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Enhanced Recovery After Surgery (ERAS) is a multimodal and multidisciplined approach to improving outcomes post-operatively. Initially, ERAS protocol began with colorectal procedures and has now been integrated into the OB-GYN field for Cesarean sections (C-sections); however, it has not been adopted into all healthcare facilities (3, 5). ERAS protocol for C-sections can shorten a patient’s length of stay, improve outcomes, and increase patient satisfaction.

Introduction: What is the ERAS Protocol? 

The overarching concept of the ERAS protocol combines several evidence-based interventions that aid in accelerated patient recovery times (2). Of course, the purpose is to get patients discharged faster, but it is also to prevent readmissions by decreasing the incidence of complications; in short, it is both a patient and provider satisfier. The ERAS protocol interventions span the entire process of a hospital stay, including pre-, intra-, and post-operative care. Each intervention is targeted toward improving the main causes of recovery delays such as slow return of bowel function, inadequate pain control, and delayed ambulation (6). In addition, the ERAS medication combination is shown to reduce the need for postoperative opioids, which is an important step in combating the opioid crisis in the U.S. (5).  

Concepts of ERAS for Cesarean Section 

Prior to ERAS protocol implementation, patients were given sodium citrate with citric acid to decrease stomach acid and reduce the incidence of nausea, vomiting, and aspiration during cesarean section (c-section) procedures. On top of this, they were told not to eat or drink past midnight the night before a scheduled procedure. Since then, the ERAS protocol changed all of that and more.  

ERAS protocol includes drinking two hours before the surgery, active warming of the patient, goal-direct fluid therapy, early oral intake, gum-chewing postoperatively, early removal of the urinary catheter, early ambulation, and regular medications (5). 

If you aren’t following ERAS in your current practice, you may think it sounds like a disaster waiting to happen. I can assure you my colleagues thought it might produce more work for them and would be terrible for patients. Additionally, they expected vomiting, the inability of patients to urinate on their own, and increased falls.  

Surgical Stress Response 

The body undergoes a myriad of hormonal and metabolic changes that impact immune and endocrine responses (2). The inflammatory response affects multiple systems in the body, including respiratory, cardiac, and clotting factors. Preventing the surgical stress response is the key to the rapid recovery desired (2). Studies have shown that the higher the compliance with protocol, the shorter the patient’s length of stay and better outcomes overall (2).  

Pre- and Intraoperative Concepts 

One of the new concepts within the ERAS protocol is instructing the patient to consume a carbohydrate-rich sports beverage two hours prior to their procedure. Studies have shown that this not only reduces thirst, but decreases hunger, preoperative anxiety, and postoperative insulin resistance (5).  

In fact, a clinical trial was conducted to evaluate the incidence of regurgitation after allowing women to consume one sports beverage so closely to their procedure, and out of 411 cases, there was only one incidence of regurgitation in both the control and case groups; there was no incidence of aspiration (8). Both the energy consumption during labor and the need to maintain fluid levels for adequate uteroplacental circulation benefited from the beverage (7).  

Fluid balance is one of the core principles thought to benefit the patient in several ways, as it keeps the patient well hydrated and prevents drops in blood pressure when receiving epidural or spinal anesthesia. Hypotension can lead to nausea and vomiting, and a decrease in blood flow to the placenta which can lead to a drop in fetal oxygenation, requiring immediate intervention (5). 

An additional ERAS protocol concept that differs from typical surgical protocols is once the patient is in the operating room (OR), they are kept warm; ranging around at least 72 degrees. By utilizing warmed IV fluids and a whole-body warmer, this can help to prevent hypothermia during the procedure and allows for skin-to-skin contact with the newborn immediately following delivery (3).  

Providers can reduce a patient’s surgical stress, risk of nausea, vomiting, and surgical pain by administering antiemetics and pain-relieving medications prior to and during the C-section (3). Ketorolac and acetaminophen given during the procedure showcases increased pain control when given two hours prior to surgery (6). This combination of medications shows improved outcomes in postoperative nausea and pain control, which requires less opioid pain medication for an analgesic effect (5). Gabapentin and COX-2 inhibitors, such as celecoxib, were previously included in ERAS protocols for C-sections, but have since shown a number of side effects with minimal benefit to pain control (6). As such, these medications are not routinely used but may be helpful in reducing post-operative opioid use in patients with chronic pain or opioid use (6).  

Postoperative Concepts 

Once in the post-anesthesia care unit (PACU), the patient is given 30 units of Pitocin in a 500cc bag over four hours. Typically, oral intake is delayed until the return of bowel sounds, but research-based evidence shows that early oral intake encourages the return of bowel function (1, 6). Gum is chewed in the PACU to stimulate the gut.  

Once the patient is out of the PACU, the medication regimen continues with: 

• Three additional doses of 30mg of ketorolac via IV every six hours. 

• 600mg of ibuprofen (taken orally) for the remainder of stay. 

• 1000mg of acetaminophen every eight hours for the remainder of stay (6).  

Under traditional postoperative protocol, the urinary catheter is normally left in for about 12 hours, but early removal of the catheter is now performed 6 hours after recovery starts. Early ambulation is an ERAS protocol concept that encourages early ambulation (within eight hours of recovery). Patients should be monitored closely for increased fall risk as part of your nursing care plan.  

Case Study 

Sally: The day before the scheduled Cesarean Section 

Sally is a 30-year-old female who is scheduled for a C-section at 0800 tomorrow. She is a G2P1 at 39 weeks and two days. With her first baby two years ago, Sally had a C-section for cephalopelvic disproportion (CPD) due to the baby being too large to fit through the birth canal.  

Sally has been instructed to eat a meal rich in carbohydrates for dinner and remain NPO after midnight. She is to arrive at the hospital at 0530 to begin prepping for her procedure. She decided to have pasta with meat sauce and breadsticks for dinner around 1830, and she followed up with a sports beverage before going to bed at 2100, which was instructed by her nurse at her last OB-GYN appointment.  

• What is the reasoning behind having the patient consume a carb-rich meal? 

Sally: The day of the C-Section (Pre-operative) 

Sally and her husband, John, arrived at the maternity registration desk on time to check in, where she was given instructions to change into the hospital gown, and get into the bed. From there, the nurse explained what they were going to do to get her ready for surgery.  

“Hi Sally, I’m Kendall, and I will be your nurse today. I see in the chart here that we’re going to have a baby girl, have you chosen a name yet?” 

Nurse Kendall wants to ensure that Sally and John are as relaxed and comfortable as possible while she instructs them on what to expect during the procedure and in post-op. Although Sally has had a C-Section before, it is very important to educate every patient before a procedure.  

In this case, the hospital where she is delivering will be utilizing the ERAS protocol. The facility where she had her first child did not, so this is going to be a new experience for her.  

“Sally, I’m going to give you a sports drink and a couple of oral acetaminophen pills at 6:00. Along with the medications given to you during the surgery, 1000mg of acetaminophen will help with any pain or discomfort you might have afterwards.”  

Kendall comes back to the room at 0730 and gives sodium citrate with citric acid, which will decrease stomach acid, reducing the risk of regurgitation and aspiration.  

She asks, “Are you all ready to meet this sweet baby girl? Let’s get this show on the road!”  

• How does decreasing stomach acid reduce the risk of regurgitation and aspiration? 

Sally: 0800 (Intra-Operative) 

Sally is in the OR and has been placed on a full body warming blanket. She has been given warmed IV fluids to keep her body temperature warm. Kendall is the circulating nurse during the surgery.  

She explains to Sally that these are a few more of the changes since her last C-section, as Sally recalls that it was freezing last time. While Sally is being positioned on the table, Kendall reminds her that she will be receiving medication during her surgery as well.  

The anesthesiologist is administering the medications during the C-section. He tells her that she is getting Zofran, a medication that will help with any nausea.  

Sally: 0835 (The Procedure) 

Baby girl Layla is born at 0835 and weighs 6lbs, 7oz; She is placed on Sally so she can receive skin-to-skin warmth. Layla is tucked into the hospital gown against bare skin and covered with warm blankets. Sally is told that she is now getting a dose of a pain medication called ketorolac 30mg into her IV, which will help control her pain after the anesthesia wears off.  

• What complications can hypothermia cause? 

Body Temperature Management 

Normothermia reduces postoperative wound infections, blood loss, and coagulopathy, and therefore, the need for transfusion (5). The incidence of hypothermia in C-section patients is greater than 60 percent (5). The temperature drop can occur in as little as one hour, but it takes greater than four hours to return to normothermia (5). When the newborn is skin-to-skin with the mother, her body temperature will actively keep the baby warm, but if she is cold, it will take longer to reach the temperature required for the newborn (7). Skin-to-skin contact between newborns and their mothers has multiple benefits and is recommended after delivery.  

Newborns can bond with their mother, have better temperature regulation, cry less, experience more stable heart rates, have stronger immune systems, can absorb and digest nutrients better, and breastfeeding rates are increased if skin-to-skin contact is performed upon delivery (4 ,7). Moms also are less likely to experience postpartum hemorrhage and postpartum depression with skin-to-skin contact (7).  

Case Study Continued 

Sally: 0915 (Post-Operative) 

It is 0915, and Sally is taken to the PACU for her initial recovery phase, where she will stay for about 1-2 hours. While monitoring her vital signs and the anesthesia wearing off, her bleeding is monitored for potential postpartum hemorrhage. This is her second C-section, and therefore she is at a greater risk for hemorrhage.  

Kendall instructs Sally that she will give her some sugar-free gum to chew to wake up her intestines. She explains to her that this is a new intervention under the ERAS protocol (1).  

Chewing the sugar-free gum stimulates the digestive cephalic phase, thereby tricking the body into thinking it has eaten a meal, increasing intestinal motility. This then accelerates the healing process and decreases maternal discomfort by decreasing the amount of time for abdominal distension, gas, nausea, and vomiting (1).  

Studies have shown that the passing of gas and bowel movements happened in about half the time when this gum-chewing ERAS protocol intervention was utilized (1).  

Sally is excited to hear this because with her last C-section, she was bloated and could not pass gas. She had to walk the halls, take laxatives, and drink warm prune juice to attempt to get the gut motility going. It was the part she dreaded most about having another C-section.  

• What are the advantages of using chewing gum over stool softeners or laxatives? 

Sally: Postpartum Room (Day of Delivery) 

Kendall makes a call to the mother-baby nurse, Amanda, to let her know they will be coming in about 10 minutes. John gathers the bags, and Sally holds Layla on her chest. 

The room is designed to accommodate mom, dad, and the baby in a home-like environment.  

Everything the healthcare team will need to care for Sally and Layla is already in the room except for the medications that Amanda will bring. Amanda explains the newest interventions associated with the ERAS protocol, such as taking the urinary catheter out at six hours from when she entered recovery and ambulating within eight hours of that time (5).  

Sally is nervous about the catheter coming out so soon because she had difficulty urinating last time and had to be catheterized again to drain her bladder. She was told then that her bladder had just not quite woken up, which was sometimes common. Amanda reminds her that she will be given pain medications at regular intervals as part of the ERAS protocol, which will help minimize discomfort. She teaches Sally that evidence has shown that this is better for the patient and helps with early ambulation as well (3). Amanda then gives Sally a checklist that includes the times for each of the interventions to be performed so she knows what to expect and when.  

• What complications can be caused by keeping a Foley catheter in longer than 6 hours? 

Sally: 14:30 

Amanda comes into the room and reminds Sally that it is time to remove her urinary catheter, and that her acetaminophen 1000mg tablets along with ketorolac 30mg IV are scheduled to help control her pain. Sally asks if she can get up at this time and clean up a bit in the bathroom. Amanda calls the care partner, Julie, to come help get Sally out of bed and ambulate to the bathroom. They sit Sally up at the bedside to see how she feels. Sally is a bit weak and feels a little dizzy after sitting up. They help her back into the bed and get her comfortable. Amanda removes the catheter and helps Sally with her peri-care. Amanda tells Sally that they will try to get up again within the next two hours and reminds her to call if she needs to get up. Sally agrees and promises not to get up without them.  

• What causes patients to feel lightheaded post-operatively? 

Sally: 16:30 

Amanda and Julie come back into the room. Julie gets a set of vital signs and reminds Sally that it is time to try and ambulate again. Sally feels like she needs to urinate, so the timing is perfect for her to get up to the bathroom. The medications are controlling her pain well. She sits up at the bedside and is not dizzy this time. Amanda and Julie get her up, and she is steady, so they ambulate to the bathroom which is about twenty steps from the bed. Sally does well ambulating and can urinate without difficulty. She reports that she feels as if she has completely emptied her bladder. Julie assists Sally with her peri-care, instructing her so she can do it on her own next time.  

Sally decides to try to walk in the hallway a bit and manages to get to the nutrition room, which is about 50 feet away, where she can get ice and a snack. She feels a bit sore after that walk, so for the rest of the evening, she only wants to walk in the room. Amanda tells her to expect that the night shift nurse will most likely have her walk in the hallway again because the physician has ordered her to ambulate three times daily. Sally decides that she should rest if she needs to do that again. John is doing a great job of helping to care for Layla while Sally is recovering, which is making her feel more at ease.  

Sally: 2230 

The night nurse, Jennifer, comes in to give another dose of acetaminophen 1000mg. The ketorolac given earlier is helping, but Sally is concerned about having to ambulate again. Jennifer reminds her that ambulating is helping her body return to a normal state more quickly because it aids in the motility of the intestines. Sally ambulates another lap around the unit, going farther than last time, but this time John walks with her while pushing Layla in the bassinet. John is giving Sally much encouragement and praise for her good effort. After the walk, Sally needs to feed the baby and get some rest afterwards while Layla sleeps. She comments to John that she is pleasantly surprised at how well her pain is controlled so far. She wasn’t sure what to expect with the new ERAS protocol.  

Sally: Post-Operative Day One 

Amanda is back and is taking care of Sally and baby Layla again. She assesses mom and the baby then goes over the expectations for the day. Following, she gives the last dose of ketorolac 30mg and informs Sally that from now on she will be receiving ibuprofen 600mg orally instead on that same schedule. Amanda prepares Sally for a shower and instructs her that they will be removing her abdominal dressing, and getting it wet in the shower.  

Amanda reminds Sally to walk in the halls three times today. Sally says that she is feeling pretty good today, the breastfeeding is going well, that she is tolerating regular food, passing gas, and rating her pain at about 4 out of 10.  

Later in the day, Amanda talks to Sally about possibly receiving a survey after discharge about her experience during her stay. She asks if she has any concerns at this time that they could address or if there is anything they could do to make her stay better. Sally feels like her ERAS protocol experience has been a good one. She and John both agree that so far, this recovery has been all-around more satisfying than her last C-section.  

• Why is IV ketorolac 30mg converted to 600mg of PO ibuprofen? 

The scenario above is an example of the ERAS protocol under optimal conditions and a patient experiencing a good outcome. As nurses, we know that doesn’t always happen. Situations occur such as health issues outside of the pregnancy, emergent C-section delivery, non-compliance, excessive blood loss during surgery, etc. In some cases, ERAS is not used based on the patient’s condition. 

Emergency Cesarean Section 

Emergent surgical operations are a greater mortality risk to the patient and the ERAS protocols may be advantageous to an even greater extent under these conditions (2). Often, if an emergent situation occurs, it is due to the mother’s health conditions and/or baby that is not tolerating labor. This could be due in part to the mother’s condition, such as in the case of high blood pressure. Mom’s elevated pressure could lead to complications such as a detachment of the placenta, which would decrease the oxygen to the baby and therefore have an ominous outcome; this situation requires immediate delivery to save the infant (4).  

In an emergent surgical delivery situation, one or more of the steps in the ERAS protocol may be skipped, such as the pre-meds given prior to going to the OR, the carb-rich meal, and the sports beverage two hours before the procedure. The medications could be given upon arrival to the operating room and/or while the surgery is underway. The other steps will most likely still be followed, but there is a chance that the outcomes will differ (2). 

Skipping the pre-meds could affect the pain control afterward or nausea during and after the procedure. Skipping the sports beverage could affect the hydration and carbohydrate load, keeping the patient feeling less thirsty and hungry afterward; it also balances blood sugar which could be affected if skipped. If blood sugar drops, that could lead to nausea and vomiting, increasing dehydration, risk of aspiration, and early feeding, so you see how this can have a domino effect (2). All the steps in the protocol are meant to work together, but when that is not possible, every effort is made to get back on track as soon as it is safe to do so.  

Conclusion 

The ERAS protocol has been studied for several years now in multiple disciplines and has been shown to be an effective method for shortening the length of a patient’s stay following a C-section delivery (2, 5). ERAS protocol uses a multimodal method that addresses the major factors that cause patients to have longer lengths of stay due to complications in the initial recovery process (2, 5). Preventing these issues is a patient satisfier on multiple levels from earlier eating, to reduced pain, to earlier discharge from the hospital. If your facility is not following the ERAS protocol, this could be a great opportunity for discussion with your team. 

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