Implementing an enhanced recovery after surgery program for cesarean delivery is associated with reduced length of stay, cost of care, and opioid analgesia use.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols are mechanisms for obtaining value-based improvements in surgery and they have become embedded within multiple surgical disciplines including colorectal, urological, gynecological, and hepatobiliary surgery. ERAS has been shown to result in both clinical and health system benefits1. The objective of this study is to evaluate the effect of such a program on opioid use in cesarean sections (CS) at a community teaching hospital. METHODS: The ERAS pathway was applied to all patients undergoing CS since its implementation. 98% of patients received transversus abdominis plane (TAP) blocks in the immediate postoperative period. All patients were started on scheduled multimodal analgesia with a combination of ibuprofen, acetaminophen, and dextromethorphan until discharge. Patients whose pain was not well controlled with the above regimen were given opioids for pain control. A retrospective review of patients undergoing CS after the implementation of the ERAS pathway (January 2019-current) was performed. The number of opioid units utilized, as well as mean morphine equivalents were compared to a historical patient cohort (January 2018 – June 2018). RESULTS: An historical cohort of patients (n = 2109) was compared to patients in the ERAS pathway (n = 1463). Patients that were admitted to the hospital > 3 days prior to cesarean section were excluded in an effort to remove antepartum cases (n = 110). Planned CS were designated as those that were scheduled prior to patient check-in to hospital. There was no difference in age, race or body mass index (BMI). There was a significant difference in average length of stay in days between the two cohorts (3.19 vs 2.63, p<0.001). There was also a significant difference in average direct cost in dollars (4290 vs 3957, p < 0.001). The number of patients requiring opioids was also significantly reduced (1766 vs 341, p<0.001). There were 8082 opioid units utilized prior to the implementation of the ERAS pathway whereas 803 opioid units have been utilized since the advent of ERAS for CS. CONCLUSIONS: Post-operative pain control can be achieved in a majority of patients undergoing CS without routine use of opioids in a standardized ERAS pathway.

influenced the conclusions. Given the constituents of the metaanalysis, it is certainly difficult for obstetricians to have a clear view. Looking at the study data, all trends of obstetrical outcomes indeed favor delayed pushing although differences are no longer significant. Given the increased risk of chorioamnionitis (and the absence of effect on the rate of spontaneous delivery), it seems likely that obstetricians would modify their practice and use more frequently early pushing at the start of the second stage. I suspect however that given the "grey zone" results seen here, obstetricians will not frankly adopt this attitude and will continue using delayed pushing, at least for specific cases and particularly in patients with the fetus positioned at a high station.What does this mean for anesthesiologists and is there any consequence for our practice? The simple answer is no as in all cases, the anesthesiologist working in obstetrics has the duty to provide effective analgesia, all along the duration of labor, whatever the underlying obstetrical management. It is however common to observe that patients who are receiving neuraxial analgesia do not feel any urge to push. This means that pushing must then be directed by the obstetrician or the midwife.