Eras Part 1

Special Report ajog.
org
Guidelines for Antenatal and Preoperative care

in Cesarean Delivery: Enhanced Recovery After
Surgery (ERAS) Society Recommendations (Part 1)
R. Douglas Wilson, MD, MSc; Aaron B. Caughey, MD, PhD; Stephen L. Wood, MD; George A. Macones, MD;
Ian J. Wrench, MB ChB, PhD; Jeffrey Huang, MD; Mikael Norman, MD, PhD; Karin Pettersson, MD, PhD;
William J. Fawcett, MBBS, FRCA, FFPMRCA; Medhat M. Shalabi, MD; Amy Metcalfe, PhD;
Leah Gramlich, MD; Gregg Nelson, MD, PhD
E nhanced Recovery After Surgery

(ERAS) is a standardized, periop-
erative care program that now is
This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean de-
livery will provide best practice, evidenced-based, recommendations for preoperative, intra-
embedded firmly within multiple surgi- operative, and postoperative phases with, primarily, a maternal focus. The focused pathway
cal disciplines that include colorectal, process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery
urologic, gynecologic, and hepatobiliary Guideline will consider from the time from decision to operate (starting with the 30e60 minutes
surgery.1,2 Bisch et al3 reported on the before skin incision) to hospital discharge. The literature search (1966e2017) used Embase and
ERAS use in gynecologic oncology with PubMed to search medical subject headings that included “Cesarean Section,” “Cesarean
the conclusion that the systematic Section,” “Cesarean Section Delivery” and all pre- and intraoperative ERAS items. Study selection
implementation of ERAS gynecologic allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant
oncology guidelines across a healthcare articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized
system improves patient outcomes and controlled studies, reviews, and case series were considered for each individual topic. Quality
assessment and data analyses that evaluated the quality of evidence and recommendations were
saves resources. ERAS has been shown to
evaluated according to the Grading of Recommendations, Assessment, Development and
Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean
Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and un-
From the Department of Obstetrics & scheduled surgery starting from 30e60 minutes before skin incision to maternal discharge) with
Gynecology, Oregon Health & Science
ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic med-
University, Portland, OR (Dr Caughey); the
Department of Obstetrics & Gynecology, ications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ),
Cumming School of Medicine, University of intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical
Calgary, Calgary, Alberta, Canada (Drs Wilson, technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space,
Wood, Metcalfe, and Nelson); the Department of and skin closure), perioperative fluid management, and postoperative elements (chewing gum,
Obstetrics & Gynecology, Washington management of nausea and vomiting, analgesia, timing of food intake, glucose management,
University in St Louis, St. Louis, MO (Dr antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal
Macones); Sheffield Teaching Hospitals Trust,
and neonate discharge). Limited topics for optimized care and for antenatal education and
Royal Hallamshire Hospital, Glossop Road,
Sheffield, United Kingdom (Dr Wrench); counselling and the immediate neonatal needs at delivery are discussed. Strong recommen-
University of Central Florida, Orlando, FL (Dr dations for element use were given for preoperative (antenatal education and counselling, use of
Huang); the Divisions of Pediatrics (Dr Norman) antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours
and Obstetrics (Dr Pettersson), Department of surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative
Clinical Science, Intervention and Technology, (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous
Karolinska Institutet, Stockholm, Sweden; the
fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal im-
Department of Anaesthesia, Royal Surrey
County Hospital, Egerton Road, Guildford,
mediate care needs that include delayed cord clamping), and postoperative (fluid management to
United Kingdom (Dr Fawcett); the Departments prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory
of Anesthesiology and Intensive Care, Alzahra drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic
Hospital, Dubai, United Arab Emirates (Dr compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary
Shalabi); and the Department of Medicine, catheter). Recommendations against the element use were made for preoperative (maternal
University of Alberta, Edmonton, Alberta, sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired ox-
Canada (Dr Gramlich).
ygen), and postoperative (heparin should not be used routinely venous thromboembolism pro-
Received April 19, 2018; revised Aug. 13, 2018; phylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/
accepted Sept. 10, 2018.
processes) are studied, implemented, audited, evaluated, and optimized by the maternity care
The authors report no conflict of interest. teams, this will create an opportunity for the focused and optimized areas of care research with
Corresponding author: R. Douglas Wilson, MD, further enhanced care and recommendation.
MSc. [email protected]
0002-9378/$36.00 Key words: cesarean delivery, enhanced recovery, intraoperative, postoperative, preoper-
ª 2018 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2018.09.015
ative, quality, safety
MONTH 2018 American Journal of Obstetrics & Gynecology 1

Special Report ajog.org
perform a cesarean delivery, and once

AJOG at a Glance the decision is made a process with
Why was this study conducted? evidence-based factors and decreased
This ERAS Society Guideline was created to support the most common surgical variance for enhanced recovery is being
procedure in the industrialized healthcare world, the cesarean delivery. This proposed.
ERAS cesarean delivery guideline has the goal to enhance the quality and safety of
the cesarean delivery for improved maternal and fetal/neonatal outcomes Methods
through evaluation and audit. Literature search
The author group was selected and vet-
Key Findings ted by the ERAS Society Guideline
The broad ERAS cesarean delivery elements and recommendations (Parts 1e3) Committee in May 2017 based on in-
break down the surgical delivery process into a “focused” pathway that starts at ternational expertise in the area, and a
30e60 minutes before skin incision for both scheduled and unscheduled consensus ERAS CDeenhanced recov-
cesarean deliveries until hospital discharge along with a longer “optimized” ery topic list was determined. The
pathway that manages antenatal education, maternal comorbidities, and ERAS Gynecologic/Oncology guide-
immediate neonatal needs after delivery. lines5,6 were used as templates; however,
several other elements unique to cesar-
What does this add to what is known? ean section delivery were added. After
This ERAS Cesarean Delivery Guideline has taken the evidence-based knowledge the topics were agreed on, they were then
that has been created from the cesarean delivery research, has evaluated it criti- allocated among the group according
cally, and, with authorship consensus, has published recommendations for to expertise. The literature search
process-directed maternal care for the pre-, intra-, and postoperative cesarean (1966e2017) used Embase and PubMed
delivery timing in a 3-part guideline with the use of the ERAS Society principles to search medical subject headings that
and process for improved surgical quality and safety for obstetric surgical included “Cesarean Section,” “Cesarean
deliveries that promote enhanced recovery for maternal and neonatal outcomes. Delivery,” “Cesarean Section Delivery,”
and all pre- and intraoperative ERAS
items. Reference lists of all eligible arti-
result in both clinical benefits (re- delivery with, primarily, a maternal cles were crosschecked for other relevant
ductions in length of stay, complications, focus. The “focused” pathway process studies.
and readmissions) and health system for scheduled and unscheduled ERAS
benefits (reduction in cost).1e3 CD has been created, for the complete Study selection
ERAS is a tool for process manage- ERAS CD Guideline (Parts 1e3), from Titles and abstracts were screened by in-
ment, creating a focused care process. decision-to-operate (30e60 minutes dividual reviewers to identify potentially
The use of audit and feedback allows an before skin incision) to hospital relevant articles. Metaanalyses, systematic
implementation process, whereby clini- discharge, which includes the immediate reviews, randomized controlled studies,
cians are provided with comparative data neonatal care. The Appendix (Part 1) has nonrandomized controlled studies, re-
to educate, change, and decrease the additional information that would assist views, and case series were considered for
‘harmful’ clinical variances that are providers with optimizing the maternal each individual topic.
identified in certain high volume clinical antenatal care when comorbidities are
care processes and procedures. This present that may impact maternal and Quality assessment and data analyses
ERAS process will enhance the quality of neonatal heath with additional potential The quality of evidence and recom-
care, patient safety, and health outcomes. operative impact. mendations were evaluated according to
ERAS Guideline for perioperative care As a final introduction comment, Panda the Grading of Recommendations,
in cesarean delivery will provide et al4 researched clinicians’ views of factors Assessment, Development, and Evalua-
evidenced-based practice recommenda- for cesarean delivery using systematic re- tion system,7 as used and described in
tions for preoperative (Part 1), intra- view and metasynthesis of qualitative, previous ERAS Guidelines (Table 1).5e7
operative (Part 2), and postoperative quantitative, and mixed methods. Three Briefly, the following recommendations
(Part 3) phases and allow audit assess- main themes were identified: (1) clinicians’ are given: Strong recommendations
ment and measurement of the desired personal beliefs, (2) healthcare systems indicate that the panel is confident that
outcome. Although certain ERAS prin- (litigation, resources, private vs public in- the desirable effects of adherence to a
ciples have been established for other surance payments, guidelines, manage- recommendation outweigh the undesir-
abdominal/pelvic surgeries,3,4 this pre- ment policy), (3) clinicians’ characteristics able effects. Weak recommendations
sent ERAS Cesarean Delivery (ERAS (personal convenience, clinicians’ de- indicate that the desirable effects
CD) pathway will provide additional mographics, confidence, and skill). of adherence to a recommendation
evidenced-based recommendations for Obstetricians and midwives are probably outweigh the undesirable
the surgical pathway related to cesarean directly involved in the decision to effects, but the panel is less confident.
2 American Journal of Obstetrics & Gynecology MONTH 2018

ajog.org Special Report
Recommendations are based not only on

the quality of evidence (high, moderate, TABLE 1
low, and very low) but also on the bal- Grading of Recommendations, Assessment, Development and Evaluation
ance between desirable and undesirable system for rating quality of evidence5
effects. In some cases strong recom- Rating quality Definition
mendations may be reached from low- Evidence level
quality data and vice versa. The Core High quality Further research is unlikely to change confidence in estimate
ERAS CD Team (A.B.C., G.A.M., S.L.W., of effect
G.N., and R.D.W.) reviewed the evidence
Moderate quality Further research is likely to have important impact on
in detail for each section and assigned confidence in the estimate of effect and may change the
both the recommendation and evidence estimate
level. Discrepancies were resolved by the Low quality impact on Further research is very likely to have important impact on
lead and senior authors. confidence estimate confidence estimate of effect and likely to change the estimate
Recommendations for each ERAS CD
Very low quality Any estimate of effect is very uncertain
element in pre-/intra-/postoperative
(Parts 1e3) have been identified, dis- Recommendation strength
cussed, and agreed upon with the pre- Strong When desirable effects of intervention clearly outweigh the
operative ERAS CD (Part 1) elements undesirable effects or clearly do not
presented in Table 2. Weak When trade-offs are less certain, either because of low quality
evidence or because evidence suggests desirable and
Results undesirable effects are closely balanced
Antenatal and preoperative ERAS CD Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018.
topics (Part 1)
The cesarean delivery pathway and the
process elements have a wider scope for elective cesarean delivery. They identi- is 2 cm.9 No clinical value was found
the maternal antenatal and preoperative- fied 5 clinical protocols with a total of 25 for manual cervical dilation for uterine
natal care and can be considered within clinical components, with 3 (early oral drainage, subcutaneous drains in the
the ERAS CD pathways. intake, mobilization, removal of the wound, or maternal supplemental oxy-
The preoperative pathway is a focused urinary catheter) of the 25 components gen for the reduction of infective
pathway that starts 30e60 minutes present in all 5 protocols. The Appraisal morbidity.9
before the cesarean incision and ends at of Guidelines for Research and Evalua- These systematic reviews, subsequent
maternal (fetal) discharge from hospital, tion II scores were generally low. Sys- other systematic reviews, and meta-
which allows for a more consistent and tematic reviews of single components analyses in the reference lists have been
generalizable ERAS CD process that in- identified a reduced length of stay after used in this ERAS CD Guideline to
cludes the same comprehensive care to cesarean delivery of 0.5e1.5 days with evaluate the present status of the previ-
both unscheduled and scheduled cesar- the use of the studied factors (minimally ous and new clinical care factors for the
ean delivery. invasive Joel-Cohen surgical technique, enhanced quality, safety, and recovery of
An antenatal optimized pathway start early catheter removal, postoperative pregnant women who require a cesarean
from 10e20 weeks of gestational age antibiotic prophylaxis). They concluded delivery.
with a highlighted clinical process for that more ERAS CD research is required
maternity care by a multidisciplinary to evaluate and audit directed pathways Antenatal preadmission information,
team to support preadmission informa- for enhanced recovery.8 education, and counselling (Optimized
tion, education, counselling, and A 2013 systematic review for cesarean Element)
maternal comorbidities (ERAS CD delivery had the objective to provide an Appropriate antenatal care should
Expanded Program). Within the clinical updated evidence-based guide for sur- include preparation of pregnant women
scenario, there are complex maternity gical decisions during the cesarean de- and their partners for delivery, which
patients who may require an unplanned livery.9 Recommendations, with a high includes the possibility of either vaginal
cesarean delivery but may need access to level of certainty for clinical value, were or surgical delivery. Documentation of a
the team-based optimized antenatal care made for preeskin incision prophylactic preadmission information and counsel-
to minimize the operative risks for antibiotics, cephalad-caudad blunt ling process should include when the
themselves and their offspring, if surgery uterine extension, spontaneous placental procedure will occur, the type of pro-
is required. removal, and surgeon preference on cedure, by whom the information was
Corso et al8 undertook a rapid review uterine exteriorization; single layer provided, and a comment on how the
of clinical protocols and an umbrella uterine closure when future fertility is information was accepted or understood
review of systematic reviews that are undesired, and suture closure of the by the patient. Additionally, because
related to enhanced recovery after subcutaneous tissue when the thickness unscheduled or emergent cesarean

TABLE 2
Guidelines for perioperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society
recommendations
Evidence Recommendation
Item Recommendation level grade
Antenatal pathway: OPTIMIZED
Preadmission information, 1. Although high-quality evidence is lacking, good clinical practice Very Strong
education and counselling includes informing the patient about procedures before, during, and Low-Low
(optimized element) after cesarean delivery. The information should be adapted to whether
cesarean delivery is an unscheduled or is a scheduled surgery.
2. Cesarean delivery without medical indication should not be Very Strong
recommended without a solid preadmission evaluation of harms Low-Low
and benefits, both for the mother and her baby.
Preoperative pathway: FOCUSED
Preanesthetic medications 1. Antacids and histamine H2 receptor antagonists should be Low Strong
(focused elements) administered as premedication to reduce the risk from aspiration
pneumonitis.
2. Preoperative sedation should not be used for scheduled cesarean Low Strong
delivery because of the potential for detrimental effects on the
mother and neonate.
Preoperative bowel preparation 1. Oral or mechanical bowel preparation should not be used before High Strong
(focused element) cesarean delivery.
Preoperative fasting 1. Women should be encouraged to drink clear fluids (pulp-free High Strong
(focused element) juice, coffee, or tea without milk) until 2 hours before surgery.
2. A light meal may be eaten up to 6 hours before surgery. High Strong
Preoperative carbohydrate 1. Oral carbohydrate fluid supplementation, 2 hours before cesarean Low Weak
supplementation delivery, may be offered to nondiabetic women.
(focused element)
Appendix: Preoperative maternal 1. Maternal obesity (body mass index, >40 kg/m2) significantly increases High Strong
comorbidity optimization risks of maternal and fetal complications. Optimal gestational weight gain
(optimized elements) management should be used to control their weight during pregnancy.
Surgical complexity requires multidisciplinary planning.
2. Maternal hypertension should be managed during pregnancy because High Strong
maternal chronic hypertension has been found to increase significantly
the incidence of maternal and fetal morbidity and cesarean delivery.
3. Maternal gestational diabetes mellitus has been found to significantly High Strong
increase the risk for maternal and fetal morbidity. Maternal diabetes
should receive timely and effective management during preconception
and pregnancy.
4. Maternal anemia during pregnancy is associated with low birthweight, Moderate Strong
preterm birth, and increases perioperative morbidity and mortality rates.
The cause of the anemia should be identified and corrected.
5. Maternal cigarette smoking is associated with adverse medical and High Strong
reproductive morbidity and should be stopped before or in early
pregnancy.
Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018.
deliveries can occur with very little lead should be provided. The information situation, such as to whether the cesar-
time, it is important to inform all women and recommendations will differ in ean delivery was unscheduled or was a
about the potential need for a cesarean relation to whether there is a clear repeat (indicated/rejected vaginal birth
delivery and the risks, benefits, and medical indication for caesarean delivery after cesarean delivery (VBAC) or not a
alternatives of the procedure. or whether surgery is performed VBAC candidate/not indicated) or pri-
In case of a cesarean delivery, infor- on maternal request. Maternity and mary cesarean delivery.
mation about the procedure before, support providers should also adapt In an unscheduled cesarean delivery,
during, and after the cesarean delivery their communication to the required the informed consent process demands

instructive and reassuring behavior with adapted to whether cesarean delivery is sodium citrate to neutralize gastric acid)
clear and essential information to the an unscheduled or is a scheduled surgery and histamine H2 receptor antagonists
patient or partner presented by the (Evidence Level: Very Low/Recommen- (ranitidine act by inhibiting the secretion
attending surgeon, appropriate level dation Grade: Strong). (2) Cesarean of acid into the stomach decreasing both
obstetrics trainee, and anesthesiologist. delivery without medical indication volume and acidity) was more effective
In this unscheduled situation, a short should not be recommended without a than no intervention and was superior to
description of the indication for the ce- solid preadmission evaluation of risks antacids alone in the prevention of low
sarean delivery, the recommended type and benefits, both for the mother and gastric pH. Although these findings were
of anesthesia, and the surgical informa- her baby. (Evidence Level: Very Low/ for women who had a general anesthetic,
tion related to the procedure and its Recommendations Grade: Strong). they still have some relevance for cesar-
urgency is important. Antenatal optimization of maternal ean delivery, under regional techniques,
When a need for neonatal care of the comorbidities and their impact on a because a proportion of the women may
newborn infant is identified and when cesarean delivery is beyond the scope of require conversion to general anesthesia.
time allows, the pregnant woman and this direct and focused ERAS process/ The preoperative administration of
her partner should have the option to pathway guideline. A limited maternal gabapentin has been found to improve
meet a neonatologist or pediatrician and comorbidity (body mass index, chronic postcesarean delivery pain control in
to visit the neonatal unit before the hypertension, diabetes mellitus, iron some,42,43 but not all,44 studies. How-
cesarean delivery is performed. deficiency anemia) and a pregnancy ever, a systematic review of perioperative
Cesarean delivery without a medical outcome summary are provided in the gabapentin for postoperative pain man-
indication should not be considered Appendix for the interested maternity agement for a variety of different types of
without a comprehensive preadmission providers because these maternal factors surgery found little benefit, with an
evaluation of harms and benefits have perinatal and surgical impact. increased incidence of serious adverse
for both the mother and her baby.10e13 events.45
Information about the increased surgi- Preoperative pathway One study that considered post-
cal risk of short-term complications This focused preoperative 30- to cesarean delivery maternal sedation
(injuries to the abdominal organs, 60-minute time period is very com- (either scheduled or unscheduled cesar-
postoperative infection, thrombosis, and pressed for the women who undergo an ean delivery surgeries)46 reported more
pain)14e17 and the known long-term unscheduled cesarean delivery because sedation (self-reported or observer
effects (risk of uterine rupture and the scheduled cesarean delivery allows assessment) after the unscheduled
placental complications in subsequent for an expanded antenatal/preoperative cesarean delivery surgery. Sedating
pregnancies)18e21 should be compared knowledge translation. medications (fentanyl, midazolam,
with the benefit and risk profile of A checklist for the focused ERAS CD meperidine, ketamine) were given more
vaginal delivery as part of the preopera- will allow for the patient and operative frequently in the unscheduled cesarean
tive counselling. staff to have a summarized version delivery group for management of side-
Short-term outcomes for the of the informed knowledge that the effects and breakthrough pain. It has
infant22e25 and associations to longer patient requires and the overall ERAS been suggested that maternal sedation
term outcomes in childhood21,26e31 CD pre-/intra-/postoperative elements may delay skin-to-skin contact between
should be discussed. In an evaluation (Figure 135e39). Some of the pre- and mother and baby and therefore should
of longer term outcomes that are asso- intraoperative elements will have a be used judiciously.47
ciated with scheduled cesarean delivery, different time sequence, which is There is little published information
it is important to help the pregnant dependent on the individual surgical regarding the use of sedative premed-
woman interpret the relative and abso- team processes, but all elements are ication before cesarean delivery. The
lute risks for different pediatric chronic covered in ERAS CD Parts 1 and 2. administration of benzodiazepines in
disorders in childhood and young pregnancy have been associated with
adulthood that are associated with Preoperative anesthetic medications “floppy baby syndrome,”47,48 disturbed
cesarean delivery and that, although (Focused Element) neonatal thermogenesis,41 and lower
the underlying mechanisms remain to Although rare, aspiration pneumonitis is Apgar scores.48 A Cochrane review of
be explored, causality has not been still a cause of maternal death during sedative premedication for adult outpa-
proved.32e34 anesthesia for a cesarean delivery, even in tient surgery found that there was an
well-resourced countries.40 Interven- impairment in psychomotor function up
Summary and recommendations tions to reduce the risk of aspiration to 3 hours after the operation (total 11
(1) Although high-quality evidence is pneumonitis, at cesarean delivery, have studies: 3/11 no effect; 6/11 some effect;
lacking, good clinical practice includes been considered.41 Although the quality 2/11 significant effect).49 Therefore
informing the patient about procedures of evidence was poor, it was found that considering the potential for maternal
before, during, and after cesarean the preoperative administration of a and neonatal side-effects, preoperative
delivery. The information should be combination of antacids (nonparticulate sedation should be avoided.

leak. However, a recent metaanalysis,50

FIGURE
which included gynecologic surgery
Checklist for focused Enhanced Recovery After Surgery (ERAS) cesarean trials,51 found no benefit of bowel
delivery patient “informed knowledge” preparation. The only clear effect was to
The patient/maternal has a clear understanding of the following factors:
cause a “more unpleasant patient
1. The reason/indication for the cesarean delivery experience.”
2. The location and type of abdominal laparotomy incision There is only 1 small clinical trial of
3. The abdominal skin incision closure technique that is used by the attending mechanical bowel preparation before
surgeon (randomized controlled trial evidence supports subcuticular skin closure cesarean delivery that did not document
for patient satisfaction and cosmetic outcome1) any benefit.52
4. The preventive efforts that are used to minimize postoperative maternal infective
morbidity (wound/uterus/pelvis/bladder); estimated prevalence of 3–15%2,3 Summary and recommendation. Oral or
5. The patient’ s estimated individualized postoperative risk assessment for
mechanical bowel preparation should
thromboembolism and whether additional medical prophylaxis is needed beyond
the standard mechanical techniques (elastic stockings or sequential compression not be used before cesarean delivery
devices); estimated prevalence is 0.5–2.2 per 1000 pregnancies or prevalence of (Evidence Level: High/Recommendation
venous thromboembolism ranges from 1–2 per 1000, with 80% an indication of Grade: Strong).
antepartum deep vein thrombosis and 20–25% an indication of pulmonary
embolism4; pulmonary embolism, 40–60% after delivery5 Preoperative fasting (Focused Element)
6. The gastrointestinal/oral intake plans for pre- and postoperative time periods Preoperative fasting was first described
7. The anticipated postoperative activities and locations of mother and baby as a measure to prevent vomiting after
the use of ether anesthetics. After a
List of ERAS cesarean delivery elements:
Preoperative syndrome of post-operative aspiration
1. Anesthetic medications pneumonia was described, it became
2. Fasting more common to recommend fasting
3. Carbohydrate supplementation periods increase from 6 hours to the
4. Antimicrobial prophylaxis standard “NPO after midnight.”53 A
5. Skin wash/vaginal preparation to minimize infectious risk Cochrane Review concluded that there
6. Procedures for prevention of intraoperative hypothermia was no increase in the volume or
Intraoperative decrease in pH of gastric contents or an
1. Pre- and intraoperative anesthetic management
increase in complications with shorted
2. Abdominal/vaginal antimicrobial cleansing
3. Cesarean delivery surgical techniques (opening-delivery-closure) preoperative fasting intervals.54 The
4. Perioperative fluid management European Society of Anaesthesiology
5. Neonatal immediate care/delayed cord clamping Guideline recommended that adults and
Postoperative children should be encouraged to drink
1. ERAS sham feeding/chewing gum clear fluids up to 2 hours before elective
2. Nausea and vomiting management surgery (including cesarean delivery).
3. Analgesia Solid food should be prohibited for 6
4. Perioperative nutritional care/early feeding
hours before elective surgery in adults
5. Glucose control
6. Thromboembolism prevention and children.55 There have been no
7. Early mobilization “fasting” trials in cesarean delivery pa-
8. Urinary drainage management tients, but 2 trials found similar results in
Maternal and neonate discharge patients immediately after delivery.56,57
Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018. Contemporary perioperative guidelines,
which include cesarean delivery, reflects
these data and this approach.55,58e65
Summary and recommendations. (1) effects on the mother and neonate (Evi- Summary and Recommendations. (1)
Antacids and histamine H2 receptor an- dence Level: Low /Recommendation Women should be encouraged to drink
tagonists should be administered as pre- Grade: Strong). clear fluids (pulp-free juice, coffee, or tea
medication to reduce the risk from without milk) until to 2 hours before
aspiration pneumonitis (Evidence Level: Bowel preparation (Focused Element) surgery (Evidence Level: High/Recom-
Low/Recommendation Grade: Strong). Preoperative oral and/or mechanical mendation Grade: Strong). (2) A light
(2) Preoperative sedation should not be bowel preparation has been used pri- meal may be eaten up to 6 hours before
used for scheduled cesarean delivery marily in colorectal surgery to prevent surgery (Evidence Level: High/Recom-
because of the potential for detrimental postoperative infection and anastomotic mendation Grade: Strong).

Preoperative carbohydrate supplementa-

tion (Focused Element) TABLE 3
There have been multiple trials of oral Enhanced Recovery After Surgery (ERAS) for cesarean delivery
carbohydrate supplementation use up to preoperative modifiable clinical factors
2 hours before surgery. A Cochrane Re- Nonmodifiable clinical factor Modifiable clinical factors/audit
view found most trials had a high risk of Maternal age
bias and that treatment was associated
Paternal age
with only a small reduction in the length
of stay (0.3 days) and a decreased time to History (obstetrics/medical/ Optimization of selected comorbidities
surgery/body mass index) (hypertension/diabetes mellitus/anemia/smoking)
passage of flatus (0.39 days). Overall, (small for gestational age/large for gestational age/
postoperative complications were not stillbirth/preterm birth <34 weeks gestation)
changed, and there were no reported
Family history (genetics/birth Surgical pathway (preoperative;
cases of aspiration pneumonia.66 defects/multifactorial disease) intraoperative; postoperative)
Patient outcomes may be improved by
Gestational weeks 0e20
a shorter fasting period preceded by pre- (chromosomes/birth defects/
scribed carbohydrate intake. Postoperative miscarriage)
insulin is preserved by carbohydrate Caughey. ERAS for cesarean delivery. Am J Obstet Gynecol 2018.
drinks (100 g the night before surgery and
50 g 2 hours before surgery/intravenous
glucose 5 mg/k/min).67 Metaanalysis of
low-to-moderate quality and small clinical childbirth, and the most common sur- forceps or vacuum delivery, 3%); repeat
trials indicate more evidence is required to gery is a cesarean delivery. With this indications (no VBAC attempt, 82; failed
establish benefit.68,69 clinical volume of obstetric surgical ac- VBAC attempt, 17%; failed forceps or
The use of carbohydrate loading, tivity, it seems appropriate that the ERAS vacuum delivery, 0.4%).
preoperatively, is controversial and un- process be applied to this surgical care Cesarean delivery has associated risk
accepted for pregnant women with dia- area because there are always 2 patients and benefit profiles for both processes
betes mellitus. The preoperative use of (mother and fetus[es]) impacted. of unscheduled or scheduled surgery.
carbohydrate loading in the nonpreg- There are quality, industry-based Complications that are associated with
nant patient with diabetes mellitus “Deming Principles” that can be unscheduled (emergency) care and the
was evaluated in a prospective, non- directed toward healthcare process man- time from decision to incision have been
inferiority cohort; preoperative carbo- agement72: quality improvement is the evaluated.75 The maternal and neonatal
hydrate loading was found to be science of process management; if you outcomes were compared for decision to
noninferior to fasting, and neither group cannot measure it, you cannot improve it; incision of <30 minutes (1814 patients)
showed superiority for preoperative managed care means managing the pro- and >30 minutes (994 patients). The
blood glucose concentration, hypergly- cesses of care (not the human resources of adverse maternal outcomes for decision
cemia, or length of stay.70 care); getting the right data in the right to incision of <30 minutes compared
Several clinical trials have evaluated format at the right time in the right with >30 minutes were endometritis
carbohydrate supplementation or feed- hands; and engaging the human health- (11.7%; 13.0%), wound complication
ing in labor to improve labor outcomes. care resources (physicians, nurses, and (1.3%; 0.9%), and operative injury
Although ineffective for this purpose, other allied health professionals). Certain (0.3%; 0.5%), respectively, in the later
the practice appears safe.71 There are no significant pregnancy-related factors can timed cohort. The adverse neonatal
trials of oral carbohydrate supplemen- be measured but cannot be modified outcomes were 5-minute APGAR 3
tation before cesarean delivery for (Table 3). (1.0%; 0.9%), umbilical artery pH <7.0
either pregnant diabetic or nondiabetic The frequency of a cesarean delivery (4.8%; 1.6%), hypoxic ischemic en-
women. has increased from 4.5% in 1970 to cephalopathy (0.7%; 0.5%), fetal death
31.9% in 2015 in the United States. In in labor (0.2%; 0%), and neonatal death
Summary and recommendation. Oral response to this increasing surgical ac- with no malformation (0.4%; 0.1%) and
carbohydrate fluid supplementation, 2 tivity, process change has been initiated, with malformations (0.4%; 0.3%),
hours before cesarean delivery, may be but the clinical care goals have not been respectively. Hypoxic ischemic enceph-
offered to nondiabetic pregnant women achieved.73 alopathy was the only significant
(Evidence Level: Low/Recommendation The indications for a cesarean delivery comparison (P¼.001) against the <30-
Grade: Weak). were summarized by the Maternal Fetal minute delivery group.
Medicine Unit Network74: primary in- Complications associated with preg-
Comment dications (dystocia, 37%; nonreassuring nancy outcomes after a scheduled low-
In North America, the most common fetal heart rate, 25%; abnormal fetal risk cesarean delivery (46,766 patients)
indication to be admitted to hospital is presentation, 20%; other, 15%; failed and planned vaginal birth (2,292,420

patients) have been reported.76 The surgical process and activity measure- patient outcomes. Gynecol Oncol 2018;15:
overall maternal morbidity (cesarean ments of the services provided (Surgical 117–23.
4. Panda S, Begley C, Daly D. Clinicians’ views
delivery, 2.23%; vaginal birth, 0.9%) was Safety Checklist/ERAS/National Surgical of factors influencing decision-making for
not significant for all comparisons.76 Quality Improvement Program), the caesarean section: a systematic review and
Other investigators have reported a identification and removal of unjustified metasynthesis of qualitative, quantitative and
2-fold increase for cesarean delivery with system- and human-based variance, mixed methods studies. PLoS ONE 2018;13:
an increased morbidity outcome as the team building practice (simulation), and e0200941.
5. Nelson G, Altman A, Nick A, et al. Guidelines
result of puerperal infection, hemor- the introduction of new training ap- for pre- and intraoperative care in gynecologic/
rhage, and thromboembolism.77,78 proaches and oversight. oncology surgery: enhanced recovery after
Comparisons of multiple repeat ce- The ERAS CD Guideline/Pathway surgery (ERAS) society recommendations e
sarean deliveries has shown that, after (Part 1) has initiated a Focused Pathway part I. Gynecol Oncol 2016;140:313–22.
the second repeat cesarean delivery, there (for scheduled and unscheduled surgery 6. Nelson G, Altman A, Nick A, et al. Guidelines
for postoperative care in gynecologic/oncology
is an increasing risk for wound and starting from 30e60 minutes before skin surgery: enhanced recovery after surgery
uterine hematoma (4e6%), placenta incision to maternal discharge) with 4 (ERAS) society recommendations e part II.
previa (1e2%), red cell transfusions focused preoperative elements with 6 Gynecol Oncol 2016;140:323–32.
(1e4%), hysterectomy (0.5e4%), and recommendations: 3 recommendations 7. Guyatt GH, Oxman AD, Vist GE, et al.
placenta accrete (0.25e3%).79 are strong for their use, antacids and GRADE: an emerging consensus on rating
quality of evidence and strength of recommen-
Initiatives to reduce the frequency of histamine H2 receptor antagonists, fast- dations. BMJ 2008;336:924–6.
cesarean delivery and enhance maternal ing only 2 hours, and small meal within 6 8. Corso E, Hind D, Beever D, et al. Enhanced
safety have been proposed.80 hours before surgery; 2 recommenda- recovery after elective caesarean: a rapid review
The focused ERAS CD pathway (Parts tions against their use, maternal sedation, of clinical protocols, and an umbrella review of
1e3) will summarize the evidenced- and bowel preparation, and 1 recom- systematic reviews. BMC Pregnancy Childbirth
2017;17:91–101.
based preoperative, intraoperative, and mendation for antenatal optimized 9. Dahlke JD, Mendez-Figueroa H, Rouse DJ,
postoperative clinical care processes. element (2 strong recommendations for Berghella V, Baxter JK, Chauhan SP. Evidence-
The ERAS CD (Part 1) Antenatal/Pre- use; Table 2). based surgery for cesarean delivery: an updated
operative recommendations with the This 3-part ERAS CD Guideline/ systematic review. Am J Obstet Gynecol
level of evidence and the recommenda- Pathway will follow with intraoperative 2013;209:294–306.
10. Bettes BA, Coleman VH, Zinberg S, et al.
tion grade are summarized in Table 2. (Part 2) and optimized immediate Cesarean delivery on maternal request: obste-
Each of the elements or processes within neonatal care elements and post- trician-gynecologists’ knowledge, perception,
the focused ERAS CD pathway has operative (Part 3) to maternal discharge. and practice patterns. Obstet Gynecol
the opportunity to be measured, The maternity clinical care process has 2007;109:57–66.
compared between services/providers, both normal and complex pathways that 11. Dodd JM, Crowther CA, Grivell RM,
Deussen AR. Elective repeat caesarean section
and improved as required. The opti- are dependent on the patient’s a priori versus induction of labour for women with a
mized ERAS CD elements have a broad obstetric risk, but there are increasing previous caesarean birth. Cochrane Database
antenatal clinical scope that add risk management factors for the Syst Rev 2017;7:CD004906.
complexity, but the management of the maternal and fetal patient that are related 12. Khunpradit S, Tavender E, Lumbiganon P,
comorbid maternal factors should be to obstetric comorbid medical, genetic, Laopaiboon M, Wasiak J, Gruen RL. Non-clinical
interventions for reducing unnecessary
considered for enhanced outcomes. surgical, and lifestyle factors. More caesarean section. Cochrane Database Syst
Quality and safety elements to prospective and quality assessment/ Rev 2011;6:CD005528.
consider, for the creation of a clinical improvement research, evaluation, 13. Lavender T, Hofmeyr GJ, Neilson JP,
audit tool, require that81 (1) the audited audit, and collaboration will be required Kingdon C, Gyte GM. Caesarean section for
pathway has an important impact in for enhancement of the maternal and non-medical reasons at term. Cochrane Data-
base Syst Rev 2012;3:CD004660.
terms of costs, resources, or risk, (2) fetal health outcomes, quality, and 14. Blondon M, Casini A, Hoppe KK, Boehlen F,
strong scientific evidence is available, safety. - Righini M, Smith NL. Risks of venous thrombo-
and (3) improvements to be made on the embolism after cesarean sections: a meta-
topic in question can be evaluated easily analysis. Chest 2016;150:572–96.
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Appendix: Early Recovery After preferred; abdominal skin/pannus adverse fetal complications, such as in-
Surgery (ERAS) cesarean delivery preparation with chlorhexidine wash trauterine growth restriction, low birth-
(CD): Part 1 Pathway and [day of the scheduled cesarean delivery] weight, preterm delivery, and neonatal
Appendix Table 1 and no shaving), (2) intraoperative care respiratory distress syndrome.30 Appro-
ERAS CD: antenatal optimization (review of plan for pannus management priate management of maternal chronic
(Optimized Element) and operative field draping; wound care: hypertension during pregnancy can
Preoperative medical optimization is intravenous antibiotic prophylaxis with improve the clinical outcome, reduce the
an important clinical goal for better higher dosing; no manual removal of the complications, and decrease cesarean
surgical outcomes and requires multi- placenta; intraabdominal uterine delivery rate.25,30,31
disciplinary team-based care. This ERAS closure; closure of subcutaneous layer In pregnancy, the goal of antihyper-
CD optimization is directed at women >2 cm; minimize creation of dead space tensive treatment includes the preven-
who are pregnant with a comorbidity with surgical technique; consider the use tion of severe hypertension and the
and is not directed at preconception an absorbable suture for skin closure; do possibility of prolonging gestation to
care. Evidence supports that modifiable not use wound drains), and (3) post- allow the fetus more time to mature
clinical factors for the pregnant woman operative care (enhanced postpartum before delivery. Treatment of mild-to-
could include body mass index (obesity), follow up for wound assessment). moderate hypertension (systolic blood
preexisting hypertension, preexisting New guidelines for the prevention, pressure 140e169 mm Hg/diastolic
diabetes mellitus, and anemia.1,2 detection, evaluation, and management blood pressure 90e109 mm Hg) has
Pregnancy-associated hypertension and of high blood pressure in adults provide reduced the progression to severe hy-
diabetes mellitus require optimization guidance for women with preexisting pertension by 50% compared with pla-
after diagnosis that is based on severity hypertension during pregnancy.23,24 cebo but has not been shown to prevent
and gestational age. Although preexist- First-trimester screening for pre- preeclampsia, preterm birth, small for
ing obesity (body mass index >40 kg/m2 eclampsia is not considered in this ERAS gestational age, or infant death. Beta-
prevalence of 7%) impacts clinical out- CD optimization. blockers and calcium channel blockers
comes, it is very difficult to modify once Classification of blood pressure in appear superior to alpha-methyldopa for
pregnant.1 adults requires the following values25: the prevention of preeclampsia.31
A systematic review (22 review arti- Normal: systolic pressure <120 mm Women with hypertension who become
cles, 624 studies) reported that maternal Hg/diastolic pressure <80 mm Hg; pregnant should be transitioned to
obesity significantly increased the inci- Elevated: systolic pressure range methyldopa, nifedipine, or labetalol
dence of gestational diabetes mellitus 120e128mm Hg/diastolic pressure <80 during pregnancy.32 Women with hy-
(GDM), hypertension, preeclampsia, mm Hg; pertension who become pregnant should
depression, cesarean delivery, and Hypertension: stage 1 systolic not be treated with angiotensin-
infection.10 In addition, the study 130e139 mm Hg/diastolic 80e89 mm converting enzyme inhibitors, angio-
demonstrated that maternal obesity Hg; stage 2 systolic 140 mm Hg/dia- tensin II receptor blockers, or direct
increased the risk of fetal complications stolic 90 mm Hg. renin inhibitors because they are
such as preterm birth, congenital Maternal chronic hypertension is a fetotoxic.31
anomalies, neonatal macrosomia, and common comorbidity during preg- The 2013 American College of Ob-
perinatal death.10 Optimal gestational nancy.26 A systemic review and meta- stetricians and Gynecologists (ACOG)
weight gain should be based on the analysis (55 studies; 795,221 patients) Task Force on Hypertension in Preg-
prepregnancy maternal body mass index reported that chronic hypertension nancy recommends systolic 120e160
to enhance pregnancy outcomes.11e13 significantly increased the incidence of mm Hg/diastolic 80e105 mm Hg for
Surgical complexity for cesarean de- preeclampsia, cesarean section delivery, pregnant women with chronic hyper-
livery is present for women with a body fetal growth restriction, preterm de- tension as the optimal blood pressure
mass index >40 kg/m2 14e22: (1) pre- livery, neonatal unit admission, and target.24 Blood pressure values of systolic
operative care (identification of an perinatal death.27 Twenty-five percent of 150e160 mm Hg/diastolic 100e110
appropriate operating room table with women with chronic hypertension will mm Hg should be treated.24 Drug choice
air mattress, lift device, wheel chair, and experience superimposed preeclamp- of antihypertensive medications in hy-
toilet; adequate human resource plan- sia,28 which will further increase the risk pertensive pregnant women is limited
ning [medical and nursing staffing]; of the development of serious maternal to those medications that have been
abdominal incision planning based on problems, such as kidney failure, liver proved relatively safe and that have a
the primary obesity location and the failure, abnormalities of the clotting long history of clinical use in pregnancy
relationship to the position of the uterus/ system, and stroke.29 Preeclampsia with acceptable side-effects (such as
lower uterine segment/fetal position; (caused by chronic or pregnancy-related labetalol, nifedipine, methyldopa, and
transverse abdominal wall incision is hypertension) increases the risk of hydralazine).28,29 There are insufficient
MONTH 2018 American Journal of Obstetrics & Gynecology 10.e1

data regarding the best regimen to treat glucose values at fasting [<95 mg/dL]/1 delivery, and admission to the neonatal
hypertension in pregnancy because of hour [<191 mg/dL]/2 hours [<160 mg/ intensive care unit.44
the lack of adequately powered, ran- dL]; National Diabetes Data Group Optimization of maternal diabetic
domized trials.29 100-g load with normal plasma glucose glycemic control in pregnant women
Diabetes mellitus during pregnancy values at fasting [<105 mg/dL]/1 hour decreases the risk of preeclampsia, fetal
comprises both preexisting diabetes [<190 mg/dL]/2 hours [<165 mg/dL]/3 macrosomia, shoulder dystocia, and ce-
mellitus (type 1 or type 2) and GDM that hours (<145 mg/dL]).40,41 sarean delivery.43
was first diagnosed during pregnancy The new IADPSG criteria oral glucose Multidisciplinary team care can opti-
(typically at 24e28 weeks of gestation tolerance test increases the prevalence of mize maintenance of euglycemia,45 but
after GDM screening).33e35 Women with GDM to 19.6% from the Australasian optimal glycemic targets have not been
preexisting diabetes mellitus or GDM are Diabetes in Pregnancy Society oral identified by controlled trials.40
at an increased risk for maternal and fetal glucose tolerance test rate of 9.8%.42 The WHO has reported that globally
complications (type 1 and 2 GDM).33e35 Glycemic targets in pregnancy (ADA; 38.2% of pregnant women are anemic
Poorly controlled diabetes mellitus in ACOG)39,40 are similar for both preex- with the use of the WHO redefined
pregnancy increases the risk of sponta- isting diabetes mellitus and GDM definition of hemoglobin levels <11.0 g
neous abortion, fetal anomalies, pre- (>24e28 weeks of gestation) with fast- %.46,47 Iron deficiency anemia accoun-
eclampsia, fetal death, macrosomia ing and either 1- or 2-hour postprandial ted for most maternal anemia cases. The
and neonatal hyperglycemia, and/or testing (preprandial testing for preexist- National Health Service Blood Trans-
hyperbilirubinemia.34e37 A matched ing diabetes mellitus with insulin pumps fusion Committee Guidelines supports
control study with 2775 patients reported and basal-bolus therapy is considered): the use of preoperative screening for
that untreated GDM carried significant (1) fasting <95 mg/dL (<5.3 mmol/L), maternal anemia.47 Iron deficiency and
risks for perinatal morbidity and death (2) 1-hour postprandial <140 mg/dL any underlying disorder should be
(stillbirth, neonatal macrosomia, (<7.8 mmol/L), (3) 2 postprandial <120 identified and corrected by oral supple-
neonatal hypoglycemia, erythrocytosis, mg/dL (<6.7 mmol/L). mentation or parenteral intravenous
and hyperbilirubinemia).38 Hemoglobin A1C level should only be iron if the disorder is unresponsive to
The American Diabetes Association used as a secondary measure of glycemic oral therapy before any scheduled
“Management of Diabetes in Preg- control in pregnancy.39 surgery.48,49
nancy”39 and the revised ACOG Practice GDM management starts with life- Maternal anemia during pregnancy is
Bulletin on Gestational Diabetes Melli- style management (medical nutrition, associated with low neonatal birthweight
tus40 have new recommendations for physical activity, weight management) that affects 25% of newborn infants
diabetic management in pregnancy. with the use of the glycemic targets listed (adjusted odds ratio, 1.23; 95% confi-
There are a variety of glucose chal- earlier. This approach has a 70e85% dence interval, 1.06e1.43)50,51 and pre-
lenge test screening tools that are used success rate for the American Diabetes term birth.51 Risk of maternal death is
internationally at 24e28 weeks of Association criteria but lower success for associated with severe anemia in preg-
gestation.41 There are 2-step and 1-step the IADPSG criteria.39 nancy and the postpartum period
protocols recommended, and their use If unable to meet the glycemic targets, (adjusted odds ratio, 2.36; 95% confi-
tends to be regional or country directed. pharmacologic therapy will require the dence interval, 1.60e3.48; propensity
The World Health Organization (WHO) use of medication with insulin as the score analysis [conditional probability]
and the International Association of the preferred choice because both metfor- adjusted odds ratio, 1.86; 95% confidence
Diabetes and Pregnancy Study Groups min (greater transfer/less neonatal hy- interval, 1.39e2.49).52 There was a linear
(IADPSG) recommend a 1-step screen poglycemia) and glyburide (higher relationship between maternal anemia
(with the use of a 75-g glucose load with neonatal hypoglycemia and macro- and death; with each 10 g/L increase in
normal plasma glucose measurements of somia) cross the placenta.39 maternal hemoglobin, there was a 29%
fasting [92e125 mg/dL]/1 hour [<180 A randomized, controlled trial (948 reduction in maternal mortality rate
mg/dL]/2 hour [WHO 153e199 mg/dL; patients) demonstrated that women who (odds ratio, 0.71; 95% confidence inter-
IADSPG <153 mg/dL]). The 2-step were treated for GDM reduced the risks val, 0.60e0.85).53 In addition, preopera-
approach initially uses a primary 50-g of fetal overgrowth, shoulder dystocia, tive anemia increased the perioperative
glucose load (with no fasting required) cesarean delivery, and hypertensive dis- morbidity and mortality rates.54
with a 1-hour normal plasma glucose of orders.43 Another metaanalysis (42 tri- Clinical evidence has demonstrated
<135 mg/dL. If levels are normal, no als) showed that a combination of the relationship between smoking and
further testing is recommended; how- treatments that start with dietary modi- adverse reproductive outcomes.32,55e58
ever, when the plasma glucose is fication, exercise, glucose monitoring, The United States Surgeon General’s
elevated, a 75- or 100-g glucose challenge and pharmacologic treatments reduced report demonstrated that there is a
test is required (American Diabetic As- the risks of neonatal hypoglycemia, strong association between smoking
sociation 75-g load with normal plasma macrosomia, preeclampsia, cesarean during pregnancy and fetal growth
10.e2 American Journal of Obstetrics & Gynecology MONTH 2018

restriction/low birthweight, preterm 16. Satpathy HK, Fleming A, Frey D,

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10.e4 American Journal of Obstetrics & Gynecology MONTH 2018

APPENDIX TABLE
Summary of maternal and fetal adverse events for maternal obesity body mass index >40 kg/m2
Odds ratio for adverse maternal outcomes associated with body Odds ratio for adverse fetal outcomes for maternal
mass index >35 kg/m2a obesityb
Adverse outcome Odds ratio Fetal outcome Odds ratio
Gestational diabetes mellitus 4.0 (3.1e5.2) NTD 1.87 (1.62e2.15)
Gestational hypertension 3.2 (2.6e4.0) CL/P 1.20 (1.03e1.40)
Preeclampsia 3.3 (2.4e4.5) Hydrocephalus 1.68 (1.19e2.36)
Operative vaginal delivery 1.7 (1.2e2.2) Limb reduction 1.34 (91.03e1.73)
Fetal macrosomia >4500 g 2.4 (1.5e3.8) Cardiac 1.30 (1.12e1.51)
IUFD 3.90 (2.44e6.22)
CL/P, cleft lip/palate; IUFD, intrauterine fetal death; NTD, neutral tube defect.
a
Data from75; b data from76. United States data indicate that 8% of all reproductive age women have a body mass index of >40 kg/m2.75 Maternal obesity and associated fetal risks would include
congenital anomalies, stillbirth, macrosomia, and long-term implications such as childhood obesity and type II diabetes mellitus. Fetal anomalies will impact the providers, counselling, and
planning.76
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Special Report ajog.

Guidelines for Antenatal and Preoperative care

E nhanced Recovery After Surgery

MONTH 2018 American Journal of Obstetrics & Gynecology 1

perform a cesarean delivery, and once

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Recommendations are based not only on

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leak. However, a recent metaanalysis,50

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Preoperative carbohydrate supplementa-

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10 American Journal of Obstetrics & Gynecology MONTH 2018

MONTH 2018 American Journal of Obstetrics & Gynecology 10.e1

10.e2 American Journal of Obstetrics & Gynecology MONTH 2018

restriction/low birthweight, preterm 16. Satpathy HK, Fleming A, Frey D,

MONTH 2018 American Journal of Obstetrics & Gynecology 10.e3

10.e4 American Journal of Obstetrics & Gynecology MONTH 2018

MONTH 2018 American Journal of Obstetrics & Gynecology 10.e5

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