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Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3)

Published:April 14, 2019DOI:https://doi.org/10.1016/j.ajog.2019.04.012

      Background

      This Enhanced Recovery After Surgery Guideline for postoperative care in cesarean delivery will provide best practice, evidenced-based recommendations for postoperative care with primarily a maternal focus.

      Objective

      The pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider time from completion of cesarean delivery until maternal hospital discharge.

      Study Design

      The literature search (1966–2017) used Embase and PubMed to search medical subject headings that included “Cesarean Section,” “Cesarean Delivery,” “Cesarean Section Delivery,” and all postoperative Enhanced Recovery After Surgery 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 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 Enhanced Recovery After Surgery Guidelines.

      Results

      The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a pathway for postoperative care. Specifics include sham feeding, nausea and vomiting prevention, postoperative analgesia, nutritional care, glucose control, thromboembolism prophylaxis, early mobilization, urinary drainage, and discharge counseling. A number of elements of postoperative care of women who undergo cesarean delivery are recommended, based on the evidence.

      Conclusion

      As the Enhanced Recovery After Surgery cesarean delivery pathway (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, there will be an opportunity for focused and optimized areas of care and recommendations to be further enhanced.

      Key words

      Enhanced recovery after surgery (ERAS) is a standardized, perioperative care program that is embedded firmly within multiple surgical disciplines that include colorectal, urologic, gynecologic, and hepatobiliary surgery. ERAS has been shown to result in both clinical benefits (reductions in length of stay, complications, and readmissions) and health system benefits (reduction in cost).
      • Steenhagen E.
      Enhanced recovery after surgery: It’s time to change practice!.
      • Elias K.M.
      Understanding enhanced recovery after surgery guidelines: An introductory approach.

      Why was this study conducted?

      • This Enhanced Recovery After Surgery Society guideline was created to support the most common surgical procedure in the industrialized healthcare world, the cesarean delivery. It has the goal to enhance the quality and safety of the cesarean delivery for improved maternal and fetal/neonatal outcomes through evaluation and audit.

      Key findings

      • The broad Enhanced Recovery After Surgery Society cesarean delivery elements and recommendations (Parts 1–3) break down the surgical delivery process into a pathway that starts at 30–60 minutes before skin incision, for both scheduled and unscheduled cesarean deliveries, until hospital discharge and presents a longer pathway that manages antenatal education, maternal comorbidities, and immediate neonatal needs at delivery. This postoperative section (Part 3) focuses on the time from the completion of cesarean delivery until maternal discharge.

      What does this add to what is known?

      • This Enhanced Recovery After Surgery Society cesarean delivery guideline has taken the evidenced-based knowledge that was created from the cesarean delivery research and has critically and with consensus published the information in a 3-part guideline that uses the Enhanced Recovery After Surgery Society principles and process for improved surgical quality and safety for obstetric surgical deliveries.
      ERAS is a tool for process management, with the creation of a focused care process. The use of audit and feedback, whereby clinicians are provided with comparative data to educate, change, and decrease the “harmful” clinical variances that are identified in certain high-volume clinical care processes and procedures that will increase quality of care, patient safety, and health outcomes.
      This serialized ERAS guideline for perioperative care in cesarean delivery will provide best practice recommendations for part 1 (antenatal/preoperative),
      • Wilson R.D.
      • Caughey A.B.
      • Wood S.L.
      • et al.
      Guideline for antenatal and preoperative care in cesarean delivery: Enhanced Recovery after Surgery Society recommendations (part 1).
      part 2 (intraoperative),
      • Caughey A.B.
      • Wood S.L.
      • Macones G.A.
      • et al.
      Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery after Surgery Society recommendations (part 2).
      and part 3 (postoperative phases) that are the focus of this document. Although certain ERAS principles have been established for other abdominal/pelvic surgeries, this present ERAS cesarean delivery pathway will provide evidenced-based recommendations for the surgical pathway that is related to cesarean delivery with, primarily, a maternal focus.

      Methods

      Literature search

      The author group was selected and vetted by the ERAS Society Guideline Committee in 2017 based on expertise in the area, and a consensus topic list was determined. After the topics were agreed on, they were allocated among the group according to expertise. The literature search (1966–2017) used Embase and PubMed to search medical subject headings that included “Cesarean Section,” “Cesarean Delivery,” “Cesarean Section Delivery,” and all postoperative ERAS items. Reference lists of all eligible articles were cross-checked for other relevant studies.

      Study selection

      Titles and abstracts were 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

      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 (Table 1).
      • Wilson R.D.
      • Caughey A.B.
      • Wood S.L.
      • et al.
      Guideline for antenatal and preoperative care in cesarean delivery: Enhanced Recovery after Surgery Society recommendations (part 1).
      • Caughey A.B.
      • Wood S.L.
      • Macones G.A.
      • et al.
      Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery after Surgery Society recommendations (part 2).
      Briefly, recommendations are given in the following manner: “Strong” recommendations indicate that the panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects. “Weak” recommendations indicate that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is less confident. Recommendations are based not only on the quality of evidence (high, moderate, low, and very low) but also on the balance between desirable and undesirable effects. In some cases, strong recommendations may be reached from low-quality data and vice versa. The core ERAS cesarean delivery team (A.B.C., G.A.M., S.L.W., G.N., and R.D.W) reviewed the evidence in detail for each section and assigned both the recommendation and evidence level (Table 2). Discrepancies were resolved by the lead and senior authors.
      Table 1Grading of Recommendations, Assessment, Development and Evaluation system
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      VariableDefinition
      Rating quality of evidence: evidence level
       High qualityFurther research is unlikely to change confidence in estimate of effect.
       Moderate qualityFurther research is likely to have important impact on confidence in estimate of effect and may change the estimate.
       Low qualityFurther research is very likely to have important impact on confidence in estimate of effect and likely to change the estimate.
       Very low qualityAny estimate of effect is very uncertain.
      Rating strength of recommendations: recommendation strength
       StrongWhen desirable effects of intervention clearly outweigh the undesirable effects, or clearly do not.
       WeakWhen trade-offs are less certain: either because of low quality evidence or because evidence suggests desirable and undesirable effects are closely balanced.
      Macones et al. ERAS cesarean: part 3. Am J Obstet Gynecol 2019.
      Table 2Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations
      VariableItemRecommendation
      Evidence levelRecommendation grade
      Postoperative pathway
       Chewing gum after cesarean section (focused element)Gum chewing appears to be effective and is low risk. It may be a redundant treatment if a policy for early oral intake is being used. However, it should be considered if delayed oral intake is planned.LowWeak
       Nausea and vomiting prevention (focused element)(1) Fluid preloading, the intravenous administration of ephedrine or phenylephrine, and lower limb compression are effective ways to reduce hypotension and the incidence of intraoperative and postoperative nausea and vomiting.Moderate (multiple interventions)Strong
      (2) Antiemetic agents are effective for the prevention of postoperative nausea and vomiting during cesarean delivery. Multimodal approach should be applied to treat postoperative nausea and vomiting.ModerateStrong
       Postoperative analgesia (focused element)Multimodal analgesia that include regular nonsteroidal antiinflammatory drugs and paracetamol is recommended for enhanced recovery for cesarean delivery.ModerateStrong
       Perioperative nutritional care (focused element)A regular diet within the 2 hours after cesarean delivery is recommended.HighStrong
       Perioperative glucose control (focused element)Tight control of capillary blood glucose is recommended.LowStrong
       Prophylaxis against thromboembolism (focused element)(1) Pneumatic compression stockings should be used to prevent thromboembolic disease in patients who undergo cesarean delivery.LowStrong
      (2) Heparin should not be used routinely for venous thromboembolism prophylaxis in patients after cesarean delivery.LowWeak
       Early post–cesarean delivery mobilization (focused element)Early mobilization after cesarean delivery is recommended.Very lowWeak
       Post–cesarean delivery urinary drainage (focused element)Urinary catheter should be removed immediately after cesarean delivery, if placed during surgery.LowStrong
      Postoperative/postpartum mother pathway
       Discharge counselling (focused element)Standardized written discharge instructions should be used to facilitate discharge counselling.LowWeak
      Macones et al. ERAS cesarean: part 3. Am J Obstet Gynecol 2019.

      Postoperative Cesarean Delivery Pathway (Focused Elements)

      ERAS sham feeding (chewing gum) after cesarean delivery

      Sham postoperative feeding (chewing gum) after abdominal surgery has been evaluated in multiple clinical trials and, in a Cochrane review, appeared to reduce the time to recovery of gastrointestinal function.
      • Short V.
      • Herbert G.
      • Perry R.
      • et al.
      Chewing gum for postoperative recovery of gastrointestinal function.
      In a separate review of gum chewing after cesarean delivery, 15 clinical trials were identified.
      • Pereira Gomes Morais E.
      • Riera R.
      • Porfirio G.J.
      • et al.
      Chewing gum for enhancing early recovery of bowel function after caesarean section.
      The regimens for gum chewing varied widely in studies: initiation from immediately after the operation to up to 12 hours after the operation, duration of each session of 15–60 minutes, and number of sessions per day from 3 to >6. In 10 of these studies, the comparator group was traditional delayed feeding until return of intestinal function (bowel sounds or flatus). In 2 studies, the comparator group had an early feeding policy. With gum chewing (using a variety of gum types and duration of chewing), the time to first report of flatus was 5.9 hours in early feeding trials and 7.8 hours in the traditional feeding trials. This was a 7-hour improvement in time to flatus compared with those who did not chew gum. Only 4 studies reported postoperative ileus that was reduced with gum chewing (odds ratio, 0.39; 95% confidence interval, 0.19–0.80). Hospital stay was not changed: –0.36 days (95% confidence interval, –0.53 to 0.18). Quality of evidence was rated “low” mainly because of lack of blinding. Applicability to all settings is limited because a high proportion of subjects had general anesthesia in many of the trials.

      Summary and recommendation

      Gum chewing appears to be effective and is low risk. It may be a redundant treatment if a policy for early oral intake is being used. However, it should be considered if delayed oral intake is planned. (Evidence level: low/ recommendation grade: weak.)

      Nausea and vomiting prevention

      Nausea and vomiting are common symptoms that are experienced during cesarean delivery and that happen during the surgery if the patient is awake or after the procedure in the recovery room.
      • Griffiths J.D.
      • Gyte G.M.L.
      • Paranjothy S.
      • Brown H.C.
      • Broughton H.K.
      • Thomas J.
      Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section.
      The overall incidence of nausea and vomiting during regional anesthesia for cesarean delivery is variable (21–79%).
      • Griffiths J.D.
      • Gyte G.M.L.
      • Paranjothy S.
      • Brown H.C.
      • Broughton H.K.
      • Thomas J.
      Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section.
      • Pan P.H.
      • Moore C.H.
      Comparing the efficacy of prophylactic metoclopramide, ondansetron and placebo in cesarean section patients given epidural anesthesia.
      • Harmon D.
      • Ryan M.
      • Kelly A.
      • Bowen M.
      Acupressure and prevention of nausea and vomiting during and after spinal anaesthesia for cesarean section.
      • Carvalho J.C.A.
      • Cardoso M.M.S.C.
      • Capelli E.L.
      • et al.
      Prophylactic ephedrine during cesarean delivery under spinal anesthesia. Dose-response study of bolus and continuous infusion administration.
      • Abouleish E.I.
      • Rashid S.
      • Haque S.
      • Giezentanner A.
      • Joynton P.
      • Chuang A.Z.
      Ondansetron versus placebo for the control of nausea and vomiting during caesarean section under spinal anaesthesia.
      • Ure D.
      • James K.S.
      • McNeil M.
      Glycopyrrolate reduces nausea during spinal anaesthesia for caesarean section without affecting neonatal outcome.
      • Stein D.J.
      • Birnbach D.J.
      • Danzer B.
      • Kuroda M.M.
      • Grunebaum T.
      • Thys D.M.
      Acupressure versus iv metoclopramide to prevent nausea and vomiting during spinal anesthesia for cesarean section.
      • Lussos S.A.
      • Datta S.
      • Bader A.M.
      The antiemetic efficacy and safety of prophylactic metoclopramide for elective cesarean delivery during spinal anesthesia.
      • Chestnut D.H.
      • Vandewalker G.E.
      • Owen C.L.
      Administration of metoclopramide for prevention of nausea and vomiting during epidural anesthesia for elective cesarean section.
      • Santos A.
      • Datta S.
      Prophylactic use of droperidol for control of nausea and vomiting during spinal anesthesia for cesarean section.
      Maternal symptoms can potentially prolong the duration of the surgery and increase the risk of bleeding and surgical trauma. Nausea and vomiting can increase the potential risk of aspiration, which is a recognized cause of maternal death.
      • Paranjothy S.
      • Griffiths J.D.
      • Broughton H.K.
      • Gyte G.M.
      • Brown H.C.
      • Thomas J.
      Interventions at caesarean section for reducing the risk of aspiration pneumonitis.
      Nausea and vomiting reduced patient satisfaction and delayed discharge from hospital.
      There are multiple causes of nausea and vomiting during cesarean delivery. Maternal hypotension from regional anesthesia is a common cause. Several approaches are used currently to minimize or prevent hypotension and likely to decrease the incidence of nausea and vomiting. A Cochrane review study (75 studies and 4624 women who received spinal anesthesia for cesarean delivery) showed that colloid or crystalloid preloading, the intravenous administration of ephedrine or phenylephrine, and lower limb compression (by bandages, stockings, or inflatable boots) reduced the incidence of spinal anesthesia–related hypotension.
      • Emmett R.S.
      • Cyna A.M.
      • Andrew M.
      • Simmons S.W.
      Techniques for preventing hypotension during spinal anesthesia for caesarean section.
      Antiemetic agents that have been used prophylactically during cesarean delivery under regional anesthesia are effective for the prevention of nausea and vomiting.
      • Balki M.
      • Carvalho J.C.
      Intraoperative nausea and vomiting during cesarean section under regional anesthesia.
      A multimodal approach to nausea and vomiting prevention is quickly becoming a standard of care. A Cochrane review study (41 studies and 5046 patients) demonstrated that 5-HT3 antagonists (eg, ondansetron, granisetron), dopamine antagonists (eg, metoclopramide, droperidol), and sedatives (eg, midazolam, propofol) were effective in the reduction of intraoperative nausea and vomiting.
      • Emmett R.S.
      • Cyna A.M.
      • Andrew M.
      • Simmons S.W.
      Techniques for preventing hypotension during spinal anesthesia for caesarean section.
      Corticosteroids (such as dexamethasone) were found to reduce only intraoperative nausea and vomiting.
      • Griffiths J.D.
      • Gyte G.M.L.
      • Paranjothy S.
      • Brown H.C.
      • Broughton H.K.
      • Thomas J.
      Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section.
      Anticholinergic agents (eg, scopolamine) were effective at the reduction of postoperative nausea and vomiting.
      • Emmett R.S.
      • Cyna A.M.
      • Andrew M.
      • Simmons S.W.
      Techniques for preventing hypotension during spinal anesthesia for caesarean section.
      Other interventions (opioids, supplemental oxygen, supplemental intravenous fluid, acupressure/acupuncture) did not reduce intraoperative nausea or postoperative nausea and vomiting.
      • Griffiths J.D.
      • Gyte G.M.L.
      • Paranjothy S.
      • Brown H.C.
      • Broughton H.K.
      • Thomas J.
      Interventions for preventing nausea and vomiting in women undergoing regional anaesthesia for caesarean section.
      A metaanalysis (33 trials with data from 3447 patients) reported that combination regimens (5-HT is combined with either droperidol or dexamethasone) are significantly more effective than 5-HT3 alone.
      • Habib A.S.
      • El-Moalem H.E.
      • Gan T.J.
      The efficacy of the 5-HT3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexamethasone. A meta-analysis of randomized controlled trials.
      The efficacy of combination antiemetic agents to prevent nausea and vomiting in patients who underwent cesarean delivery was demonstrated in a randomized prospective study.
      • Voigt M.
      • Fröhlich C.W.
      • Hüttel C.
      • et al.
      Prophylaxis of intra- and postoperative nausea and vomiting in patients during cesarean section in spinal anesthesia.
      Tropisetron 2 mg and metoclopramide 20 mg are highly effective in the prevention of nausea and vomiting.

      Summary and recommendation

      (1) Fluid preloading, the intravenous administration of ephedrine or phenylephrine, and lower limb compression are effective in the reduction of hypotension and the incidence of intraoperative and postoperative nausea and vomiting. (Evidence level: moderate; recommendation grade: strong). (2) Antiemetic agents are effective for the prevention of postoperative nausea and vomiting during cesarean delivery. Multimodal approach should be applied to treat postoperative nausea and vomiting. (Evidence level: moderate (multiple interventions); recommendation grade: strong.)

      Postoperative analgesia

      Poor postoperative pain control may be detrimental to recovery for surgery of any kind. Pain may prolong recovery and delay discharge
      American Society of Anesthesiologists Task Force on Acute Pain Management
      Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management.
      and has a negative impact on rehabilitation.
      • Horlocker T.T.
      • Kopp S.L.
      • Pagnano M.W.
      • Hebl J.R.
      Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block.
      For cesarean delivery, high pain scores have the potential to prevent early mobilization and the mother’s efforts to be independent and to care for her newborn baby. Multimodal analgesia is a key component in the management of postoperative pain as part of an enhanced recovery protocol,
      • Tan M.
      • Siu-Chun Law L.
      • Joo Gan T.
      Optimizing pain management to facilitate enhanced recovery after surgery pathways.
      which results in fewer side-effects and faster postoperative recovery.
      Postcesarean delivery analgesia may be enhanced by a number of intraoperative interventions. Long-acting intrathecal opioids, such as morphine, provide analgesia for several hours after cesarean delivery, although at the expense of a number of side-effects that include nausea, vomiting, and pruritus.
      • Dahl J.B.
      • Jeppesen I.S.
      • Jørgensen H.
      • Wetterslev J.
      • Møiniche S.
      Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials.
      • Sultan P.
      • Halpern S.H.
      • Pushpanathan E.
      • Patel S.
      • Carvalho B.
      The effect of intrathecal morphine dose on outcomes after elective cesarean delivery: a meta-analysis.
      In the absence of long-acting intrathecal opioids, the transversus abdominis plane field block provides excellent postoperative pain control.
      • Abdallah F.W.
      • Halpern S.H.
      • Margarido C.B.
      Transversus abdominis plane block for postoperative analgesia after caesarean delivery performed under spinal anaesthesia? A systematic review and meta-analysis.
      A Cochrane review of local analgesia infiltration and abdominal nerve blocks found that they improved postoperative analgesia for cesarean delivery.
      • Bamigboye A.A.
      • Hofmeyr G.J.
      Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief.
      A review of oral analgesia for postcesarean delivery pain relief concluded that there was insufficient evidence to make recommendations regarding the safest and most effective form.
      • Mkontwana N.
      • Novikova N.
      Oral analgesia for relieving post-caesarean pain.
      Nevertheless, the perioperative administration of nonsteroidal antiinflammatory drugs (NSAIDs) is known to diminish postoperative pain for cesarean delivery.
      • McDonnell N.J.
      • Keating M.L.
      • Muchatuta N.A.
      • Pavy T.J.
      • Paech M.J.
      Analgesia after caesarean delivery.
      Evidence in the obstetric population is less clear for paracetamol, although a systematic review of studies that included studies in which patients underwent cesarean delivery found that the combination of NSAIDs and paracetamol was synergistic for postoperative pain.
      • Ong C.K.
      • Seymour R.A.
      • Lirk P.
      • Merry A.F.
      Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain.
      A survey of practice surrounding cesarean delivery in the United Kingdom found that almost all units were using postoperative paracetamol and NSAIDs.
      • Aluri S.
      • Wrench I.J.
      Enhanced recovery from obstetric surgery: a UK survey of practice.
      This combination is cheap, effective, easy to administer, and opioid-sparing, which leads to fewer opioid-related side-effects,
      • Tan M.
      • Siu-Chun Law L.
      • Joo Gan T.
      Optimizing pain management to facilitate enhanced recovery after surgery pathways.
      and is compatible with ERAS regimens.

      Summary and recommendation

      Multimodal postoperative analgesia that includes regular NSAIDs and paracetamol is recommended for enhanced recovery for cesarean delivery. (Evidence level: moderate; recommendation grade: strong.)

      Perioperative nutritional care

      There are multiple randomized controlled trials on the subject of early feeding from countries across the world with differing cultural norms dating back >15 years.
      • Teoh W.H.L.
      • Shah M.K.
      • Mah C.L.
      A randomised controlled trial on beneficial effects of early feeding post-caesarean delivery under regional anaesthesia.
      • Izbizky G.H.
      • Minig L.
      • Sebastiani M.A.
      • Otano L.
      The effect of early versus delayed post caesarean feeding on women’s satisfaction: a randomized controlled trial.
      • Orji E.O.
      • Olabode T.O.
      • Kuti O.
      • Ogunniyi A.O.
      A randomized controlled trial of early initiation of oral feeding after cesarean section.
      • Masood S.N.
      • Masood Y.
      • Naim U.
      • Masood M.F.
      A randomized comparative trial of early initiation of oral maternal feeding versus conventional oral feeding after cesarean delivery.
      • Jalilian N.
      • Ghadami M.R.
      Randomized clinical trial comparing postoperative outcomes of early versus late oral feeding after cesarean section.
      • Nantasupha C.
      • Ruengkhachorn I.
      • Ruangvutilert P.
      Effect of conventional diet schedule, early feeding and early feeding plus domperidone on postcesarean diet tolerance: a randomized controlled trial.
      • Patolia D.S.
      • Hilliard R.L.
      • Toy E.C.
      • Baker B.
      Early feeding after cesarean: randomized trial.
      • Hsu Y.Y.
      • Hung H.Y.
      • Chang Y.I.
      Early oral intake and gastrointestinal function after cesarean delivery: a systematic review and meta-analysis.
      Early feeding is defined variably as feeding as early as 30 minutes
      • Teoh W.H.L.
      • Shah M.K.
      • Mah C.L.
      A randomised controlled trial on beneficial effects of early feeding post-caesarean delivery under regional anaesthesia.
      and up to 8 hours after cesarean delivery.
      • Izbizky G.H.
      • Minig L.
      • Sebastiani M.A.
      • Otano L.
      The effect of early versus delayed post caesarean feeding on women’s satisfaction: a randomized controlled trial.
      The largest trial to study early feeding randomized 1154 patients to conventional feeding within 18 hours or early feeding within 2 hours and demonstrated a reduction in thirst and hunger and improved maternal satisfaction, ambulation, and length of stay, with no impact on readmissions or gastrointestinal symptoms or infections.
      • Jalilian N.
      • Ghadami M.R.
      Randomized clinical trial comparing postoperative outcomes of early versus late oral feeding after cesarean section.
      The findings of this trial are similar to those in other trials that have demonstrated similar or enhanced satisfaction, earlier resumption of solid food, accelerated return of bowel activity, and reduced length of stay with no evidence of higher complication rates related to wound healing or infection.
      • Teoh W.H.L.
      • Shah M.K.
      • Mah C.L.
      A randomised controlled trial on beneficial effects of early feeding post-caesarean delivery under regional anaesthesia.
      • Izbizky G.H.
      • Minig L.
      • Sebastiani M.A.
      • Otano L.
      The effect of early versus delayed post caesarean feeding on women’s satisfaction: a randomized controlled trial.
      • Orji E.O.
      • Olabode T.O.
      • Kuti O.
      • Ogunniyi A.O.
      A randomized controlled trial of early initiation of oral feeding after cesarean section.
      • Masood S.N.
      • Masood Y.
      • Naim U.
      • Masood M.F.
      A randomized comparative trial of early initiation of oral maternal feeding versus conventional oral feeding after cesarean delivery.
      • Jalilian N.
      • Ghadami M.R.
      Randomized clinical trial comparing postoperative outcomes of early versus late oral feeding after cesarean section.
      • Nantasupha C.
      • Ruengkhachorn I.
      • Ruangvutilert P.
      Effect of conventional diet schedule, early feeding and early feeding plus domperidone on postcesarean diet tolerance: a randomized controlled trial.
      • Patolia D.S.
      • Hilliard R.L.
      • Toy E.C.
      • Baker B.
      Early feeding after cesarean: randomized trial.
      • Hsu Y.Y.
      • Hung H.Y.
      • Chang Y.I.
      Early oral intake and gastrointestinal function after cesarean delivery: a systematic review and meta-analysis.
      A systematic review and metaanalysis of 17 studies also supported these findings.
      • Hsu Y.Y.
      • Hung H.Y.
      • Chang Y.I.
      Early oral intake and gastrointestinal function after cesarean delivery: a systematic review and meta-analysis.
      One study did document increased nausea with early resumption of diet, but this was this was self-limited.
      • Teoh W.H.L.
      • Shah M.K.
      • Mah C.L.
      A randomised controlled trial on beneficial effects of early feeding post-caesarean delivery under regional anaesthesia.
      Descriptions of postoperative diets vary. The postoperative diet should provide more servings of milk, fruit, vegetables, and calories to support breast feeding. That diet should provide adequate fiber to prevent constipation.

      Summary and recommendation

      A regular diet within the 2 hours after cesarean delivery is recommended. (Evidence level: high; recommendation grade: strong.)

      Perioperative glucose control

      Insulin resistance is a common physiologic change in pregnancy. There are various controversies about the peripartum treatment of diabetic patients.
      • Modi A.
      • Levy N.
      • Hall G.M.
      Controversies in the peripartum management of diabetes.
      Diabetes mellitus in pregnancy is associated with adverse outcomes that include an increase in morbidity and mortality rates for both the mother and fetus.
      HAPO Study Cooperative Research Group
      Hyperglycemia and adverse pregnancy outcomes.
      • Negrato C.A.
      • Mattar R.
      • Gomes M.B.
      Adverse pregnancy outcomes in women with diabetes.
      Patients with diabetes mellitus who undergo surgery have increased complications (particularly wound infections), length of hospital stay, and death.
      • Frisch A.
      • Chandra P.
      • Smiley D.
      • et al.
      Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery.
      Patients with undiagnosed diabetes mellitus are at greater risk, with a dose-response relationship between the level of capillary blood glucose (CBG) and composite adverse events.
      • Kotagal M.
      • Symons R.G.
      • Hirsch I.B.
      • et al.
      Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes.
      Conversely, strict control of hyperglycemia can help to reduce surgical site infections.
      • De Vries F.E.
      • Gans S.L.
      • Solomkin J.S.
      • et al.
      Meta-analysis of lower perioperative blood glucose target levels for reduction of surgical-site infection.
      The level of control of CBG is a complex area; for nonobstetric patients, the ideal range is probably 6–10 mmol/L.
      • Aldam P.
      • Levy N.
      • Hall G.M.
      Perioperative management of diabetic patients: new controversies.
      Lower limits of 4–7 mmol/L are recommended at the time of delivery to reduce fetal hypoglycemia
      National Institute for Health and Care Excellence
      Diabetes in pregnancy: management from preconception to the postnatal period.
      that often will require variable rate insulin infusions, formerly known as a sliding scale. As a result, these standards have been challenged, and a higher upper limit of 8 mmol/L is suggested by Modi et al,
      • Modi A.
      • Levy N.
      • Hall G.M.
      Controversies in the peripartum management of diabetes.
      because there is little further risk of fetal hypoglycemia. Moreover, CBG meters have been shown to have, at least, a 15% error that is permitted by the US Food and Drug Administration, with a measured CBG of 4 mmol/L that could be as low as 3.4 mmol/L, thereby putting mothers at risk of severe maternal hypoglycemia (<2.8 mmol/L).
      • Aldam P.
      • Levy N.
      • Hall G.M.
      Perioperative management of diabetic patients: new controversies.
      For patients who take insulin for type I diabetes mellitus, the major issue is to never stop all insulin because ketoacidosis may develop rapidly. The manipulation of perioperative insulin is complex, with a small evidence base for patients who undergo cesarean delivery.
      Generally, the dose of once daily long-acting insulins are reduced by 20% with more frequent injections of short-acting insulin or mixtures reduced by 50%. CBG are measured on admission to hospital. The aim is to return the patient to normal insulin with food as soon as possible after surgery. The use of continuous subcutaneous insulin pumps are increasing in usage and will often be advised to reduce the basal infusion by 10–20% and to omit the bolus dose before meals.
      • Partridge H.
      • Perkins B.
      • Mathieu S.
      • Nicholls A.
      • Adeniji K.
      Clinical recommendations in the management of the patient with type 1 diabetes on insulin pump therapy in the perioperative period: a primer for the anaesthetist.
      The use of the variable rate insulin infusions is still popular for patients who take insulin or with significant hyperglycemia (>12 mmol/L), but it is associated with a number of serious side-effects that include hyperglycemia and hypoglycemia, hyponatremia, and hypokalemia. It requires appropriate fluids to run along aside the insulin with 5% dextrose and 0.45% saline solution with additional potassium chloride. Hourly CBG monitoring is required; 20% glucose (50–100 mL) is available to treat hypoglycemia.
      • Dhatariya K.
      • Levy N.
      • Kilvert A.
      • et al.
      NHS Diabetes guideline for the perioperative management of the adult patient with diabetes.
      • Barker P.
      • Creasey P.E.
      • Dhatariya K.
      • et al.
      Peri-operative management of the surgical patient with diabetes 2015.
      Cesarean deliveries are best carried out under a regional technique where possible. Not only does it avoid the risk of general anesthesia, but in addition regional anesthesia will considerably obtund the ‘stress’ response (including the hyperglycemic response) to surgery. CBG is optimally measured every 30 min from induction of general anesthesia until the mother is fully conscious.
      National Institute for Health and Care Excellence
      Diabetes in pregnancy: management from preconception to the postnatal period.
      Oral carbohydrate preloading is an area of controversy for patients with impaired glucose control. Although the patient may benefit from the advantages of preloading (such as reduced length of stay and reduced complications for some surgeries) and, in particular, a reduction in insulin resistance, there are no large trials to support or refute its use in women with diabetes mellitus. The majority of diabetic care providers would not support its use in diabetic patients because of the fear of worsening of glucose control. Patients, nevertheless, should be scheduled early in the day (particularly those who require insulin) with minimal fasting to reduce the risk of dehydration, acidosis, and ketosis
      After delivery of the fetus, maternal insulin requirements fall rapidly, and CBG should be checked if the patient is receiving insulin. There is a further risk of hypoglycemia during breast feeding too. Patients with gestational diabetes mellitus should discontinue therapy and those with type II diabetes mellitus can continue with metformin and glibenclamide even if breastfeeding.
      National Institute for Health and Care Excellence
      Diabetes in pregnancy: management from preconception to the postnatal period.
      The neonate is at risk of severe hypoglycemia after delivery; there must be assessment by a pediatrician regarding whether admission to a neonatal unit is appropriate.
      Finally these patients require counseling, advice (diet, weight control, and exercise), and follow-up evaluation to minimize the impact of poor glucose control on their future health, such as worsening of glucose control and cardiovascular disease.

      Summary and recommendations

      Tight control of CBG postoperatively is recommended. (Evidence level: low; recommendation grade: strong.)

      Prophylaxis against thromboembolism

      Pregnant and postpartum women are at an increased risk of venous thromboembolism. A variety of modalities are available to reduce the risk of post–cesarean delivery thromboembolic disease that include mechanical methods (graduated compression stockings, intermittent pneumatic compression) and pharmacologic methods (unfractionated heparin, low molecular weight heparin).
      A recent Cochrane review assessed the efficacy of some strategies for post–cesarean delivery thromboprophylaxis. In the comparison of heparin (either low molecular weight heparin or unfractionated heparin) with placebo/no treatment, there were no differences in symptomatic thromboembolic events (relative risk, 1.30; 95% confidence interval [CI], 39.0–4.27), symptomatic pulmonary embolism (relative risk, 1.10; 95% CI, 0.25–4.87), or symptomatic deep vein thrombosis (relative risk, 1.74; 95% CI, 0.23–13.31). Importantly, in this metaanalysis, there were few studies that enrolled a relatively small number of patients who were generally not of high methodologic quality. In addition, there were no included studies that compared mechanical with pharmacologic thromboprophylaxis or mechanical methods with placebo/no treatment.
      • Bain E.
      • Wilson A.
      • Tooher R.
      • Gates S.
      • Davis L.-J.
      • Middleton P.
      Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period.
      One recent study from a large health system compared rates of post–cesarean delivery pulmonary embolism deaths in the time period before a universal policy for pneumatic compression stockings to the time period after implementation. There was a significant reduction in death from post–cesarean delivery pulmonary embolism between these 2 time periods (7/458,097 cesarean births before implementation vs 1/456,880 cesarean births after implementation; P=.038).
      • Clark S.L.
      • Christmas J.T.
      • Frye D.R.
      • Meyers J.A.
      • Perlin J.B.
      Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.

      Summary and recommendation

      (1) Pneumatic compression stockings should be used to prevent thromboembolic disease in patients who undergo cesarean delivery. (Evidence level: low; recommendation grade: strong.) (2) Heparin should not be used routinely for venous thromboembolism prophylaxis in patients after cesarean delivery. (Evidence level: low; recommendation grade: weak.)

      Early mobilization after cesarean delivery

      Early mobilization theoretically can improve a number of short-term outcomes after surgery, which include rapid return of bowel function, reduced risk of thrombosis, and decreased length of stay. There are no available data to judge whether early mobilization improves outcomes after cesarean delivery.
      • Spanjersberg W.R.
      • Reurings J.
      • Keus F.
      • van Laarhoven C.
      Fast track surgery versus conventional recovery strategies for colorectal surgery.
      Early mobilization is often part of a surgical bundle “fast track” or “enhanced recovery after surgery” (ie, ERAS). These bundles include extensive preoperative counseling, improved preoperative nutrition, improved pain relief along with rapid postoperative diet resumption, and early mobilization. This bundle of care has not been evaluated in patients after cesarean delivery. Additionally, there are no randomized controlled trials of this process in gynecologic patients. A recent Cochrane review of this bundled approach in colorectal surgery patients included 4 small randomized trials of low quality. Complications were reduced with the ERAS process, although not because of a reduction in major complications. The review concluded that quantity and quality of the data in this population are low and that ERAS should not be adopted universally based on these data. It is important to note that, in addition to these studies being done on patients very different from obstetrics patients, the effects of the individual components of the bundle cannot be separated analytically.
      • Spanjersberg W.R.
      • Reurings J.
      • Keus F.
      • van Laarhoven C.
      Fast track surgery versus conventional recovery strategies for colorectal surgery.

      Summary and recommendation

      Early mobilization after cesarean delivery is recommended. (Evidence level: very low; recommendation grade: weak.)

      Urinary drainage after cesarean delivery

      Urinary catheter placement during cesarean delivery is a widely accepted practice. It is believed generally that bladder drainage can measure urinary output, reduce urinary system injuries, and decrease postoperative urinary retention.
      • Ghoreishi J.
      Indwelling urinary catheters in cesarean delivery.
      However, urinary tract infection is 1 of the most common complications after cesarean delivery.
      • Schwartz M.A.
      • Wang C.C.
      • Eckert L.O.
      • Critchlow C.W.
      Risk factors for urinary tract infection in the postpartum period.
      • Barnes J.S.
      Is it better to avoid urethral catheterization at hysterectomy and cesarean section?.
      • Bartzen P.J.
      • Hafferty F.W.
      Pelvic laparotomy without an indwelling catheter. A retrospective review of 949 cases.
      • Leigh D.A.
      • Emmanuel F.X.
      • Segdwick J.
      • Dean R.
      Post-operative urinary tract infection and wound infection in women undergoing cesarean section: a comparison of two study periods in 1985 and 1987.
      Indwelling urinary catheters can increase the incidence of urinary tract infection, urethral pain, and difficult voiding. These complications result in delayed ambulation, prolonged hospital stay, and increased costs.
      In 2003, Ghoreishi
      • Ghoreishi J.
      Indwelling urinary catheters in cesarean delivery.
      conducted a prospective study with 270 patients who underwent cesarean delivery. The results indicated that placement of a urinary catheter during cesarean delivery did not improve surgical exposure of the lower uterine segment or reduce injury to the urinary tract. Patients without indwelling urinary catheters had a shorter mean ambulation time and length of hospital stay. In a nonrandomized clinical trial with 344 patients, Senanayake
      • Senanayake H.
      Elective cesarean section without urethral catheterization.
      demonstrated that there was low incidence of postoperative urinary retention after cesarean delivery in patients without an indwelling urinary catheter.
      In a prospective study, 420 patients who underwent elective cesarean delivery were assigned randomly into an noncatheterized group or a catheterized group (the catheter was removed 12 hours postoperatively).
      • Nasr A.M.
      • El Bigawy A.F.
      • Abdelamid A.E.
      • Al-Khulaidi S.
      • Al-Inany H.G.
      • Sayed E.H.
      Evaluation of the use vs nonuse of urinary catheterization during cesarean delivery: a prospective, multicenter, randomized controlled trial.
      The study reported that mean time to patient ambulation, first postoperative voiding, oral rehydration, bowel movement, and length of hospital stay were significantly less in the noncatheterized group (P<.001). Even though the urinary catheter was removed 12 hours after surgery, the incidence of urinary tract infection was significantly higher (5.7% vs 0.5%; P<.001). A systemic review (2 randomized controlled trials and 1 nonrandomized controlled trial) concluded that urinary catheter usage is associated with higher rates of urinary tract infections.
      • Li L.
      • Wen J.
      • Wang L.
      • Li Y.P.
      • Li Y.
      Is routine indwelling catheterisation of the bladder for caesarean section necessary? A systematic review.
      Urinary catheter does not reduce postoperative urinary retention or decrease intraoperative surgical difficulties.
      • Li L.
      • Wen J.
      • Wang L.
      • Li Y.P.
      • Li Y.
      Is routine indwelling catheterisation of the bladder for caesarean section necessary? A systematic review.
      In another prospective randomized clinical trial of immediate (n=150) vs 12-hour (n=150) removal of the urinary catheter in women who undergo elective cesarean delivery, the incidence of postoperative bacteriuria, dysuria, burning on the micturition, urinary frequency and urgency, the time till the first voiding, mean postoperative ambulation time, and length of hospital stay were significantly lower in the immediate urinary catheter removal group.
      • El-Mazny A.
      • El-Sharkawy M.
      • Hassan A.
      A prospective randomized clinical trial comparing immediate versus delayed removal of urinary catheter following elective cesarean section.
      A Cochrane review (5 randomized controlled trials with 1065 patients) showed that the use of urinary catheters in patients who underwent cesarean delivery was associated with increased time to first voiding, higher incidence of discomfort because of catheterization, delayed postoperative ambulation, and prolonged stay in hospital.
      • Abdel-Aleem H.
      • Aboelnasr M.F.
      • Jayousi T.M.
      • Habib F.A.
      Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section.

      Summary and recommendation

      In women who do not need ongoing strict assessment of urine output, the urinary catheter should be removed immediately after cesarean delivery, if placed during surgery. (Evidence level: low; recommendation grade: strong.)

      Postoperative/Postpartum Mother Pathway (Focused Element)

      Discharge counseling

      There is limited research on specific optimal discharge counselling for women after cesarean delivery. However, active surveillance of complications after discharge after cesarean delivery suggests that surgical site infections occur in approximately 10% of patients, >80% of which develop after discharge,
      • Ward V.P.
      • Charlett A.
      • Fagan J.
      • Crawshaw S.C.
      Enhanced surgical site infection surveillance following caesarean section: experience of a multicentre collaborative post-discharge system.
      which indicates a need for women to be provided with comprehensive information on the normal discharge course, signs and symptoms of infection, activity restrictions, and instructions on when to seek medical attention. The Perceived Readiness for Discharge After Birth Scale is a validated tool that may help clinicians to identify patients who are at increased risk of problems after discharge.
      • Weiss M.E.
      • Ryan P.
      • Lokken L.
      Validity and reliability of the perceived readiness for discharge after birth scale.
      Web-based opportunities have been explored, but there are not extensive support data at present.
      • Castillio E.
      • McIsaac C.
      • MacDougall B.
      • Wilson D.
      • Kohr R.
      Post-caesarean section surgical site infection surveillance using an online database and mobile phone technology.
      Looking at what can be learned from other areas, a systematic review of 30 randomized controlled trials that have evaluated discharge planning across multiple patient groups and medical specialties found that overall discharge planning may lead to a small reduction in length of stay, a reduced risk of readmission for some patient groups, and increased satisfaction for both patients and health professionals.
      • Goncalves-Bradley D.C.
      • Lannin N.A.
      • Clemson L.M.
      • Cameron I.D.
      • Shepperd S.
      Discharge planning from hospital.
      With a focus exclusively on surgical patients, 2 trials reported a nonsignificant reduction in length of stay (–0.06 days; 95% CI, –1.23 to 1.11); 1 trial reported a nonsignificant difference in readmission rates (+3%; 95% CI, –7 to 13%).
      • Goncalves-Bradley D.C.
      • Lannin N.A.
      • Clemson L.M.
      • Cameron I.D.
      • Shepperd S.
      Discharge planning from hospital.
      Additionally, a prospective before-and-after study of 1219 patients found that compliance with discharge instructions in the emergency department was increased from 26.2% to 36.2% (odds ratio, 1.59; 95% CI, 1.2–2.1) with the provision of standardized written information that included information on the diagnosis, medication dosage and length of treatment, potential medication side-effects, and suggested time and location of out-patient clinic follow up.
      • Vukmir R.B.
      • Kremen R.
      • Ellis G.L.
      • DeHart D.A.
      • Plewa M.C.
      • Menegazzi J.
      Compliance with emergency department referral: the effect of computerized discharge instructions.

      Summary and recommendations

      Standardized written discharge instructions should be used to facilitate discharge counselling. (Evidence level: low; recommendation grade: weak)

      Comment

      The ERAS cesarean delivery guideline/pathway has created a pathway (for scheduled and unscheduled surgery starting from 30–60 minutes before skin incision to maternal discharge) with 5 pre- elements (8 recommendations); 4 intraoperative elements (9 recommendations); 9 postoperative elements (11 recommendations, which are the focus of this document); and 1 neonatal element (6 recommendations).
      The maternity clinical care area has complex pathways, but there are increasing risk management factors that are related to obstetric comorbid medical, genetic, surgical, and lifestyle factors. More prospective and quality assessment/improvement research, evaluation, audit, and collaboration will be required for enhancement of the maternal and fetal health outcomes, quality, and safety.

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