Enhanced recovery (ER), otherwise called ‘fast-track’ surgery, is a relatively recent approach to perioperative patient management that is now being applied in obstetric practice. The aim is to facilitate patient recovery and expedite discharge, thereby reducing morbidity and improving outcomes while lessening the strain on healthcare systems. The practice is in congruence with the National Institute for Health and Care Excellence (NICE) recommendations on the management of women for caesarean section (see Chapter 33, Caesarean section), which state that women who have an uncomplicated postoperative course may get discharged 24 hours after the procedure.
A successful ER pathway in obstetrics requires collaboration between multiple teams - including the pregnant woman - and the existence of clear protocols to guide perioperative management. The initial phase begins with the antenatal screening of women to enable the selection of appropriate candidates and the identification and optimisation of factors that may delay recovery and hinder early discharge, such as preoperative anaemia. Involvement and education of patients at this stage play a vital role, as they tackle issues that may generate potential delays in leaving hospital, such as difficulty with breastfeeding. Psychological preparedness may also drive the woman’s enthusiasm to quicken her recovery.
The goal in the perioperative period is to reduce the burden associated with anaesthesia and surgery and enable the restoration of normal function as soon as possible. This may be accomplished by addressing modifiable factors that may cause physiological derangements such as dehydration, hypothermia, nausea and vomiting. Preoperative fasting time may be reduced by allowing the mother to drink clear fluids up to 2 hours before surgery. Simple intraoperative measures such as warming, temperature monitoring and routine prophylactic antiemesis should be employed. Postoperatively, oral intake maybe resumed as soon as is feasible. Effective analgesia may be achieved by the intraoperative use of neuraxial opioids in combination with postoperative multimodal analgesia, which - along with early removal of the indwelling urinary catheter - may enable the patient to mobilise sooner.
Enhanced recovery is thought to confer several benefits that extend to the mother, infant, and medical organisations. In addition to the clinical gains, the accelerated return to normalcy may facilitate bonding between the mother and neonate by allowing early skin- to-skin contact and initiation of breastfeeding. The reduction in the length of hospital stay can contribute to a significant reduction in expenditure and consumption of healthcare resources, although it is believed that this may be limited to some extent by the increased need for post-discharge care in the community.
While not yet a nationally implemented protocol, ER continues to be adopted by an increasing number of maternity units in the UK. Some organisational barriers to its widespread uptake still exist, however: for instance, the need for dedicated elective caesarean lists and the implications for human and financial resources, and the need for a robust system to ensure that follow-up and postoperative care are achieved to a high standard.
Key points
• Enhanced recovery is a collaborative effort that aims to reduce the length of hospital stay after caesarean section and subsequently improve patient outcomes.
• Patient selection and education are key to successful implementation.
Further reading
Corso E, Hind D, Beever D, et al Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella of systematic reviews. BMC Pregnancy Childbirth 2017; 17: 91.
Laronche A, Popescu L, Benhamou D. An enhanced recovery programme after caesarean delivery increases maternal satisfaction and improves maternal-neonatal bonding: a case control study. Eur J Obstet Gynecol Reprod Biol 2017; 210: 212-16.
Lucas DN, Gough KL. Enhanced recovery in obstetrics: a new frontier? Int J Obstet Anesth 2013; 22: 92-5.
Wrench IJ, Allison A, Galimberti A, Radley S, Wilson MJ. Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience. Int J Obstet Anesth 2015; 24: 124-30.