Guidelines for Antenatal and Preoperative care in

Cesarean Delivery: Enhanced Recovery After

Surgery (ERAS) Society Recommendations (Part 1)
R. Douglas Wilson, MD, MSc; Aaron B. Caughey, MD, PhD; Stephen L. Wood, MD; George A. Macones, MD;
Ian J. Wrench, MB ChB, PhD; Jeffrey Huang, MD; Mikael Norman, MD, PhD; Karin Pettersson, MD, PhD;
William J. Fawcett, MBBS, FRCA, FFPMRCA; Medhat M. Shalabi, MD; Amy Metcalfe, PhD;
Leah Gramlich, MD; Gregg Nelson, MD, PhD

E nhanced Recovery After Surgery

(ERAS) is a standardized, periop-
erative care program that now is
This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean de-
livery will provide best practice, evidenced-based, recommendations for preoperative, intra-
embedded firmly within multiple surgi- operative, and postoperative phases with, primarily, a maternal focus. The focused pathway
cal disciplines that include colorectal, process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery
urologic, gynecologic, and hepatobiliary Guideline will consider from the time from decision to operate (starting with the 30 e60 minutes
surgery.1,2 Bisch et al3 reported on the before skin incision) to hospital discharge. The literature search (1966e2017) used
ERAS use in gynecologic oncology with Embase and PubMed to search medical subject headings that included “Cesarean
the conclusion that the systematic Section,” “Cesarean Section,” “Cesarean Section Delivery” and all pre- and intraoperative
implementation of ERAS gynecologic ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers
to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized
oncology guidelines across a healthcare
controlled studies, nonrandomized controlled studies, reviews, and case series were
system improves patient outcomes and
considered for each individual topic. Quality assessment and data analyses that evaluated the
saves resources. ERAS has been shown
quality of evidence and recommendations were evaluated according to the Grading of
to 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 un- scheduled surgery starting from
From the Department of Obstetrics &
Gynecology, Oregon Health & Science
30e60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery
University, Portland, OR (Dr Caughey); the consensus recommendations preoperative elements (anesthetic med- ications, fasting,
Department of Obstetrics & Gynecology, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative
Cumming School of Medicine, University of elements (anesthetic management, maternal hypothermia prevention, surgical technique,
Calgary, Calgary, Alberta, Canada (Drs Wilson, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin
Wood, Metcalfe, and Nelson); the Department closure), perioperative fluid management, and postoperative elements (chewing gum,
of Obstetrics & Gynecology, Washington
University in St Louis, St. Louis, MO (Dr
management of nausea and vomiting, analgesia, timing of food intake, glucose management,
Macones); Sheffield Teaching Hospitals Trust, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal
Royal Hallamshire Hospital, Glossop Road, and neonate discharge). Limited topics for optimized care and for antenatal education and
Sheffield, United Kingdom (Dr Wrench); counselling and the immediate neonatal needs at delivery are discussed. Strong recommen-
University of Central Florida, Orlando, FL (Dr dations for element use were given for preoperative (antenatal education and counselling, use
Huang); the Divisions of Pediatrics (Dr of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6
Norman)
hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol),
and Obstetrics (Dr Pettersson), Department of
Clinical Science, Intervention and Technology,
intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air,
Karolinska Institutet, Stockholm, Sweden; the warmed intravenous fluids, room temperature]), perioperative (fluid management for
Department of Anaesthesia, Royal Surrey euvolemia and neonatal im- mediate care needs that include delayed cord clamping), and
County Hospital, Egerton Road, Guildford, postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia
United Kingdom (Dr Fawcett); the with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight
Departments of Anesthesiology and Intensive capillary glucose control, pneumatic compression stocking for venous thromboembolism
Care, Alzahra Hospital, Dubai, United Arab
prophylaxis, immediate removal of urinary catheter). Recommendations against the element
Emirates (Dr Shalabi); and the Department of
Medicine, University of Alberta, Edmonton, use were made for preoperative (maternal sedation, bowel preparation), intraoperative
Alberta, Canada (Dr Gramlich). (neonatal oral suctioning or increased inspired ox- ygen), and postoperative (heparin should not
Received April 19, 2018; revised Aug. 13, 2018;
be used routinely venous thromboembolism pro- phylaxis). Because these ERAS cesarean
accepted Sept. 10, 2018. delivery pathway recommendations (elements/ processes) are studied, implemented,
The authors report no conflict of interest.
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
Corresponding author: R. Douglas Wilson, MD,
MSc. [Link]@[Link] recommendation.
0002-9378/$36.00
ª 2018 Elsevier Inc. All rights reserved. Key words: cesarean delivery, enhanced recovery, intraoperative, postoperative, preoper-
[Link] ative, quality, safety

MONTH 2018 American Journal of Obstetrics & Gynecology 1

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 ajog.o Special
the surgical pathway related to cesarean

result in both clinical benefits (re- delivery with, primarily, a maternal

ductions in length of stay, complications, focus. The “focused” pathway process
and readmissions) and health system for scheduled and unscheduled ERAS
benefits (reduction in cost).1e3 CD has been created, for the complete
ERAS is a tool for process manage- ERAS CD Guideline (Parts 1e3), from
ment, creating a focused care process. decision-to-operate (30e60 minutes
The use of audit and feedback allows before skin incision) to hospital
an implementation process, whereby discharge, which includes the immediate
clini- cians are provided with neonatal care. The Appendix (Part 1) has
comparative data to educate, change, additional information that would assist
and decrease the ‘harmful’ clinical providers with optimizing the maternal
variances that are identified in certain antenatal care when comorbidities are
high volume clinical care processes present that may impact maternal and
and procedures. This neonatal heath with additional potential
ERAS process will enhance the quality of operative impact.
care, patient safety, and health outcomes. As a final introduction comment, Panda
ERAS Guideline for perioperative care et al4 researched clinicians’ views of factors
in cesarean delivery will provide for cesarean delivery using systematic re-
evidenced-based practice recommenda- view and metasynthesis of qualitative,
tions for preoperative (Part 1), intra- quantitative, and mixed methods. Three
operative (Part 2), and postoperative main themes were identified: (1)
(Part 3) phases and allow audit assess- clinicians’ personal beliefs, (2) healthcare
ment and measurement of the desired systems (litigation, resources, private vs
outcome. Although certain ERAS prin- public in- surance payments, guidelines,
ciples have been established for other manage-
abdominal/pelvic surgeries,3,4 this pre- ment policy), (3) clinicians’ characteristics
sent ERAS Cesarean Delivery (ERAS (personal convenience, clinicians’ de-
CD) pathway will provide additional mographics, confidence, and skill).
evidenced-based recommendations for Obstetricians and midwives are
directly involved in the decision to
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 Special ajog.o
perform a cesarean delivery, and onceat arecommendations
AJOG Glance indicate that
the decision is made a process with the desirable
Why was this study
evidence-based factorsconducted?
and decreased effects of adherence to a
This ERAS
variance for Society
enhancedGuideline
recovery was created recommendation
is being to support the most commonoutweigh
probably surgical procedure in the industrialized healthcare world, the c
Key Findings
proposed. the undesirable effects, but the panel
The broad ERAS cesarean delivery elements and confident.
is less recommendations (Parts 1e3) break down the surgical delivery process into a “focuse
What does this add to what is known?
Methods
This ERASsearch
Literature Cesarean Delivery Guideline has taken the evidence-based knowledge that has been created from the cesarean delivery res
The author group was selected and
vet- ted by the ERAS Society Guideline
Committee in May 2017 based on in-
ternational expertise in the area, and
a consensus ERAS CDeenhanced
recov- ery topic list was determined.
The ERAS Gynecologic/Oncology
guide- lines5,6 were used as templates;
however, several other elements
unique to cesar- ean section delivery
were added. After the topics were
agreed on, they were then allocated
among the group according to
expertise. The literature search
(1966e2017) used Embase and PubMed
to search medical subject headings
that
included “Cesarean Section,”
“Cesarean Delivery,” “Cesarean
Section Delivery,” and all pre- and
intraoperative ERAS
items. Reference lists of all eligible
arti- cles were crosschecked for other
relevant studies.

Study selection
Titles and abstracts were screened by
in- dividual reviewers to identify
potentially relevant articles.
Metaanalyses, systematic reviews,
randomized controlled studies,
nonrandomized controlled studies, re-
views, and case series were considered
for each individual topic.

Quality assessment and data analyses

The quality of evidence and recom-
mendations were evaluated according
to the Grading of
Recommendations, Assessment,
Development, and Evalua- tion
system,7 as used and described in
previous ERAS Guidelines (Table
1).5e7 Briefly, the following
recommendations are given: Strong
recommendations indicate that the
panel is confident that the desirable
effects of adherence to a
recommendation outweigh the
undesir- able effects. Weak

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 ajog.o Special
Recommendations are based not only on recovery after
TABLE 1
the quality of evidence (high, moderate,
low, and very low) but also on the bal-
Grading of Recommendations, Assessment, Development and Evaluation system f
ance between desirable and undesirable
effects. In some cases strong recom- Rating quality Definition
mendations may be reached from low- Evidence level High quality
quality data and vice versa. The Core
ERAS CD Team (A.B.C., G.A.M., S.L.W., Further research is unlikely to change confidence in estimate
G.N., and R.D.W.) reviewed the evidence of effect
Moderate quality Further research is likely to have important impact on confidence in th
in detail for each section and assigned Further research is very likely to have important impact on confidence
both the recommendation and evidence Any estimate of effect is very uncertain
level. Discrepancies were resolved by the
lead and senior authors. Low quality impact on
confidence estimate Very low quality
Recommendations for each ERAS CD
Recommendation strength
element in pre-/intra-/postoperative Strong
(Parts 1e3) have been identified, dis-
cussed, and agreed upon with the pre- When desirable effects of intervention clearly outweigh the
operative ERAS CD (Part 1) elements undesirable effects or clearly do not
presented in Table 2. When trade-offs are less certain, either because of low quality eviden
Weak

Results
Antenatal and preoperative ERAS Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018.
CD topics (Part 1)
The cesarean delivery pathway and the
process elements have a wider scope for elective cesarean delivery. They identi-
the maternal antenatal and fied 5 clinical protocols with a total of 25
preoperative- natal care and can be clinical components, with 3 (early oral
considered within the ERAS CD intake, mobilization, removal of the
pathways. urinary catheter) of the 25 components
The preoperative pathway is a focused present in all 5 protocols. The Appraisal
pathway that starts 30e60 minutes of Guidelines for Research and Evalua-
before the cesarean incision and ends at tion II scores were generally low. Sys-
maternal (fetal) discharge from hospital, tematic reviews of single components
which allows for a more consistent and identified a reduced length of stay after
generalizable ERAS CD process that in- cesarean delivery of 0.5e1.5 days with
cludes the same comprehensive care to the use of the studied factors (minimally
both unscheduled and scheduled cesar- invasive Joel-Cohen surgical technique,
ean delivery. early catheter removal, postoperative
An antenatal optimized pathway start antibiotic prophylaxis). They concluded
from 10e20 weeks of gestational age that more ERAS CD research is required
with a highlighted clinical process for to evaluate and audit directed pathways
maternity care by a multidisciplinary for enhanced recovery.8
team to support preadmission A 2013 systematic review for cesarean
informa- tion, education, counselling, delivery had the objective to provide an
and maternal comorbidities (ERAS CD updated evidence-based guide for sur-
Expanded Program). Within the clinical gical decisions during the cesarean de-
scenario, there are complex maternity livery.9 Recommendations, with a high
patients who may require an unplanned level of certainty for clinical value, were
cesarean delivery but may need access made for preeskin incision prophylactic
to the team-based optimized antenatal antibiotics, cephalad-caudad blunt
care to minimize the operative risks for uterine extension, spontaneous placental
themselves and their offspring, if surgery removal, and surgeon preference on
is required. uterine exteriorization; single layer
Corso et al8 undertook a rapid uterine closure when future fertility is
review of clinical protocols and an undesired, and suture closure of the
umbrella review of systematic reviews subcutaneous tissue when the thickness
that are related to enhanced
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 Special ajog.o
emergent cesarean

is 2 cm.9 No clinical value was found ≥

for manual cervical dilation for
uterine drainage, subcutaneous
drains in the wound, or maternal
supplemental oxy- gen for the
reduction of infective morbidity.9
These systematic reviews,
subsequent other systematic reviews,
and meta- analyses in the reference
lists have been used in this ERAS CD
Guideline to evaluate the present
status of the previ- ous and new
clinical care factors for the enhanced
quality, safety, and recovery of
pregnant women who require a
cesarean delivery.

Antenatal preadmission information,

education, and counselling (Optimized
Element)
Appropriate antenatal care should
include preparation of pregnant women
and their partners for delivery, which
includes the possibility of either
vaginal or surgical delivery.
Documentation of a preadmission
information and counsel- ling process
should include when the procedure
will occur, the type of pro- cedure, by
whom the information was provided,
and a comment on how the
information was accepted or
understood by the patient.
Additionally, because unscheduled or
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TABLE 2
Guidelines for perioperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society
recommendations
Evidence Recommendation
Item Recommendation level grade
Antenatal pathway: OPTIMIZED
Preadmission information, 1. Although high-quality evidence is lacking, good clinical practice Very Strong
education and counselling includes informing the patient about procedures before, during, and Low-Low
(optimized element) after cesarean delivery. The information should be adapted to whether
cesarean delivery is an unscheduled or is a scheduled surgery.
2. Cesarean delivery without medical indication should not be Very Strong
recommended without a solid preadmission evaluation of harms Low-Low
and benefits, both for the mother and her baby.
Preoperative pathway: FOCUSED
Preanesthetic medications 1. Antacids and histamine H2 receptor antagonists should be Low Strong
(focused elements) administered as premedication to reduce the risk from aspiration
pneumonitis.
2. Preoperative sedation should not be used for scheduled cesarean Low Strong
delivery because of the potential for detrimental effects on the
mother and neonate.
Preoperative bowel preparation 1. Oral or mechanical bowel preparation should not be used before High Strong
(focused element) cesarean delivery.
Preoperative fasting 1. Women should be encouraged to drink clear fluids (pulp-free High Strong
(focused element) juice, coffee, or tea without milk) until 2 hours before surgery.
2. A light meal may be eaten up to 6 hours before surgery. High Strong
Preoperative carbohydrate 1. Oral carbohydrate fluid supplementation, 2 hours before cesarean Low Weak
supplementation delivery, may be offered to nondiabetic women.
(focused element)
Appendix: Preoperative maternal 1. Maternal obesity (body mass index, >40 kg/m2) significantly increases High Strong
comorbidity optimization risks of maternal and fetal complications. Optimal gestational weight gain
(optimized elements) management should be used to control their weight during pregnancy.
Surgical complexity requires multidisciplinary planning.
2. Maternal hypertension should be managed during pregnancy because High Strong
maternal chronic hypertension has been found to increase significantly
the incidence of maternal and fetal morbidity and cesarean delivery.
3. Maternal gestational diabetes mellitus has been found to significantly High Strong
increase the risk for maternal and fetal morbidity. Maternal diabetes
should receive timely and effective management during preconception
and pregnancy.
4. Maternal anemia during pregnancy is associated with low birthweight, Moderate Strong
preterm birth, and increases perioperative morbidity and mortality rates.
The cause of the anemia should be identified and corrected.
5. Maternal cigarette smoking is associated with adverse medical and High Strong
reproductive morbidity and should be stopped before or in early
pregnancy.
Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018.

deliveries can occur with very little should be provided. The information situation, such as to whether the cesar-
lead time, it is important to inform all and recommendations will differ in ean delivery was unscheduled or was a
women about the potential need for a relation to whether there is a clear repeat (indicated/rejected vaginal birth
cesarean delivery and the risks, medical indication for caesarean delivery after cesarean delivery (VBAC) or not a
benefits, and alternatives of the or whether surgery is performed VBAC candidate/not indicated) or pri-
procedure. on maternal request. Maternity and mary cesarean delivery.
In case of a cesarean delivery, infor- support providers should also adapt In an unscheduled cesarean delivery,
mation about the procedure before, their communication to the required the informed consent process demands
during, and after the cesarean delivery
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instructive and reassuring behavior with adapted to whether cesarean delivery is administration of a combination of
clear and essential information to the an unscheduled or is a scheduled surgery antacids (nonparticulate
patient or partner presented by the (Evidence Level: Very Low/Recommen-
attending surgeon, appropriate level dation Grade: Strong). (2) Cesarean
obstetrics trainee, and anesthesiologist. delivery without medical indication
In this unscheduled situation, a short should not be recommended without a
description of the indication for the ce- solid preadmission evaluation of risks
sarean delivery, the recommended type and benefits, both for the mother and
of anesthesia, and the surgical her baby. (Evidence Level: Very Low/
informa- tion related to the procedure Recommendations Grade: Strong).
and its urgency is important. Antenatal optimization of maternal
When a need for neonatal care of comorbidities and their impact on a
the newborn infant is identified and cesarean delivery is beyond the scope of
when time allows, the pregnant this direct and focused ERAS process/
woman and her partner should have pathway guideline. A limited maternal
the option to meet a neonatologist or comorbidity (body mass index, chronic
pediatrician and to visit the neonatal hypertension, diabetes mellitus, iron
unit before the cesarean delivery is deficiency anemia) and a pregnancy
performed. outcome summary are provided in the
Cesarean delivery without a medical Appendix for the interested maternity
indication should not be considered providers because these maternal
without a comprehensive preadmission factors have perinatal and surgical
evaluation of harms and benefits impact.
for both the mother and her baby. 10e13
Information about the increased surgi- Preoperative pathway
cal risk of short-term complications This focused preoperative 30- to 60-
(injuries to the abdominal organs, minute time period is very com-
postoperative infection, thrombosis, and pressed for the women who undergo an
pain)14e17 and the known long-term unscheduled cesarean delivery because
effects (risk of uterine rupture and the scheduled cesarean delivery allows
placental complications in subsequent for an expanded antenatal/preoperative
pregnancies)18e21 should be compared knowledge translation.
with the benefit and risk profile of A checklist for the focused ERAS CD
vaginal delivery as part of the preopera- will allow for the patient and operative
tive counselling. staff to have a summarized version
Short-term outcomes for the of the informed knowledge that the
infant22e25 and associations to longer patient requires and the overall ERAS
term outcomes in childhood21,26e31 CD pre-/intra-/postoperative elements
should be discussed. In an evaluation (Figure 135e39). Some of the pre- and
of longer term outcomes that are asso- intraoperative elements will have a
ciated with scheduled cesarean delivery, different time sequence, which is
it is important to help the pregnant dependent on the individual surgical
woman interpret the relative and abso- team processes, but all elements are
lute risks for different pediatric chronic covered in ERAS CD Parts 1 and 2.
disorders in childhood and young
adulthood that are associated with Preoperative anesthetic medications
cesarean delivery and that, although (Focused Element)
the underlying mechanisms remain to Although rare, aspiration pneumonitis is
be explored, causality has not been still a cause of maternal death during
proved.32e34 anesthesia for a cesarean delivery, even in
well-resourced countries.40 Interven-
Summary and recommendations tions to reduce the risk of aspiration
(1) Although high-quality evidence is pneumonitis, at cesarean delivery, have
lacking, good clinical practice includes been considered.41 Although the
informing the patient about procedures quality of evidence was poor, it was
before, during, and after cesarean found that the preoperative
delivery. The information should be
6 American Journal of Obstetrics & Gynecology MONTH 2018
 ajog.o Special
sodium citrate to neutralize gastric acid) avoided.
and histamine H2 receptor antagonists
(ranitidine act by inhibiting the secretion
of acid into the stomach decreasing both
volume and acidity) was more effective
than no intervention and was superior to
antacids alone in the prevention of low
gastric pH. Although these findings were
for women who had a general anesthetic,
they still have some relevance for cesar-
ean delivery, under regional techniques,
because a proportion of the women may
require conversion to general anesthesia.
The preoperative administration of
gabapentin has been found to improve
postcesarean delivery pain control in
some,42,43 but not all,44 studies. How-
ever, a systematic review of perioperative
gabapentin for postoperative pain man-
agement for a variety of different types of
surgery found little benefit, with an
increased incidence of serious adverse
events.45
One study that considered post-
cesarean delivery maternal sedation
(either scheduled or unscheduled cesar-
ean delivery surgeries) 46 reported more
sedation (self-reported or observer
assessment) after the unscheduled
cesarean delivery surgery. Sedating
medications (fentanyl, midazolam,
meperidine, ketamine) were given more
frequently in the unscheduled cesarean
delivery group for management of
side- effects and breakthrough pain. It
has been suggested that maternal
sedation may delay skin-to-skin contact
between mother and baby and
therefore should be used
judiciously.47
There is little published information
regarding the use of sedative premed-
ication before cesarean delivery. The
administration of benzodiazepines in
pregnancy have been associated with
“floppy baby syndrome,”47,48 disturbed
neonatal thermogenesis,41 and lower
Apgar scores.48 A Cochrane review of
sedative premedication for adult
outpa-
tient surgery found that there was an
impairment in psychomotor function up
to 3 hours after the operation (total
11 studies: 3/11 no effect; 6/11 some
effect; 2/11 significant effect).49
Therefore considering the potential
for maternal and neonatal side-effects,
preoperative sedation should be

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leak. However, a recent metaanalysis, 50

FIGURE which included gynecologic surgery
Checklist for focused Enhanced Recovery After Surgery (ERAS) cesarean trials,51 found no benefit of bowel
delivery patient “informed knowledge” preparation. The only clear effect was to
The patient/maternal has a clear understanding of the following factors: cause a “more unpleasant patient
1. The reason/indication for the cesarean delivery experience.”
2. The location and type of abdominal laparotomy incision There is only 1 small clinical trial of
3. The abdominal skin incision closure technique that is used by the attending mechanical bowel preparation before
surgeon (randomized controlled trial evidence supports subcuticular skin cesarean delivery that did not document
closure for patient satisfaction and cosmetic outcome1) any benefit.52
4. The preventive efforts that are used to minimize postoperative maternal
infective morbidity (wound/uterus/pelvis/bladder); estimated prevalence of 3–
15%2,3 Summary and recommendation. Oral or
5. The patient’ s estimated individualized postoperative risk assessment for mechanical bowel preparation should
thromboembolism and whether additional medical prophylaxis is needed not be used before cesarean delivery
beyond the standard mechanical techniques (elastic stockings or sequential (Evidence Level: High/Recommendation
compression devices); estimated prevalence is 0.5–2.2 per 1000 pregnancies or Grade: Strong).
prevalence of venous thromboembolism ranges from 1–2 per 1000, with 80%
an indication of antepartum deep vein thrombosis and 20–25% an indication of Preoperative fasting (Focused Element)
pulmonary embolism4; pulmonary embolism, 40–60% after delivery5
Preoperative fasting was first described
6. The gastrointestinal/oral intake plans for pre- and postoperative time periods
as a measure to prevent vomiting after
7. The anticipated postoperative activities and locations of mother and baby
the use of ether anesthetics. After a
List of ERAS cesarean delivery elements: syndrome of post-operative aspiration
Preoperative pneumonia was described, it became
1. Anesthetic medications more common to recommend fasting
2. Fasting periods increase from 6 hours to the
3. Carbohydrate supplementation standard “NPO after midnight.”53 A
4. Antimicrobial prophylaxis Cochrane Review concluded that there
5. Skin wash/vaginal preparation to minimize infectious risk
was no increase in the volume or
6. Procedures for prevention of intraoperative hypothermia
Intraoperative
decrease in pH of gastric contents or
1. Pre- and intraoperative anesthetic management an increase in complications with
2. Abdominal/vaginal antimicrobial cleansing shorted preoperative fasting
3. Cesarean delivery surgical techniques (opening-delivery-closure) intervals.54 The European Society of
4. Perioperative fluid management Anaesthesiology Guideline
5. Neonatal immediate care/delayed cord clamping recommended that adults and children
Postoperative should be encouraged to drink clear
1. ERAS sham feeding/chewing gum fluids up to 2 hours before elective
2. Nausea and vomiting management
3. Analgesia
surgery (including cesarean delivery).
4. Perioperative nutritional care/early feeding Solid food should be prohibited for 6
5. Glucose control hours before elective surgery in adults
6. Thromboembolism prevention and children.55 There have been no
7. Early mobilization “fasting” trials in cesarean delivery pa-
8. Urinary drainage management tients, but 2 trials found similar results in
Maternal and neonate discharge patients immediately after delivery.56,57
Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018. Contemporary perioperative guidelines,
which include cesarean delivery, reflects
these data and this approach.55,58e65

Summary and recommendations. (1) effects on the mother and neonate Summary and Recommendations. (1)
Antacids and histamine H2 receptor (Evi- dence Level: Low Women should be encouraged to drink
an- tagonists should be administered as /Recommendation Grade: Strong). clear fluids (pulp-free juice, coffee, or tea
pre- medication to reduce the risk without milk) until to 2 hours before
from aspiration pneumonitis (Evidence Bowel preparation (Focused Element) surgery (Evidence Level: High/Recom-
Level: Low/Recommendation Grade: Preoperative oral and/or mechanical mendation Grade: Strong). (2) A light
Strong). bowel preparation has been used pri- meal may be eaten up to 6 hours
(2) Preoperative sedation should not be marily in colorectal surgery to prevent before surgery (Evidence Level:
used for scheduled cesarean delivery postoperative infection and anastomotic High/Recom- mendation Grade:
because of the potential for detrimental
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Strong).

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Preoperative carbohydrate supplementa-

TABLE 3
tion (Focused Element)
There have been multiple trials of oral
Enhanced Recovery After Surgery (ERAS) for cesarean delivery preoperative mod
carbohydrate supplementation use up to
2 hours before surgery. A Cochrane Nonmodifiable clinical factor Modifiable clinical factors/audit
Re- view found most trials had a high
Maternal age Paternal
risk of bias and that treatment was
associated with only a small reduction in age
the length
of stay (0.3 days) and a decreased time History (obstetrics/medical/ Optimization of selected comorbidities
surgery/body mass index) (hypertension/diabetes mellitus/anemia/smoking) (small
to passage of flatus (0.39 days). for gestational age/large for gestational age/
Overall, postoperative complications stillbirth/preterm birth <34 weeks gestation)
were not changed, and there were no Family history (genetics/birth Surgical pathway (preoperative; intraoperative;
reported cases of aspiration defects/multifactorial disease) postoperative)
pneumonia.66
Gestational weeks 0e20
Patient outcomes may be improved by (chromosomes/birth defects/
a shorter fasting period preceded by pre- miscarriage)
scribed carbohydrate intake.
Postoperative
insulin is preserved by carbohydrate
Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018.
drinks (100 g the night before surgery
and 50 g 2 hours before
surgery/intravenous glucose 5
mg/k/min).67 Metaanalysis of
low-to-moderate quality and small Grade: Weak). childbirth, and the most common sur-
clinical trials indicate more evidence is gery is a cesarean delivery. With this
required to establish benefit.68,69 Comment clinical volume of obstetric surgical ac-
The use of carbohydrate loading, In North America, the most common tivity, it seems appropriate that the ERAS
preoperatively, is controversial and un- indication to be admitted to hospital is process be applied to this surgical care
accepted for pregnant women with ≥ area because there are always 2 patients
dia- betes mellitus. The preoperative use (mother and fetus[es]) impacted.
of carbohydrate loading in the There are quality, industry-based
nonpreg- nant patient with diabetes “Deming Principles” that can be
mellitus was evaluated in a directed toward healthcare process man-
prospective, non- inferiority cohort; agement72: quality improvement is the
preoperative carbo- hydrate loading science of process management; if you
was found to be noninferior to fasting, cannot measure it, you cannot improve it;
and neither group showed superiority managed care means managing the pro-
for preoperative blood glucose cesses of care (not the human resources of
concentration, hypergly- cemia, or care); getting the right data in the right
length of stay.70 format at the right time in the right
Several clinical trials have evaluated hands; and engaging the human health-
carbohydrate supplementation or feed- care resources (physicians, nurses, and
ing in labor to improve labor other allied health professionals). Certain
outcomes. Although ineffective for this significant pregnancy-related factors can
purpose, the practice appears safe. 71 be measured but cannot be modified
There are no trials of oral carbohydrate (Table 3).
supplemen- tation before cesarean The frequency of a cesarean delivery
delivery for either pregnant diabetic or has increased from 4.5% in 1970 to
nondiabetic women. 31.9% in 2015 in the United States. In
response to this increasing surgical ac-
Summary and recommendation. Oral tivity, process change has been initiated,
carbohydrate fluid supplementation, 2 but the clinical care goals have not been
hours before cesarean delivery, may be achieved.73
offered to nondiabetic pregnant women The indications for a cesarean delivery
(Evidence Level: Low/Recommendation were summarized by the Maternal Fetal

10 American Journal of Obstetrics & Gynecology MONTH 2018

ajog.o Special
Medicine Unit Network74: primary in- forceps or vacuum delivery, 3%);
dications (dystocia, 37%; repeat indications (no VBAC attempt,
nonreassuring fetal heart rate, 25%; 82; failed VBAC attempt, 17%; failed
abnormal fetal presentation, 20%; forceps or vacuum delivery, 0.4%).
other, 15%; failed Cesarean delivery has associated risk
and benefit profiles for both
processes of unscheduled or
scheduled surgery. Complications that
are associated with unscheduled
(emergency) care and the time from
decision to incision have been
evaluated.75 The maternal and
neonatal
outcomes were compared for decision
to incision of <30 minutes (1814
patients)
and >30 minutes (994 patients). The
adverse maternal outcomes for decision
to incision of <30 minutes compared
with >30 minutes were endometritis
(11.7%; 13.0%), wound
complication
(1.3%; 0.9%), and operative injury
(0.3%; 0.5%), respectively, in the later
timed cohort. The adverse neonatal
outcomes were 5-minute APGAR 3
≤
(1.0%; 0.9%), umbilical artery pH
<7.0
(4.8%; 1.6%), hypoxic ischemic en-
cephalopathy (0.7%; 0.5%), fetal
death in labor (0.2%; 0%), and
neonatal death with no malformation
(0.4%; 0.1%) and with malformations
(0.4%; 0.3%), respectively. Hypoxic
ischemic enceph- alopathy was the
only significant comparison (P .001)
against the <30- minute delivery ¼
group.
Complications associated with
preg- nancy outcomes after a
scheduled low- risk cesarean delivery
(46,766 patients) and planned vaginal
birth (2,292,420

MONTH 2018 American Journal of Obstetrics & Gynecology 11

 Special ajog.o

patients) have been reported.76 The consent), improved

surgical process and activity measure-
overall maternal morbidity (cesarean
ments of the services provided (Surgical
delivery, 2.23%; vaginal birth, 0.9%) was
Safety Checklist/ERAS/National Surgical
not significant for all comparisons.76
Quality Improvement Program), the
Other investigators have reported a 2-
identification and removal of unjustified
fold increase for cesarean delivery with
system- and human-based variance,
an increased morbidity outcome as the
team building practice (simulation), and
result of puerperal infection, hemor-
the introduction of new training ap-
rhage, and thromboembolism.77,78
proaches and oversight.
Comparisons of multiple repeat ce-
The ERAS CD Guideline/Pathway
sarean deliveries has shown that, after
(Part 1) has initiated a Focused Pathway
the second repeat cesarean delivery, there
(for scheduled and unscheduled surgery
is an increasing risk for wound and
starting from 30e60 minutes before skin
uterine hematoma (4e6%), placenta
incision to maternal discharge) with 4
previa (1e2%), red cell transfusions
focused preoperative elements with 6
(1e4%), hysterectomy (0.5e4%), and
recommendations: 3 recommendations
placenta accrete (0.25e3%).79
are strong for their use, antacids and
Initiatives to reduce the frequency of
histamine H2 receptor antagonists, fast-
cesarean delivery and enhance maternal
ing only 2 hours, and small meal within 6
safety have been proposed.80
hours before surgery; 2 recommenda-
The focused ERAS CD pathway (Parts
tions against their use, maternal sedation,
1e3) will summarize the evidenced-
and bowel preparation, and 1 recom-
based preoperative, intraoperative, and
mendation for antenatal optimized
postoperative clinical care processes.
element (2 strong recommendations for
The ERAS CD (Part 1) Antenatal/Pre-
use; Table 2).
operative recommendations with the
This 3-part ERAS CD Guideline/
level of evidence and the recommenda- Pathway will follow with intraoperative
tion grade are summarized in Table 2. (Part 2) and optimized immediate
Each of the elements or processes within neonatal care elements and post-
the focused ERAS CD pathway has operative (Part 3) to maternal discharge.
the opportunity to be measured, The maternity clinical care process has
compared between services/providers, both normal and complex pathways that
and improved as required. The opti- are dependent on the patient’s a priori
mized ERAS CD elements have a broad obstetric risk, but there are increasing
antenatal clinical scope that add risk management factors for the
complexity, but the management of the maternal and fetal patient that are related
comorbid maternal factors should be to obstetric comorbid medical, genetic,
considered for enhanced outcomes. surgical, and lifestyle factors. More
Quality and safety elements to prospective and quality assessment/
consider, for the creation of a clinical improvement research, evaluation,
audit tool, require that81 (1) the audit, and collaboration will be required
audited pathway has an important for enhancement of the maternal and
impact in terms of costs, resources, or fetal health outcomes, quality, and
risk, (2) strong scientific evidence is
safety. ■
available, and (3) improvements to be
made on the topic in question can be
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69.

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Appendix: Early Recovery After incision is preferred; abdominal skin/pannus
Surgery (ERAS) cesarean delivery (CD): preparation with chlorhexidine wash
Part 1 Pathway and Appendix Table [day of the scheduled cesarean delivery]
1 and no shaving), (2) intraoperative care
ERAS CD: antenatal optimization (review of plan for pannus management
(Optimized Element) and operative field draping; wound care:
Preoperative medical optimization is intravenous antibiotic prophylaxis with
an important clinical goal for better higher dosing; no manual removal of the
surgical outcomes and requires multi- placenta; intraabdominal uterine
disciplinary team-based care. This closure; closure of subcutaneous layer
ERAS CD optimization is directed at >2 cm; minimize creation of dead space
women who are pregnant with a with surgical technique; consider the use
comorbidity and is not directed at an absorbable suture for skin closure; do
preconception care. Evidence supports not use wound drains), and (3) post-
that modifiable clinical factors for the operative care (enhanced postpartum
pregnant woman could include body follow up for wound assessment).
mass index (obesity), preexisting New guidelines for the prevention,
hypertension, preexisting diabetes detection, evaluation, and management
mellitus, and anemia.1,2 Pregnancy- of high blood pressure in adults provide
associated hypertension and diabetes guidance for women with preexisting
mellitus require optimization after hypertension during pregnancy.23,24
diagnosis that is based on severity and First-trimester screening for pre-
gestational age. Although preexist- eclampsia is not considered in this ERAS
ing obesity (body mass index >40 kg/m2 CD optimization.
prevalence of 7%) impacts clinical out- Classification of blood pressure in
comes, it is very difficult to modify adults requires the following values25:
once pregnant.1 Normal: systolic pressure <120 mm
A systematic review (22 review arti- Hg/diastolic pressure <80 mm Hg;
cles, 624 studies) reported that maternal Elevated: systolic pressure range
obesity significantly increased the inci- 120e128mm Hg/diastolic pressure <80
dence of gestational diabetes mellitus mm Hg;
(GDM), hypertension, preeclampsia, Hypertension: stage 1 systolic
depression, cesarean delivery, and 130e139 mm Hg/diastolic 80e89 mm
infection.10 In addition, the study Hg; stage 2 systolic 140 mm Hg/dia-
demonstrated that maternal obesity ≥
≥ stolic 90 mm Hg.
increased the risk of fetal Maternal chronic hypertension is a
complications such as preterm birth, common comorbidity during preg-
congenital anomalies, neonatal nancy.26 A systemic review and meta-
macrosomia, and perinatal death.10 analysis (55 studies; 795,221 patients)
Optimal gestational weight gain should reported that chronic hypertension
be based on the prepregnancy maternal significantly increased the incidence of
body mass index to enhance pregnancy preeclampsia, cesarean section delivery,
outcomes.11e13 fetal growth restriction, preterm de-
Surgical complexity for cesarean de- livery, neonatal unit admission, and
livery is present for women with a perinatal death.27 Twenty-five percent of
body mass index >40 kg/m2 14e22: (1) women with chronic hypertension will
pre- operative care (identification of experience superimposed preeclamp-
an appropriate operating room table sia,28 which will further increase the risk
with air mattress, lift device, wheel of the development of serious maternal
chair, and toilet; adequate human problems, such as kidney failure, liver
resource plan- ning [medical and failure, abnormalities of the clotting
nursing staffing]; abdominal incision system, and stroke.29 Preeclampsia
planning based on (caused by chronic or pregnancy-related
the primary obesity location and the hypertension) increases the risk of
relationship to the position of the
uterus/ lower uterine segment/fetal
position; transverse abdominal wall
MONTH 2018 American Journal of Obstetrics & Gynecology 10.e1
 Special ajog.o
adverse fetal complications, such as insufficient
in- trauterine growth restriction, low
birth- weight, preterm delivery, and
neonatal respiratory distress
syndrome.30 Appro- priate
management of maternal chronic
hypertension during pregnancy can
improve the clinical outcome, reduce
the complications, and decrease
cesarean delivery rate.25,30,31
In pregnancy, the goal of antihyper-
tensive treatment includes the preven-
tion of severe hypertension and the
possibility of prolonging gestation to
allow the fetus more time to mature
before delivery. Treatment of mild-to-
moderate hypertension (systolic blood
pressure 140e169 mm Hg/diastolic
blood pressure 90e109 mm Hg) has
reduced the progression to severe hy-
pertension by 50% compared with
pla- cebo but has not been shown to
prevent preeclampsia, preterm birth,
small for gestational age, or infant
death. Beta- blockers and calcium
channel blockers appear superior to
alpha-methyldopa for the prevention
of preeclampsia.31 Women with
hypertension who become pregnant
should be transitioned to
methyldopa, nifedipine, or labetalol
during pregnancy.32 Women with hy-
pertension who become pregnant
should not be treated with
angiotensin- converting enzyme
inhibitors, angio- tensin II receptor
blockers, or direct renin inhibitors
because they are fetotoxic.31
The 2013 American College of
Ob- stetricians and Gynecologists
(ACOG) Task Force on Hypertension
in Preg- nancy recommends systolic
120e160 mm Hg/diastolic 80e105 mm
Hg for pregnant women with
chronic hyper- tension as the
optimal blood pressure target.24 Blood
pressure values of systolic 150e160 ≥ ≥
mm Hg/diastolic 100e110
mm Hg should be treated.24 Drug
choice of antihypertensive
medications in hy- pertensive
pregnant women is limited to those
medications that have been proved
relatively safe and that have a long
history of clinical use in pregnancy
with acceptable side-effects (such as
labetalol, nifedipine, methyldopa,
and hydralazine).28,29 There are

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 ajog.o Special
data regarding the best regimen to treat elevated, a 75- or 100-g glucose glucose values at fasting [<95 mg/dL]/1
hypertension in pregnancy because of challenge test is required (American hour [<191 mg/dL]/2 hours [<160 mg/
the lack of adequately powered, ran- Diabetic As- sociation 75-g load with dL]; National Diabetes Data Group
domized trials.29 normal plasma 100-g load with normal plasma glucose
Diabetes mellitus during pregnancy values at fasting [<105 mg/dL]/1 hour
comprises both preexisting diabetes [<190 mg/dL]/2 hours [<165 mg/dL]/3
mellitus (type 1 or type 2) and GDM hours (<145 mg/dL]).40,41
that was first diagnosed during The new IADPSG criteria oral glucose
pregnancy (typically at 24e28 weeks of tolerance test increases the prevalence of
gestation after GDM screening).33e35 GDM to 19.6% from the Australasian
Women with preexisting diabetes Diabetes in Pregnancy Society oral
mellitus or GDM are at an increased risk glucose tolerance test rate of 9.8%.42
for maternal and fetal complications Glycemic targets in pregnancy (ADA;
(type 1 and 2 GDM). 33e35 Poorly ACOG)39,40 are similar for both preex-
controlled diabetes mellitus in isting diabetes mellitus and GDM
pregnancy increases the risk of sponta- (>24e28 weeks of gestation) with fast-
neous abortion, fetal anomalies, pre- ing and either 1- or 2-hour postprandial
eclampsia, fetal death, macrosomia testing (preprandial testing for preexist-
and neonatal hyperglycemia, and/or ing diabetes mellitus with insulin pumps
hyperbilirubinemia.34e37 A matched and basal-bolus therapy is considered):
control study with 2775 patients (1) fasting <95 mg/dL (<5.3 mmol/L),
reported that untreated GDM carried (2) 1-hour postprandial <140 mg/dL
significant risks for perinatal morbidity (<7.8 mmol/L), (3) 2 postprandial <120
and death (stillbirth, neonatal mg/dL (<6.7 mmol/L).
macrosomia, neonatal hypoglycemia, Hemoglobin A1C level should only be
erythrocytosis, and used as a secondary measure of glycemic
hyperbilirubinemia).38 control in pregnancy.39
The American Diabetes Association GDM management starts with life-
“Management of Diabetes in Preg- style management (medical nutrition,
nancy”39 and the revised ACOG physical activity, weight management)
Practice Bulletin on Gestational with the use of the glycemic targets listed
Diabetes Melli- earlier. This approach has a 70e85%
tus40 have new recommendations for success rate for the American Diabetes
diabetic management in pregnancy. Association criteria but lower success for
There are a variety of glucose chal- the IADPSG criteria.39
lenge test screening tools that are used If unable to meet the glycemic targets,
internationally at 24e28 weeks of pharmacologic therapy will require the
gestation.41 There are 2-step and 1-step use of medication with insulin as the
protocols recommended, and their use preferred choice because both metfor-
tends to be regional or country directed. min (greater transfer/less neonatal hy-
The World Health Organization (WHO) poglycemia) and glyburide (higher
and the International Association of neonatal hypoglycemia and macro-
the Diabetes and Pregnancy Study somia) cross the placenta.39
Groups (IADPSG) recommend a 1-step A randomized, controlled trial (948
screen (with the use of a 75-g glucose patients) demonstrated that women who
load with normal plasma glucose were treated for GDM reduced the risks
measurements of of fetal overgrowth, shoulder dystocia,
fasting [92e125 mg/dL]/1 hour [<180 cesarean delivery, and hypertensive dis-
mg/dL]/2 hour [WHO 153e199 mg/dL; orders.43 Another metaanalysis (42 tri-
IADSPG <153 mg/dL]). The 2-step als) showed that a combination of
approach initially uses a primary 50-g treatments that start with dietary modi-
glucose load (with no fasting required) fication, exercise, glucose monitoring,
with a 1-hour normal plasma glucose and pharmacologic treatments reduced
of the risks of neonatal hypoglycemia,
<135 mg/dL. If levels are normal, no macrosomia, preeclampsia, cesarean
further testing is recommended; how-
ever, when the plasma glucose is
MONTH 2018 American Journal of Obstetrics & Gynecology 10.e3
 Special ajog.o
delivery, and admission to the demonstrated that there is a strong
neonatal intensive care unit.44 association between smoking during
Optimization of maternal diabetic pregnancy and fetal growth
glycemic control in pregnant women
decreases the risk of preeclampsia, fetal
macrosomia, shoulder dystocia, and
ce- sarean delivery.43
Multidisciplinary team care can
opti- mize maintenance of
euglycemia,45 but optimal glycemic
targets have not been identified by
controlled trials.40
The WHO has reported that
globally 38.2% of pregnant women
are anemic with the use of the WHO
redefined definition of hemoglobin
levels <11.0 g
%.46,47 Iron deficiency anemia accoun-
ted for most maternal anemia cases.
The National Health Service Blood
Trans- fusion Committee Guidelines
supports the use of preoperative
screening for maternal anemia.47 Iron
deficiency and any underlying
disorder should be identified and
corrected by oral supple- mentation
or parenteral intravenous iron if the
disorder is unresponsive to oral
therapy before any scheduled
surgery.48,49
Maternal anemia during pregnancy
is associated with low neonatal
birthweight that affects 25% of
newborn infants (adjusted odds ratio,
1.23; 95% confi- dence interval,
1.06e1.43)50,51 and pre- term birth.51
Risk of maternal death is associated
with severe anemia in preg- nancy and
the postpartum period (adjusted odds
ratio, 2.36; 95% confi- dence interval,
1.60e3.48; propensity score analysis
[conditional probability] adjusted odds
ratio, 1.86; 95% confidence interval,
1.39e2.49).52 There was a linear
relationship between maternal anemia
and death; with each 10 g/L increase
in maternal hemoglobin, there was a
29% reduction in maternal mortality
rate (odds ratio, 0.71; 95% confidence
inter- val, 0.60e0.85).53 In addition,
preopera- tive anemia increased the
perioperative morbidity and mortality
rates.54
Clinical evidence has demonstrated
the relationship between smoking
and adverse reproductive
outcomes.32,55e58 The United States
Surgeon General’s report

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 ajog.o Special
restriction/low birthweight, preterm Recommendation Grade: Strong).
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42.

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APPENDIX TABLE
Summary of maternal and fetal adverse events for maternal obesity body mass index >40 kg/m2
Odds ratio for adverse maternal outcomes associated with body Odds ratio for adverse fetal outcomes for maternal
mass index >35 kg/m2 obesity
Adverse outcome Odds ratio Fetal outcome Odds ratio
Gestational diabetes mellitus 4.0 (3.1e5.2) NTD 1.87 (1.62e2.15)
Gestational hypertension 3.2 (2.6e4.0) CL/P 1.20 (1.03e1.40)
Preeclampsia 3.3 (2.4e4.5) Hydrocephalus 1.68 (1.19e2.36)
Operative vaginal delivery 1.7 (1.2e2.2) Limb reduction 1.34 (91.03e1.73)
Fetal macrosomia >4500 g 2.4 (1.5e3.8) Cardiac 1.30 (1.12e1.51)
IUFD 3.90 (2.44e6.22)

CL/P, cleft lip/palate; IUFD, intrauterine fetal death; NTD, neutral tube defect.
a Data from; b data from. United States data indicate that 8% of all reproductive age women have a body mass index of >40 kg/[Link] obesity and associated feta
Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018.

10.e8 American Journal of Obstetrics & Gynecology MONTH 2018