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To compare the rate of early hospital discharges among women who underwent cesarean delivery with enhanced recovery after surgery (ERAS) or standard perioperative care (SC).
Study Design
Patients undergoing nonemergent cesarean delivery at ≥ 37 weeks gestation were randomized to ERAS or SC. ERAS involved multiple evidence-based interventions bundled into one protocol. The primary outcome was discharge on postoperative day 2 (POD#2). Secondary outcome variables included pain medication requirements, breastfeeding rates and various measures of patient satisfaction. To detect an increase in the primary outcome of 20% with a baseline rate of 10% of patients discharged on POD#2 with a power of 0.80 and a two-tailed alpha of 0.05, 59 women per study group were required. Analysis was according to the intent-to-treat principle.
Results
From September 27, 2017 to May 2, 2018, 58 women were randomized to ERAS and 60 to SC. The groups were similar in medical comorbidities, demographic and perioperative characteristics. ERAS was not associated with a significantly increased rate of POD#2 discharges when compared with SC, 8.6% vs. 3.3%, respectively (OR: 2.74, 95% CI 0.51-14.70). ERAS was associated with a significantly reduced postoperative length of stay (LOS) when compared with standard care, with median LOS of 73.5 [(IQR): 71.08-76.62)] v. 75.5 [(IQR: 72.86-76.84)] hours from surgery, difference in median LOS: (-1.92, 95% CI -3.80 - -0.29). ERAS was not associated with a reduction in postoperative narcotic use, 117.16 ± 54.17 vs. 119.38 ± 47.98 morphine milligram equivalents (Mean difference: -2.22, 95% CI -20.86-16.42). ERAS was associated with an increase in breastfeeding, 67.2% vs. 48.3% (p=0.046). When patients were surveyed 6 weeks postpartum, those in the ERAS group were more likely to feel that their expectations were met, achieve their postoperative milestones earlier and report continued breastfeeding.
Conclusion
ERAS after cesarean was not associated with an increase in the number of women discharged on POD#2, but that may have been related to factors other than patients’ medical readiness for discharge. Evidence that ERAS after cesarean may have the potential to improve outcomes such as day of discharge are suggested by the observed reduction in overall postoperative LOS, improved patient satisfaction and an increase in breastfeeding. Even better results may accrue with more provider and patient experience with ERAS.
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