Original Research ajog.

org

OBSTETRICS
Enhanced recovery after surgery at cesarean delivery to
reduce postoperative length of stay: a randomized
controlled trial
Nickolas C. Teigen, MD; Nicole Sahasrabudhe, MD; Georgios Doulaveris, MD; Xianhong Xie, PhD; Abdissa Negassa, PhD;
Jeffrey Bernstein, MD; Peter S. Bernstein, MD, MPH

OBJECTIVE: Our objective was to determine whether an enhanced
recovery after surgery pathway at the time of cesarean birth
would permit a reduction in postoperative length of stay and
improve postoperative patient satisfaction compared to standard
perioperative care.
MATERIALS AND METHODS: Patients undergoing nonemergent
cesarean delivery at
37 weeks of gestation were randomized to
enhanced recovery after surgery or standard care. Enhanced recovery
after surgery involved multiple evidence-based interventions bundled into
1 protocol. The primary outcome was discharge on postoperative day 2.
Secondary outcome variables included pain medication requirements,
breastfeeding rates, and various measures of patient satisfaction.
RESULTS: From September 27, 2017, to May 2, 2018, a total of 58
women were randomized to enhanced recovery after surgery and 60 women
to standard care. The groups were similar in medical comorbidities and in
demographic and perioperative characteristics. Enhanced recovery after
surgery was not associated with a significantly increased rate of post-
operative day 2 discharges when compared with standard care (8.6% vs
3.3%, respectively; odds ratio, 2.74; 95% confidence interval,
0.51e14.70), but it was associated with a significantly reduced post-
operative length of stay when compared with standard care, with a median
length of stay of 73.5 hours (interquartile range, 71.08e76.62) vs 75.5
hours (interquartile range, 72.86e76.84) from surgery, difference in
median length of stay (e1.92; 95% confidence interval, e3.80 to e0.29).
Enhanced recovery after surgery was not associated with a reduction in
postoperative narcotic use (117.16  54.17 vs 119.38  47.98 morphine
milligram equivalents; mean difference, e2.22; 95% confidence interval,
e20.86 to 16.42). More subjects randomized to the enhanced recovery
after surgery protocol reported breastfeeding at discharge (67.2% vs
48.3%; P ¼ .046). When patients were surveyed 6 weeks postpartum,
those in the enhanced recovery after surgery group were more likely to feel
that their expectations were met and that they had achieved their post-
operative milestones earlier, and to report continued breastfeeding.
CONCLUSION: Enhanced recovery after surgery at cesarean delivery
was not associated with an increase in the number of women discharged
on postoperative day 2, but that may have been related to factors other
than patients’ medical readiness for discharge. Evidence that enhanced
recovery after surgery at cesarean delivery may have the potential to
improve outcomes such as day of discharge is suggested by the observed
reduction in overall postoperative length of stay, improved patient satis-
faction, and an increase in breastfeeding rates. Even better results may
accrue with more provider and patient experience with enhanced recovery
after surgery.
Key words: enhanced recovery, ERAS, cesarean delivery, postoperative
recovery

E nhanced recovery after surgery

(ERAS) involves changes to multi-
ple aspects of perioperative care with the
aim of standardizing postoperative pa-
tient care, improving patient outcomes,
reducing postoperative length of stay,
and optimizing patient satisfaction.1
Enhanced recovery pathways have been
widely implemented in many different
areas of surgery. Initially, these pathways
were introduced in colorectal surgery
nearly 15 years ago, but have found more
Cite this article as: Teigen NC, Sahasrabudhe N, Dou-
laveris G, et al. Enhanced recovery after surgery at ce-
sarean delivery to reduce postoperative length of stay: a
randomized controlled trial. Am J Obstet Gynecol
2020;222:372.e1-10.
0002-9378/$36.00
ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2019.10.009
widespread use in surgical specialties
including urology, orthopedics, breast
surgery, and gynecologic surgery. Initi-
ation of enhanced recovery programs
have consistently resulted in reduced
hospital length of stay, financial savings,
and improved patient satisfaction.2
To date, only observational and
retrospective studies have been per-
formed looking at the introduction of
enhanced recovery pathways at cesarean
delivery. In 1 observational study, the
investigators were able to successfully
introduce an enhanced recovery pro-
gram to their obstetrics unit, and noted a
greater proportion of patients dis-
charged earlier with improved patient
satisfaction, without a concomitant in-
crease in readmission rates.3 A recent
retrospective study showed that imple-
mentation of an ERAS program for
women having planned or unplanned
cesarean delivery was associated with
significantly decreased postoperative
length of stay (4.86 hours) and signifi-
cant cost savings per patient, without an
increase in hospital readmissions.4
The components of enhanced recovery
pathways vary significantly, although all
seek to provide benefits to patients by
optimizing the postoperative recovery
course through the combination of mul-
tiple evidence-based components.5-7 In a
previous study aimed at postecesarean
delivery discharge timing, comparing
early vs usual discharge time, there was no
difference observed in the number of
maternal readmissions, maternal anti-
biotic use, maternal well-being and anx-
iety, or depression.8
Components of enhanced recovery
pathways can include standardization of

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ajog.org OBSTETRICS Original Research

standard perioperative recovery.

AJOG at a Glance Randomization was computer-
Why was this study conducted? generated before the first patient was
To compare whether an enhanced recovery after surgery (ERAS) pathway at enrolled, using Randomization.com with
cesarean delivery would increase the rate of early hospital discharges and improve block sizes of 4. The randomization
postoperative patient satisfaction compared to standard perioperative care. allocation was concealed in opaque,
identical, sequentially numbered, sealed
Key findings envelopes. The numbered envelope was
ERAS at cesarean delivery was not associated with an increase in the number of opened after written consent was ob-
women discharged early. Evidence that ERAS after cesarean may have the po- tained and before the patient entered the
tential to improve outcomes such as day of discharge is suggested by the observed operating room. Preoperative surgical
reduction in overall postoperative length of stay, improved patient satisfaction, preparation and antibiotic prophylaxis
and an increase in breastfeeding rates. followed standard institutional pro-
tocols. All women received neuraxial
What does this add to what is known? analgesia: spinal, epidural, or combined
This prospective randomized trial adds to the paucity of literature on ERAS at spinal and epidural. Cesarean delivery
cesarean delivery and reaffirms the potential benefits of ERAS at cesarean delivery techniques followed the preference of
to improve postoperative outcomes including overall postoperative length of stay the attending surgeon. Following the
and exclusive breastfeeding rates. completion of surgery, computerized
postoperative order sets were placed for
each patient based on the study arm to
the use of prophylactic antibiotics, informed consent was obtained from all which they were previously assigned
venous thromboembolism prophylaxis, women prior to enrollment. Women (Figure 1). Postoperative recovery fol-
minimizing starvation times, use of were eligible for enrollment if they had a lowed the usual service protocols
antiemetics, earlier resumption of gestational age of 37 0/7 completed including ambulation at the patient’s
feeding postoperatively, use of chewing weeks or greater based on the best ob- discretion, diet initiation at the patient’s
gum postoperatively, early removal of stetric estimated due date and were un- discretion, urinary catheter removal on
dressings and urinary catheters, and dergoing a scheduled or nonemergent postoperative day 1, postoperative dres-
standing postoperative pain medication cesarean delivery. Best obstetric esti- sing removal on postoperative day 1, and
orders.9 mated due date was used to establish the ketorolac and narcotic pain medication
Currently, no randomized studies subject’s due date: either last menstrual as needed for pain. Alternatively, the
exist in the literature specifically period or ultrasound if the last men- components of the enhanced recovery
addressing the potential impact of an strual period was unknown, or if a protocol included several evidence-
enhanced recovery pathway among discrepancy with last menstrual period based recommendations: early ambula-
women undergoing cesarean delivery on was noted as per American College of tion, early diet initiation, early removal
postoperative outcomes and post- Obstetricians and Gynecologists guide- of urinary catheter, early removal of
operative length of stay. ERAS after ce- lines. Patients were excluded if they were postoperative dressing, and standing
sarean delivery is not practiced at our less than 37 weeks of gestation, were ketorolac for 24 hours postoperatively
institution and is not practiced nation- undergoing an emergent cesarean birth, (Table 1).
ally in a consistent fashion. were receiving general anesthesia, or had Demographic features, medical
Our objective was to determine a pregnancy complicated by an active comorbidities, and known perioperative
whether an enhanced ERAS pathway at infection, morbidly adherent placenta, risk factors for postoperative complica-
the time of cesarean delivery would pre-existing hypertension, or tions were recorded. The primary
permit a reduction in postoperative pregnancy-induced hypertension pre- outcome was discharge on postoperative
length of stay and improve postoperative operatively that would potentially pro- day 2 and was determined by review of
patient satisfaction compared to stan- long their hospitalization. Patients were the postecesarean delivery medical re-
dard perioperative care (SC). also excluded if they had any renal cord. The discharging provider was not
impairment, peptic ulcer disease, or aware of the group allocation. Only the
Materials and Methods known hypersensitivity to ketorolac, all provider who performed the cesarean
This was a prospective randomized reasons for which they would not be able delivery was aware of the group alloca-
clinical trial enrolling pregnant women to receive ketorolac. tion, as they placed the postoperative
at the Jack D. Weiler Hospital of Mon- Participants were enrolled by 1 of the orders upon completion of the surgery.
tefiore Medical Center (Bronx, NY) in an authors on the day of cesarean delivery Discharge timing of the women in our
urban academic hospital setting. The and after obtaining informed consent study was based on provider and patient
study protocol was approved by the were randomized to either an ERAS expectations and not based on medical
institutional review board, and written protocol for their perioperative care or eligibility for discharge. Postoperative

APRIL 2020 American Journal of Obstetrics & Gynecology 372.e2

Original Research OBSTETRICS
FIGURE 1
Algorithm of randomization
Assessed for eligibility
(n=223)
Randomized
(n=121)
Enhanced Recovery
(n=58)
Protocol Deviaons
(n=3)
Completed Follow-up
Survey
(n=56)
Teigen et al. Enhanced recovery after surgery at cesarean delivery. Am J Obstet Gynecol 2020.
day 2 was selected as the primary
outcome as the day of discharge after
cesarean delivery in our institution has
traditionally been postoperative day 3.
Secondary outcomes assessed were
postoperative pain medication use,
postoperative complications (wound
complications, urinary infections, post-
partum depression, hospital read-
mission), breastfeeding initiation
determined from the medical record and
postoperative telephone survey, and
breastfeeding continuation determined
from postoperative telephone survey.
Patient satisfaction and outcome infor-
mation were determined by telephone
contact 6 weeks after the procedure with
a telephone interview and survey.
To detect a reduction of the pri-
mary outcome on early hospital dis-
charges on postoperative day 2 at a
rate decrease of 20% with power of
0.80 and a 2-tailed a of 0.05, 59
women per study group were required
for a total of 118 in the study. We
assumed a baseline rate of early
hospital discharges of 10% in our
institution based on a pilot of imple-
menting early hospital discharges and
372.e3 American Journal of Obstetrics & Gynecology APRIL 2020
Excluded (n=33)
Declined (n=69)
Standard
(n=60)
Completed Follow-up
Survey
(n=53)
querying obstetric providers regarding
our institution’s practice.
Postoperative telephone surveys
were conducted 6 weeks postpartum
to assess patient satisfaction and
postoperative experience and compli-
cations. Women were asked a series of
multiple-choice questions using a
Likert scale.
Demographic characteristics, medi-
cal comorbidities, and perioperative
information were described by the
study group as mean (SD) or median
(range) for continuous variables and
frequency (%) for categorical variables
as appropriate. Differences between
study arms were assessed using a t test
or nonparametric equivalent for
continuous variables and a Pearson c2
or Fisher exact test for categorical
variables as appropriate. Odds ratios
(OR) and 95% confidence intervals
(CI) were used to assess and to
quantify effect on postoperative com-
plications. Analysis was based on
intention-to-treat principle. All P
values were 2-sided, and a P value of
.05 was deemed statistically signifi-
cant. Statistical analysis was performed
ajog.org
using STATA (StataCorp, College Sta-
tion, TX). The study was registered
with ClinicalTrials.gov, NCT02956616.
Results
From September 27, 2017, to May 2,
2018, a total of 223 women were assessed
for inclusion; 33 women were excluded
because they met 1 or more exclusion
criteria and 69 women declined partici-
pation in the study, leaving 121 women
who were randomized. Of those ran-
domized, there were 3 protocol breaches
assigned to the incorrect study arm,
resulting in 58 women randomized to
ERAS and 60 women randomized to
standard perioperative care (Figure 1).
Randomization resulted in groups that
were similar in regard to demographic
characteristics, medical comorbidities,
and perioperative characteristics
(Table 2).
The use of ERAS at cesarean delivery
was not associated with a significantly
increased rate of early hospital dis-
charges on postoperative day 2 when
compared with standard recovery (8.6%
vs 3.3%; effect estimate, 2.74; 95% CI,
0.51e14.70, P ¼ .24). We did observe a
significantly reduced postoperative
length of stay in the enhanced recovery
protocol group when compared with
standard perioperative care group, 73.5
hours (71.1e76.6) compared with 75.5
hours (72.8e76.8) (effect estimate,
e1.92; P ¼ .046. No differences were
noted in regard to postoperative narcotic
requirement (117.16  standard devia-
tion [SD], 54.17, vs 119.38  SD 47.98
morphine milligram equivalents; effect
estimate, e2.22; 95% CI, e20.86 to
16.42, P ¼ .81).
The use of ERAS at cesarean de-
livery was associated with an increase
in exclusive breastfeeding post-
operatively, with 67.2% of participants
exclusively breastfeeding in the
enhanced recovery arm compared to
48.3% in the standard recovery group
(P¼.046). There were no differences in
breastfeeding protocols between the
study arms.
There were no statistically significant
differences between the groups when
comparing postoperative complications,
including postoperative infections,
ajog.org
TABLE 1
Enhanced recovery after surgery (ERAS) protocol
Chewing gum (Xylitol) to reduce postoperative ileus
Intravenous NSAIDs (ketorolac) for 24 h postoperatively to reduce postoperative narcotic use
Early initiation of feeding after cesarean delivery: clear liquid diet immediately in the PACU, Regular diet at 30 minutes
Early removal of urinary catheter at 12 h
Early removal of dressing at 6 h
Early mobilization at 12 h
Incentive spirometry encouraged every 8 h
NSAID, nonsteroidal anti-inflammatory drugs; PACU, postanesthesia care unit.
Teigen et al. Enhanced recovery after surgery at cesarean delivery. Am J Obstet Gynecol 2020.
gastrointestinal complications, genito-
urinary complications, wound compli-
cations, bleeding complications, hospital
readmissions, hypertensive disorder
complications, or postpartum depres-
sion (Table 3).
Postoperative telephone surveys
were conducted at 6 weeks post-
partum to assess patient satisfaction
and postoperative experience and
complications. Women in the
enhanced recovery arm were more
likely to feel that their recovery met
expectations and were more satisfied
with postoperative dietary allowances,
more satisfied with their ability to
ambulate, and more satisfied with
their ability to breastfeed. There were,
however, no differences in their
perception of preoperative education,
postoperative pain control, or their
perceived ability to bond with their
infants (Table 4).
Discussion
Principal findings of the study
The use of ERAS at cesarean delivery
was not associated with an increased
rate of early hospital discharges on
postoperative day 2 compared with
standard perioperative care. However,
ERAS at cesarean delivery was associ-
ated with a reduction in overall post-
operative length of stay compared with
standard perioperative care (73.5
hours vs 75.5 hours). Notably, ERAS
at cesarean delivery was also associated
with an increase in the percentage of
women who exclusively breastfed their
infants in the postpartum period.
OBSTETRICS
Results
Although our primary outcome measure
did not show an increased rate of early
hospital discharges, this is in direct
contrast to an enhanced recovery pro-
tocol in colorectal surgery that permitted
earlier hospital discharges and improved
patient satisfaction.10 Adequate com-
parisons of benefits of enhanced recov-
ery vs standard recovery after cesarean
delivery are lacking. An observational
study from the United Kingdom was able
to successfully introduce an enhanced
recovery program to their obstetrics unit
and noted a greater proportion of pa-
tients discharged earlier, 1.6% on post-
operative day 1 vs 25.2% on
postoperative day 2.11 Implementation
of this program occurred over the span
of 2 years without a concomitant in-
crease in hospital readmissions. In
addition, a retrospective cohort study
evaluating implementation of an ERAS
pathway for women having cesarean
deliveries was associated with decreased
postoperative length of stay and with
cost savings.12
However, no prospective random-
ized trials have been conducted spe-
cifically addressing the impact of an
ERAS program on postoperative day of
discharge and other postoperative
outcomes.
Clinical implications
The use of ERAS at cesarean delivery
may have many novel clinical benefits,
including reducing postoperative length
of stay, improving patient satisfaction,
increasing the rate of exclusive
APRIL 2020 American Journal of Obstetrics & Gynecology
Original Research
breastfeeding, and reducing post-
operative narcotic use. These in-
terventions may potentially reduce
healthcare costs and decrease use of
hospital resources.
The specific effect of enhanced re-
covery on exclusive breastfeeding is un-
clear. There may be components of
enhanced recovery such as encourage-
ment of early ambulation, early feeding,
and early resumption of normal activity
that may help new mothers to feel well
after their surgery and more able to
exclusively breastfeed their newborns.
Specifically addressing this effect of
enhanced recovery on breastfeeding may
have clinical utility in improving
breastfeeding rates in the postpartum
period.
The use of ERAS at cesarean delivery
was not associated with a reduction in
postoperative narcotic use. We speculate
that the lack of reduction in post-
operative narcotic use may be multifac-
torial. Administration of narcotics in the
postoperative period can be affected by
the underlying culture within the insti-
tution of providing postoperative pain
control based on the provider’s percep-
tion of the patient’s need for narcotics
and not based on a true objective mea-
sure of a patient’s narcotic need derived
from pain scores. Patients in the
enhanced recovery arm received ketor-
olac 15 mg intravenously every 6 hours
for 24 hours (60 mg in total) in com-
parison to ketorolac administered on an
as-needed basis in the standard recovery
arm. In the control group, patients
received a median of 30 (0e60) g vs 60
372.e4
Original Research OBSTETRICS ajog.org

TABLE 2
Patient demographics, perioperative information, and medical comorbidities
Characteristic ERAS (n ¼ 58) Standard recovery (n ¼ 60) P value
Age, y, mean  SD 30.43  4.92 31.93  5.43 .12
BMI, kg/m , mean  SD
2
34.79  6.78 33.34  6.09 .22
Ethnicity, n (%) .77
White 4 (6.9) 4 (6.7)
African American 13 (22.4) 16 (26.7)
Hispanic 33 (56.9) 29 (48.3)
Asian 3 (5.2) 2 (3.3)
Other 5 (8.6) 9 (15.0)
Gestational age, wk, median (IQR) 39.0 (39.0e39.3) 39.1 (39.0e39.4) .62
Multiparous, n (%) 48 (88.9) 48 (85.7) .62
Prior cesarean delivery, median (IQR) 1 (1e2) 1 (1e2) .88
Indication for cesarean delivery, n (%) .66
Prior cesarean delivery 50 (86.2) 46 (76.7)
Malpresentation 4 (6.9) 6 (10.0)
Suspected macrosomia 2 (3.5) 6 (6.7)
Prior myomectomy 0 (0) 1 (1.7)
Active HSV 0 (0) 1 (1.7)
Twin gestation 2 (3.5) 1 (1.7)
Primary elective 0 (0) 1 (1.7)
Estimated blood loss, mL, median (IQR) 800 (700e1000) 800 (800e1000) .79
Estimated blood loss
1000 mL, n (%) 19 (32.8) 21 (35.0) .80
Skin closure, n (%) 1.00
Monocryl 55 (94.8) 55 (91.7)
Vicryl 0 (0) 1 (1.7)
Staples 3 (5.2) 1 (6.7)
Preoperative HCT, mean  SD 35.34  3.32 35.52  2.97 .75
Postoperative day 1 HCT, mean  SD 30.52  3.42 30.89  3.31 .55
Chronic hypertension, n (%) 0 (0) 0 (0) NA
Diabetes mellitus, n (%) 6 (10.3) 12 (20.0) .14
Hypertensive disorder of pregnancy, n (%) 4 (6.9) 6 (10.0) .74
Birthweight, mean  SD 3409.97  422.74 3348.12  487.69 .46
Apgar >7 at 5 min, n (%) 55 (94.8) 57 (95.0) 1.00
NICU admission, n (%) 2 (3.5) 2 (3.3) 1.00
BMI, body mass index; ERAS, enhanced recovery after surgery; HCT, hematocrit; HSV, Herpes Simplex Virus; IQR, interquartile range; NA, Not applicable; NICU, neonatal intensive care unit.
Teigen et al. Enhanced recovery after surgery at cesarean delivery. Am J Obstet Gynecol 2020.

(60e60) g (P < .001). The significant
variability in the administration of
ketorolac in the standard recovery arm
may reflect that patients and staff were
opting to manage postoperative pain
without turning to narcotics, and thus
mitigating any reduction in post- outcome measure may be due to limi-
operative narcotic requirements. tations of using postoperative day of
discharge as a primary outcome measure
Research implications of medical stability of discharge in our
The inability of our study to show a study population. Determination of
significant difference in the primary timing of a patient’s medical eligibility

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TABLE 3
Study outcomes
Outcome ERAS Standard recovery Effect estimate (95% CI) P value
Primary outcome
Discharge on POD 2, n (%) 5 (8.6) 2 (3.3) 2.74 (0.51, 14.70) .24
Secondary outcomes
Postoperative hospital length of stay, h, median (IQR) 73.58 (71.08e76.62) 75.50 (72.86e76.84) e1.92 (e3.80 to e0.29) .046
Postoperative narcotic use (MME), mean  SD 117.16  54.17 119.38  47.98 e2.22 (e20.86 to 16.42) .81
Breastfeeding, n (%) .046
Breastfeeding 39 (67.2) 29 (48.3)
Bottle feeding 4 (6.9) 2 (3.3)
Both 15 (25.9) 29 (48.3)
Postoperative infection, n (%) 0 (0) 2 (3.3) 0.20 (0.00e2.53) .31
Gastrointestinal complication, n (%) 1 (1.7) 7 (11.7) 0.13 (0.02e1.12) .06
Wound complication, n (%) 0 (0) 4 (6.7) 0.11 (0.00e1.04) .14
Bleeding complication, n (%) 19 (32.8) 20 (33.3) 0.97 (0.45e2.10) .95
Postpartum depression, n (%) 4 (6.9) 10 (16.7) 0.37 (0.11e1.26) .11
Hospital readmission, n (%) 0 (0) 5 (8.3) 0.09 (0.0e0.79) .10
Hypertensive disorder complication, n (%) 4 (6.9) 7 (11.7) 0.56 (0.16e2.03) .38
Any postoperative complication, n (%) 20 (34.5) 28 (46.7) 0.60 (0.29e1.26) .17
CI, confidence interval; ERAS, enhanced recovery after surgery; IQR, interquartile range; MME, morphine milligram equivalents; POD, postoperative day; SD, standard deviation.
Teigen et al. Enhanced recovery after surgery at cesarean delivery. Am J Obstet Gynecol 2020.

for discharge may be confounded by
factors such as prolonged neonatal
observation in the postpartum period
and sociodemographic factors that may
preclude early hospital discharge when a
woman is deemed medically stable for
discharge. Furthermore, discharge
timing may be based on patient and
provider preferences, expectations, and
habits and not based on medical eligi-
bility criteria alone. To show whether the
difference that we observed in our pri-
mary outcome was statistically signifi-
cant, we performed a post hoc analysis
and found that 309 subjects per group
would be needed for such a study.
Further investigation that includes more
in-depth perioperative education mate-
rials and a larger study based on our
findings, including an economic anal-
ysis, is warranted.
Strengths and limitations
The main strength of our study was
the prospective, randomized study
design. The structure of our inter-
vention, however, was not without
limitations. Key to an enhanced re-
covery protocol is perioperative pa-
tient education. The perioperative
education that was provided in our
study related to enhanced recovery
was limited to when informed con-
sent was obtained for participation in
the study, which was completed just
prior to surgery. Given our in-
stitution’s multiple offices and non-
centralized presurgical process, we
believed that the only way to achieve
standardized education and informed
consent was to perform this at the
site where the procedure was occur-
ing, and this was possible only on the
day of the procedure. A more thor-
ough perioperative education compo-
nent may be beneficial at better
establishing patient and provider ex-
pectations for discharge. In addition,
the discharge timing of the women in
our study was based on provider and
patient expectations and preferences
and often not on their medical eligi-
bility. We anticipated that 10% of the
patients in our standard recovery arm
would opt for discharge on post-
operative day 2 but actually found
that only 3.3% did. It was not
possible to determine from the med-
ical record the reasons why patients
were not discharged on postoperative
day 2. An additional limitation of our
study was that it was not blinded;
performing a blinded study would be
difficult to do with this sort of
intervention. The majority of the
procedures (115 of 118) were sched-
uled and performed during the
morning or early afternoon hours,
and therefore we did not anticipate
that the time of day that the pro-
cedure was performed would have an
impact on the primary outcome
measure. An additional limitation of
our study was that 102 of the eligible
223 subjects were not included in our

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TABLE 4
Survey results
Standard
Question ERAS recovery P value
Do you feel that you were properly educated about the recovery process before your cesarean .18
delivery? n (%)
Strongly agree 26 (46.4) 18 (34.0)
Agree 30 (53.6) 35 (66.0)
Disagree 0 (0) 0 (0)
Strongly disagree 0 (0) 0 (0)
Do you feel that the recovery process after your delivery met your expectations? n (%) .003
Strongly disagree 0 (0) 0 (0)
Disagree 0 (0) 0 (3.8)
Agree 16 (28.6) 29 (54.7)
Strongly agree 40 (71.4) 22 (41.5)
Do you feel that you were prevented from eating or drinking for too long prior to the procedure? n (%) .004
Strongly agree 0 (0) 0 (0)
Agree 21 (37.5) 36 (67.9)
Disagree 32 (57.1) 16 (30.2)
Strongly disagree 3 (5.4) 1 (1.9)
Did you encounter any postopertive nausea or vomiting after your cesarean delivery? n (%) .68
Yes 5 (8.9) 6 (11.3)
No 51 (91.1) 47 (88.7)
Did you encounter any difficulty eating after your cesarean delivery? n (%) 1.00
Yes 3 (5.4) 2 (3.9)
No 53 (94.6) 50 (96.2)
Approximately how soon after your cesarean delivery were you able to begin drinking? n (%) .0002
0e30 min 0 (0) 0 (0)
30e60 min 1 (1.8) 1 (1.9)
1e3 h 34 (60.7) 13 (24.5)
4e6 h 21 (37.5) 39 (73.6)
Approximately, how soon after your cesarean delivery were you able to begin eating? n (%) .69
0e30 min 0 (0) 0 (0)
30e60 min 0 (0) 0 (0)
1e3 h 6 (10.7) 7 (13.2)
4e6 h 50 (89.3) 46 (86.8)
Approximately how soon after your cesarean delivery were you able to get out of bed? n (%) .01
0e2h 0 (0) 0 (0)
2e4 h 1 (1.8) 0 (0)
4e6 h 21 (37.5) 9 (17.0)
6 hþ 34 (60.7) 44 (83.0)
Teigen et al. Enhanced recovery after surgery at cesarean delivery. Am J Obstet Gynecol 2020. (continued)

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TABLE 4
Survey results (continued)
Standard
Question ERAS recovery P value
Approximately how soon after your cesarean delivery were you able to resume our normal activities? .41
n (%)
0e2h 0 (0) 0 (0)
2e4h 0 (0) 0 (0)
4e6h 12 (21.4) 15 (28.3)
6 hþ 44 (78.6) 38 (71.7)
Did you encounter any difficulty urinating after your cesarean delivery? n (%) .61
Yes 1 (1.8) 2 (3.9)
No 54 (98.2) 50 (96.2)
Were you able to have skin-to-skin contact with your baby after your cesarean delivery? n (%) .72
Strongly agree 3 (5.4) 1 (1.9)
Agree 51 (91.1) 50 (94.3)
Disagree 2 (3.6) 1 (1.9)
Strongly disagree 0 (0) 1 (1.9)
Were you satisfied with your ability to bond with your baby after your cesarean delivery? n (%) .44
Strongly agree 11 (19.6) 7 (13.2)
Agree 45 (80.4) 45 (84.9)
Disagree 0 (0) 1 (1.9)
Strongly disagree 0 (0) 0 (0)
Were you satisfied with your ability to breastfeed? n (%) .56
Strongly agree 8 (14.8) 3 (7.5)
Agree 43 (79.6) 36 (90.0)
Disagree 1 (1.9) 1 (2.5)
Strongly agree 2 (3.7) 0 (0)
How long after the birth of your baby did you continue to breastfeed? n (%) .001
Few hours 0 (0) 0 (0)
Few days 0 (0) 4 (7.6)
Few weeks 11 (19.6) 15 (28.3)
Few months 40 (71.4) 20 (37.7)
No breastfeeding 5 (8.9) 14 (26.4)
Do you feel that your pain was well-controlled after your cesarean delivery? n (%) .52
Strongly agree 4 (7.1) 1 (1.9)
Agree 51 (91.1) 50 (94.3)
Disagree 1 (1.8) 2 (3.8)
Strongly disagree 0 (0) 0 (0)
Did you encounter any infections or complications with your incision after your .35
cesarean delivery? n (%)
Yes 1 (1.8) 3 (5.7)
No 55 (98.2) 50 (94.3)
Teigen et al. Enhanced recovery after surgery at cesarean delivery. Am J Obstet Gynecol 2020. (continued)

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Original Research OBSTETRICS ajog.org

TABLE 4
Survey results (continued)
Standard
Question ERAS recovery P value
Did you encounter any urinary infections after your cesarean delivery? n (%) NA
Yes 0 (0) 0 (0)
No 56 (100) 53 (100)
Were you readmitted to the hospital for any reason after your cesarean delivery? n (%) .20
Yes 1 (1.8) 4 (7.6)
No 55 (98.2) 49 (92.5)
Did you experience postpartum depression? n (%) 1.00
Yes 2 (3.6) 1 (1.9)
No 54 (96.4) 52 (98.1)
Do you feel that you were satisfied with the overall experience after your cesarean delivery? n (%) .15
Strongly agree 28 (50.0) 24 (45.3)
Agree 28 (50.0) 25 (47.2)
Disagree 0 (0) 4 (7.6)
Strongly disagree 0 (0) 0 (0)
ERAS, enhanced recovery after surgery; NA, not applicable.
Teigen et al. Enhanced recovery after surgery at cesarean delivery. Am J Obstet Gynecol 2020.

study because they declined partici-
pation. This large rate of declining
participation could introduce bias,
but that should have been mitigated
by the fact that randomization
occurred after patients agreed to
participate. We do not anticipate that
the cesarean delivery technique would
add bias because the patients were
randomized. An additional limitation
of our study is that there may have
been cross-over, with some patients
receiving interventions from the
enhanced recovery order set that
nursing staff found potentially bene-
ficial for their patient. Finally, the
generalizability of our study may be
limited, as it was performed at a
single center.
Conclusion
In conclusion, we were unable to show
an increase in our primary outcome
measure of early hospital discharges on
postoperative day 2 when patients un-
derwent ERAS after cesarean delivery
in comparison to standard recovery.
However, our study was able to show
a significant reduction in total
postoperative length of stay as well as a
significant increase in exclusive breast-
feeding with ERAS, which is a novel
finding. n 533.
References
1. Wilson R, Caughey A, Wood S, et al. Guide-
lines for antenatal and preoperative care in ce-
sarean delivery: Enhanced Recovery After
Surgery Society Recommendations. Am J
Obstet Gynecol 2018;219:523–44.
2. Adamina M, Kehlet H, Tomlinson GA,
Senagore AJ, Delaney CP. Enhanced recovery
pathways optimize health outcomes and
resource utilization: a meta-analysis of random-
ized controlled trials in colorectal surgery. Sur-
gery 2011;149:830–40.
3. 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;24:124–30.
4. Fay E, Bollag L, Delgado C, et al. An enhanced
recovery after surgery pathway for cesarean
delivery decreases hospital stay and cost. Am J
Obstet Gynecol 2019;221:349.
5. Douglas WR, Caughey AB, Wood SL,
et al. Guidelines for antenatal and preopera-
tive care in cesarean delivery: Enhanced
Recovery After Surgery Society recommen-
dations (part 1). Am J Obstet Gynecol
2019;219:523.
6. Caughey, Aaron B, et al. Guidelines for intra-
operative care in cesarean delivery: Enhanced
Recovery After Surgery Society recommenda-
tions (part 2). Am J Obstet Gynecol 2019;219:
7. Macones GA, Caughey AB, Wood SL,
et al. Guidelines for postoperative care in
cesarean delivery: Enhanced Recovery After
Surgery (ERAS) Society recommendations
(part 3). Am J Obstet Gynecol 2019;219:
247.
8. Brooten D, Roncoli M, Finkler S, Arnold L,
Cohen A, Mennuti M. A randomized trial of early
hospital discharge and home follow-up of
women having cesarean birth. Obstet Gynecol
1994;84:832–8.
9. Wilson R, Caughey A, Wood S, et al. Guide-
lines for antenatal and preoperative care in ce-
sarean delivery: Enhanced Recovery After
Surgery Society recommendations. Am J
Obstet Gynecol 2018;219:523–44.
10. Adamina M, Kehlet H, Tomlinson GA,
Senagore AJ, Delaney CP. Enhanced recovery
pathways optimize health outcomes and
resource utilization: a meta-analysis of random-
ized controlled trials in colorectal surgery. Sur-
gery 2011;149:830–40.
11. 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:
124–30.
12. Fay E, Hitti JE, Delgado CM, et al. An
enhanced recovery after surgery pathway for

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ajog.org OBSTETRICS Original Research

cesarean delivery decreases hospital stay and
cost. Am J Obstet Gynecol 2019;221:349.
Author and article information
From Georgia Perinatal Consultants (Dr Teigen), Atlanta,
GA; Department of Obstetrics & Gynecology (Dr Sahas-
rabudhe), Kaiser Permanente Southern California,
Downey, CA; Department of Obstetrics & Gynecology and
Women’s Health (Drs Doulaveris and P.S. Bernstein),
Albert Einstein College of Medicine / Montefiore Medical
Center, Bronx, NY; Department of Epidemiology and
Population Health (Drs Xie and Negassa), Albert Einstein
College of Medicine / Montefiore Medical Center, Bronx,
NY; Department of Anesthesia (Dr J. Bernstein), New York
University, New York, NY.
Received July 16, 2019; revised Oct. 1, 2019;
accepted Oct. 16, 2019.
The authors report no conflict of interest.
This study received no financial support.
ClinicalTrials.gov Identifier: NCT02956616. Date of
registration: Nov. 7, 2016. Date of initial participant
enrollment: Sept. 1, 2017. https://clinicaltrials.
gov/ct2/show/NCT02956616?cond¼enhancedþrecoveryþ
cesarean&rank¼1
Presented in part as a poster presentation at the
SMFM 39th Annual Meeting, Las Vegas, NV, Feb.
11e16, 2019.
Corresponding author: Nickolas Teigen, MD. nickolas.
teigen@gmail.com

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