Optimizing maternal recovery: insights into enhanced recovery after Cesarean delivery

Hyo-Seok Na

doi:10.17085/apm.25211

Anesth Pain Med > Volume 20(2); 2025 > Article

Na: Optimizing maternal recovery: insights into enhanced recovery after Cesarean delivery

Obstetric Anesthesia

Review

Anesthesia and Pain Medicine 2025;20(2):101-108.

Published online: April 30, 2025

DOI: https://doi.org/10.17085/apm.25211

Optimizing maternal recovery: insights into enhanced recovery after Cesarean delivery

Hyo-Seok Na^1,²

¹Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

²Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea

Corresponding author: Hyo-Seok Na, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea
Tel: 82-31-787-7507 Fax: 82-31-787-4063 E-mail: hsknana@gmail.com

Received January 23, 2025 Revised March 10, 2025 Accepted March 11, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Enhanced recovery after surgery (ERAS) is an innovative perioperative management approach designed to shorten the recovery time, improve patient safety and quality of care, and enhance overall satisfaction. Successful implementation of ERAS requires active collaboration between healthcare providers and patients to facilitate a timely return to daily activities. The ERAS protocol, originally developed for colorectal surgery, has gradually been expanded and adapted to other major surgeries, and more recently, to Cesarean deliveries. Enhanced recovery after Cesarean delivery (ERAC) presents unique challenges due to its distinct patient population, comprising relatively young women. Its dual focus on maternal recovery and neonatal well-being sets it apart from conventional ERAS protocols. Several components of the ERAC protocol have been adapted from the ERAS recommendations; however, supporting evidence remains limited. This review examines the current ERAC protocol and considers the types of research needed to establish an evidence-based ERAC protocol in the future.

Keywords: Cesarean section; Enhanced recovery after surgery; Intraoperative period; Patient satisfaction; Postoperative period; Preoperative period; Safety

INTRODUCTION

Enhanced recovery after surgery (ERAS) was initially introduced in patients undergoing colorectal surgery [1], and has since been extended to patients who have undergone other major surgical procedures [2-5]. The primary population targeted by ERAS comprises elderly patients with multiple comorbidities who are at an elevated risk of morbidity and mortality associated with perioperative complications.

ERAS has been actively adopted by hospitals as it has been demonstrated to shorten postoperative hospital stays and improve clinical outcomes [6]. Enhanced recovery after Cesarean delivery (ERAC) refers to a comprehensive set of perioperative practices aimed at improving postoperative outcomes, functional recovery, mother-newborn bonding, and overall surgical experience [7-9]. Successful implementation of ERAC requires not only patient engagement, but also multidisciplinary collaboration among anesthesiologists, obstetricians, nursing staff, and hospital systems. ERAC seeks to enhance outcomes in both mothers and newborns by standardizing perioperative management following Cesarean delivery.

In South Korea, the exact length of hospital stay following Cesarean delivery has not been clearly reported; however, a postoperative hospital stay of approximately 3-5 days is generally recommended. ERAS has been actively implemented for Cesarean deliveries in the United Kingdom, resulting in a remarkable reduction in the length of postoperative hospital stay [10].

Even outside the context of ERAC, the perioperative management of Cesarean delivery has already been aligned with certain principles pursued by ERAS. For instance, regional anesthesia (spinal anesthesia) is commonly used as the primary anesthetic method, the fasting period after surgery is relatively short, oral analgesics are used, and early ambulation is encouraged. However, ERAC differs from traditional ERAS in several respects. It primarily targets young and healthy female patients. Cesarean delivery is not considered a highly invasive surgery, the perioperative mortality rate is quite low, and fetal outcomes must also be considered.

ERAC has now gained worldwide attention, leading the ERAS Society to publish official guidelines [7-9]. However, some of these guidelines lack sufficient evidence specific to pregnant women (Table 1), necessitating the application of general ERAS principles. Further research is required to establish robust evidence supporting these recommendations.

ANTENATAL AND PREOPERATIVE CARE IN CESAREAN DELIVERY

Mothers who are well-informed about the perioperative process of Cesarean delivery are likely to develop a comprehensive understanding of the procedure, which may facilitate faster recovery and, consequently, reduce the length of postoperative hospital stay. Therefore, it is essential to provide pregnant women with detailed explanations about their surgical procedures, as well as about the processes that the newborn undergoes after birth [11]. Such information should include the indications for Cesarean delivery and a comprehensive discussion of its advantages and disadvantages, and should ideally be communicated through verbal explanation, written materials, or official electronic resources provided by the hospital.

Preoperative sedation is generally not recommended, whether for general anesthesia or regional anesthesia, due to its potential effects on the neonate through placental transfer [12,13]. Furthermore, bowel preparation is not required for Cesarean delivery [14]. Anatomical and physiological changes increase the likelihood of gastroesophageal reflux and subsequent aspiration pneumonitis in full-term pregnant women. Therefore, antacid prophylaxis is necessary to mitigate the risk of aspiration in cases where Cesarean delivery is planned under general anesthesia [15].

In general, ERAS protocols recommend minimizing the duration of preoperative fasting as much as possible. Similarly, ERAC guidelines suggest avoiding solid food intake starting 6 h before surgery and permitting the intake of clear fluids up to 2 h before the procedure [7,16]. However, even with an appropriate fasting duration, a considerable proportion of pregnant women may still present with substantial residual gastric volumes, necessitating continued caution [17].

Preoperative evaluations and interventions should be tailored to the underlying conditions of the pregnant women. While physiological anemia that is commonly observed during pregnancy does not necessarily require correction prior to surgery, severe cases warrant further investigation to rule out other underlying causes, and blood transfusions may be considered if necessary [18].

Pregnancy is generally associated with weight gain. However, in cases of moderate-to-severe obesity, there is an elevated risk of pregnancy-related complications, increased surgical complexity, and a higher incidence of perioperative complications [19]. The complexity of both regional and general anesthesia is also greater, making it essential for anesthesiologists to be informed of such cases in advance.

INTRAOPERATIVE CARE IN CESAREAN DELIVERY

Prophylactic antibiotics are generally administered within 60 min before the start of surgery [20]. The surgical site is disinfected with chlorhexidine, and additional vaginal disinfection has been reported to reduce the risk of postoperative endometritis, fever, and wound infection in cases of emergency surgery accompanied by amniotic membrane rupture [8,21]. However, there is no clear evidence supporting the efficacy of this practice in elective Cesarean deliveries [22,23].

Regional anesthesia is preferred over general anesthesia because it is associated with the recognition of airway-related risks associated with general anesthesia, reduced blood loss, limited neonatal drug transfer, the benefit of allowing the mother to remain awake to experience childbirth, lower surgical stress response, and decreased incidence of postoperative nausea and vomiting, thus allowing for earlier resumption of diet. The addition of opioids to local anesthetics in regional anesthesia enhances intraoperative block quality and provides effective postoperative pain relief [24]. Additionally, combining regional anesthesia with a transversus abdominis plane block can further optimize pain management both intraoperatively and postoperatively [25].

According to ERAS recommendations, body temperature should be monitored to maintain normothermia. Hypothermia, defined as a core temperature below 36°C, is generally associated with increased intraoperative blood loss and a higher frequency of blood transfusions. It is also linked to an elevated risk of surgical site infections and can prolong both the length of stay in the post-anesthesia care unit and the overall hospital stay [26-28]. First and foremost, it is recommended to maintain the operating room temperature at 23°C or higher [29]. Additionally, active warming methods, such as heat mattresses, forced-air warming devices, warming blankets, and warmed fluid infusions, should be employed during surgery to prevent maternal hypothermia [30].

Regarding surgical techniques for Cesarean delivery, practices such as blunt transverse expansion of the uterine hysterotomy, two-layer closure of the hysterotomy, and skin closure using subcuticular sutures are recommended. Although these approaches are supported by only moderate level of evidence and with weak strength of recommendation, they have been shown to reduce operative time and blood loss while improving surgical outcomes.

Delayed cord clamping, defined as clamping of the umbilical cord at least one minute after delivery instead of immediately after it, has been shown to positively affect neonatal outcomes. The benefits include increased hemoglobin levels, reduced need for neonatal transfusion, maintenance of optimal blood pressure, improved neurodevelopment, and decreased incidence of pathological conditions such as intraventricular hemorrhage, chronic lung disease, necrotizing enterocolitis, and sepsis [31-33]. Delayed cord clamping is recommended by organizations such as the World Health Organization and the National Institute for Health and Care Excellence [34].

Once the newborn's condition stabilizes after Cesarean delivery, facilitation of skin-to-skin contact with the mother has been shown to support the success of breastfeeding [35]. This practice also enhances maternal satisfaction and reduces stress levels in newborns.

POSTOPERATIVE CARE FOLLOWING CESAREAN DELIVERY

Oral intake of clear fluids can begin once the mother's condition is stable after a Cesarean delivery performed under regional anesthesia. Solid food can be introduced within 1-2 h of completion of the procedure; this can alleviate thirst and hunger, promote early ambulation, and reduce the length of hospital stay without gastrointestinal complications [36-38]. Sham feeding using postoperative chewing gum has been studied in case of various surgical procedures [39]. Although chewing gum regimens vary, studies have reported that patients who underwent this intervention achieve normal intestinal function faster than those who did not undergo the intervention. However, previous studies are limited in that they were conducted in patients who underwent surgery under general anesthesia, whereas Cesarean delivery is performed under regional anesthesia.

ERAC reduces postoperative pain and subsequently decreases opioid use. Multimodal analgesia after surgery includes the use of high-dose paracetamol and non-steroidal anti-inflammatory drugs, which reduce opioid consumption and associated side effects [40,41]. Opioid formulations can be administered orally and may be used to effectively manage breakthrough pain effectively [42]. The incidence of intraoperative and postoperative nausea and vomiting in patients undergoing Cesarean delivery has been reported to be as high as 80% [43]. As in other types of surgery [44], combination prophylactic regimens are more effective in Cesarean deliveries [45,46].

It has been reported that early removal of the urinary catheter placed during surgery can help shorten the postoperative hospital stay [47]. However, when regional anesthesia is used, there is a period during which the mother may not feel the urge to urinate. This raises concerns regarding the risk of urinary retention and neurogenic bladder during this period. Nevertheless, numerous studies have reported that urinary catheters may be unnecessary in Cesarean deliveries [48,49], and this controversy has not been definitively resolved.

Although venous thromboembolism (VTE) increases maternal morbidity and mortality, the guidelines for VTE prophylaxis primarily rely on expert opinions or findings extrapolated from non-pregnant patients [50,51]. In particular, data limited to Cesarean deliveries are lacking. The use of conventional pneumatic compression stockings is feasible, whereas the routine administration of heparin for VTE prophylaxis is not recommended [9]. Further research is needed considering that these recommendations are based on limited data [52].

Early mobilization after surgery is a core principle of ERAS protocols; however, it has not been extensively studied in the context of Cesarean deliveries, leading to limited supporting evidence [53]. Since most Cesarean deliveries are performed under regional anesthesia, early ambulation within a few hours of the procedure is not feasible due to the residual effects of anesthesia. Lower limb strength typically recovers within 6-8 h following spinal anesthesia; however, this timeframe may vary among patients. As such, assistance should be provided during initial attempts at ambulation to ensure safety and prevent potential accidents.

CURRENT STATUS AND FUTURE DIRECTIONS

Several components of the ERAC protocol still lack sufficient evidence (Table 1) and require further research for the medical community to have confidence in its impact. In particular, further rigorous research is warranted for interventions such as preoperative carbohydrate supplementation [54], postoperative chewing gum [55,56], early mobilization [57], and discharge counseling [58] as they have weak recommendation strengths and low levels of evidence. In addition, efforts should be made to verify Cesarean delivery-specific elements, including intraoperative skin-to-skin contact between the newborn and the mother as well as the initiation of breastfeeding within 2 h after Cesarean delivery. This may contribute to promoting breastfeeding, enhancing maternal-newborn bonding, and improving postpartum recovery and neonatal health [59-62].

Despite the inclusion of some low-evidence practices in the ERAC program, its implementation was associated with improvements in certain maternal outcomes, including reduced length of postoperative hospital stay, time to first ambulation, urinary catheter use, and opioid consumption [63,64]. A survey of the ERAC program conducted in Austria and Canada revealed variations in implementation rates for each item [65,66]. Currently, no information is available on the extent to which ERAC has been implemented at each center in our country. Therefore, the gap between the recognition and actual implementation of ERAC must be investigated and any barriers to its application must be identified. Additionally, it is possible to selectively introduce ERAC components that are suitable for the circumstances specific to each center.

CONCLUSION

Many challenges remain in implementing ERAC, and hospitals that actively utilize ERAS protocols may consider extending their application to Cesarean deliveries. Additionally, numerous components of ERAC lack robust evidence and are supported by weak recommendations. Addressing these limitations and developing a systematic ERAC protocol requires ongoing research and multidisciplinary collaboration to strengthen the evidence.

In South Korea, mothers typically remain hospitalized for approximately 3-5 days following Cesarean delivery. After discharge, they often transition to postpartum care centers or return home with the assistance of postpartum care helpers, reflecting unique cultural practices. Establishing a Korean ERAC protocol requires close collaboration between obstetricians and anesthesiologists. Furthermore, the active participation of postpartum mothers is essential for successful implementation of these changes.

Notes

FUNDING

None.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

DATA AVAILABILITY STATEMENT

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Table 1.

ERAC Items Recommended from the ERAS Guidelines

Items	Evidence level	Recommendation strength
Antenatal and preoperative care
Giving information and education	Very low to low	Strong
Antacid medication	Low	Strong
Absence of sedative premedication	Low	Strong
No bowel preparation	High	Strong
Minimum fasting	High	Strong
Carbohydrate supplementation	Low	Weak
Maternal comorbidity optimization
Obesity, hypertension, diabetes, smoking	High	Strong
Anemia	Moderate	Strong
Intraoperative care
Prophylactic antibiotics	High	Strong
Chlorhexidine-alcohol skin preparation	Low	Strong
Povidone-iodine vaginal preparation	Moderate	Weak
Regional anesthesia	Low	Strong
Normothermia by active warming	High	Strong
Euvolemia	Low to moderate	Strong
Delayed cord clamping for at least 1 min	Moderate	Strong
Postoperative care
Chewing gum	Low	Weak
Early diet	High	Strong
Antiemetic agents	Moderate	Strong
Multimodal analgesia with NSAIDs and paracetamol	Moderate	Strong
Thromboembolism prophylaxis	Low	Strong
Early mobilization	Very low	Weak
Immediate removal of urinary catheter	Low	Strong
Discharge counselling	Low	Weak

The evidence level was classified as very low, low, moderate, or high. The strength of recommendations was classified as either weak or strong. ERAC: enhanced recovery after Cesarean delivery, ERAS: enhanced recovery after surgery, NSAIDs: nonsteroidal anti-inflammatory drugs.

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