Over the last decade, there has been a massive shift in how we care for patients following surgery with hospitals trialling and implementing Enhanced Recovery After Surgery (ERAS) programs.
The main goal of ERAS programs has been to shorten the time a patient spends in hospital post-surgery. Partly because, as we all know, healthcare resources are limited. Shorter stays allow for more patients to move through the system (which then relieves the load on hospital surgery waiting lists). But the benefits are not limited to the hospital system. Patient outcomes and patient experience have also been shown to improve significantly when they are able to get home sooner.
ERAS programs originated in colorectal surgery with a basis in optimizing pain control, nutrition, fluids and mobility. They are now being shown to be very effective in improving the patient outcome and experience in women who’ve undergone a caesarean section.
To understand the benefits of an ERAS program for caesarean sections, let’s contrast the experiences of two women: Mary and Melissa.
Mary had her baby via caesarean 10 years ago. During the procedure, Mary had a combined spinal block and an epidural. When she returned to the ward after theatre, she had tubes everywhere: IV fluids, a catheter and a pump attached to her epidural. Mary was not allowed to have anything to eat until her bowels started working and was only allowed sips of water. She was bedbound and uncomfortable for the first 24 hours and struggled to hold her baby due to all the tubes. Her partner had to bring her baby to her for feeding and she was still in her hospital gown while greeting visitors on that first day. When she did start walking on day two, her pain levels were high and she was reliant on the midwife to administer her pain medication. By the time that medication arrived, her pain levels had gone from ‘high’ to ‘significant’ and required stronger pain relief which left her feeling light-headed and unable to get up to attend her baby. When her baby became unsettled, she needed to call the midwife or her partner for help. By day three she was still in pain, was struggling with feeding and was suffering from constipation that made her abdominal pain worse.
Contrast Mary’s experience with that of Melissa who had a caesarean more recently.
Melissa’s anaesthetist spoke with her ahead of her caesarean about pain expectations and told her she would commence regular, self-administered oral analgesia immediately following delivery. After her birth, Melissa returned to the maternity ward with only two tubes: IV fluids and a catheter. She was allowed to drink straight away and as she was not feeling sick, the IV fluids were stopped immediately. As the anaesthetic started to wear off, Melissa was helped to walk around, her catheter was removed, and she was able to have a shower and change into her own clothes before meeting visitors as they arrived that afternoon. Because Melissa was in charge of her pain relief and was vigilant about not letting pain levels get too high before self-administering that pain relief, her pain was manageable and the levels of medication she was taking did not affect her ability to function. This allowed Melissa to hold and comfort her baby when needed and while she had difficulties with feeding, her midwife was able to dedicate time to helping and guiding her with feeding around this as her time wasn’t taken up supporting Melissa with her pain or comfort levels. By day three, Melissa’s pain was well-controlled, she was mobilising well, she was independent and able to dedicate energy to establishing breastfeeding and bonding with her baby.
As you can see, taking an ERAS approach to recovery after caesarean doesn’t just lead to better outcomes for the mother, it leads to better outcomes for the baby too as both the mother and the midwives supporting her are able to dedicate more time to mother-crafting (lactation and maternal attachment) in those first three days.
So, what does an ERAS program after caesarean section look like? In the ideal world it would have five components:
- An education program delivered by the multi-disciplinary team – based on explaining the components on the ERAS program. It should also focus on optimising the patient’s health prior to the caesarean section – including an exercise program during pregnancy and maintenance of weight.
- Adequate pain relief. The basis of pain relief during caesarean is a single shot spinal analgesia, with the use of either morphine or fentanyl. On returning to the ward, the patient should receive multi-modal analgesia – with the patient being able to give themselves the medication (self- medication program). The use of a self-medication program has been shown to lead to timely administration of analgesia. (As a reminder: delays lead to inadequate analgesia, increased pain scores and increased use of opioid analgesia.) The use of self-medication programs has been shown to reduce pain scores, increase both patient and midwife satisfaction and lead to decreased overall use of opioid analgesia.
- Early mobilisation. Early mobilisation is an important part of recovery, with patients being encouraged to mobilise once the local anaesthetic effects of the spinal have worn off, with mobilisation occurring between 6 and 12 hours post caesarean section.
- Early reintroduction of nutrition is important and leads to earlier recovery
- Early removal of catheter – with the aim of removing the catheter at 2 hours rather than the traditional 12-24 hours. The early removal of the urinary catheter has been associated with reduced mobilisation time, reduced hospital stay and decreased incidence of urinary frequency. With appropriate bladder management, there were was no significant increase in either bacteria or urinary retention.
While individual components of an ERAS program are in place in many institutions, the evidence is clear that we should be investing in the development of a more consistent approach to optimising the management of women after caesarean sections. With improvement in the care that we offer, we have the potential to significantly improve patient satisfaction and early postnatal outcomes.