ERAS guidelines for antenatal and preoperative care in caesarean delivery

By: Anaesthesiology.asia | Last updated: 21 January 2019 | In: Anaesthesiology, ERAS, News

Article Keywords

ERAS, ERAS society, Guideline, preoperative care, caesarean

The Enhanced Recovery after Surgery (ERAS) Society recently published Part 1 of the Society’s 3-part caesarean delivery guidelines, focussed on pre-operative care for women undergoing scheduled and unscheduled caesarean delivery, in the American Journal of Obstetrics & Gynecology.¹

Caesarean delivery is the most common surgical procedure in the modern world.

The newly release ERAS caesarean delivery guideline aims to enhance the quality and safety of the caesarean delivery and to improve both maternal and fetal/neonatal outcomes.

Methods

A literature search using Embase and PubMed articles published between 1996 and 2017 was performed by an ERAS Society Guideline Committee selected author panel. Individual reviewers screened the titles and abstracts of selected studies to identify potentially relevant articles. The board then evaluated the quality of evidence and recommendations according to the Grading of Recommendations, Assessment, Development, and Evaluation system. Whereas a weak recommendation indicates that the panel is less confident on the intervention, a strong recommendation shows the panel’s confidence that the effectivity outweighs the undesirable effects (Table 1).

Symbol

Recommendation Grading

Description

–

Weak

The trade-offs are less certain, due to:

Low-quality evidence;
Evidence suggests the desirable and undesirable effects are closely balanced.

++

Strong

The desirable effects of an intervention:

Clearly outweigh the undesirable effects;
Clearly do not outweigh the undesirable effects.

Table 1. recommendation grading according to the Grading of Recommendations, Assessment, Development, and Evaluation system.

Results

Table 2 summarises the ERAS Society’s evidence-based recommendations for process-directed maternal care for the preoperative caesarean delivery guidelines for improved surgical quality and safety during obstetric surgical deliveries promoting the enhanced recovery for maternal and fetal/neonatal outcome.

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Item	Recommendation Grading	Level of Evidence	Recommendation
Optimisation element (antenatal pathway)
Preadmission data, patient education and counselling	++	Very low-low	High-quality evidence lacking. Optimised clinical practice include: Informing the patient before, during, and after caesarean delivery about the procedures; Adapting the information for both unscheduled and scheduled caesarean deliveries.
Preadmission data, patient education and counselling	++	Very low-low	Caesarean delivery without medical indication: Not be recommended without a thorough preadmission evaluation assessing the risks/benefits for mother and child.
Focussed preoperative elements (preoperative pathway)
Preanaesthetic drugs	++	Low	Reduction of aspiration pneumonitis risks: Administer antacids and histamine H2 receptor antagonists as premedication.
Preanaesthetic drugs	++	Low	Preoperative sedation: Do not use for scheduled caesarean delivery: Potential detrimental effects on mother and child.
Bowel preparation	++	High	Oral or mechanical bowel preparation: Do not use before caesarean delivery.
Fasting	++	High	Encourage women to drink: Clear fluids until 2 hours before surgery: Pulp-free juice; Coffee without milk; Tea without milk.
Fasting	.++	High	Light meals: Allowable up to 6 hours before surgery.
Carbohydrate supplementation	–	Low	Oral carbohydrate fluid supplementation: For non-diabetic women; Two hours before caesarean delivery.
Maternal comorbidity optimisation (appendix)	++	High	Maternal obesity Maternal obesity (body mass index (BMI) >40 kg/m²): Significantly increases maternal and fetal complication-risk; Optimal gestational weight-gain management: Control weight during pregnancy; Obesity adds surgical complexity: Requires multidisciplinary planning.
	++	High	Maternal hypertension Manage maternal hypertension; Chronic hypertension significantly increases the incidence of: Maternal and fetal morbidity; Caesarean delivery.
	++	High	Maternal gestational diabetes mellitus (DM) Manage maternal DM: Timely and effectively during preconception and pregnancy; DM significantly increases the incidence of: Maternal and fetal morbidity.
	++	Moderate	Maternal anaemia Identify the cause of anaemia; Maternal anaemia during pregnancy may cause: Low birthweight; Preterm birth; Increased perioperative morbidity and mortality.
	++	High	Maternal tobacco smoking Associated with adverse medical and reproductive morbidity; Tobacco smoking should be stopped before or in early pregnancy.

Table 2. Recommendations for preoperative care by the ERAS Society Guideline Committee appointed panel on caesarean delivery.

Reference

Wilson RD, et al. Am J Obstet Gynecol 2018;219(6):523.e1-523.e15. doi: 10.1016/j.ajog.2018.09.015.

Disclaimer

This article is not medical advice. Patients should seek personal assessment by a licenced specialist. Physicians are recommended to read the full publication(s) as cited in the article before making medical decisions. This article does not supersede nor replace the published article(s).