Favorable outcomes have been noted using standardized perioperative care, referred to as "enhanced recovery after surgery" (ERAS) pathways (Macones et al., 2019). Use of ERAS in other disciplines has shown improved outcomes including decreased length of stay (LOS) and surgical complications, cost reduction, and decreased readmissions (Wilson et al., 2018). Cesareans are the most often performed surgery in the United States but many health systems are not routinely using ERAS pathways (Wilson et al.). Three articles outlining an ERAS pathway for cesareans were recently published. They contain many elements for care that begins up to 30 to 60 minutes before skin incision and follow the woman through hospitalization (Caughey et al., 2018). The bedside nurse's role in the ERAS pathway is summarized as follows and does not include recommendations against certain treatments or surgeon-driven elements, such as surgical technique, that are also addressed in the full pathway.
Preoperative Care (Wilson et al., 2018): begins up to 60 minutes before incision where allowed. In emergent cases, some items may be done postoperatively. Ideally, teaching on the entire care process and the patient's role as a team member should be discussed preoperatively. Where possible, patients should have nothing to eat for at least 6 hours before surgery; clear fluids are encouraged up until 2 hours before surgery, including oral carbohydrate fluid drinks in women without diabetes. All women should be premedicated with an antacid and histamine2 (H2)-receptor antagonist.
Intraoperative Care (Caughey et al., 2018): focuses on time in the operating room (OR); first recommendation is for intravenous (IV) cephalosporin antibiotics to be given 60 minutes before incision for all women to decrease risk of surgical site infection, with the addition of azithromycin advised for women who were in labor or with ruptured membranes. For skin preparation, chlorhexidine-alcohol is preferred over povidone-iodine; however, vaginal cleansing with povidone-iodine may be protective against surgical site infection. Avoidance of hypothermia via temperature monitoring and treatment with forced air warming, IV fluid warming, and increasing OR temperature are strong recommendations. Ensuring euvolemia both peri- and intraoperative has shown improvement in maternal and fetal outcomes after cesarean birth. Neonatal care is covered with recommendations to delay cord clamping (1 minute at term and at least 30 seconds for preterm), ensure temperature management to maintain the newborn between 36.5 [degrees]C and 37.5 [degrees]C, resuscitation with room air over oxygen supplementation, and ability to initiate immediate neonatal resuscitation in all settings performing cesareans.
Postoperative Care (Macones et al., 2019): covers avoidance of postoperative nausea and vomiting through fluid and blood pressure management, with addition of lower limb compression, which may provide benefit in LOS and patient satisfaction. Gum chewing may provide benefit but is likely redundant if early feeding (a regular diet within 2 hours after surgery) is implemented. Management and tight control of blood glucose are important to aid in wound healing. Regular and scheduled use of nonsteroidal anti-inflammatory medications paired with acetaminophen can help control pain while limiting need for opiates. Early ambulation, removal of any urinary catheter placed during surgery immediately after, and use of pneumatic compression stockings can help decrease complications.
The pathways are best implemented with an interdisciplinary-based approach among nurses, surgeons, anesthesiologists, postpartum care providers, and nursery teams. Review the ERAS guidelines for opportunities to improve clinical practice on your maternity unit.
References