E  Editorial

Enhanced Recovery After Surgery for Cesarean Delivery

Michael J. Scott, MB ChB, FRCP, FRCA, FFICM,* and Ian Wrench, MB ChB, BMed Sci, PhD, FRCA†
See Article, p 1362

GLOSSARY
ACC = American College of Cardiology; AHA = American Heart Association; ERAS = Enhanced
Recovery After Surgery; NICE = National Institute for Health and Care Excellence (UK); SOAP =
Society for Obstetric Anesthesia and Perinatology

I
n this issue of Anesthesia & Analgesia, the Society
for Obstetric Anesthesia and Perinatology (SOAP)
have presented their guidelines for enhanced
recovery after surgery (ERAS) for cesarean delivery.1
The authors are considered experts in obstetric anes-
thesia in the United States. These particular guidelines
are focused on the anesthesia and perioperative com-
ponents of the surgical episode of cesarean delivery.
The authors present 25 specific recommendations to
form the pathway to enhance maternal recovery and
maternal-infant bonding and to optimize perioperative
outcomes. The group use the 2016 American College
of Cardiology (ACC) and American Heart Association
(AHA) Clinical Practice Guideline Recommendation
Classification Systems to evaluate each of the element’s
level of evidence following a literature search.2
The SOAP guidelines echo existing national guide-
lines for cesarean delivery published in the United
Kingdom by the National Institute for Health and
Care Excellence (NICE) since 2012, as well as the inter-
national ERAS Society Guidelines published since
2005.3 In particular, the ERAS Society (Stockholm,
Sweden) recently published 3 part guidelines cov-
ering antenatal and preoperative, intraoperative,
and postoperative care in cesarean delivery, mainly
focusing on maternal outcome.4–6 The ERAS Society
has also published guidance on developing ERAS
From *Department of Anesthesiology and Critical Care Medicine, University
of Pennsylvania, Philadelphia, Pennsylvania; and †Sheffield Teaching
Hospitals Trust, Sheffield, United Kingdom.
Accepted for publication February 10, 2021.
Funding: None.
Conflicts of Interest: See Disclosures at the end of the article.
Reprints will not be available from the authors.
Address correspondence to Michael Scott, MB ChB, FRCP, FRCA, FFICM,
Department of Anesthesiology and Critical Care Medicine, University of
Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104. Address e-mail to
michael.scott@pennmedicine.upenn.edu.
Copyright © 2021 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000005517
Guidelines which uses Grade recommendation for
assessing the level of evidence and recommending
the evidence.7 The major difference with the SOAP
guidelines is the dual focus on both maternal and
neonatal outcomes.
The overarching aim of ERAS pathways is to opti-
mize patients before surgery; mitigate stress, pain,
and iatrogenic harm during surgery; and then accel-
erate the return of body homeostasis and metabolic
function by returning the patient to a functional state
of eating, drinking, mobilizing, and sleeping. This in
turn leads to reduction of complications and reduced
length of hospital stay.8 For cesarean delivery, the
inclusion of guidance regarding care of the neonate
and for breastfeeding is important as both are com-
mon causes of delay in discharge and are integral to
full functional recovery for new mothers.
Obstetric anesthesiologists will find many of the
recommendations to be familiar and likely already
part of their routine practice. One could argue that
cesarean delivery was ahead of the game for many
years and one of the precursors of modern ERAS as
patients have usually eaten and ambulated either the
day or morning after surgery. There has been much
focus by Obstetricians and Obstetric anesthesiologists
on optimizing outcomes such as
• The use of regional anesthesia as a standard of
care
• Optimizing analgesia while minimizing opiates
using spinal opiates and multimodal analgesia
• Maintaining cardiac output and mean arterial
pressure during anesthesia using a combination
of fluid and vasopressors/infusions
• Reducing blood loss and early recognition and
correction of massive maternal hemorrhage
The development of fetal medicine and high-risk
obstetric clinics has been one of the best health system

May 2021 • Volume 132 • Number 5 www.anesthesia-analgesia.org 1359

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 Enhanced Recovery for Cesarean Delivery
solutions to deliver preoperative medicine to preemp-
tively reduce risk for both mother and fetus.
The guidelines recommend prophylactic phen-
ylephrine infusions to manage spinal anesthesia–
induced hypotension in line with current thinking.
They also advocate the rapid coadministration of 1 L
of intravenous crystalloid immediately following the
instigation of spinal anesthesia, whereas ideal body
weight targets in milliliters per kilogram may have
been preferable considering the wide range of patient
sizes, weights, and obesity. Perioperative intravenous
fluid management is not usually challenging for the
vast majority of women; however, as the authors state,
ideal intravenous fluid parameters are not well estab-
lished. Emerging noninvasive methods of assessing
fluid status and tracking blood pressure changes may
play a role in the future.
Other recommendations will require health sys-
tem innovations but are well supported in the litera-
ture. Anemia is common in pregnancy and may affect
recovery. As such, the focus on detection and manage-
ment of anemia is highly appropriate. Although this
requires the allocation of some resources (eg, addi-
tional blood tests and intravenous iron), these are
likely outweighed by the benefits accrued.
The authors have used the best available evidence
to inform their choices. By necessity, much of it is
inferred from other areas or from studies which did
not assess enhanced recovery directly. This is not sur-
prising considering the comparatively recent devel-
opment of enhanced recovery for cesarean delivery
pathways along with the difficulty in investigating
such a multicomponent intervention. There are con-
siderable overlap and concordance with the recently
published ERAS Society guidelines for this patient
group.4–6 For example, while direct evidence of the
benefit of carbohydrate loading for these women does
not currently exist, there is enough indirect evidence
to support its use pending appropriate research and
potential harms are likely to be minimal if any. The
increasing adoption of bedside ultrasound and ability
to measure gastric volumes should lead to definitive
studies on oral fluid loading in maternal settings and
risk of aspiration.
Some of the recommendations reflect the profes-
sional focus of the SOAP authorship panel, which
consisted entirely of anesthesiologists. A multidisci-
plinary team may have suggested different interven-
tions, particularly for care either entirely or partially
under the jurisdiction of other specialties such as
midwifery and obstetrics. Hopefully, this will not
reduce the impact of these sections of the guide-
lines. For example, the suggestion that postdelivery
a relatively small bolus of oxytocin (1 IU) should be
given—entirely in keeping with the evidence—is at
odds with the advice of some obstetric professional
1360   
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organizations.9 Moreover, the panel recommended
removal of urinary catheters between 6–12 hours
postsurgery, but a systematic review of trials where
urinary catheters were removed in theatre found that
there was earlier postoperative mobilization and dis-
charge home for women following cesarean delivery.10
This is one of the few areas of research where a com-
ponent of an enhanced recovery protocol for cesar-
ean delivery has been shown to reduce the length of
postoperative stay. Future research could be commis-
sioned to more accurately assess the balance between
the need for recatheterization and the improved out-
comes which have been found with very early catheter
removal. The SOAP guidelines do not contain advice
as to surgical technique other than the suggestion that
exteriorization of the uterus during cesarean delivery
should be avoided. The Joel-Cohen incision for cesar-
ean delivery is associated with less fever, better pain
control, less blood loss, shorter duration of surgery,
and reduced length of hospital stay11; all of which are
consistent with an enhanced recovery protocol. This
is another area where input from an obstetrician may
have been helpful.
Advice has been included regarding aspects of
care which are likely to have only a peripheral effect
on speed of recovery. For example, there is a section
on thromboprophylaxis, whereas problems related
to blood clots rarely affect postoperative recovery.
Inclusion of such areas is essential considering that
enhanced recovery concerns the entire patient path-
way. Consequently, the guidelines could be con-
sidered to be a state-of-the-art description of good
standard care for this patient group. As it is not pos-
sible to be sure what the postoperative course will be
preoperatively (eg, unexpected excess bleeding dur-
ing surgery), it makes sense to apply the guidelines to
all, particularly as many are inexpensive and easy to
implement.
Anesthesiologists are well positioned within the
multidisciplinary team to influence pre-, intra-, and
postoperative aspects of patient care and to lead
robust implementation of perioperative guidelines.
There is evidence from colorectal surgery that closer
adherence to protocols improves outcomes.12 This
may well be the case also for obstetric surgery so that
when implementing an enhanced recovery protocol,
it will be important to ensure that the various compo-
nents are applied to as high a proportion of women
as possible.
These guidelines represent an important bench-
mark for the future and will hopefully lead to stan-
dardization of care across the United States, not just
in academic institutions but private practice where
variability of care is more common. The widespread
acceptance of the standards outlined in the guidelines
could facilitate future studies to identify interventions
ANESTHESIA & ANALGESIA
 E  Editorial
to improve outcomes as other parts of the care path-
way are standardized. There would be the opportu-
nity for multisite research projects with the collection
of large amounts of data. Many aspects of patient
information are now recorded electronically, and this
would facilitate the process. However, there would
then be a need for sophisticated analysis to discern
the best treatment strategies. Collection and analy-
sis of real-world data may produce more timely and
accurate results compared to a traditional approach
with assessment of individual components of care
in selected populations. However, it is vital that the
different stakeholders such as obstetricians and mid-
wives contribute to future guidelines to ensure the
necessary steps above will be taken. E
DISCLOSURES
Name: Michael J. Scott, MB ChB, FRCP, FRCA, FFICM.
Contribution: This author helped design and draft the manu-
script and critically revise the manuscript for important intel-
lectual content.
Conflicts of Interest: M. Scott is on the ERAS Society Executive
Board and President of ERAS USA. M. Scott has received
honorarium and travel expenses for speaking from Edwards
Lifescience, Baxter, Deltex, Trevena, and Merck.
Name: Ian Wrench, MB ChB, BMed Sci, PhD, FRCA.
Contribution: This author helped design and draft the manu-
script and critically revise the manuscript for important intel-
lectual content.
Conflicts of Interest: I. Wrench is coauthor of the ERAS Society
guidelines for enhanced recovery for cesarean delivery.
This manuscript was handled by: Jill M. Mhyre, MD.
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