinely VTE prophylaxis).
CONCLUSION: As these ERAS Cesarean Delivery pathway recommendations (elements / processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.
PMID: 30240657 [PubMed - as supplied by publisher]