Special Report
Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

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This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30–60 minutes before skin incision) to hospital discharge. The literature search (1966–2017) used Embase and PubMed to search medical subject headings that included “Cesarean Section,” “Cesarean Section,” “Cesarean Section Delivery” and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30–60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (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), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because 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.

Section snippets

Literature search

The author group was selected and vetted by the ERAS Society Guideline Committee in May 2017 based on international expertise in the area, and a consensus ERAS CD–enhanced recovery topic list was determined. The ERAS Gynecologic/Oncology guidelines5, 6 were used as templates; however, several other elements unique to cesarean section delivery were added. After the topics were agreed on, they were then allocated among the group according to expertise. The literature search (1966–2017) used

Antenatal and preoperative ERAS CD topics (Part 1)

The cesarean delivery pathway and the process elements have a wider scope for the maternal antenatal and preoperative-natal care and can be considered within the ERAS CD pathways.

The preoperative pathway is a focused pathway that starts 30–60 minutes before the cesarean incision and ends at maternal (fetal) discharge from hospital, which allows for a more consistent and generalizable ERAS CD process that includes the same comprehensive care to both unscheduled and scheduled cesarean delivery.

An

Comment

In North America, the most common indication to be admitted to hospital is childbirth, and the most common surgery is a cesarean delivery. With this clinical volume of obstetric surgical activity, it seems appropriate that the ERAS process be applied to this surgical care area because there are always ≥2 patients (mother and fetus[es]) impacted.

There are quality, industry-based “Deming Principles” that can be directed toward healthcare process management72: quality improvement is the science of

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    The authors report no conflict of interest.

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