Dr. Laurent Bollag (Co-Chair)
Dr. Mohammed Tiouririne (Co-Chair)
Dr. Grace Lim (Member) – on behalf of SOAP Education Committee
Dr. Brendan Carvalho (Member)
Dr. Mark Zakowski (Member)
Dr. Sumita Bhambhani (Member) – on behalf of SOAP Patient Safety Committee
Dr. Eric Hunt (Consultant)
Dr. Ruth Landau (Consultant)
Dr. Ashraf Habib (Consultant)
Background of Enhanced Recovery after Cesarean (ERAC)
An ERAC protocol aims to standardize the perioperative care of the pregnant patient. By reducing variabilities in care and creating a specific evidence-based care pathway, maternal and fetal outcomes can be improved1-4. In this document, we present the core values and elements that a cesarean delivery-specific enhanced recovery after surgery program should include and present outcome metrics that will allow one to measure the success of the program. Many elements have been adapted from other successful enhanced recovery after surgery (ERAS) programs, predominantly enhanced recovery after colorectal surgery. The level of evidence is provided for each element, based on American College of Cardiology (ACC) and American Heart Association (AHA) Grading Criteria (Appendix), and is subject to change as further evidence is published.
Inherent to any enhanced recovery program is the interdisciplinary approach and the inclusion of all parties involved in the care of patients including anesthesiology, obstetricians, perinatologists, pediatricians, neonatologists, nursing, lactation specialists, pharmacy, hospital administration, the patient and patients’ support systems. Implementing change is always challenging and buy-in from stakeholders varies, but individual practices should still be evidence-based in your subspecialty. Importantly, successful implementation of ERAC may not necessarily lead to a reduction in length of stay for mother and/or newborn or be a cost reduction intervention, rather the mission of ERAC is to improve the global quality of care and optimize quality of recovery after cesarean delivery.
Goal of Enhanced Recovery after Cesarean (ERAC)
The goal of ERAC is to help provide all women with evidence-based, patient-centered care using a standardized, multidisciplinary approach that optimizes recovery from cesarean delivery and improves maternal and newborn outcomes. Central to this goal is a culture of critically examining and applying current knowledge through continual process improvements and collaborations.
ERAC should be considered a continuum of care from preconception outreach, antepartum optimization, intrapartum care including the anesthetic, and concluding with postpartum inpatient care and outpatient support. In this guideline, we will focus on elements of the care pathway for the preoperative, intraoperative and postoperative periods, presented in table format below. Some elements may not be implemented at your clinical site, while others are likely already part of your patient workflow and care models. Success of the ERAC program lies in interdisciplinary collaborations.
The committee has identified a few core elements that are required for a program to be called ERAC. These core elements are identified by bolded text with asterisks** within each table. ERAC pathways have been developed for scheduled cesarean delivery. However, many elements of the pathway can be applied to non-scheduled cesarean delivery. Examples of various ERAC-related documents, including patient education materials, can be found in the Appendix to help with successful implementation.
Class of Recommendations and Level of Evidence
A review of the literature was conducted for each recommendation. Existing evidence was evaluated for each of the core elements as they relate to enhanced maternal and neonatal recovery after cesarean delivery. The 2016 American College of Cardiology (ACC) and American Heart Association (ACC/AHA) Clinical Practice Guideline Recommendation Classification System1 have been applied to each of the Core Elements, based on the best available evidence. The classification system is available in the Appendix.