Published online: 2020-06-02

Original Article

Enhanced Recovery after Surgery for Cesarean

Delivery Decreases Length of Hospital Stay and Opioid
Consumption: A Quality Improvement Initiative
Julia K. Shinnick, MD1 Merima Ruhotina, MD1 Phinnara Has, MS2 Bridget J. Kelly, MD1
E. Christine Brousseau, MD1 James O’Brien, MD1 Alex Friedman Peahl, MD3,4

1 Department of Obstetrics and Gynecology, Warren Alpert Medical Address for correspondence Julia K. Shinnick, MD, Department of
School of Brown University, Providence, Rhode Island Obstetrics and Gynecology, Warren Alpert Medical School of Brown
2 Division of Research, Department of Obstetrics and Gynecology, Warren University, 101 Dudley Street, 3rd Floor, Providence, RI 02905
Alpert Medical School of Brown University, Providence, Rhode Island (e-mail: JShinnick@wihri.org).
3 National Clinician Scholars Program, University of Michigan, Ann
Arbor, Michigan
4 Department of Obstetrics and Gynecology, University of Michigan,
Ann Arbor, Michigan

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Am J Perinatol

Abstract
Keywords
► enhanced recovery
after surgery
► cesarean delivery
► opioid medications
► length of hospital stay
Objective The aim of this study is to assess the effect of a resident-led enhanced
recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on
hospital length of stay and postpartum opioid consumption.
Study Design This retrospective cohort study included patients who underwent
scheduled prelabor cesarean deliveries before and after implementation of an ERAS
protocol at a single academic tertiary care institution. The primary outcome was length
of stay following cesarean delivery. Secondary outcomes included protocol adherence,
inpatient opioid consumption, and patient-centered outcomes. The protocol included
multimodal analgesia and antiemetic medications, expedited urinary catheter remov-
al, early discontinuation of maintenance intravenous fluids, and early ambulation.
Results A total of 250 patients were included in the study: 122 in the pre-ERAS cohort
and 128 in the post-ERAS cohort. There were no differences in baseline demographics,
medical comorbidities, or cesarean delivery characteristics between the two groups.
Following protocol implementation, hospital length of stay decreased by an average of
7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to
the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg
of oxycodone per patient, with no significant differences in pain scores from postoper-
ative day 1 to postoperative day 4 (all p > 0.05).
Conclusion A resident-driven quality improvement project was associated with
decreased length of hospital stay, decreased opioid consumption, and unchanged
visual analog pain scores at the time of hospital discharge. Implementation of this ERAS
protocol is feasible and effective.

received Copyright © by Thieme Medical DOI https://doi.org/

December 13, 2019 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0040-1709456.
accepted after revision New York, NY 10001, USA. ISSN 0735-1631.
March 2, 2020 Tel: +1(212) 760-0888.
Enhanced Recovery after Surgery Protocol for Cesarean Delivery
Key Points
• Telehealth for prenatal care is feasible.
• Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol
adherence.
• Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain
medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.
• Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures
(e.g., protocol adherence) and outcome measures (e.g., opioid use).
Enhanced recovery after surgery (ERAS) is a philosophy of
perioperative care that has been utilized in other fields since
the 1990s, yet only recently has been applied to obstetric
care.1–7 In various subspecialties, ERAS protocols have been
shown to achieve the triple aim: increasing patient satisfac-
tion, decreasing cost, and improving quality.8 As key mater-
nity care stakeholders seek to improve care quality and costs,
ERAS may be a promising solution for addressing value in the
postpartum period.9,10
Components of published ERAS for cesarean delivery
guidelines are evidence based; however, there is little avail-
able evidence regarding actual protocol implementation in
an obstetric population.5,6,11–13 This gap includes a lack of
data on protocol adherence (a hospital’s ability to implement
all components reliably), outcomes (including length of stay,
urinary catheter removal, pain control, and patient-centered
outcomes), and unintended adverse events (including read-
mission). ERAS protocols often include sweeping changes to
patterns of postcesarean care. It is therefore critical to first
examine the feasibility of implementation, as well as consid-
er the influence that such protocols have on patient out-
comes and safety.
In 2016, a group of obstetrics and gynecology (Ob/Gyn)
residents at a single, tertiary academic center identified the
need for an ERAS protocol for postcesarean delivery patients
in light of two main events: (1) pending statewide legislation
limiting postsurgical discharge prescriptions for opioids and
(2) the success of ERAS protocols implemented for gyneco-
logic surgery at their institution and others. The current
study describes a resident-driven quality improvement proj-
ect to implement an ERAS for cesarean delivery protocol at a
large academic institution. In this study, we assess protocol
adherence, clinical and patient-centered outcomes, and po-
tential adverse events associated with implementation of an
ERAS protocol for cesarean delivery.
Materials and Methods
Study Design
This retrospective cohort study compared patients who
underwent scheduled prelabor cesarean deliveries before
implementation of an ERAS protocol (January 1, 2016–
February 23, 2016) to patients who underwent the same
procedure after protocol implementation (August 16, 2018–
October 2, 2018). Patients with antenatal preeclampsia/
eclampsia were excluded because at the time of implemen-
American Journal of Perinatology
Shinnick et al.
tation, these patients did not receive nonsteroidal antiin-
flammatory drugs as part of routine postpartum pain
management. Additionally, we excluded patients <18 years
of age and patients with substance use disorder receiving
medication-assisted therapy. Planned cesarean deliveries
were included to best capture the effect of full ERAS protocol
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implementation from before surgery to discharge. After a full
review, this study was approved by the institutional review
board of Women and Infants Hospital.
Data collection was performed from November 2018 to
May 2019 via chart review. Hospital billing data were used to
identify all patients who underwent cesarean delivery dur-
ing the prespecified time periods. Two authors (J.K.S. and M.
R.) screened patients for inclusion and subsequently ab-
stracted variables into a REDCap database.14,15 Variables
abstracted from the electronic medical record included
patient demographics, pregnancy characteristics, protocol
adherence, and postpartum outcomes (►Table 1). The pri-
mary outcome was length of stay, defined as the time from
end of surgery to the time of discharge.
Based on data from Corso et al, to achieve 80% power with
a significance level of 5% to detect an 18 hour (0.75 day)
decrease in length of stay with a standard deviation of 2 days,
125 subjects were needed in each group to investigate the
primary outcome.2 Secondary outcomes included adherence
to the ERAS protocol (as defined by the number of patients
who were ordered for, and subsequently received, each care
component), measures of pain management including cu-
mulative opioid consumption, pain control as measured by
visual analog scores, and possible unanticipated outcomes of
the protocol including neonatal Apgar scores, postpartum
complications, and readmissions.
Analysis
Univariate distributions of all variables were described. Cate-
gorical variables were compared by Chi-square or Fisher’s
exact test. Continuous variables were compared using Stu-
dent’s t test or nonparametric Wilcoxon rank-sum test. The p-
values were two sided, with p < 0.05 considered statistically
significant. Data analysis performed with Stata/SE 15.1 (Col-
lege Station, TX).
Protocol Design
The Ob/Gyn residents assembled an interdisciplinary team to
ensure the protocol was designed with input from all key
stakeholders (►Table 2).
 Enhanced Recovery after Surgery Protocol for Cesarean Delivery Shinnick et al.

Table 1 Abstracted variables Table 2 ERAS interdisciplinary team

Patient characteristics Resident Ob/Gyns

Age Academic and community Ob/Gyns
American Society of Anesthesiologists status Director of Obstetrics
Body mass index Attending Family Medicine MDs
Tobacco use Midwives
Maternal chronic medical problems Attending Anesthesiologists
Maternal pregnancy complications Pharmacy administration
Pregnancy characteristics Pharmacists
Gravidity Operating Room administration
Parity Nurse managers
Gestational age at time of cesarean delivery Perioperative nurses
Group β strep carrier status Surgical technicians
Number of prior cesarean deliveries Intraoperative nurses
Division of children youth and families involvement Nurse educators

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Protocol adherence Patient experience team
Orders verified by nursing for each variable of the order set Perioperative care administration
Modifications to orders in the order set Perioperative secretaries and schedulers
Documentation of execution of the orders in the order set Hospital administration
Surgical characteristics
Abbreviation: ERAS, enhanced recovery after surgery; Ob/Gyn, obstetrics
Length of surgery and gynecology.
Type of anesthesia
Skin closure technique cesarean delivery protocol for this institution (►Table 3).
Postpartum hemorrhage Several elements of the ERAS protocol were consistent with
Blood transfusion existing perioperative practice and remained unchanged:
administration of long-acting neuraxial analgesia, chlorhex-
Bladder injury
idine, and isopropyl alcohol-based abdominal preparation
Bowel injury
prior to incision, and use of sequential compression devices
Hysterectomy from surgery until postoperative ambulation. An educational
Intraoperative intravenous fluid volume campaign for staff and providers was executed, including a
Postoperative outcomes grand rounds presentation, online learning modules re-
Hospital length of stay quired for all nursing staff, and sharing of protocol
documents/elements at clinical huddles. A new order set
Postoperative pain scale score
was created within the electronic medical record to facilitate
Opioid pain medication use
implementation.
Nonopioid analgesic medication use
Episodes of emesis
Results
Hospital readmission
Time to ambulation A total of 367 patients were screened for inclusion (►Fig. 1).
Duration of urinary catheterization The most common reason for exclusion in both the pre- and
post-ERAS implementation groups was unscheduled cesare-
Complications up to 3 months postoperatively (abscess,
hematoma, acute kidney injury, ileus, cellulitis, fascial de- an delivery. Participants’ demographic information is shown
hiscence, superficial wound separation, thromboembolic in ►Table 4. Pre- and post-ERAS implementation groups did
complications, and blood transfusion) not differ by maternal age, body mass index, gestational age
Neonatal outcomes at time of delivery, or comorbidities.
Birth weight
Apgar scores Cesarean Delivery Characteristics
Intraoperative cesarean delivery characteristics were similar
Neonatal intensive care unit admissions
between groups before and after ERAS protocol implemen-
tation. There were no significant differences in operative
The team reviewed existing literature on ERAS protocols time for the included cesarean deliveries (mean: 45.8-min-
in other surgical specialties, as well as available obstetrics ute pre-ERAS vs. 48.3-minute post-ERAS; p ¼ 0.31). Intra-
literature for relevant protocol elements. Following this operative complications were rare in both groups, with no
review, consensus was used to determine an ERAS for significant differences between pre- and post-ERAS

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Enhanced Recovery after Surgery Protocol for Cesarean Delivery
Table 3 Enhanced recovery after surgery protocol for
cesarean delivery components
Preoperative elements
Discussion of anticipated recovery process
Intraoperative elements
Titration of intraoperative fluid administration to maintain
euvolemia
Antibiotics administered prior to incision per ACOG guidelines
Abdominal skin prep with chlorhexidine gluconate 2% and
isopropyl alcohol 70%
Sequential compression devices applied upon initiation of
neuraxial anesthesia and maintained while the patient was in
bed throughout the hospital stay
Neuraxial anesthesia with long-acting intrathecal morphine
Intraoperative warming blanket
Postoperative elements
Discussion of anticipated recovery process
Foley out 8 hours after surgery
Colace 100 mg PO scheduled twice daily
Ambulation by 8 a.m. postoperative day 1
General diet starting postoperative day 0
Polyethyline glycol 17 g PO twice daily as needed
Acetaminophen 975 mg PO scheduled q8 hours
Postoperative oxycodone 5 to 10 mg PO q4 hours as needed
Morphine 2 to 4 mg IV as needed for pain, without a patient-
controlled device
Ondansetron 8 mg IV q8 hours as needed
Promethazine 6.25 mg IV q4 hours as needed for nausea re-
fractory to ondansetron
Ketorolac 30 mg IV q6 hours for the first 24 h postpartum
Ibuprofen 600 mg PO q6 hours for 24 h to start after cessation of
ketorolac
A total of no more than 100 cc/h of total intravenous fluids
postoperatively
Order for peripheral IV locked when patient tolerates >600cc PO
or 8 a.m. on postoperative day 1
Abbreviations: ACOG, American College of Obstetricians and Gynecolo-
gists; ERAS, enhanced recovery after surgery; IV, intravenous; PO, per os.
Note: Outline of elements incorporated into an enhanced recovery after
surgery protocol for patients undergoing cesarean delivery.
implementation. The most common complication was vacu-
um-assisted fetal extraction in the operating room (2/122
[1.6%] vs. 1/128 [0.8%]; p ¼ 0.62). Fetal weight was signifi-
cantly higher in the post-ERAS group (median: 3,328 vs.
3,470 g; p ¼ 0.04). There were no significant differences in
mean estimated blood loss (653cc ERAS vs. 679cc post-ERAS;
p ¼ 0.38) or mean intraoperative urine output (197cc pre-
ERAS vs. 213cc -ERAS; p ¼ 0.31).
Protocol Adherence
Adherence to each variable in the ERAS protocol for post-ERAS
implementation patients was nearly 90% (►Supplementary
American Journal of Perinatology
Shinnick et al.
Table S1 [available in the online version]). Patients in the post-
ERAS cohort received significantly less intraoperative fluid
(median: 2,500cc; IQR: 2,200–2,800 pre-ERAS vs. 2,200cc, IQR:
1,800–2,500 post-ERAS; p < 0.001). Additionally, 125/128
(98.0%) of patients had an order to remove the urinary catheter
<8 hours after surgery post-ERAS vs. 16/122 (13.1%) pre-ERAS,
(p < 0.001) with 110/128 (85.9%) of post-ERAS patients actu-
ally having their catheter removed in this time frame vs.
57/116 (49.1%) pre-ERAS, (p < 0.001). After implementation
of the ERAS protocol, 117/128 (91.4%) of patients were ambu-
latory by 8 a.m. on postoperative day 1, compared with only
74/116 (63.8%) pre-ERAS (p < 0.001). There were no differ-
ences in the timing of discontinuation of intravenous fluids
after protocol implementation (post-ERAS: 126/128 [98.0%];
pre-ERAS: 117/122 [95.9%; p ¼ 0.27]).
More patients received scheduled nonopioid pain medi-
cation after ERAS implementation: acetaminophen (96.1 vs.
0%), ketorolac (92.2 vs. 0%), and ibuprofen (93.8 vs. 0%) all
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p < 0.001, ►Supplementary Table S1 [available in the online
version]). Prior to implementation of the ERAS protocol,
113/122 (92.6%) of patients were written for the combined
tablet of oxycodone–acetaminophen, whereas only 4/128
(3.1%) were written for combined oxycodone–acetamino-
phen post-ERAS (p < 0.001).
Maternal and Fetal Outcomes
After ERAS protocol implementation, hospital length of stay
decreased an average of 7.9 hours (pre-ERAS 82.1 vs. post-
ERAS 74.2, p < 0.001, ►Fig. 2). In-house opioid consumption
decreased by an average of 36.5 mg of oxycodone per patient,
in conjunction with increasing nonopioid pain medication
consumption (►Table 5).
There were no significant differences in number of emesis
episodes postoperatively before and after ERAS implementa-
tion (pre-ERAS 7.6 vs. post-ERAS 2.6%, p ¼ 0.17). While mean
postoperative day 0 visual analog pain scores were higher
post-ERAS implementation (1.9 vs. 2.5, p ¼ 0.03), there were
no significant differences in pain scores from postoperative
day 1 to postoperative day 4 (all p > 0.05; ►Fig. 3). There were
no differences in postoperative complications including hem-
orrhage, blood transfusion, or hospital readmissions between
the two groups (all p > 0.05). Neonatal outcomes were similar
between groups, with median 5-minute Apgar’s scores of 9 in
both the pre- and post-ERAS groups (p ¼ 0.16).
Discussion
This resident-led ERAS for cesarean delivery initiative dem-
onstrated successful protocol implementation, shorter hos-
pital length of stay, and decreased opioid medication
consumption with no clinically significant changes in post-
operative pain or adverse events. Our data add to the growing
body of literature demonstrating that ERAS protocols for
cesarean delivery are feasible, effective, and safe. This study
adds more granular data regarding protocol characteristics
and adherence than has previously been published, provid-
ing a better understanding of the association between ERAS
implementation and outcomes.2–7,11–13
 Enhanced Recovery after Surgery Protocol for Cesarean Delivery Shinnick et al.

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Fig. 1 Patient inclusion diagram. Inclusion diagram demonstrating common reasons for patient exclusion at each study stage. PEC,
preeclampsia; ROM, rupture of membranes; sPEC, severe preeclampsia.

Table 4 Demographics

Pre-ERAS (n ¼ 122) Post-ERAS (n ¼ 128) p-Value

Maternal age at surgery 0.28a
Median (min–max) 33 (20–54) 31.5 (22–43)
IQR (Q1–Q3) (28–36) (28–35)
Gestational age at delivery (wk) 0.09a
Median (min–max) 39.0 (31.9–40.4) 39.1 (33.9–41.6)
IQR (Q1–Q3) (39.0–39.3) (39.0–39.6)
BMI at first prenatal visit (n ¼ 95) (n ¼ 100) 0.95a
Median (min–max) 28.7 (18.3–52.3) 28.6 (13.7–58.0)
IQR (Q1–Q3) (23.8–36.6) (25.0–35.6)
BMI at time of surgery (n ¼ 120) (n ¼ 128) 0.44a
Median (min–max) 33.1 (22.0–57.1) 33.9 (23.1–67.9)
IQR (Q1–Q3) (29.1–39.2) (29.6–39.4)
Number of prior cesarean deliveries n (%) n (%) 0.05b
0 20 (16.4) 39 (30.7)
1 70 (57.4) 61 (48.0)
2 23 (18.9) 21 (16.5)
3 9 (7.4) 5 (3.9)
4 0 (–) 1 (0.79)
Number of fetuses at time of caesarean section n (%) n (%) 0.22b
Singleton 116 (95.1) 123 (96.1)
Twin 5 (4.1) 4 (3.1)
Triplet 0 (–) 1 (0.78)
Quadruplet 1 (0.82) 0 (–)
(Continued)

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Enhanced Recovery after Surgery Protocol for Cesarean Delivery Shinnick et al.

Table 4 (Continued)

Pre-ERAS (n ¼ 122) Post-ERAS (n ¼ 128) p-Value

Comorbiditiesc n (%) n (%)
Type 1 diabetes mellitus 0 (–) 1 (0.78) 1.00b
Type 2 diabetes mellitus 4 (3.3) 1 (0.78) 0.20b
A1 gestational diabetes mellitus 7 (5.7) 6 (4.7) 0.78b
A2 gestational diabetes mellitus 7 (5.7) 4 (3.1) 0.37b
Gestational hypertension 6 (4.9) 6 (4.7) 1.00b
Chronic hypertension 9 (7.4) 8 (6.3) 0.80b
Fibromyalgia 2 (1.6) 0 (–) 0.24b
Chronic pain 0 (–) 1 (0.78) 1.00b
Tobacco use 3 (2.5) 1 (0.78) 0.36b
Severe preeclampsia (postpartum) 1 (0.82) 0 (–) 0.49b
History of substance abuse 0 2 (1.6) 0.49b
Other 30 (24.6) 41 (32.0) 0.21b

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Hypertensive disorder of pregnancy NOS 0 (–) 5 (3.9) 0.06b

Abbreviations: BMI, body mass index; ERAS, enhanced recovery after surgery; IQR, interquartile range; Max, maximum; Min, minimum; NOS, not
otherwise specified.
Note: Patient demographics before and after implementation of an enhanced recovery after surgery protocol.
Categorical data are n (%).
a
Wilcoxon’s rank-sum test.
b
Fisher’s exact test.
c
Check all that applies; does not sum to 100%.

Fig. 3 Mean visual analog pain scale score by postoperative day. VAS scores rated on a scale of 0 to 10, with 10 being the most severe pain and 0
being no pain. Mean postoperative day 0 VAS scores were 2.5 in the post-ERAS cohort and 1.9 in the pre-ERAS cohort, p < 0.03. There were no
significant differences between scores on subsequent postoperative days. ERAS, enhanced recovery after surgery; VAS, visual analog pain scale.

The ERAS protocol currently described had nearly 90% and involved simply modifying the existing order set and
adherence to all components. This suggests that substantial providing education across key groups. We believe the
quality improvement can occur with fairly limited resources: intuitive protocol, standardized order sets, key stakeholder
implementation of our protocol required no extra funding, engagement, and local champions were crucial parts of

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 Enhanced Recovery after Surgery Protocol for Cesarean Delivery Shinnick et al.

Table 5 In-house opioid, acetaminophen, and nonsteroidal antiinflammatory drug consumption

Pre-ERAS (n ¼ 122) Post-ERAS (n ¼ 128) p-Value

Oxycodone total (mg) <0.001a
Median (min–max) 85 (0–240) 50 (0–260)
IQR (Q1–Q3) (60–115) (13.5–90)
Ibuprofen total (mg) <0.001a
Median (min–max) 5,600 (0–13,600) 6,800 (0–16,000)
IQR (Q1–Q3) (4,000–7,200) (5,600–7,200)
Acetaminophen total (mg) <0.001b
Median (min–max) 5,850 (0–13,000) 10,725 (975–33,800)
IQR (Q1–Q3) (3,900–7,475) (9,750–11,700)

Abbreviations: ERAS, enhanced recovery after surgery; IQR, interquartile range; Max, maximum; Min, minimum; Mg, milligram.
Median in-patient oxycodone, ibuprofen, and acetaminophen consumption before and after implementation of an enhanced recovery after surgery
protocol.
a
Wilcoxon’s rank-sum test.
b

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Fisher’s exact test.

Fig. 2 Length of stay before and after enhanced recovery protocol implementation. LOS was significantly shorter after implementation of an
enhanced recovery after cesarean delivery protocol. Before protocol implementation, mean LOS was 82.1 hours and after protocol
implementation, mean LOS was 74.2 hours, p < 0.001. Outliers are defined as points that are greater than 1.5 times the IQR above the third or
below the first quartile. Comparisons of LOS by ERAS implementation period were performed using Wilcoxon’s rank-sum test. ERAS, enhanced
recovery after surgery; LOS, length of stay.

achieving such high adherence. Additionally, our adherence
was likely high in part because the post-ERAS cohort was
sampled approximately 1 year after protocol implementa-
tion. This decision was made with the expectation that a
large-scale change at a high-volume institution would take
time to implement consistently, and with the knowledge that
ongoing educational efforts were required to facilitate pro-
vider comfort in the first year of protocol implementation.
Future work evaluating ERAS through an implementation
science lens, utilizing frameworks like the Consolidated
Framework for Implementation Research, will give more
insight into the key drivers of success.14
One of the variables with the poorest uptake was urinary
catheter removal within 8 hours of surgery (85.9%). Timeliness

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Enhanced Recovery after Surgery Protocol for Cesarean Delivery
of urinary catheter removal was likely influenced by provider-
specific factors including ease of monitoring urine output with
a catheter, concern for urinary retention in patients with long-
acting neuraxial anesthesia, and uncertainty about patients’
ability to ambulate to the restroom postoperatively. Though
recently published ERAS for cesarean delivery guidelines rec-
ommend immediate catheter removal, their recommendation
cites evidence from older trials with unspecified regional
analgesia.4,15 Our protocol is consistent with anesthesia guide-
lines that recommend maintaining the urinary catheter for 8 to
12 hours postoperatively in the setting of long-acting neuraxial
analgesia.16 Future work will need to balance the risks of early
removal, such as urinary retention, with the benefits including
easier ambulation and decreased catheter-associated urinary
tract infections.
Hospital length of stay was significantly decreased post-
ERAS protocol implementation, with no increase in postop-
erative complications or readmissions. This is similar to
findings by Fay et al, where implementation of an ERAS
protocol for cesarean delivery was associated with a signifi-
cant reduction in length of hospital stay.5 Safely reducing
hospital length of stay without compromising quality is an
important way to decrease the approximately $111 billion
each year spent on maternity care in the United States. As
more payers use bundled payments as a lever for reducing
costs, safely decreasing length of stay will continue to be an
important consideration.17,18
Of women in the United States who fill an opioid
prescription following cesarean delivery, 1 in 50 will
continue to fill prescriptions in the year after child birth.19
Therefore, reducing opioid prescribing at the time of
delivery is a priority for maternity care providers.10 Over
90% of our patients received scheduled, nonopioid medi-
cations, with an associated 40% decrease in inpatient
opioid prescribing. This decrease is equivalent to more
than 7 of the 5 mg oxycodone tabs per patient over the
course of a 3-day hospital stay. Other studies of opioid-
sparing regimens have demonstrated a similar decline in
inpatient opioid use (50–75% reduction)20,21; however,
they have not adequately assessed patients’ pain con-
trol.5,20–22 In our study, postoperative day 0 visual analog
scale (VAS) pain scores were 0.6 points higher in the post-
ERAS group, though evidence suggests the minimum clin-
ically significant difference in VAS scores is greater than 1
point.23 Thus, the difference in VAS scores on postopera-
tive day 0 in this study does not likely represent a clinically
meaningful difference in pain control. Providers can be
further reassured that opioid-sparing protocols adequately
address pain by the similar pain scores on postoperative
day 1 to 4.
The findings of this observational study support the
effectiveness of our institution’s ERAS protocol in decreasing
hospital length of stay and in-hospital opioid consumption.
Still, publications on ERAS for cesarean delivery in recent
years have included different protocol elements, a variety of
outcomes, and inconsistent measures of patient-centered
outcomes. Further studies, including randomized controlled
trials or cluster-step-wedge designs, will be needed to rec-
American Journal of Perinatology
Shinnick et al.
oncile the multiple ERAS protocols implemented across the
country and determine which elements are most effective
and appropriate in an obstetric population.
This study has many strengths. This was a large retrospec-
tive cohort study that broadly investigated maternal and
neonatal outcomes after implementation of an ERAS proto-
col for cesarean delivery. There was uniform application of
the postintervention cesarean delivery protocol, resulting in
excellent adherence to protocol variables. The hospital where
the study took place is the largest obstetric hospital in the
state and a tertiary referral center, thus minimizing the
expected number of patients who may have presented to
outside hospitals with postoperative complications.
Our study has several limitations. While the ERAS pro-
tocol implementation was the only known change that
occurred during the study period, we cannot assess the
effect of external factors such as increased awareness of the
opioid epidemic and impending outpatient opioid prescrib-
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ing legislation. Additionally, we were unable to capture
additional measures of patient satisfaction beyond pain
scores, specifically preparation for discharge and protocol
experience. The development of patient-centered surveys
for ERAS for cesarean delivery will be an important step in
capturing patients’ experiences. Finally, we included a
narrow cohort in our study focused on patients with
prelabor cesareans only. This allows us to examine the
ERAS protocol in the most ideal setting, planned cesarean,
but expansion to wider patient populations will also pro-
vide important data.
Conclusion
In conclusion, ERAS principles can be effectively applied to
cesarean delivery with good protocol adherence and associ-
ated decreases in length of hospital stay and opioid con-
sumption. At a time when maternity care providers are
focused on improving peripartum care and reducing costs,
ERAS for cesarean delivery should be considered as an option
that may comprehensively improve recovery.
Funding
None.
Conflict of Interest
None declared.
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