By Jeanine Mikek, MSN, RN, CEN
Maternal Child Health Educator, Labor & Delivery, Mother Baby, Neonatal Intensive Care Unit & Pediatrics, IU Arnett Hospital, Lafayette, IN
Ms. Mikek reports no financial relationships relevant to this field of study.
SYNOPSIS: Implementation of an enhanced recovery bundle after cesarean delivery reflected diverse positive outcomes. However, length of stay was reduced only by an average of two hours.
SOURCE: Teigen NC, Sahasrabudhe N, Doulaveris G, et al. Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: A randomized controlled trial. Am J Obstet Gynecol 2020;222:372.e1-372.e10.
Studies of an enhanced recovery after surgery (ERAS) bundle for postoperative patients in surgical specialties, including but not limited to orthopedics, gastroenterology, and urology, demonstrated positive outcomes, such as reduced length of stay, improved patient satisfaction, and improved fiscal responsibility.1 However, how an ERAS protocol affects postpartum women after cesarean delivery is unclear. From late 2017 to mid-2018, doctors at an urban academic hospital in Bronx, NY, completed a randomized, controlled trial of 118 women undergoing a cesarean birth to determine if an ERAS bundle would reduce length of stay. These authors primarily were interested in reducing the postoperative length of stay from three days to two days. Secondary outcomes included postoperative pain medicine use, postoperative complications, patient satisfaction, and breastfeeding rates.
Pregnant women with a gestational age of at least 37 0/7 weeks were invited to participate. Exclusions included emergent cesarean births, use of general anesthesia, hypertensive disorders of pregnancy, active intra-amniotic infection, or an adherent placenta. In addition, patients who were not candidates to receive ketorolac were excluded.
One hundred eighteen pregnant women were randomized, with 60 receiving standard care and 58 placed in the ERAS group. Components of the ERAS bundle focused on early oral intake, use of xylitol chewing gum (to promote gastric motility), removal of the surgical dressing by six hours, use of incentive spirometry, removal of urinary catheter with ambulation by 12 hours, and scheduled administration of intravenous ketorolac for 24 hours. The primary outcome was patient discharge on the second day. Other secondary outcomes assessed included postoperative length of stay in hours, postoperative narcotic use, breastfeeding rates, surgical complications, and gastrointestinal issues. Six weeks after delivery, participants used a Likert scale to score their experiences related to the secondary outcomes.
In contrast to other surgical studies evaluating ERAS protocols, a significant reduced length of stay was not observed in this randomized clinical trial. On average, discharge times were reduced by only approximately two hours rather than a full day (73.5 hours vs. 75.5 hours; P = 0.046). Interestingly, patients who received standard care had higher rates of hospital readmission (8.3% vs. 0%; P = 0.10), hypertensive complications (11.7% vs. 6.9%; P = 0.38), and gastrointestinal issues (11.7% vs. 1.7%; P = 0.06). Women randomized to the ERAS protocol showed improved patient satisfaction, earlier rates of ambulation, and greater success with breastfeeding. Only 8.9% of ERAS participants stated they did not attempt breastfeeding compared to 26.4% of women who received standard postoperative care (P = 0.001). In addition, exclusive breastfeeding at six weeks was significantly higher in the ERAS group compared to the control group, with a nearly 20% difference (67.2% and 48.3% respectively; P = 0.046).
Postoperative length of stay was not affected by ERAS protocol in a significant way for women delivering by cesarean. However, from personal experience, many mothers who deliver by cesarean birth desire to be discharged home prior to the standard 72-hour mark. So, although these results were not as promising as hoped, with average length of stay reduced by two hours compared to one day, this small difference may be meaningful to some women. Furthermore, a number of the secondary outcomes were positively affected, not the least of which was patient satisfaction. Women randomized to ERAS demonstrated reduced postoperative nausea or vomiting as well as improved perception of pain control. Small improvements in the plan of care, such as introducing chewing gum early to curb nausea, could improve the patient experience and potentially reduce the need for additional medications, such as ondansetron.2 Less need for medication and an enhanced patient experience could help keep the focus on the maternal-infant dyad, and any factor that allows a woman to return to normal functional capacity is worth considering. A quality improvement project such as this could be a terrific opportunity for nursing staff on the unit to help implement.
- Wilson RD, Caughey AB, Wood SL, et al. Guidelines for antenatal and preoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1). Am J Obstet Gynecol 2018;219:523.e1-523.e15.
- Darvall JN, Handscombe M, Leslie K. Chewing gum for the treatment of postoperative nausea and vomiting: A pilot randomized controlled trial. Br J Anaesth 2017;118:83-89.