About 15 years ago, a set of protocols was developed for patients undergoing colorectal surgery. These guidelines, known as enhanced recovery after surgery (ERAS), include evidence-based aspects of care before, during, and after surgery to accelerate patient recovery.
Over the years, other surgical specialties have adopted ERAS protocols. Hospitals in more than 20 countries follow ERAS, and we use them here at UT Southwestern. Research has shown that ERAS protocols result in shorter hospital stays, reductions in complications and readmissions, reduced health care costs, and improved patient satisfaction.
The benefits of ERAS have been well-documented in many specialties. We're continuously refining protocols for patients who deliver by cesarean section (C-section), helping better prepare them for planned – and unplanned – C-sections.
For example, new research from UT Southwestern and Parkland Memorial Hospital has shown that multimodal pain management after C-section – not relying solely on opioid medications – can control pain effectively and may increase breastfeeding success.
If you have had a C-section in the past or know someone who has, you may notice that we'll provide a few new pieces of information as you prepare for your next delivery.
ERAS and C-section education
Depending on where you live, approximately one-third of patients have C-sections. The American College of Obstetricians and Gynecologists estimates that 2.5% of C-sections are done at the mother's request.
Others are planned, such as in complex pregnancies or if a patient has undergone one or more C-sections in the past. However, sometimes an unplanned C-section is necessary if the mother or baby are at risk.
During prenatal visits, your doctor will discuss with you what could cause the need for an unplanned C-section. However, just because the doctor talks to you about C-sections doesn’t mean you’ll have one.
Rather, we want patients to know what to expect with an unscheduled C-section before it's time to deliver. ERAS protocols are helping our Ob/Gyn teams prepare patients. In the event of an actual emergency or urgent situation, there is limited time to explain the procedure and patients are typically preoccupied with their medical situation.
Related reading: Why you should ask about your hospital's C-section rates
C-section protocol changes with ERAS
Eating and drinking before C-section
The adage was that patients shouldn’t eat or drink anything for eight hours before surgery. However, ERAS guidelines recommend patients drink clear liquids, juice, and sports drinks up to two hours before surgery, and have a light meal six hours beforehand.
Studies show this can improve outcomes after colorectal surgery, and research suggests that some of these benefits may transfer to other types of surgery. Therefore, we have begun to recommend that some patients eat or drink prior to C-section to potentially:
- Return to normal bowel function sooner
- Improve the patient experience
- Potentially speed recovery
These rules may differ among patients, so make sure you understand the directions from your doctor regarding eating and drinking before a C-section.
Urinary catheter removal
We used to leave a patient's urinary catheter in place for 12 to 14 hours after surgery. Now, we often take it out right away. We’ve found that this protocol has reduced the risk of difficulty urinating. It also means the patient can become mobile again sooner. Speaking of which, we encourage women to get out of bed and move around as soon as possible after a C-section.
Eating and drinking early after surgery can help the return of bowel function, and studies have shown that chewing gum can have the same effect. We may recommend you chew gum if you are nauseated or not hungry after your procedure.
Multimodal pain relief
To help reduce opioid use because of the associated risks, especially in breastfeeding women, we've begun to use a combination of non-opioid medications to help control your pain along with non-steroidal anti-inflammatory medications (NSAIDs) such as Motrin or acetaminophen.
In a recent study, a team of UT Southwestern providers including senior author Elaine Duryea, M.D., found that NSAIDs can effectively control pain after a C-section and may increase breastfeeding rates.
Prior to July 2020, women who had C-sections at Parkland Memorial Hospital traditionally received a morphine patient-controlled analgesia (PCA) device for 12 hours after delivery. The device allows patients to self-administer opioid pain medication as needed. After 12 hours, patients would start receiving NSAIDs as needed based on their pain rating.
In July 2020, after discussions with the obstetrics anesthesia team, Ob/Gyns at Parkland changed to a new C-section multimodal pain management protocol in which NSAIDs became the frontline medication and opioids were given only when needed based on a patient’s pain rating.
The researchers – including anesthesiologists, Ob/Gyns, and nurses – compared data from before and after the transition to the new protocol. They found that women who had frontline NSAIDs used approximately 4 times less morphine during their stay, reported less pain, and had a similar length of stay at the hospital.
Approximately 9% of patients in the multimodal group who wanted to exclusively breastfeed required formula supplementation compared to 12% in the traditional group.
Related reading: Having a C-section? What pregnant women should know
How we hope moms benefit from ERAS
One of the main intentions when ERAS was developed was to reduce the time patients had to stay in the hospital, which is a worthy goal for most surgical procedures. But for C-sections, we don’t necessarily want to send patients home right away for a couple reasons.
First, there is your baby. Pediatricians often want to watch the baby over the course of a day or two to make sure they are adjusting to life outside the womb, gaining weight, and learning to breastfeed. Also, patients may have conditions such as preeclampsia or chorioamnionitis, a bacterial infection that can occur before or during labor. These patients should not go home right away regardless of how quickly they recover from surgery.
Second, some literature indicates ERAS protocols might increase breastfeeding rates. This is likely because the patient feels better. She can get up and around faster and focus on breastfeeding instead of post-op pain or complications.
Our main goal in implementing ERAS is to improve our patients’ experience, both under our care and during recovery. This is why, for example, we try to offer a “gentle C-section,” which brings elements of a vaginal delivery into the operating room.
While obstetrics and gynecology may not have the amount of data other surgical specialties have regarding ERAS benefits for C-section patients, we’re starting to catch up. Cesarean sections are among the most common surgical procedures performed on women – improving the patient experience is always top of mind.