BJA Education, 20(10): 354e357 (2020)
doi: 10.1016/j.bjae.2020.05.003
Matrix codes: 1D02,
2B03, 3B00
Enhanced recovery for elective Caesarean section
D. Adshead, I. Wrench and M. Woolnough*
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
*Corresponding author: melanie.woolnough@nhs.net
Keywords: elective Caesarean section; enhanced recovery; length of stay; obstetrics; perioperative management
Learning objectives
By reading this article you should be able to:
 Identify key components of the enhanced recov-
ery after obstetric surgery (EROS) pathway.
 Discuss these components of care with patients
awaiting elective Caesarean section.
 Work as part of a multidisciplinary team
including obstetricians and midwives to optimise
outcomes for mothers and their babies.
Fast-track surgery pathways were pioneered in the 1990s.
They aimed to meet the typical criteria that would allow a
patient to be discharged from hospital after their planned
operation but in a more accelerated time frame. Over time,
this evolved into the principle of enhanced recovery after
surgery (ERAS), whereby many components of perioperative
care are optimised in line with the best available evidence.1
ERAS was first established for patients undergoing colo-
rectal surgery and has since been introduced for major sur-
gery in many specialties. Typically most patients enrolled are
Duncan Adshead BMedSci (Hons) FRCA is a specialty registrar in
anaesthesia in the Yorkshire and Humber School of Anaesthesia.
Ian Wrench BMedSci PhD FRCA is a consultant anaesthetist at
Sheffield Teaching Hospitals Trust. His main interests are research,
audit, service evaluation and quality improvement. He was formally
a member of the Obstetric Anaesthetists’ Association committee and
subcommittees. He has published work on enhanced recovery for
obstetric surgery and has helped to write guidelines for this area as
part of an ERAS society multinational group.
Melanie Woolnough BMedSci (Hons) FRCA is an obstetric anaes-
thetist in Sheffield. She is the lead anaesthetist for the percreta ser-
vice in Sheffield. She has published on the prevention of preoperative
hypothermia in obstetrics.
Accepted: 22 May 2020
Crown Copyright © 2020 Published by Elsevier Ltd on behalf of British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: permissions@elsevier.com
Advance Access Publication Date: 15 July 2020
Key points
 Enhanced recovery for obstetric surgery (EROS) is
now established in the UK.
 EROS leads to shorter hospital stay with atten-
dant cost savings.
 The anaesthetist is well positioned within the
multidisciplinary team to influence care before,
during and after surgery.
 Standard practice for the perioperative manage-
ment of women presenting for elective Caesarean
section is largely compatible with EROS.
 Further research is required to assess the efficacy
of individual components and to discern the best
way to organise the overall package of care.
older with a significant incidence of comorbidities and
therefore at increased risk of perioperative morbidity and
mortality.
It has been clear for many years that introduction of ERAS
results in fewer days in hospital after surgery and this is likely
to have been one of the important drivers of uptake. There is
also evidence that ERAS reduces morbidity and that closer
adherence to protocols reduces length of stay and improves
clinical outcomes.2
NHS statistics for 2010e11 revealed that 7.1% of women
who had a Caesarean section went home the next day.3 At
that time, the National Institute for Health and Care Excel-
lence (NICE) accepted the feasibility of next day discharge
after elective Caesarean section.4 Coupled with growing
financial pressures, this led to widespread interest in
enhanced recovery for obstetric surgery (EROS), with one of
the first examples of an EROS protocol published in 2015.5 The
proportion of units reporting that they either had, or were
planning to introduce an EROS protocol increased from 6% in
2013 (in an Obstetric Anaesthetists’ Association-approved UK
wide survey) to 80% in 2015 (in a survey of 36 UK obstetric
354
 Elective Caesarean section

the appropriate day of discharge should be determined in the

Table 1 Selected recommendations from the ERAS society postoperative period. While the financial benefits of EROS are
guidelines. Level of evidence is gradeddvery low quality/low significant, it is also important to note that many women are
quality/moderate quality/high quality. Strength of recom- very positive about next-day discharge from hospital and are
mendation is graded strong/weak pleased to find that it is an option. Whilst EROS was developed
for elective Caesarean section, many of the features may also
Aspect of care Level of Recommendation
be applied to emergency cases.
evidence
Interest in EROS is now worldwide, so much so that the
Preoperative antacids Low Strong ERAS society (a multinational organisation based in Sweden)
Avoid sedative Low Strong recently published guidelines with grading of the level of ev-
premedication idence and strength of recommendation for each component
Minimal starvation period High Strong of the perioperative pathway (Table 1).9e11 It must be
Preadmission counselling/ Low Strong
acknowledged that evidence supporting individual in-
information
Maternal comorbidities High Strong terventions and practices having a specific benefit to EROS is,
optimiseddobesity, in the most part, lacking. Thus, much of the guidance is based
hypertension, diabetes, on the not unreasonable assumption that best practice stan-
anaemia, smoking dard care should result in a more timely maternal recovery.
Antimicrobial prophylaxis High Strong Much of the following advice is taken from the ERAS society
Chlorhexidine skin Low Strong
guidelines.
preparation
Spinal rather than general Low Strong
anaesthesiadwith or
without regional opioids
Maintain perioperative Low- Strong
The preoperative period and preparation of
euvolaemia moderate patients
Warming and temperature High Strong
Next-day discharge is more likely where the indication for
monitoring
Blunt extension of uterine Moderate Weak surgery is that the women have had one previous Caesarean
hysterotomydJoel Cohen section.5 This may be because these returning mothers are
incision accustomed to the postoperative course and caring for the
Early removal of urinary Low Strong newborn. This suggests that women who are better informed
catheter are more able to deal with the perioperative course, and so
Regular diet within 2 h High Strong
recover more quickly.
Early mobilisation Very low Weak
Multimodal analgesia Moderate Strong Preadmission counselling and information should be pro-
Antithrombotic Low Strong vided to all women before surgery verbally, in print, via the
therapiesdstockings internet or a combination of all three.9 Interactive information
Antithrombotic Low Weak technology has the potential to guide women through the
therapiesdheparin should perioperative course so that they know what to expect and
not be used routinely
how to deal with common problems. Digital resources should
be accessible via mobile phone, as many women search for
information this way. The mother should be informed of the
units).6 By 2018e19, 38.5% of women presenting for elective indication for Caesarean section along with risks and benefit
Caesarean section went home on the first day after surgery.7 analysis for both mother and baby as part of the informed
The survey of UK units in 2013 revealed that standard consent process.8
practice for management of women undergoing a Caesarean Antacid prophylaxis is indicated because of the prevalence
delivery already had many of the features of ERAS.6 These of gastro-oesophageal reflux attributable to physiological and
included using predominantly regional (spinal) anaesthesia, anatomical changes in term parturients and the associated
minimal interruption of oral intake, mainly oral analgesia risk of aspiration pneumonitis if general anaesthesia is
after surgery, and rapid postoperative mobilisation. However, required.9 Sedative premedication is not recommended
EROS has a number of important differences to the ERAS because of the potential to obtund the neonate.9 Bowel prep-
protocols from which it was derived. Women who undergo aration is not required for Caesarean section.9
Caesarean section are usually comparatively young and fit, The perioperative starvation period should be as short as
and the surgery itself whilst not minor is a lesser physical possible. Typically, solid food may be taken up to 6 h before
insult than, for example, bowel resection or aortic aneurysm surgery.9 Patients should be encouraged to drink clear fluids
surgery. Perioperative mortality is extremely low. An EROS up to 2 h before surgery.9 This includes milk-free tea and
protocol should also include provision for the baby. Neonatal coffee and pulp-free fruit juices. Carbohydrate-rich drinks
health, bonding and breastfeeding are all examples of factors may be given to non-diabetic mothers9 and there is now evi-
that may result in a longer postoperative stay. dence from a randomised controlled trial that they reduce the
Any EROS pathway should be designed and planned by a incidence of ketosis when given before elective Caesarean
multidisciplinary team. Anaesthetists are central to this pro- section (K. Litchfield, Glasgow, personal communication).
cess and often take a leading role.8 All women should be Any concurrent medical condition in pregnancy should be
provided with information to underpin shared decision- optimised.9 This includes diseases such as pregnancy-
making and to empower them. It is not possible to predict induced hypertension and gestational diabetes mellitus.
reliably which women will be able to go home the day after Whilst physiological anaemia is a common consequence of
surgery and for a small minority (e.g. those with significant pregnancy, any patient with anaemia should be investigated
comorbidities) this will clearly be inappropriate. Ultimately, for an underlying cause and treated appropriately.9

BJA Education - Volume 20, Number 10, 2020 355

Elective Caesarean section
Pregnant women who smoke should be encouraged to stop
with referral to the local support service.9
Maternal obesity is known to increase complications
for the neonate and the mother.9 Women who are obese
should be identified at their booking visit and provided
with support to manage their weight safely throughout
the course of the pregnancy. Obesity can lead to increased
complexity of surgery and anaesthesia, and carries a
higher incidence of comorbidities and pregnancy-related
complications.
In our experience, women who have their surgery sched-
uled at the beginning of the day are more likely to go home
after a single night in hospital.
The intraoperative period
I.V. antibiotics (barring a first-generation cephalosporin al-
lergy) should be given within 60 min before skin incision.10
Although there is evidence that postoperative prophylactic
antibiotics reduce length of stay, this is not standard practice.
A chlorhexidine-alcohol solution should be used to clean the
abdominal skin.10 Vaginal cleansing with antiseptic solution
before surgery reduces postoperative intrauterine infection in
the emergency setting, but evidence is lacking for elective
Caesarean section.10 Euvolaemia should be maintained
perioperatively.10
Compared with general anaesthesia, there is less blood
loss and a reduced stress response to surgery when regional
techniques are used for Caesarean section.12 Regional anaes-
thesia is also associated with a lower incidence of post-
operative nausea and vomiting and earlier reinstatement of
oral hydration and nutrition.10 Whilst outcomes for epidural
and spinal anaesthesia are similar, spinal anaesthesia is faster
in onset and results in a lower incidence of intraoperative
pain.10 Intrathecal opioids further reduce breakthrough pain
in the operating theatre and enhance postoperative anal-
gesia.10 Practitioners who wish to avoid intrathecal opioids,
because of concerns regarding adverse effects, may obtain
similar post-surgery pain relief by the co-administration of
transversus abdominis plain blocks.10
Intraoperative hypothermia, defined as a core body tem-
perature <36 C, should be avoided. It is associated with higher
rates of allogenic blood transfusion and greater operative
blood loss.13 Intraoperative hypothermia is also associated
with a higher incidence of wound infection.14 Furthermore,
there is an association with delay in discharge from both the
PACU and from the hospital as a whole.15 Maternal hypo-
thermia is also a barrier to providing skin-to-skin contact, as
this may lead to neonatal hypothermia. Active warming
measures such as a forced air warmer, conductive heat
mattress, and warmed i.v. fluids should be used as guided by
the measured core temperature of the mother. Active warm-
ing may not be required where the operating theatre tem-
perature is maintained at no less than 23 C.16
Standard surgical access for Caesarean section is via a
transverse opening in the lower abdominal wall.10 Transverse
incisions for gastrointestinal surgery are thought to reduce
postoperative pain and improve outcomes as they cross fewer
dermatomes than vertical ones. Although a Pfannenstiel
incision is commonly used for Caesarean delivery, a Joel
Cohen incision, which is made 3 cm higher up the abdomen
and relies more on blunt dissection, is associated with better
outcomes including shorter duration of surgery and reduced
blood loss.10
356 BJA Education - Volume 20, Number 10, 2020
Delayed cord clamping permits physiological placental
transfusion to the newborn and is associated with a range of
benefits to the newborn including increased haemoglobin
concentrations and iron storage, improved neuro-
development, higher arterial BP and lower blood transfusion
requirement, along with lower rates of intraventricular hae-
morrhage, chronic lung disease, necrotising enterocolitis and
late-onset sepsis.17 Delayed cord clamping is recommended
by WHO, NICE, the Royal College of Obstetricians and
Gynaecologists, and the American College of Obstetricians
and Gynaecologists.
Preoperative intention to breastfeed is associated with
longer postoperative stay, presumably as a consequence of
the time taken in establishing this method of feeding.5
Mothers should be closely supported through any difficulties
that they encounter by appropriately trained staff. Immediate
or early skin-to-skin contact after a Caesarean delivery (also
known as kangaroo care) may increase the chances of suc-
cessful breastfeeding.18 It may also increase maternal satis-
faction, enhance bonding, and reduce neonatal stress.18
The postoperative period
In line with ERAS bundles generally, early mobilisation after
surgery is recommended, although evidence of benefit in ob-
stetric patients is lacking. A spinal block for Caesarean section
takes approximately 6 h to wear off completely, but there is
wide variation. Consequently it is important to confirm the
absence of residual anaesthesia before the first postoperative
steps and to provide close support to the mother when she
takes them.
Where regional anaesthesia has been used and provided
monitoring is satisfactory, women may take clear fluids in the
immediate recovery period and eat 1e2 h after surgery.11 On
those rare occasions that it is necessary to be ‘nil-by-mouth’,
chewing gum has been shown to reduce the time to first flatus
and first bowel movement.11
Introduction of an EROS protocol has been shown to reduce
pain and opioid requirements after surgery.19 Postoperative
multimodal analgesia should include regular paracetamol and
NSAIDs, with principally oral opioids for breakthrough pain.
Higher doses of NSAIDs (e.g. ibuprofen 600 mg q.d.s.) may
provide better analgesia and with short-term use are unlikely
to cause significant adverse effects in these patients.
Demands placed on new mothers on returning home,
caring for the newborn baby and possibly other children may
cause significant levels of pain. An international survey of
analgesic use after Caesarean section found that opioids were
used rarely after discharge home.20 However, it is likely that
many centres did not routinely allow women home the day
after surgery. In health systems such as in the USA, the
practice of sending women home with strong opioids such as
oxycodone may have led to opioid dependence.20
With earlier discharge home, it is even more important
that support is available outside hospital for women and their
babies. Although this may often be provided in part by family
members, midwifery home visits are a vital source of advice
and guidance. Readmission may also be expedited via this
route, but there is no evidence to date that women who go
home the day after surgery are more likely to return to
hospital.5
Removal of the urinary catheter at the end of surgery is
associated with reduced length of stay.11 Whilst there are
some concerns that this may lead to urinary retention with

the risk of permanent bladder damage, evidence of this is yet
to emerge.
Pregnant women are known to have a high risk for throm-
boembolic events during pregnancy and in the puerperium.
Pneumatic compression stockings should be provided and whilst
heparin s.c. should not be given routinely without due consid-
eration, many women will fulfil the criteria for its use.11
Summary
In the UK, approximately 40% of women go home the day after
their planned Caesarean section with many being enrolled on
EROS pathways. Work is still required to establish whether
this proportion could be higher and whether it would be safely
achievable for both the mother and her baby. EROS is a rela-
tively novel entity in the context of ERAS in general; very little
research has been undertaken to determine the efficacy of
individual components and how they should be best inte-
grated. Future work should address these deficiencies.
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) are
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
References
1. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after
surgery: a review. JAMA Surg 2017; 152: 292e8
2. Ronellenfitsch U. What are the effects of Enhanced Recovery
after Surgery (ERAS) compared with conventional recovery
strategies in people undergoing colorectal surgery? Cochrane
Clin Answers 2016. https://doi.org/10.1002/cca.545
3. The Health and Social Care Information Centre. Hospital
episode statistics. NHS Maternity Statistics; 2011e12.
Available from: https://digital.nhs.uk/data-and-
information/publications/statistical/nhs-maternity-
statistics/2011-12. [Accessed 31 January 2020]
4. Nice Institute for Clinical Health and Excellence. Clinical
guideline on Caesarean section. Available from: http://
publications.nice.org.uk/caesarean-section-cg132/
guidance#care-of-the-woman-after-cs (accessed 31
January 2020).
5. Wrench IJ, Allison A, Galimberti A, Radley S, Wilson MJ.
Introduction of enhanced recovery for elective caesarean
section enabling next day discharge: a tertiary centre
experience. Int J Obstet Anesth 2015; 24: 124e30
6. Aluri S, Wrench IJ. Enhanced recovery from obstetric surgery:
a UK survey of practice. Int J Obstet Anesth 2014; 23: 157e60
Elective Caesarean section
7. Secondary Care Analysis, NHS Digital. NHS maternity sta-
tistics. 2018-19. Available from:http://digital.nhs.uk/pubs/
maternity1819. [Accessed 31 January 2020]
8. White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F,
Fast-Track Surgery Study Group. The role of the anes-
thesiologist in fast-track surgery: from multimodal anal-
gesia to perioperative medical care. Anesth Analg 2007;
104: 1380e96
9. Wilson RD, Caughey AB, Wood SL et al. Guidelines for
antenatal and preoperative care in cesarean delivery:
enhanced recovery after surgery society recommenda-
tions (Part 1). Am J Obstet Gynecol 2018; 219: 523e32
10. Caughey AB, Wood SL, Macones GA et al. Guidelines for
intraoperative care in cesarean delivery: enhanced re-
covery after surgery society recommendations (Part 2).
Am J Obstet Gynecol 2018; 219: 533e44
11. Macones GA, Caughey AB, Wood SL et al. Guidelines for
postoperative care in cesarean delivery: enhanced Re-
covery after Surgery (ERAS) Society recommendations
(Part 3). Am J Obstet Gynecol 2019; 221. 247e1e247e9
12. Loughran PG, Moore J, Dundee JW. Maternal stress
response associated with caesarean delivery under gen-
eral and epidural anaesthesia. Br J Obstet Gynaecol 1986;
93: 943e9
13. Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of
mild perioperative hypothermia on blood loss and
transfusion requirement. Anesthesiology 2008; 108: 71e7
14. Kurz A, Sessler DI, Lenhardt R. Perioperative normo-
thermia to reduce the incidence of surgical-wound
infection and shorten hospitalization. Study of Wound
Infection and Temperature Group. N Engl J Med 1996; 334:
1209e15
15. Lenhardt R, Marker E, Goll V et al. Mild intraoperative
hypothermia prolongs postanesthetic recovery. Anesthe-
siology 1997; 87: 1318e23
16. Chebbout R, Newton RS, Walters M, Wrench IJ,
Woolnough M. Does the addition of active body warming
to in-line intravenous fluid warming prevent maternal
hypothermia during elective caesarean section? A rand-
omised controlled trial. Int J Obstet Anesth 2017; 31: 37e44
17. Qian Y, Ying X, Wang P, Lu Z, Hua Y. Early versus delayed
umbilical cord clamping on maternal and neonatal out-
comes. Arch Gynecol Obstet 2019; 300: 531e43
18. Stevens J, Schmied V, Burns E, Dahlen H. Immediate or
early skin-to-skin contact after a Caesarean section: a
review of the literature. Matern Child Nutr 2014; 10: 456e73
19. Kleiman AM, Chisholm CA, Dixon AJ et al. Evaluation of
the impact of enhanced recovery after surgery protocol
implementation on maternal outcomes following elective
cesarean delivery. Int J Obstet Anesth 2019. https://doi.org/
10.1016/j.ijoa.2019.08.004
20. Wong CA, Girard T. Undertreated or overtreated? Opioids
for post-delivery analgesia. Br J Anaesth 2018; 121: 339e42
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