Guidelines for antenatal and preoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 1)—2025 update
Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal...
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| Published in | American journal of obstetrics and gynecology |
|---|---|
| Main Authors | , , , , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
United States
Elsevier Inc
28.04.2025
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| Subjects | |
| Online Access | Get full text |
| ISSN | 0002-9378 1097-6868 1097-6868 |
| DOI | 10.1016/j.ajog.2025.01.014 |
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| Abstract | Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018.
Interventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.
The 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong).
The first 3 recommendations are for use in the antenatal period (10–38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient’s recovery and the fetal-neonatal outcome. |
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| AbstractList | Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018.BACKGROUNDEnhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018.Interventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.METHODSInterventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.The 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong).RESULTSThe 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong).The first 3 recommendations are for use in the antenatal period (10-38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient's recovery and the fetal-neonatal outcome.CONCLUSIONThe first 3 recommendations are for use in the antenatal period (10-38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient's recovery and the fetal-neonatal outcome. Enhanced recovery after cesarean delivery protocols include evidence-based interventions designed to improve patient experience, pregnancy, and neonatal outcomes while reducing healthcare-related costs. This is the first update of the Enhanced Recovery After Surgery Society guidelines for antenatal and preoperative care before cesarean delivery after the original publication in 2018. Interventions were selected based on expert consensus using the Delphi method. An updated literature search was conducted in September 2024 using the Embase, PubMed, MEDLINE, EBSCO CINAHL (Cumulative Index of Nursing and Allied Health Literature), Scopus, and Web of Science databases. Targeted searches were performed by a medical librarian to identify relevant articles published since the 2018 Enhanced Recovery After Surgery Society guidelines publication, which evaluated each antenatal and preoperative enhanced recovery after cesarean delivery intervention, focusing on randomized clinical trials and large observational studies (≥800 patients) to maximize search feasibility and relevance. Following a review of the evidence, a consensus was reached regarding the quality of evidence and the strength of recommendation for each proposed intervention according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. The 6 recommended enhanced recovery after cesarean delivery interventions are (1) antenatal pathway patient education for scheduled caesarean delivery (evidence low to very low, recommendation strong); (2) multidisciplinary medical and surgical staff education regarding enhanced recovery after cesarean delivery support, intervention implementation, and measurement (evidence low, recommendation strong); (3) optimization of the medical care for pregnant patients with comorbid conditions, such as anemia, obesity, hypertension, prepregnancy and gestational diabetes, smoking (tobacco, cannabis, vaping), congenital heart disease, epilepsy, autoimmune disease, and asthma (evidence moderate, recommendation strong); (4) abdominal skin preparation with chlorhexidine gluconate impregnated cloth (evening before scheduled cesarean delivery) (evidence moderate; recommendation weak); (5) the duration of preoperative fasting based on the content intake (evidence low, recommendation weak); (6) the use of a preoperative, nonparticulate carbohydrate drink (evidence low-moderate, recommendation strong). The first 3 recommendations are for use in the antenatal period (10-38 weeks of gestation), which allow for the optimization of patient comorbidities, whereas the remaining 3 recommendations are for preoperative interventions (skin preparation, preoperative fasting directives, and preoperative carbohydrate supplementation). Educational tools for cesarean delivery with well-designed shared decision-making focus on comorbidity management should be developed. These management tasks are viewed as routine care; however, the measurable success and impact have clinical variance. The enhanced recovery after cesarean delivery goal for patients who are undergoing a scheduled caesarean delivery is to maximize the quality of the pregnant patient's recovery and the fetal-neonatal outcome. |
| Author | Muraca, Giulia M. Sultan, Pervez Bamber, James Macones, George A. Jago, Caitlin A. Metcalfe, Amy Panelli, Danielle M. Caughey, Aaron B. Blake, Lindsay E.A. Wilson, R. Douglas Monks, David T. Sharawi, Nadir Wood, Stephen L. Nelson, Gregg Sauro, Khara M. Shah, Prakeshkumar S. Daly, Sean |
| Author_xml | – sequence: 1 givenname: R. Douglas surname: Wilson fullname: Wilson, R. Douglas email: doug.wilson@ahs.ca organization: Department of Obstetrics and Gynecology, and Cumming School of Medicine, University of Calgary, Alberta, Canada – sequence: 2 givenname: David T. surname: Monks fullname: Monks, David T. organization: Department of Anesthesiology, Washington University in Saint Louis, MO – sequence: 3 givenname: Nadir surname: Sharawi fullname: Sharawi, Nadir organization: Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR – sequence: 4 givenname: James surname: Bamber fullname: Bamber, James organization: Department of Anaesthesia, Cambridge University Hospitals, Cambridge, UK – sequence: 5 givenname: Danielle M. surname: Panelli fullname: Panelli, Danielle M. organization: Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA – sequence: 6 givenname: Khara M. surname: Sauro fullname: Sauro, Khara M. organization: Department of Surgery, and Cumming School of Medicine, University of Calgary, Alberta, Canada – sequence: 7 givenname: Prakeshkumar S. surname: Shah fullname: Shah, Prakeshkumar S. organization: Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada – sequence: 8 givenname: Giulia M. surname: Muraca fullname: Muraca, Giulia M. organization: Departments of Obstetrics and Gynecology and Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada – sequence: 9 givenname: Amy surname: Metcalfe fullname: Metcalfe, Amy organization: Departments of Obstetrics and Gynecology, Medicine, and Community Health Sciences, University of Calgary, Calgary, Canada – sequence: 10 givenname: Stephen L. surname: Wood fullname: Wood, Stephen L. organization: Department of Obstetrics and Gynecology, and Cumming School of Medicine, University of Calgary, Alberta, Canada – sequence: 11 givenname: Caitlin A. surname: Jago fullname: Jago, Caitlin A. organization: Department of Obstetrics and Gynecology, and Cumming School of Medicine, University of Calgary, Alberta, Canada – sequence: 12 givenname: Sean surname: Daly fullname: Daly, Sean organization: Maternal Fetal Medicine, Rotunda Hospital, Dublin, Ireland – sequence: 13 givenname: Lindsay E.A. surname: Blake fullname: Blake, Lindsay E.A. organization: University of Arkansas Medical Sciences Library, Little Rock, AR – sequence: 14 givenname: George A. surname: Macones fullname: Macones, George A. organization: Department of Women’s Health, Dell Medical School, University of Texas, Austin, Texas – sequence: 15 givenname: Aaron B. surname: Caughey fullname: Caughey, Aaron B. organization: Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR – sequence: 16 givenname: Pervez surname: Sultan fullname: Sultan, Pervez organization: Department of Anesthesiology, Critical Care, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA – sequence: 17 givenname: Gregg surname: Nelson fullname: Nelson, Gregg organization: Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/40335350$$D View this record in MEDLINE/PubMed |
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| Keywords | preoperative care shared obstetrical decision-making scheduled obstetrical intervention variance antenatal care quality protocol adherence knowledge transfer unscheduled safety cesarean delivery prevention pregnant patient comorbidity management |
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| SubjectTerms | antenatal care cesarean delivery knowledge transfer obstetrical intervention variance pregnant patient comorbidity management preoperative care prevention protocol adherence quality safety scheduled shared obstetrical decision-making unscheduled |
| Title | Guidelines for antenatal and preoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 1)—2025 update |
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