The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Abstract

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS.Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software.Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD −7.47 h, 95% CI: −8.36 to −6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: −1.23, 95% CI: −1.32 to −1.15, p < 0.00001), opioid use (SMD: −0.46, 95% CI: −0.58 to −0.34, p < 0.00001), and hospital cost (SMD:−0.54, 95% CI: −0.63 to −0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62).Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

ERACS Method as a Solution to Allow Hospital and Patient Financing

“…In addition, there is also evidence to suggest that discharge the first day or two appears to be safe and acceptable in low-risk patients undergoing cesarean delivery. In the future, ongoing evaluation of maternal outcomes, and neonatal factors [20].…”

Measuring enhanced recovery in obstetrics: a narrative review

“…Three studies 14 , 15 , 19 from the Sultan et al meta-analytic study were not included, and an RCT published in Chinese (without a full English translation), involving 572 women, was added. 24 Meng at al 46 also found that the primary outcome of LOS was reduced with ERAC and that secondary outcomes (complication rates, pain scores, opioid consumption, and hospitalization costs) were improved with ERAC. There were no differences in maternal readmission rates.…”

“…There have since been 11 new peer-reviewed ERAC studies published that fulfill the same inclusion criteria as Sultan et al, 12 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 and 2 published meta-analyses comparing ERAC with standard care. 33 , 46 In the 22 ERAC implementation studies published to date, the outcomes described are wide-ranging and heterogeneous ( Table 1 ). Of these studies, 4 are randomized controlled trials (RCTs) 13 , 20 , 23 , 24 and 2 are multicenter studies.…”

“…Overall, as previously reported, the levels of evidence from available studies ranged from low to very low for all outcomes assessed (findings for LOS, time to first mobilization, time to urinary catheter removal, and opioid consumption were rated as low-level evidence, whereas those for the outcome of readmission after hospital discharge were rated as very low-level evidence). Simultaneously published in 2021, a meta-analysis by Meng et al 46 included 10 ERAC studies. Three studies 14 , 15 , 19 from the Sultan et al meta-analytic study were not included, and an RCT published in Chinese (without a full English translation), involving 572 women, was added.…”

Analgesic Effect of Erector Spinae Plane Block versus Transversus Abdominis Plane Block After Elective Cesarean Section

“…Therefore, more interest is growing to achieve better perioperative management and outcome of CS in form of enhanced recovery after surgery (ERAS) concept [2]. Effective analgesia allows early mobilization, increases breastfeeding success, and fast recovery; it reduces hospital stay, costs and indeed a comfort to surgeons and increases the overall patient satisfaction [3,4]. Systemic opioid is commonly used as one of the pain control approaches, however, there are side effects such as pruritus, nausea, and vomiting.5 Peripheral nerve blocks have become vital for multimodal opioid-sparing analgesia in a multitude of surgical procedures.…”