Guidelines for Enhanced Recovery after Caesarean __ | Section Mo}UDGSMC/DSS'GUD/001/Vers. Effective Date: Jnuary/2019 Review Date: Januay/2022 Institution Name: Directorate General of Specialized Medical Care, MoH Document Title: Guidelines for Enhanced Recovery after Caesarean Section Written by Reviewed by Validated by Approved by Name Dr. Mariam Al Waili Mr. Shabib Al Kalbani Enhanced Recovery after Caesarean Section Taskforce Dr. Qamra Al-Sariri Dr. Kadhim Jaffer Approval Process Title Institution Date _—_ Signature Director of DGSMC A /20% Supportive V/A [204 i. Services Head of Hospital DGSMC ——t__ | Dietetics and A/\ (204 = _ Catering i Taskforce Ministry of Health 13 | Ufo Director General Ministry of Quality Health Assurance Center Director General Ministry of of Specialized Health Medical Care Page 1 of 27‘Guidlines factRAbiieed Recoventanes Glas MoluDGSMC/DSSIGUD/OO Wer O1 jelines for Enhanced Recovery after Caesarean alvOGsMc/DssiGUD\ta Section Review Date: January/2022 Contents Table: 1, Acknowledgment Acronyms Introduction Scope Purpose. Definitions Guidelines. Audit Continued Quality Improvement Team Activities Document History and Version Control References: Appendix 1: Medications Appendix 2: Pre-Anesthetic Fasting Instructions for Enhanced Recovery Patients.Guidelines for Enhanced Recovery after Caesarean MoH/DGSMC/DSS/GUD/001/Vers 01 aes Effective Date: January/2019 Section Review Date anuay/202 Acknowledgement The Directorate General of Specialized Medical Care would like to take this opportunity to thank all staff who participated in reviewing this Guideline on Enhanced Recovery After Caesarean Section (ERACS) during the conference that took place on the second of February 2018 in Crowne plaza hotel, in their contributed immensely in discussing the guideline and providing their technical input. Particular the following team: Dr. Maher Al Bahrani Assistant Director General of Medical Af amla Al Qassab Director of Anestehtics- Royal Hospital Dr Rula Eskander S. Consultant Obs & Gyn- Khoula Hospital Dr Fatma Al Abri_ S. Specialist Obs & Gyn- Ibri Hospital Debbie Rawcliffe Head of Nursing- Sur Hospital Tamader AT Shehhi Head of Nursing- Khasab Hospital Dr Medhat Shalabi Head of Anesthesiology & Intensive Care- Al Zabra Hospital, Dubai UAE Please do not hesitate to communicate with us through the following email if you have any further ‘ding this guideline. Shabib.alkalbani@yahoo.com Page 3 of 27SS TecEaee nee faciars MolV/DGSMC/DSS/GUD/001/Vers. Guidelines for Enhanced Recovery after Caesarean Sere Section Review Date Janiary/2022 Caesarean Section "Enhanced Recovery Afier Surgery _ Ministry of Health Enhanced Recovery Afier Caesarean Section World Health Organization Preoperative Anesthetic Clinic Deep Vein Thrombosis Intravenous Thromboembolic Deterrent LMWH Low Molecular Weight Heparin 1D Identification American Society of Anesthesiologist Lower Segment Caesarean Section General Anesthesia “Quarter die sumendum’ 4 times a day Pro re nata” when necessary Operation — Page 4 of 27dati 5 ‘Mol¥/DGSMC/DSS/GUD/D01/Vers.01 Guidelines for Enhanced Recovery after Caesarean per ecpeacn Section Review Date: Januney/2022 idelines for Enhanced Recovery after Caesarean Se Introduction Cesarean section (CS) rate in Oman has gradually increased over ten years from 9.7% in 2000 to 15.72% in 2009, according to the annual report on the Ministry of Health, Oman. According to 2016 report, total deliveries of 71,222 had been recorded, of which 13,866 (19.47%) have been conducted by CS. Of the total Cesarean sections conducted, 4646 deliveries (33.51%) were elective, whereas 9220 (66.5%) were emergency. There is gradual increase in elective cesarean section since 2012, Furthermore, the overall percentage of CS in Oman since 2012 has been deviating away from World Health Organization (WHO) guidelines which state that the percentage of CS from all deliveries must be less than 15%. The rate of elective CS continues to rise, despite initiatives to counter this trend. Birth by CS is associated with prolonged hospital stay in comparison to spontaneous birth. Drastic changes with guidelines, therefore, need to be established. So far, two conferences have been conducted in enhanced recovery guidelines, of which the latest one was conducted on 2/2/2018 to address Caesarean Section, which was followed by an interactive discussion of this guideline manual Enhanced recovery or “fast track surgery” pathways are multimodal care pathways designed to accelerate patient recovery by reducing the surgical stress response and supporting the physiologic function, thereby reducing length of stay without impeding patient satisfaction or safety. The concept of a recovery pathway was first integrated into colorectal surgery but has since been implemented in a number of other elective surgery fields. Ministry of Health (MOH) obstetric units are facing increased pressure to maintain hig! quality maternal and neonatal care while juggling rising costs and demands with limited gestion for balancing these opposing forces in caesarean section (CS) is the implementation of an enhanced recovery pathway. If successful, an enhanced recovery pathway would result in the early discharge of women (within no more than 2 days post CS) which would not only benefit both the mother and new born child but could also resultGuidelines for Enhanced Recovery after Caesarean __—_‘M#VDGSMC/DSSIGUDINOLVes01 y Erectve Da Jamy/2019 Section Review Dat famay/2022 in significant reduction in obstetric unit cases. By introducing this guideline, we plan to reduce that number to one or two nights for suitable patients. Currently, enhanced recovery has been implemented inconsistently in Caesarean section in Oman but the young and low risk population would make an ideal patient sample to implement an enhanced recovery after surgery (ERAS) pathway Scope 2.1 Enhanced recovery guidelines primarily encompass the following healthcare Obstetricians Pain Management Team Neonatologist Anaesthetists Midwives Concerned nurses Nutritionists/dieticians Physiotherapists Clinical Pharmacists Health Educators Administrators/Managers Infection control specialists Discharge Planner 1.14 Patient(s) Purpose 3.1 To support the health care professional, as an interdisciplinary team that includes the patient, to implement and continually improve Enhanced Recovery after Caesarean Section(ERACS) pathways across the continuum of care from before admission to return home. Page 6 of 2ietinea ite Han aneedR ee eee ‘MolVDGSMC/DSS/GUD/001/Vers. 01 Guidelines for Enhanced Recovery after Caesarean re eet aa Section Review Date January/2022 By collaboratively developing specialty and facility specific evidence-based ERAS pathways, the team limits individual provider variation in care to improve patient engagement, quality of recovery, safety and outcomes. Definition 41 Cesarean Section (CS): (C-section) is surgery to deliver a baby. The baby is taken out through the mother's abdomen. Some C-sections are planned, but many are performed when unexpected problems occur during delivery, which include; health problems in the mother, the mother carrying multiple babies, the size or position of the baby, the baby’s health is in danger, or labor is not moving along as it should Epidural Anesthesia: epidural administration is a medical route of administration in which a drug or contrast agent is injected into the epidural space of the spinal cord. Techniques such as epidural analgesia and epidural anaesthesia employ this route of administration. The epidural route is frequently employed by certain physicians and nurse anaesthetists to administer diagnostic (e.g. radiocontrast agents) and therapeutic (e.g., glucocorticoids) chemical substances, as well as certain analgesic and local anaesthetic agents. Epidural techniques frequently involve injection of drugs through a catheter placed into the epidural space. The injection can result in a loss of sensation—including the sensation of pain—by blocking the transmission of signals through nerve fibres in or near the spinal cord. Spinal Anesthesia: also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of regional anaesthesia involving the injection of a local anaesthetic into the subarachnoid space, generally through a fine needle, usually 9 em (3.5 in) long. For obese patients longer needles are available (12.7 em / 5 inches). The tip of the spinal needle has a point or small bevel. Recently, pencil point needles have been made available (Whitacre, Sprotte, Gertie Marx and others). Enhanced Recovery(ER): is a multimodal, multidisciplinary approach to the care of the surgical patient. Enhanced Recovery After Surgery process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient Page 7 of 27Guidelines for Enhanced Recovery after Caesarean Ps ase y Effective Date Janoary/2019 Section Review Date January’2022 Anesthesia: in the practice of medicine (especially surgery and dentistry), anesthesia or anaesthesia is a state of temporary induced loss of sensation or awareness. It may include analgesia (relief from or prevention of pain), paralysis (muscle relaxation) amnesia (loss of memory), or unconsciousness. A patient under the effects of anesthetic drugs is referred to as being anesthetized. Anesthesia enables the painless performance of medical procedures that would cause severe or intolerable pain to an unanesthetized patient Analgesic: or painkiller is any member of the group of drugs used to achieve analgesia, relief from pain. Analgesic drugs act in various ways on the peripheral and central nervous systems. They are distinct from anesthetics, which temporarily affect, and in some instances completely eliminate, sensation, Analgesics include paracetamol (known in North America as acetaminophen or simply APAP), the nonsteroidal anti-inflammatory drugs (NSAIDs) such as the salicylates, and opioid drugs such as morphine and oxycodone. Apyrexial: normal, no fever Dietician: is an expert in dietetics; that is, human nutrition and the regulation of diet. A dietitian alters their patient's nutrition based upon their medical condition and individual needs. Dietitians are regulated healthcare professionals licensed to assess, diagnose, and treat nutritional problems. Nutritionist: is a person who advises on how food and nutrition impacts on health. Different professional terms are used in different countries, employment settings and contexts — some examples include: nutrition scientist, public health nutritionist, dietitian-nutritionist, clinical nutritionist, and sports nutritionist. In many countries and jurisdictions, the title "nutritionist" is not subject to professional regulation; thus any person may call themselves a nutritionisUnutrition expert even if they are wholly self-taught. Midwife: is a professional in midwifery, specializing in pregnancy, childbirth, postpartum, women's sexual and reproductive health (including annual gynecological exams, family planning, menopausal care and others), and newborn care. They are also educated and trained to recognize the variations of normal progress of labor, and understand how to deal with deviations from normal. They may intervene in high risk Page 8 of 27a A MolV/DGSMC/DSS:GUD/O1/Vers 01 Guidelines for Enhanced Recovery after Caesarean Reus veg une Section Review Date: January2022 situations such as breech births, twin births and births where the baby is in a posterior position, using non-invasive techniques. Physiotherapist: help people affected by injury, illness or disability through movement and exercise, manual therapy, education and advice. They maintain health for people of all ages, helping patients to manage pain and prevent disease. The profession helps to encourage development and facilitate recovery, enabling people to stay in work while helping them to remain independent for as long as possible. Primiparous: 4.12.1 Pregnant for the first time 4.12.2 Having given birth to only one child 4.12.3 Bearing a first offspring; having borne only one previous offspring Multiparous: producing many or more than one at a birth 4.13.1 Having experienced one or more previous parturitions Placenta Accreta: a serious pregnancy condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With placenta acereta, part or all of the placenta remains firmly attached. This can cause severe blood loss after delivery. It is also possible for the placenta to invade the muscles of the uterus (placenta increta) or grow through the uterine wall (placenta perereta), Placenta accreta is considered a high-risk pregnancy complication. If placenta accreta is suspected during pregnancy, a female would likely need an early C-section delivery followed by the surgical removal of your uterus (hysterectomy), 5 Hemoglobin: hemoglobin Hb or Hgb, is the iron-containing oxygen-transport metalloprotein in the red blood cells Hemoglobin in the blood carries oxygen from the respiratory organs (lungs or gills) to the rest of the body (i.e. the tissues). There it releases the oxygen to permit aerobic respiration to provide energy to power the functions of the organism in the process called metabolism. In mammals, the protein makes up about 96% of the red blood cells’ dry content (by weight), and around 35% of the total content (including water). Hemoglobin has an oxygen-binding capacity of 1.34 mL Q2 per gram, which increases the total blood Page 9 of 27Guidelines for Enhanced Recovery after Caesarean Eee aa eat Section Review Date: anuxy/2022 ‘oxygen capacity seventy-fold compared to dissolved oxygen in blood. The mammalian hemoglobin molecule can bind (carry) up to four oxygen molecules. 4.16 Phlebotomist: are people trained to draw blood from a patient [mostly from veins] for clinical or medical testing, transfusions, donations, or research. Phlebotomists collect blood primarily by performing venipuncture (or, for collection of minute quantities of blood, finger sticks] Guidelines 5.1 Common components of Enhanced Recovery ‘Common Components of Enhanced Recovery ‘reoperative Phase Intraoperative Phase ] Postoperative Phase Patient/Family Education (videos, | -- _-‘Spinal/CSE/GA/TAP | __—- __ Early removal of urinary leaflets ete. bloc! catheter. Shortened fasting, = Continuous wound Avoid salt and water Fluid & Carbohydrate loadit irrigation, overload. No bowel preparation Normothermia Prevention and a Antibiotic, Perioperative fluid management of post- Prophylaxis/Thromboprophylaxis. management. operative nausea and Pre-Anaesthetic Medication. Avoidance (if possible) PONV). of tubes, drains, and Non-opioid oral analgesia lines. Early oral nutrition Defined discharge criteria and patient education Gum chewing, Mobilization. Normothermia, Page 10 of 27Guidelines for Enhanced Recovery after Caesarean MaHIDOSMCIDSS/GUDVO01/Vers01 y Effective Date: Jnsary/2019 Section Review Date Januay/2022 Preoperative Phase 5.2.1 Documentation 5.2.1.1 Plan for enhanced recovery should be clearly documented on electronic Cesarean booking system (ALSHIFA 3+) in order to “Enhanced recovery” to appear on operating list and is visible to the whole theatre team. 2 Preoperative Preparation: 5.2.2.1 Pre- operative risk assessment of patient health and fitness: $.2.2.1.1 Patient will be selected and offered the enhanced recovery process by the anesthetist at the pre-operative anesthesia clinic (PAC) ot by the obstetrician when the decision is made for caesarean delivery Full medical and surgical history is mandatory for each patient Medical examination with airway and back assessment and request for additional examination or consultation if required. Blood results assessment (full blood count and coagulation profile). Assurance that patient has blood group and screen done before LSCS (including presence of antibodies) or request if not present If blood transfusion is required, patient consent shall be taken, Optimization of hemoglobin, according to MOH guidelines fe -operative counselling and provision of information 5.2.2.2.1 As soon as a decision is made for the expecting mother to have an elective LSCS, the obstetrician should initiate, facilitate and communicate proper patient education according to the patient’s mother tongue language. Page 11 of 27Guidelines for Enhanced Recovery after Caesarean ADEE p iat Effective Date: January/2019 Section Review Date January/2022 Counselling necessitates close collaboration between all members of the surgical team and the imparting of both written and verbal information. A verbal explanation and a written information leaflet about enhanced recovery should be given to the patient to facilitate proper education, A video might also be used if available. Antenatal education about postoperativ esia and thrombo-prophylaxis, Education on proper diet, smoking and alcohol cessation should also be given, 6 A consent form explaining all the details of the procedure must be signed by the patient or his/her caregiver On the Day at admission to the Hospital Premedication (prior to surgery) 6.2.2.3.1 Sodium Citrate (30 ml) or if not available, bicarbonate soda must be given just before taking the patient to the operating theatre + Prescribe and supply oral Ranitidine 150 mg and advise patient to take 1 tablet at 10 pm the night before surgery, 1 tablet 3 hours before surgery with Gabapentin (300mg single dose). Antibiotic Prophylaxis (15-60 minutes before surgery) or as per Ministry of Health (MOH)'s guidelines. 5.2.2.4 Optimization of nutrition: 2.4.1 Fasting 2.2.4.1.1 Patients should not have anything to eat or drink before surgery as below Page 12 of 27