Review Article

Enhanced Recovery after Cesarean Delivery & Role of Anesthesiologists:

A Narrative Review

Abstract Samina Ismail,

Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

Enhanced recovery after cesarean delivery (ERAC) is an evidence‑based interdisciplinary protocol Malika Hameed
with an aim to improve quality of care and patient satisfaction while lowering health care cost by Department of Anaesthesiology,
reducing length of hospital stay. It is an approach that combines several evidence‑based perioperative Aga Khan University Hospital,
care components to hasten patient recovery. ERAC uses multidisciplinary approach with inclusion of Karachi, Pakistan
all stakeholders including anesthesiologists, obstetricians, pediatricians, nurses, pharmacists, patients,
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/24/2024

and hospital administration. Therefore, institutional support, local infrastructure, and compliance
of all supporting systems are necessary for the successful implementation of ERAC. The role of
anesthesiologists in implementation of standardized care cannot be disregarded as they are involved
in the provision of perioperative services to improve maternal outcomes and healthcare quality. The
purpose of this narrative review is to explore the components and guidelines from the enhanced
recovery after surgery for caesarean delivery, highlight the responsibility of anesthesiologists in the
existing and emerging ERAC programs and the difficulties associated with implementing the ERAC
in resource‑constrained environments.

Keywords: Cesarean Section, enhanced recovery after surgery, obstetric anesthesia, postoperative
period, patient Satisfaction, resource limited countries, spinal hypotension

Introduction peer reviewed studies,[10‑18] systemic reviews

and meta‑analysis.[19‑23]
Enhanced recovery after surgery (ERAS)
is a comprehensive multi‑disciplinary Despite a robust literature on ERAC,
protocol‑based approach with well‑defined there is no global consensus on what
perioperative interventions. The activity interventions should formulate an ERAC
of ERAS begins from the time of protocol. None of the published studies
preoperative assessment and extends applied all the recommended interventions,
into the postoperative period with the with few studies focused on implementation
three‑fold aim of providing best quality methodology utilized to ensure compliance
of care, cutting down cost and improving and success of ERAC protocols.
patient satisfaction level.[1] ERAS was the The aim of this narrative review is to discuss Received : 13-Dec-2022
brainchild of Henrik Kehlet and was first the elements and recommendations from Revised : 17-Jan-2023
started in 1997 for colorectal surgeries,[2] ERAS society for cesarean delivery (CD), Accepted : 22-Jan-2023
Published : 09-Mar-2023
and was later adopted by other surgical role of anesthesiologists in the current and
specialties. United Kingdom was the first emerging ERAC and challenges of ERAC
country to publish literature on enhanced implementation in resource limiting setting. Address for correspondence:
recovery for cesarean delivery (ERAC) in Dr. Samina Ismail,
2013.[3‑5] ERAS society introduced their Methodology Department of Anaesthesiology,
The Aga Khan University
guidelines on ERAC in 2018, which was A comprehensive review of anesthesia and Hospital, Stadium Road P.O.
then followed by the consensus guidelines obstetric literature was done by searching Box ‑ 3500, Karachi, Pakistan.
from the Society of Obstetric Anesthesia database of PubMed and Google Scholar for
E‑mail: samina.ismail@aku.edu
and Perinatology (SOAP) in 2020.[6‑9] studies which evaluated the improvement
Following the seal of approval from ERAS after the introduction of ERAC protocol, Access this article online
and SOAP, ERAC utilization and research systematic reviews, meta‑analysis, and Website: www.joacc.com
increased, resulting in number of published editorials. The guidelines and consensus
DOI: 10.4103/JOACC.JOACC_74_22
endorsed by ERAS society and SOAP were
Quick Response Code:
This is an open access journal, and articles are also appraised for this review.
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are How to cite this article: Ismail S, Hameed M.
licensed under the identical terms. Enhanced recovery after cesarean delivery & role
of anesthesiologists: A narrative review. J Obstet
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com Anaesth Crit Care 2023;13:3-8.

© 2023 Journal of Obstetric Anaesthesia and Critical Care | Published by Wolters Kluwer - Medknow 3
 Ismail and Hameed: ERAC for anesthesiologists
ERAS society guidelines for Cesarean delivery
The ERAS society has used evidence‑based knowledge
gained from research based on CD and after critical
appraisal and consensus, classified the pathway into a
1) focused pathway and 2) optimized pathway. Focused
pathway is initiated from 30‑60 minutes before the skin
Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
incision, for both scheduled and unscheduled CD, until
hospital discharge. Optimized pathway incorporates the
provision of antenatal education, identifying and managing
maternal comorbidities, and providing immediate neonatal
needs at the time of delivery.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/24/2024
The focused pathway is based on three‑parts documents;
with the first document (part 1) focused on preoperative
care beginning 30‑60 minutes before the skin incision,
for both scheduled and unscheduled CD, second
document (part 2) focused on the intraoperative care
and the third document (part 3) on the postoperative
care until hospital discharge.[6‑8] Guidelines for enhanced
recovery after CD (focused pathway) with preoperative,
intraoperative, and postoperative pathway is summarized in
Tables 1-3.
Role of anesthesiologist in the current and emerging
ERAC protocol
ERAC uses multidisciplinary approach with inclusion of
all stakeholders including anesthesiologists, obstetricians,
pediatricians, nurses, pharmacists, patients, and hospital
administration. Therefore, successful implementation
of ERAC is dependent on institutional support, local
infrastructure, and compliance of all supporting systems.
Anesthesiologists play an important role in implementing
standardized care to improve maternal outcomes, improve
quality of care, and minimize opioid exposure and
patient satisfaction. Anesthesiologist involvement in the
preoperative, intraoperative, and postoperative period
involves the following elements:
Preoperative element
Preoperative education/discussion helps to reduce
anxiety, manage expectation, and helps in improving
Table 1: Guidelines for Enhanced Recovery After
Cesarean Delivery Preoperative Pathway
Recommendations
Pre‑anesthetic H2 receptor antagonist and antacids to reduce
Medications the risk of aspiration pneumonia
Limitation of Women should be encouraged to drink clear
fasting interval fluids (pulp‑free juice, coffee, or tea without
and Carbohydrate milk) until 2 h before surgery.
loading A light meal may be eaten up to 6 h before
surgery
Preoperative Oral carbohydrate fluid supplementation, 2 h
carbohydrate before cesarean delivery, may be offered to
supplementation non‑diabetic women
4 Journal of Obstetric Anaesthesia and Critical Care | Volume 13 | Issue 1 | January-June 2023
compliance with ERAC protocol.[24] Patient engagement in
decision‑making pertaining to the technique of anesthesia
and pain management may start preoperatively with the
anesthesiologist. Shared decision‑making has shown to
improve patient satisfaction and reduce opioid utilization
by patients.[25]
Patient nil per oral (NPO) status is a great concern for the
anesthesiologist and hence their involvement is of utmost
importance. The SOAP and ERAC protocols suggest giving
clear juice (16 ounces/500 ml) two hours before surgery.[9]
Restricting prolonged NPO and complex carbohydrate (i.e.,
maltodextrin) loading the evening before and 2‑3 hours
prior to anesthesia with non‑particulate drink can minimize
the metabolic stress response, improve postoperative insulin
resistance, and lower protein breakdown.[26]
Intraoperative element
• Technique of Anesthesia:
ERAS guidelines and practice guidelines from American
Society of Anesthesiologists from the year 2016 for
obstetric anesthesia recommend central neuraxial
techniques including spinal, epidural, and combined
spinal‑epidural for CD.[27] Regional anesthesia is preferred
over general anesthesia as it is associated with lower
incidence of intraoperative pain, lower incidence of nausea
and vomiting, less blood loss, reduced stress response
to surgery, and decreased length of stay in hospital.[28,29]
While outcomes of both spinal and epidural anesthesia are
comparable, spinal anesthesia provides faster onset and
results in lower incidence of intraoperative pain.[30,31]
• Management of Perioperative Hypotension:
Even though neuraxial techniques are recommended
choice for CD, there are some associated maternal and
neonatal complications associated with these techniques.
Sympathectomy resulting from neuraxial techniques leads
to vasodilation and resulting fall of blood pressure, which is
the most commonly encountered side effect. The intensity of
hypotension depends on the dose of drug used and the rate
of onset of neuraxial block.[32] Spinal‑induced hypotension
is responsible for symptoms including intraoperative nausea
and vomiting and dizziness in mothers and may lead to fetal
acidosis secondary to the decrease in the uteroplacental flow.[33]
The most recommended technique for the management
of spinal‑induced hypotension is fluid therapy and
vasopressors. Preloading with both colloid and crystalloid
is effective for the prevention of maternal hypotension up
to some level.[27,34,35] Current consensus talks more about
colloid preload and crystalloid co‑loading.[33] However,
optimal fluid therapy in terms of the amount of volumes
and whether crystalloid or colloid are effective to prevent
hypotension is still unclear.
Routine prophylactic use of vasopressors is
recommended, as they have shown to be effective against
 Ismail and Hameed: ERAC for anesthesiologists

Table 2: Guidelines for Enhanced Recovery After Cesarean Delivery Intraoperative Pathway
Recommendations
Preoperative antimicrobial prophylaxis and skin Intravenous antibiotics routinely within 60 min before the skin incision.
preparation First‑generation cephalosporin is recommended for CD; in women in labor or
with ruptured membranes, the addition of azithromycin is recommended.
Chlorhexidine‑alcohol is preferred to aqueous povidone‑iodine solution for
abdominal skin cleansing.
Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

Surgical considerations Joel‑Cohen surgical approach

Avoidance of exteriorization of uterus
Avoidance of intra‑abdominal saline irrigation
Neonatal Care Delayed Cord Clamping
Prevention of neonatal hypothermia
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/24/2024

Breastfeeding and skin‑to‑skin contact

Anesthetic management
Anesthesia technique
Pain management
Prevention of spinal‑induced hypotension
Prevention of intraoperative nausea and vomiting
Prevention of intraoperative hypothermia
Regional anesthesia is the preferred method of anesthesia for cesarean deliver
Multimodal analgesic regime
Perioperative and intraoperative euvolemia, co‑loading and use of
prophylactic vasopressors
Prevention of hypotension and use of antiemetics
Operating room temperature (72F or 23C), using forced air warmer,
conducting heating mattress, and warmed IV fluids

Table 3: Guidelines for Enhanced Recovery After Cesarean Delivery Postoperative Pathway
Nausea and vomiting prevention
Postoperative analgesia
Perioperative nutritional care
Perioperative glucose control
Prophylaxis against thromboembolism
Early post‑cesarean delivery mobilization
Post‑cesarean delivery urinary drainage
Recommendations
Antiemetic agents with multimodal approach should be applied to treat postoperative nausea
and vomiting
Multimodal analgesia that includes regular non‑steroidal anti‑inflammatory drugs and paracetamol
A regular diet within the 2 h after cesarean delivery is recommended.
Tight control of capillary blood glucose is recommended.
Pneumatic compression stockings should be used to prevent thromboembolic disease in
patients who undergo cesarean delivery.
Early mobilization after cesarean delivery is recommended.
Urinary catheter should be removed immediately after cesarean delivery, if placed during surgery.

spinal‑induced hypotension.[33] Phenylephrine, which
is a pure alpha agonist is the vasopressor of choice
due to its ability to directly counteract vasodilation.
More research‑based data from obstetric patients is
required to support the use of drugs having mild beta
agonist activity like norepinephrine and metaraminol.
To avoid hypotension in 90% of parturient undergoing
elective CD, investigators recommended the effective
norepinephrine bolus dose (ED90) of 6 microgram.[36]
Investigators further determined that the estimated dose
of phenylephrine 100 mg is equivalent to norepinephrine
8 microgram.[33,37]
• Management of Spinal Anesthesia‑Induced Intra and
Postoperative Nausea and Vomiting:
Possible causes of spinal anesthesia‑induced intra
and postoperative nausea and vomiting (PONV) is
hyperactivation of the gastro‑intestinal tract secondary to
sympathetic blockade and activation of vomiting center
secondary to hypotension‑induced cerebral ischemia.[38] In
addition, opioids and some surgical maneuvers like uterine
exteriorization and intra‑abdominal saline irrigation can
also be the contributing factors.[39,40] Maintaining maternal
blood pressure by initiating prophylactic vasopressor
infusion and fluid loading, decreases the incidence
of intraoperative nausea and vomiting and maintains
uteroplacental perfusion.[41] It is recommended to combine
at least two intravenous anti‑emetics having different
mode of action.[9,39] It is suggested to use combination
of glucocorticoid, D2 receptors antagonists, and 5HT3
antagonists.[9,39]
• Prevention of Hypothermia
Spinal anesthesia can alter thermoregulation for several
hours and can cause core body temperature to fall rapidly
below36°C.[42] Perioperative hypothermia leadings to
increase rate of infection, risk of coagulopathy, myocardial
ischemia, and reduced metabolism of drugs among mother,
in addition to poor patient satisfaction associated with
shivering.
Complications in neonates like hypoglycaemia and
respiratory distress syndrome have been linked to neonatal
hypothermia secondary to maternal hypothermia.[7,43]

Journal of Obstetric Anaesthesia and Critical Care | Volume 13 | Issue 1 | January-June 2023 5
 Ismail and Hameed: ERAC for anesthesiologists
Mortality in neonates secondary to hypothermia has been
observed in preterm and very low birth weight.[7,43]
ERAS society recommends prevention of perioperative
hypothermia by using warming devices[3]. Therefore, use
of warming devises for intravenous fluid administration
combined with air warming blankets and maintaining
Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
operating room temperature to 22°C may decrease the
incidence of maternal and neonatal hypothermia.[44‑46]
• Multimodal Techniques for Perioperative Pain
Management
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/24/2024
Multimodal techniques have shown to modify the body
physiologic reaction to painful stimuli, consumption of
opioid, and chronic opioid use. Multimodal analgesic
regime should be considered along with intrathecal opioids
which may include non‑opioid analgesia and regional
techniques.[7‑9]
The use of intrathecal opioids prevents intraoperative
breakthrough pain and enhances postoperative analgesia. The
suggested doses of neuraxial morphine for CD is in the range
of 1‑3 milligram for epidural technique or 50‑150 microgram
for intrathecal use via spinal technique.[24] Unless there are
contraindication, scheduled non‑steroidal anti‑inflammatory
drugs (NSAIDS), and acetaminophen decrease the need for
opioids and its related side effects by 30% to 50% after
CD.[9] It is recommended to start scheduled acetaminophen
preoperatively or during intraoperative period. NSAIDs in the
form of ketorolac 30 mg intravenously can be administered
after peritoneal closure, followed by regular NSAIDS at
scheduled time interval, e.g., ketorolac can be prescribed in
the doses of 15‑30 mg six hourly or ibuprofen in the dose of
600 mg six hourly or naproxen in the dose of 500 mg at 12
hourly intervals can be prescribed.[24] As according to FDA
approval, the maximum dose of acetaminophen dose is 4000
milligram per 24 hours.[47]
The recommended local anesthetic techniques include both
wound infiltration and nerve blocks. Among ultrasound
guided nerve blocks transversus abdominis plane (TAP)
block and quadratus lumborum block have shown good
analgesic effect.[32] Evidence has shown that TAP block
has equal efficacy when compared to 100 mg intrathecal
morphine for CD in terms of perioperative outcomes
like pain scores, requirement of rescue analgesics,
incidence of side effects, and satisfaction of patient.[48] The
quadratus lumborum block when used as a component of
multi‑modal analgesic management is found to be effective
regional block for postoperative pain control after CD.[49]
These nerve block techniques are especially beneficial
in circumstances when neuraxial morphine is either not
available or cannot be given.
Postoperative element
Role of anesthesiologist in postsurgical recovery is now
beyond just maintaining low pain scores. It has now
6 Journal of Obstetric Anaesthesia and Critical Care | Volume 13 | Issue 1 | January-June 2023
progressed from one‑dimensional goal to a more holistic
multidimensional approach. The goal of providing efficient
pain management is not only to reduce parturient suffering
but also to improve their functional recovery and the
ability to look after their newborns. Anesthesiologists’ role
at managing postoperative pain and nausea vomiting will
facilitate in achieving key postoperative goal of ERAC,
which includes early cessation of NPO and ambulation
within the first 24 h.
Measures of postoperative outcome usually focus on
morbidity and mortality, which do not necessarily describe
the patient’s experience or quality of recovery (QoR) after
surgery. Ciechanowicz et al.[50] developed and evaluated
an obstetric quality of recovery score (ObsQoR‐11) for
specific use in parturient who had undergone elective
caesarean delivery. As a modified version of the earlier
QoR‐40 survey, the ObsQoR‐11 questionnaire contained
items derived from four clinically relevant dimensions of
good postoperative quality of recovery, including physical
comfort, emotional state, physical independence and care
of the newborn, and pain. However, quality of recovery
scoring tools validated in developed country may not be
valid in developing countries with significant cultural,
socio‐economic, and linguistic variations. Therefore, Kumar
S et al.[51] validated a Hindi version of the ObsQoR‐11 for
people of developing country like India.
Implementation of ERAC in resource limited setting a
challenge!
Robust literature on ERAC including ERAS society
guidelines followed by consensus guidelines from Society
of Obstetric Anesthesia and Perinatology is indicative
of the fact that ERAC has been embraced by many
developed countries. However, a lot needs to be ensured
before implementation of ERAC in developing countries.
Prime barriers mentioned in the literature for introducing
ERAC in resource limiting countries are lack of education,
huge disparity between rural and urban healthcare setups,
failure to recognize early warning signs and inadequate
infrastructure, paucity of trained staff for implementation of
ERAS protocols, and unavailability of adequate networks
and telecommunication facilities.[52,53] All these barriers
need support at the government level, however, as rightly
mentioned in the editorial published in 2022,[53] the priority
of the government in developing country is on reduction
of maternal mortality rate. Therefore, implementation of
ERAC is not expected to be supported by the government
soon.
It is suggested that the approach in developing countries
should be at the institutional level by taking all the stake
holders on board. Teams including anesthesiologist,
obstetrician, nursing, hospital, and patient should be taken
on board. Multidisciplinary medical teams at institutional
level should try to phase in the intervention strategies of
ERAC program. This can start by training the staff and
 Ismail and Hameed: ERAC for anesthesiologists
working on patient education. Anesthesiologist being an
important part of this team can aim to standardize the
perioperative care elements as suggested by ERAS. This
can be started by involving patients and their family in
the anesthesia plan and pain management, use of regional
anesthesia wherever possible, introducing protocols
for prevention of post‑spinal hypotension, nausea and
Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
vomiting, perioperative hypothermia, and use of multimodal
analgesia.
Conclusion
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/24/2024
The most important modification that can be made in
the practice to enhance outcomes and improve quality of
care is by implementation of ERAC standardized care.
The enhanced recovery protocol after cesarean section
should encompass best evidence‑based components in
perioperative period. A multidisciplinary approach which
includes anesthesiologists, obstetricians, pediatricians,
nurses, pharmacists, patients, and hospital administration is
recommended. Future research is still required to improve
recommendations of utilization of ERAC protocol, identify
the best procedures and interventions, and assess the most
accurate ways to monitor the impact of ERAC. This will
help to evaluate the effectiveness of implementation of
ERAC protocol and improve the care of women undergoing
cesarean delivery.
Acknowledgement
The authors wish to acknowledge Maheen Fazal for
providing support in editing and submission of the
manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Institute for Healthcare Improvement. Triple Aim initiative.
Available from: https://www.ihi.org/Engage/Initiatives/
TripleAim/pages/default.aspx. [Last accessed on 2022 Oct 23].
2. Kehlet H. Multimodal approach to control postoperative
pathophysiology and rehabilitation. Br J Anaesth 1997;78:606-17.
3. Vickers R, Das B. Enhanced recovery in obstetrics. Int J Obstet
Anesth 2013;22:349.
4. Long O, Garratt EC, Jan H, Blightman O, Sharafudeen S,
Dasan J. Audit of maternal outcomes following introduction of
an enhanced recovery in obstetric surgery (EROS) protocol for
elective caesarean section. Int J Obstet Anesth 2013;22:S8.
5. Das B, Vickers R, Machineni V. Enhanced recovery in obstetrics.
Int J Obstet Anesth 2013;22:S13.
6. Wilson RD, Caughey AB, Wood SL, Macones GA, Wrench IJ,
Huang J, et al. Guidelines for antenatal and preoperative care
in cesarean delivery: Enhanced Recovery After Surgery Society
recommendations (Part 1). Am J Obstet Gynecol 2018;219:523.
el‑15.
7. Wilson RD, Caughey AB, Wood SL, Wrench IJ, Huang J,
Journal of Obstetric Anaesthesia and Critical Care | Volume 13 | Issue 1 | January-June 2023
Norman M, et al. Guidelines for intraoperative care in
cesarean delivery: Enhanced Recovery After Surgery
Society Recommendations (Part 2). Am J Obstet Gynecol
2018;219:533‑44.
8. Macones GA, Caughey AB, Wood SL, Wrench IJ, Huang J,
Norman M, et al. Guidelines for postoperative care in cesarean
delivery: Enhanced recovery after surgery (ERAS) society
recommendations (Part 3). Am J Obstet Gynecol 2019;221:247.
e1‑9.
9. Bollag L, Lim G, Sultan P, Habib A, Landau R, Zakowski M,
et al. Society for obstetric anesthesia and perinatology:
Consensus statement and recommendations for enhanced
recovery after cesarean. Anesth Analg 2021;132:1362‑77.
10. Tamang T, Wangchuk T, Zangmo C, Wangmo T, Tshomo K.
The successful implementation of the Enhanced Recovery
After Surgery (ERAS) program among caesarean deliveries in
Bhutan to reduce the postoperative length of hospital stay. BMC
Pregnancy Childbirth 2021;21:637.
11. Macgregor CA, Neerhof M, Sperling MJ, Alspach D,
Plunkett BA, Choi A, et al. Post‑cesarean opioid use after
implementation of enhanced recovery after surgery protocol. Am
J Perinatol 2021;38:637‑42.
12. Tepper JL, Harris OM, Triebwasser JE, Ewing SH, Mehta AD,
Delaney EJ, et al. Implementation of an enhanced recovery
after surgery pathway to reduce inpatient opioid consumption
after cesarean delivery. Am J Perinatol 2021. doi: 10.1055/
s‑0041‑1732450.
13. Lester SA, Kim B, Tubinis MD, Morgan CJ, Powell MF. Impact
of an enhanced recovery program for cesarean delivery on
postoperative opioid use. Int J Obstet Anesth 2020;43:47‑55.
14. Shinnick J, Ruhotina M, Has P, Kelly BJ, Brousseau EC,
O’Brien J, et al. Enhanced recovery after surgery for
cesarean delivery decreases length of hospital stay and opioid
consumption: A quality improvement initiative. Am J Perinatol
2021;38:e215‑23.
15. Pan J, Hei Z, Li L, Zhu D, Hou H, Wu H, et al. The advantage
of implementation of enhanced recovery after surgery (ERAS)
in acute pain management during elective cesarean delivery:
A prospective randomized controlled trial. Ther Clin Risk Manag
2020;16:369‑78.
16. Xue LL, Zhang JZ, Shen HX, Hou Y, Ai L, Cui XM. The
application of rapid rehabilitation model of multidisciplinary
cooperation in cesarean section and the evaluation of health
economics. Zhonghua Yi Xue Za Zhi 2019;99:3335‑9.
17. Mullman L, Hilden P, Goral J, Gwacham N, Tauro C, Spinola K,
et al. Improved outcomes with an enhanced recovery approach
to cesarean delivery. Obstet Gynecol 2020;136:685‑91.
18. Sultan P, Sadana N, Sharawi N, Blake L, El‑Boghdadly K,
Falvo A, et al. Evaluation of domains of patient‑reported
outcome measures for recovery after childbirth: A scoping and
systematic review. JAMA Netw Open 2020;3:e205540.
19. Sultan P, Jensen SE, Taylor J, El‐Sayed Y, Carmichael S,
Cella D, et al. Proposed domains for assessing postpartum
recovery: A concept elicitation study. BJOG 2022;129:9‑20.
20. Ilyas S, Simmons S, Bampoe S. Systematic review of enhanced
recovery protocols for elective caesarean section versus
conventional care. Aust N Z J Obstet Gynaecol 2019;59:767‑76.
21. Sultan P, Sharawi N, Blake L, Habib AS, Brookfield KF,
Carvalho B. Impact of enhanced recovery after cesarean delivery
on maternal outcomes: A systematic review and meta‑analysis.
Anaesth Crit Care Pain Med 2021;40:100935.
22. Meng X, Chen K, Yang C, Li H, Wang X. The clinical efficacy
and safety of enhanced recovery after surgery for cesarean
7
 Ismail and Hameed: ERAC for anesthesiologists
section: A systematic review and meta‑analysis of randomized
controlled trials and observational studies. Front Med (Lausanne)
2021;8:694385.
23. Sultan P, Sharawi N, Blake L, Carvalho B. Enhanced
recovery after caesarean delivery versus standard care studies:
A systematic review of interventions and outcomes. Int J Obstet
Anesth 2020;43:72‑86.
24. Patel K, Zakowski M. Enhanced recovery after cesarean: Current
Downloaded from http://journals.lww.com/joac by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
and emerging trends. Curr Anesthesiol Rep 2021;11:136‑44.
25. Prabhu M, McQuaid‑Hanson E, Hopp S, Burns SM, Leffert LR,
Landau R, et al. A shared decision‑making intervention to guide
opioid prescribing after cesarean delivery. Obstet Gynecol
2017;130:42‑6.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/24/2024
26. Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N,
Francis N, et al. Guidelines for perioperative care in elective
colorectal surgery: Enhanced recovery after surgery (ERAS)
society recommendations: 2018. World J Surg 2019;43:659– 95.
27. Practice guidelines for obstetric anesthesia: An updated report
by the American Society of Anesthesiologists Task Force on
Obstetric Anesthesia and the Society for Obstetric Anesthesia
and Perinatology. Anesthesiology 2016;124:270–300.
28. McIsaac DI, Cole ET, McCartney CJ. Impact of including
regional anaesthesia in enhanced recovery protocols: A scoping
review. Br J Anaesth 2015;115(Suppl 2):ii46–56.
29. Loughran PG, Moore J, Dundee JW. Maternal stress response
associated with caesarean delivery under general and epidural
anaesthesia. Br J Obstet Gynaecol 1986;93:943‑9.
30. Ng K, Parsons J, Cyna AM, Middleton P. Spinal versus epidural
anaesthesia for caesarean section. Cochrane Database Syst Rev
2004;2004:CD003765.
31. Schewe JC, Komusin A, Zinserling J, Nadstawek J, Hoeft A,
Hering R. Effects of spinal anaesthesia versus epidural
anaesthesia for caesarean section on postoperative analgesic
consumption and postoperative pain. Eur J Anaesthesiol
2009;26:52–9.
32. American College of Obstetricians and Gynecologists’
Committee on Practice Bulletins—Obstetrics. ACOG practice
bulletin no. 209: Obstetric analgesia and anesthesia. Obstet
Gynecol 2019;133:e208–25.
33. Kinsella SM, Carvalho B, Dyer RA, Fernando R, McDonnell N,
Mercier FJ, et al. International consensus statement on the
management of hypotension with vasopressors during caesarean
section under spinal anaesthesia. Anaesthesia 2018;73:71–92.
34. Loubert C. Fluid and vasopressor management for Cesarean
delivery under spinal anesthesia: Continuing professional
development. Can J Anaesth 2012;59:604–19.
35. Kaufner L, Karekla A, Henkelmann A, Welfle S, von
Weizsacker K, Hellmeyer L, et al. Crystalloid coloading vs.
colloid coloading in elective caesarean section: Postspinal
hypotension and vasopressor consumption, a prospective,
observational clinical trial. J Anesth 2019;33:40–9.
36. Onwochei DN, Ngan Kee WD, Fung L, Downey K, Ye XY,
Carvalho JCA. Norepinephrine intermittent intravenous boluses
to prevent hypotension during spinal anesthesia for cesarean
delivery: A sequential allocation dose‑finding study. Anesth
Analg 2017;125:212–8.
37. Ngan Kee WD. A random‑allocation graded dose‑response study
of norepinephrine and phenylephrine for treating hypotension
during spinal anesthesia for cesarean delivery. Anesthesiology
2017;127:934–41.
38. Hirose N, Kondo Y, Maeda T, Suzuki T, Yoshino A, Katayama Y.
Oxygen supplementation is effective in attenuating maternal
8 Journal of Obstetric Anaesthesia and Critical Care | Volume 13 | Issue 1 | January-June 2023
cerebral blood deoxygenation after spinal anesthesia for cesarean
section. Adv Exp Med Biol 2016;876:471–7.
39. Griffiths JD, Gyte GM, Paranjothy S, Brown HC, Broughton HK,
Thomas J. Interventions for preventing nausea and vomiting in
women undergoing regional anaesthesia for caesarean section.
Cochrane Database Syst Rev 2012;2012:CD007579.
40. De Oliveira GS Jr, Castro‑Alves LJ, Ahmad S, Kendall MC,
McCarthy RJ. Dexamethasone to prevent postoperative nausea
and vomiting: An updated meta‑analysis of randomized
controlled trials. Anesth Analg 2013;116:58–74.
41. Jelting Y, Klein C, Harlander T, Eberhart L, Roewer N, Kranke P.
Preventing nausea and vomiting in women undergoing regional
anesthesia for cesarean section: Challenges and solutions. Local
Reg Anesth 2017;10:83–90.
42. Du Toit L, van Dyk D, Hofmeyr R, Lombard CJ, Dyer RA. Core
temperature monitoring in obstetric spinal anesthesia using an
ingestible telemetric sensor. Anesth Analg 2018;126:190–5.
43. Perlman J, Kjaer K. Neonatal and maternal temperature regulation
during and after delivery. Anesth Analg 2016;123:168–72.
44. Cobb B, Cho Y, Hilton G, Ting V, Carvalho B. Active
warming utilizing combined IV fluid and forced‑air warming
decreases hypothermia and improves maternal comfort during
cesarean delivery: A randomized control trial. Anesth Analg
2016;122:1490–7.
45. Jun JH, Chung MH, Jun IJ, Kim Y, Kim H, Kim JH, et al.
Efficacy of forced‑air warming and warmed intravenous fluid
for prevention of hypothermia and shivering during caesarean
delivery under spinal anaesthesia: A randomised controlled trial.
Eur J Anaesthesiol 2019;36:442–8.
46. Duryea EL, Nelson DB, Wyckoff MH, Grant EN, Tao W,
Sadana N, et al. The impact of ambient operating room
temperature on neonatal and maternal hypothermia and
associated morbidities: A randomized controlled trial. Am J
Obstet Gynecol 2016;214:505.e1–7.
47. FDA. Acetaminophen information. Food Drug Admin. 2017.
Available from: https://www.fda.gov/drugs/information-
drug‑class/acetaminophen-information. [Last accessed on 2022
Oct 23].
48. Kwikiriza A, Kiwanuka JK, Firth PG, Hoeft MA, Modest VE,
Ttendo SS. The analgesic effects of intrathecal morphine in
comparison with ultrasound‑guided transversus abdominis plane
block after caesarean section: A randomised controlled trial at a
Ugandan regional referral hospital. Anaesthesia 2019;74:167–73.
49. Blanco R, Ansari T, Girgis E. Quadratus lumborum block
for postoperative pain after caesarean section: A randomised
controlled trial. Eur J Anaesthesiol 2015;32:812–8.
50. Ciechanowicz S, Setty T, Robson E, Sathasivam C, Chazapis M,
Dick J, et al. Development and evaluation of an obstetric
quality‑of‑recovery score (ObsQoR‑11) after elective caesarean
delivery. Br J Anaesth 2019;122:69–78.
51. Kumar S, Ashok V, Jain D, Arora A, Singh A, Sikka P. Validation
of an obstetric quality of recovery scoring tool (ObsQoR‑11)
after elective caesarean delivery in a developing country:
A prospective observational study. Int J Obstet Anesth
2022;49:103235.
52. Gupta S, Gupta A. Baghel AS, Sharma K, Choudhary S,
Choudhary V. Enhanced recovery after cesarean section
protocol versus traditional protocol in elective cesarean section.
A prospective observational study. J Obstet Anaesth Crit Care
2022;12:28‑33.
53. Trikha A, Kaur M. Enhanced recovery after surgery in obstetric
patients‑Are we ready? J Obstet Anaesth Crit Care 2020;10:1‑3.