Enhanced Recovery After Cesarean Delivery: A Challenge for Anesthesiologists

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach that spans the pre-, intra-, and post-operative periods. The ultimate goal of ERAC is to enhance recovery and improve maternal and neonatal outcomes. This review highlights the critical role of anesthesiologists in ERAC protocols, providing a comprehensive overview of the purposes, essential elements, and evaluation tools used in ERAC. The review also discusses the specific areas where anesthesiologists can contribute, including the management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia, multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia.

Introduction

Enhanced recovery after surgery (ERAS) was first introduced by Kehlet in 1997 to reduce the length of hospital stay in open sigmoid resections. In China, the first ERAS Congress was established in 2015, and since then, a series of Chinese Experts Consensuses has been published on this topic. Today, ERAS has infiltrated a broad range of surgical specialties, and various guidelines have been published and updated by experts worldwide. Although ERAS protocols have been successfully implemented across many subjects and institutions, the uptake of ERAS in obstetrics has lagged behind. It was not until 2018 that the ERAS Society released guidelines for cesarean delivery (CD), and to date, relevant data in the literature remain limited.

Purposes of Enhanced Recovery After Cesarean Delivery

Cesarean delivery is the most common major abdominal surgery in the world, and women face dual challenges after CD: being post-partum and post-operative. The enhanced recovery after cesarean (ERAC) delivery protocols may effectively address these challenges for women after CD.

Accelerating Recovery and Decreasing the Length of Hospital Stay

The global CD rate reached an unprecedented high of 21% in 2015 and has not decreased in recent years. In the United States, the CD rate increased to 32% in 2017, with over 1.27 million procedures performed annually. In China, an even higher rate of 36.7% was observed in 2018. Although great efforts have been made to decrease the CD rate, improved peri-operative care of obstetric patients is also crucial. As the majority of obstetric patients are young and healthy, they have the potential for rapid recovery and are motivated to return to a normal state of functioning to care for their babies. Enhanced recovery may benefit the healthcare system by reducing the waste of scarce medical resources and lowering the overall cost of healthcare. Evidence has shown that ERAC protocols can help reduce the length of hospital stay (LOS) by 7.8% or 4.86 hours overall and decrease the total post-operative cost by 8.4% or $642.85 per patient overall.

Improving Maternal Outcomes and Satisfaction

Unlike other surgical specialties, CD has some unique characteristics. One is that it is often unexpected, making it difficult to plan. Unplanned CD is associated with negative emotions and affects mother-infant bonding, making mothers feel sadness, disappointment, and even depression. Even when CD is planned, women face the unique dual challenges of recovering from major abdominal surgery and taking care of their babies. Efforts to enhance post-operative recovery may help improve bonding and breastfeeding, as well as reduce the incidence of post-partum depression.

Reducing Maternal Morbidity and Mortality

CD is associated with an increasing risk of maternal and neonatal morbidity and mortality. Nearly one-half of maternal deaths occur in the post-partum period and are related to intra-operative complications. Hypertensive disorders, cardiovascular diseases, hemorrhage, and infection are the leading causes of maternal death. However, more than 60% of pregnancy-related deaths might be preventable. The ERAS Society recommended the “optimized” pathway specifically for women who have prior modifiable risks to optimize the management of these maternal comorbidities (ERAS CD Expanded Program), including hypertension, diabetes, anemia, and smoking. These complex women may need team-based peri-operative care to reduce operative risks and enhance their outcomes.

Limiting Opioid Use and Prescribing Post-Operatively

Opioids are frequently used and prescribed after CD, but they should be used at the lowest effective dose for the shortest duration to minimize potential risks to the mother as well as the breastfed baby. The American College of Obstetricians and Gynecologists recently released recommendations for post-partum pain management, recommending a stepwise, multi-modal, and non-opioid analgesia approach as the first-line therapy after CD. Similarly, the ERAS Society also recommended an opioid-sparing, multi-modal post-operative protocol with the combination of pre-operative education and shared decision-making intervention to limit opioid use in obstetrics. Anesthesiologists should make efforts to optimize pain management, ensuring patients get effective pain control while limiting opioid use to avoid the potential risks of excessive opioid exposure, including opioid withdrawal syndrome and the opioid crisis.

Developing an Optimized ERAC Protocol

With the increasingly robust literature regarding ERAS in general, many organizations have begun to address ERAS for CD. Similar to other ERAS protocols, ERAC is also an interdisciplinary approach involving anesthesiology, obstetricians, nurses, neonatologists, pediatricians, pharmacists, hospital administration, and supporting systems. The principles of ERAC cover the entire phase of CD, but there is wide variability in the elements of published ERAC protocols. Society guidelines for CD have two specific pathways: the “focused” (normal) pathway for both scheduled and unscheduled CD, starting at 30 to 60 minutes before incision to hospital discharge, and the “optimized” (complex) pathway, which discusses broad antenatal topics of patient education and counseling for complex and comorbid women, and the immediate neonatal care at delivery. More recently, the Society of Obstetric Anesthesia and Perinatology (SOAP) released an ERAC Consensus Statement developed for scheduled CD, but some of the elements can also be applied to unscheduled CD. The committee identifies a few essential elements that are indispensable in ERAC and provides a series of patient education materials to help with the successful implementation of the protocol.

Evaluation of the Quality of Recovery After CD (ObsQoR-11)

Quality of recovery (QoR) scores QoR-40 and QoR-15 have been extensively used and validated as tools to measure recovery outcomes after non-obstetric surgeries. However, both are not maternal-focused and do not cover some aspects related to CD. Recently, Ciechanowicz et al. developed the first obstetric-specific, 11-item QoR score derived from QoR-40. ObsQoR-11 can evaluate the quality of recovery by measuring several key elements, including physical comfort (nausea and vomiting, dizziness, shivering), pain relief, physical independence (mobilizing, personal hygiene), and emotional state (in control, comfortable), with some items related to neuraxial anesthesia and the ability to care for the baby (breastfeeding, holding the baby). The ObsQoR-11 is a reliable, valid, and responsive tool for assessment in obstetrics. However, the QoR-11 is not generalizable and was developed only for the scheduled population. Further work is warranted to investigate its validation in the unscheduled population.

Role of Anesthesiologist in ERAC

When developing ERAC protocols, interventions should be considered according to the elements in the ObsQoR-11 tool. For anesthesiologists, the focus should be on specific components that can be tackled to ultimately improve the quality of ERAC.

Management of Peri-Operative Hypotension

In the 2016 American Society of Anesthesiologists Practice Guidelines for Obstetric Anesthesia, neuraxial techniques, including epidural, spinal, and combined spinal-epidural, are recommended for most CD. However, these techniques are associated with some maternal and neonatal/fetal side effects. Maternal hypotension, primarily caused by vasodilation, is commonly seen during CD. The severity of hypotension depends on the speed of onset of neuraxial anesthesia and the dose of neuraxial medication. Maternal hypotension leads to a series of symptoms, including intra-operative nausea and vomiting (IONV), dyspnea, and dizziness frequently after severe hypotension. Severe hypotension may decrease uteroplacental flow and increase the incidence of fetal acidosis, which may be detrimental to the fetus. Fluid therapy and vasopressors are considered the gold standard for the treatment and prevention of maternal hypotension. Both colloid preloading and crystalloid coloading can be used to prevent maternal hypotension to some extent. Vasopressors can effectively prevent and treat hypotension and are recommended to be used routinely and preferably prophylactically. Pure alpha-agonist drugs (phenylephrine) are the first-line vasopressors as they can directly counteract vasodilation. Although those with a mild beta-agonist drug (norepinephrine, metaraminol) may be more beneficial for hemodynamics, more evidence-based data are needed to support their value in obstetrics. Changing the position of the parturient after spinal anesthesia by tilting the operating table or using a wedge may improve maternal hemodynamics, but more evidence is needed to confirm these findings.

Prevention and Treatment of Intra- and Post-Operative Nausea and Vomiting

Nausea and vomiting are more frequent during CD than in other non-obstetric surgeries. There are many underlying causes, including spinal anesthesia-induced acute sympathetic blockade, acute hypotension, peri-operative use of opioids, and some surgical procedures (uterine exteriorization, intra-abdominal saline irrigation). IONV/post-operative nausea and vomiting (PONV) is a major stressor for women and their families. Several interventions are commonly used for IONV/PONV. Prophylactic vasopressor infusion combined with fluid loading may decrease the incidence of hypotension-associated IONV and maintain uteroplacental perfusion. A combination of at least two IV anti-emetics with different mechanisms of action, such as 5HT3 antagonists, glucocorticoids, and D2 receptor antagonists, is suggested. A meta-analysis showed that a 4 to 5 mg dose regimen of systemic dexamethasone can effectively prevent PONV but not IONV due to its delayed onset of action. While metoclopramide (10 mg) alone decreased IONV but not PONV because of its low efficacy, combinations of treatments are generally better than single agents for IONV as well as early PONV.

Prevention of Hypothermia

Peri-operative hypothermia (core temperature 72°F/22°C) may reduce the rate of maternal and neonatal hypothermia.

Multi-Modal Peri-Operative Pain Management

Peri-operative pain control is a key component of ERAS protocols, as high pain will make it difficult for mothers to care for their babies, delay early mobilization, and even induce anxiety and depression. Multi-modal peri-operative pain management, including various techniques and medications, should be used to reduce pain, enhance recovery, and reduce opioid use. Long-acting neuraxial opioids (morphine) are the gold standard for pain control during and after CD but are accompanied by some adverse effects, including pruritus, nausea, and respiratory depression. Evidence showed that approximately 50% of women experienced mild respiratory depression after neuraxial morphine. Opioids can also be given intravenously or intramuscularly, but much attention should be paid to maternal and neonatal adverse effects, especially for breastfed infants. Scheduled NSAIDs (unless contraindicated) and acetaminophen, which decrease opioids and side effects by 30% to 50%, should be considered the mainstay of analgesia after CD. Local anesthetic techniques, including wound infiltration, nerve block (e.g., quadratus lumborum or transversus abdominis plane [TAP] block) with ultrasound guidance, may provide good analgesic effects. A recent study showed that TAP block provided clinically similar outcomes (including numerical pain rating scores, the need for rescue medication, side effects, and patient satisfaction) as intrathecal morphine (100 mg) after CD. The quadratus lumborum block after CD was also effective for post-operative pain control as part of a multi-modal approach. However, these techniques are performed when neuraxial morphine cannot be given or as a rescue technique for breakthrough post-operative pain.

Active Pre-Operative Management of Unplanned Conversion of Labor Analgesia to Cesarean Delivery Anesthesia

For planned or scheduled CD, anesthesiologists may be more involved in the intra- and post-operative periods. However, for unplanned CD, especially when the epidural catheter is in situ, pre-operative management may be the most challenging practice for anesthesiologists. Unplanned CD in labor is urgent and can be traumatic. If the conversion or the “top-up” epidural dosing fails, delayed operation will be detrimental to the fetus and raise the risks of anesthesia-related complications. Repeated spinal anesthesia after failed conversion can lead to high-level blockade and hypotension. Unplanned conversion to general anesthesia is associated with high risks of maternal aspiration, failed airway management, maternal hemorrhage, and delayed neonatal respiration. Therefore, reliable, safe, and timely conversion is crucial. Early and active pre-operative management of conversion should be started once the patient consents to CD. A small bolus before transport and a repeated bolus in the OR can be used to test the catheter and accelerate induction. Accurate and quick assessment of the surgical level should be made to avoid unintended high-level blockade and facilitate anesthesiologists’ decision-making on whether to continue induction or choose an alternate technique. Appropriate epidural solution can also accelerate induction. Active management of labor analgesia, in which anesthesiologists participate in optimizing the quality and density of analgesia, the progress of labor, the diagnosis, and the treatment of breakthrough pain, will help ensure safe and successful conversion of labor analgesia to anesthesia.

Conclusions

In general, ERAC is an approach to promote maternal and neonatal healthcare through the utilization of standardized protocols and guidelines. Although this patient population is ideal for the implementation of ERAC, to date, supportive data are sparse, and no completed randomized controlled trials of ERAC exist in the literature. Among them, unplanned CD takes a high proportion in the total number of CDs, and large-scale clinical trials are warranted to test the feasibility of ERAC protocols in unplanned CD. One concern is that we might delay large-scale ERAS implementation until high-quality data are available. However, we believe that ERAC protocols are promising and should not be delayed because robust evidence has demonstrated the effectiveness and efficacy of each component of ERAC. Certainly, close audit and feedback should be used regularly to improve the quality of ERAC. Another concern is how to precisely define “recovery” after CD, as the concept of “recovery” means different things to different people. We should focus on complete recovery, including post-discharge care and follow-up, as it may take months for women to reach their pre-operative functional level based on their expectations and social circumstances. Interestingly, in China, there is a traditional practice after childbirth called “post-partum confinement” or “sitting the month,” focusing mainly on social support rituals, such as prolonged rest, special diet, and personal hygiene. Within-culture differences between Western and Asian patients’ expectations of recovery may be quite different. Finally, ERAC is just the beginning toward developing optimized pathways across pregnancy. In the future, enhanced recovery may be considered for all women giving birth to help them quickly return to physical and mental functioning while reducing medical expenses and the waste of medical resources.

doi.org/10.1097/CM9.0000000000000644

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