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ERAS Protocol for Elective Caesarean Section

MD Anaesthesiology Exam Notes (2024-25)

Based on ERAS Society 2025 Updated Guidelines (Am J Obstet Gynecol, 2026)

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1. INTRODUCTION & BACKGROUND

• Improve maternal and neonatal outcomes
• Improve patient experience
• Reduce healthcare costs and hospital length of stay (LOS)
• Minimize opioid use

• Hospital LOS decreased by 13.78 hours (95% CI: -19.28 to -8.28; p < 0.00001)
• Opioid consumption decreased significantly (SMD: -0.91; p = 0.003)
• No increase in readmission rates or maternal complications (SSI, emetic morbidity)

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2. ERAS SOCIETY 2025 GUIDELINES - STRUCTURE

• Strong recommendation = desirable effects clearly outweigh undesirable effects
• Weak recommendation = desirable effects probably outweigh, but panel less confident

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3. PART 1 - ANTENATAL AND PREOPERATIVE CARE

A. Antenatal Interventions (10-38 weeks gestation)

1. Patient Education for Scheduled Caesarean

• Evidence: Low to very low | Recommendation: Strong
• Structured antenatal counselling about what to expect: procedure, anaesthesia, recovery, breastfeeding
• Shared decision-making tools; reduces anxiety and improves compliance with ERAC interventions

2. Multidisciplinary Staff Education

• Evidence: Low | Recommendation: Strong
• All involved staff (anaesthesiologists, obstetricians, midwives, nurses) trained in ERAC protocol implementation and measurement
• Key for protocol adherence and audit

3. Optimization of Medical Comorbidities

• Evidence: Moderate | Recommendation: Strong
• Conditions to optimize preoperatively:
  • Anaemia (Hb optimisation - iron supplementation, EPO if needed)
  • Obesity (BMI assessment, difficult airway prediction, VTE risk)
  • Hypertension (BP control, antihypertensive review)
  • Gestational / Pre-existing Diabetes (glucose control, HbA1c)
  • Smoking (tobacco, cannabis, vaping cessation)
  • Congenital heart disease, epilepsy, autoimmune disease, asthma

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B. Preoperative Interventions (Day-of-surgery)

4. Abdominal Skin Preparation

• Evidence: Moderate | Recommendation: Weak
• Chlorhexidine gluconate (CHG)-impregnated cloth the evening before scheduled caesarean
• Reduces SSI risk; shower/wash with CHG solution preferred over standard soap

5. Preoperative Fasting

• Evidence: Low | Recommendation: Weak
• Based on content (type of intake), not just a fixed time:
  • Clear fluids: up to 2 hours before procedure
  • Light meal / breast milk: 4 hours
  • Full meal: 6-8 hours
• Aim to avoid prolonged fasting - reduces maternal thirst, hypoglycaemia, and anxiety

6. Preoperative Carbohydrate Supplementation

• Evidence: Low-moderate | Recommendation: Strong
• Non-particulate carbohydrate drink (e.g., maltodextrin-based) 2-3 hours before surgery
• Reduces insulin resistance, attenuates stress response
• Improves postoperative well-being and reduces nausea
• Must be non-particulate (clear) - safe for aspiration risk profile

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4. PART 2 - INTRAOPERATIVE CARE

1. Personal Support Person (Companion in OT)

• Evidence: Very low | Recommendation: Strong
• Partner/support person present in OT during spinal anaesthesia and surgery
• Reduces maternal anxiety; improves patient experience; no adverse effect on outcomes

2. Prophylactic Antibiotics

• Evidence: Moderate to High | Recommendation: Strong
• Cefazolin 1-2 g IV (weight-based: 3 g if >120 kg) administered before skin incision (not after cord clamping)
• Reduces SSI, wound infection, endometritis
• If penicillin allergy: clindamycin + gentamicin

3. Abdominal and Vaginal Preparation

• Evidence: Moderate | Recommendation: Strong
• Povidone-iodine vaginal preparation before caesarean (reduces SSI/endometritis)
• Abdominal prep: chlorhexidine-alcohol preferred over povidone-iodine for skin
• Clipping preferred over shaving

4. Antiemetic Prophylaxis (PONV + Intraoperative nausea)

• Evidence: Low | Recommendation: Strong
• Multimodal antiemetic prophylaxis:
  • Ondansetron 4 mg IV (5-HT3 antagonist)
  • Dexamethasone 4-8 mg IV (also analgesic-sparing)
  • Metoclopramide 10 mg IV (dopamine antagonist)
• Combination superior to monotherapy
• Spinal hypotension is the primary trigger of intraoperative nausea - treat simultaneously

5. Prevention of Spinal Hypotension

• Evidence: Low | Recommendation: Strong
• Most common complication of spinal anaesthesia for caesarean (~80% incidence without prophylaxis)
• Strategies:
  • Vasopressors (first-line): Phenylephrine infusion (100-150 mcg/min prophylactically) - preferred; or norepinephrine infusion (5-10 mcg/min) - better HR maintenance
  • Lateral tilt (15°) until delivery
  • Co-loading with crystalloid (Ringer's lactate/compound sodium lactate) at time of spinal - not pre-loading alone
  • Avoid aortocaval compression
  • Note: Ephedrine reserved if HR falls with phenylephrine

6. Maintenance of Normothermia

• Evidence: Moderate | Recommendation: Strong
• Target: maternal core temperature 36-37.5°C
• Spinal anaesthesia causes impaired thermoregulation
• Interventions:
  • Forced-air warming blanket (upper body)
  • IV fluid warming (warm Hartmann's/Ringer's lactate)
  • Theatre temperature maintained at 20-22°C
  • Warm blankets for neonate
• Hypothermia causes: shivering (increases O2 demand), impaired coagulation, neonatal complications

7. Maintenance of Euvolemia

• Evidence: Low | Recommendation: Strong
• Goal-directed fluid therapy - avoid both under- and over-hydration
• Co-load with 500-1000 mL crystalloid at time of spinal
• Titrate further fluids to clinical assessment (HR, BP, urine output)
• Colloids (HES) avoided in obstetrics; albumin if needed
• Avoid routine aggressive fluid administration

8. Optimal Use of Uterotonics

• Evidence: Moderate | Recommendation: Strong
• Oxytocin remains first-line:
  • Elective caesarean: 1-3 IU slow IV bolus (not rapid bolus - causes hypotension/tachycardia)
  • Followed by infusion: 10-20 IU in 500 mL over 4-8 hours
• If uterotonic response inadequate:
  • Carbetocin (stable oxytocin analogue): single 100 mcg IV bolus - superior to oxytocin infusion for preventing PPH; WHO recommended
  • Ergometrine 0.5 mg IV/IM (avoid in hypertension)
  • Carboprost (PGF2α) 0.25 mg IM (avoid in asthma)
  • Misoprostol 600-800 mcg sublingual/rectal
• Carbetocin preferred in resource-adequate settings (heat-stable formulation available)

9. Multimodal Analgesia

• Evidence: Low | Recommendation: Strong
• Cornerstone of ERAC - minimise opioid use
• Intrathecal morphine (neuraxial opioid):
  • 100-150 mcg (low-dose) - effective for 18-24 hours
  • Monitor for delayed respiratory depression (6-12 hours)
  • Side effects: pruritus (ondansetron/nalbuphine), PONV, urinary retention
• Intrathecal fentanyl: 15-25 mcg (intraoperative analgesia, rapid onset)
• Systemic:
  • Paracetamol (acetaminophen) 1 g IV/oral regularly
  • NSAIDs: Diclofenac 75 mg IM/oral or Ketorolac 15-30 mg IV
  • Tramadol IV (avoid in breastfeeding in high doses)
• Regional adjuncts (if no intrathecal morphine available):
  • Transversus Abdominis Plane (TAP) block: bilateral; reduces pain and opioid consumption
  • Quadratus Lumborum (QL) block: deeper coverage including visceral pain
  • Wound infiltration with local anaesthetic
  • Erector Spinae Plane (ESP) block
• Dexamethasone (4-8 mg IV intraoperative) contributes to analgesia and antiemesis

10. Early Initiation of Skin-to-Skin Care

• Evidence: Moderate | Recommendation: Strong
• Immediate skin-to-skin contact in OT (if mother and neonate stable)
• Benefits: promotes breastfeeding, maternal bonding, neonatal thermoregulation
• Anaesthesiologist's role: ensure maternal haemodynamic stability; assist with positioning
• Continue during wound closure and transfer to recovery

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5. PART 3 - POSTOPERATIVE CARE

1. Early Drinking and Feeding

• Evidence: Low | Recommendation: Strong
• Oral fluids within 30 minutes of reaching recovery (if not nauseated and awake)
• Solid food within 2-4 hours of surgery
• Promotes gut motility, reduces insulin resistance, improves well-being

2. Early Discontinuation of IV Fluids

• Evidence: Very low | Recommendation: Strong
• Discontinue IV fluids as soon as oral intake tolerated (within 2-4 hours)
• Reduces risk of fluid overload, peripheral oedema, immobility

3. Early Mobilization and Ambulation

• Evidence: Low | Recommendation: Strong
• Attempt standing/walking within 6-8 hours of surgery (when block has worn off)
• Staged: bed exercises → sitting up → standing → walking
• Reduces VTE risk, improves respiratory function, accelerates recovery

4. Early Removal of Urinary Catheter

• Evidence: Low | Recommendation: Strong
• Remove within 6-12 hours postoperatively (once mobile)
• Reduces UTI risk, allows earlier ambulation

5. Scheduled Paracetamol (Acetaminophen)

• Evidence: Moderate | Recommendation: Strong
• 1 g orally/IV every 6 hours (regular, not PRN)
• Baseline analgesic; opioid-sparing effect
• Can begin within 1-2 hours post-surgery

6. Scheduled NSAIDs

• Evidence: High | Recommendation: Strong
• Ibuprofen 400 mg orally every 6-8 hours (with food) - preferred
• Or diclofenac 50-75 mg orally every 8-12 hours
• High-quality evidence for opioid-sparing
• Avoid if: renal impairment, GI ulcers, platelet dysfunction, asthma
• Safe for breastfeeding (ibuprofen preferred)

7. Oral Rescue Opioids

• Evidence: Low | Recommendation: Strong
• Opioids only as oral PRN rescue (not IV, not scheduled)
• Example: oxycodone 5 mg orally PRN (max 30 mg/day)
• Reserve for breakthrough pain not controlled by paracetamol + NSAID
• Avoid IV opioids as first-line post-caesarean

8. Standardized Rescue Medication Protocol for Side Effects

• Evidence: Low-moderate | Recommendation: Strong
• Protocols for common opioid/morphine side effects:
  • Pruritus: Nalbuphine 5 mg IV or ondansetron 4 mg IV; naloxone 40-80 mcg IV (titrated)
  • PONV: Ondansetron 4 mg IV, cyclizine, metoclopramide
  • Urinary retention: trial of void, catheterisation if needed
  • Respiratory depression: naloxone 0.1-0.4 mg IV (titrated); monitoring protocol

9. Venous Thromboembolism (VTE) Prophylaxis

• Evidence: Low | Recommendation: Strong
• All caesarean patients at higher VTE risk than vaginal delivery
• Mechanical: TED stockings + pneumatic compression devices from time of surgery
• Pharmacological: LMWH (e.g., enoxaparin 40 mg SC OD) starting 4-6 hours post-surgery if:
  • No active haemorrhage, adequate haemostasis
  • Continue for 7-10 days (up to 6 weeks if high risk)
• Risk stratify: obesity, prolonged surgery, immobility, thrombophilia, previous VTE

10. Anaemia Remediation

• Evidence: Moderate | Recommendation: Strong
• Check Hb postoperatively; treat iron deficiency anaemia
• IV iron (ferric carboxymaltose, ferric derisomaltose) if Hb < 10 g/dL or symptomatic
• IV iron preferred over oral in early postpartum (better absorption, faster response)
• Blood transfusion if Hb < 7 g/dL or symptomatic at higher thresholds
• Pre-operative optimization reduces need for transfusion

11. Breastfeeding Support and Education

• Evidence: Low | Recommendation: Strong
• Initiate skin-to-skin in OT (intraoperative, see above)
• Lactation nurse/midwife support within first hour
• Ensure analgesia regimen safe for breastfeeding (paracetamol, ibuprofen preferred)
• Avoid high-dose tramadol/codeine in breastfeeding (CYP2D6 metabolism risk)

12. Promotion of Rest Periods

• Evidence: Low | Recommendation: Strong
• Cluster care interventions (combine: maternal checks, neonatal checks, drug administration, blood draws) to minimise interruptions
• Protect dedicated sleep/rest periods
• Rationale: sleep is essential for postpartum recovery and mental health; excessive interruption worsens fatigue

13. Facilitate Patient-Centred Transition to Discharge

• Evidence: Low | Recommendation: Strong
• Discharge criteria: haemodynamically stable, tolerating oral intake, adequate pain control on oral medications, independently mobile, no active complications
• Target LOS: 24-48 hours for uncomplicated elective caesarean (vs 48-72 hours traditional)
• Discharge education: wound care, pain management, danger signs, follow-up
• Telephone or virtual follow-up at 24-72 hours

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6. ANAESTHESIA-SPECIFIC CONSIDERATIONS (Exam Highlights)

Choice of Anaesthesia

• Spinal anaesthesia is the gold standard for elective caesarean
  • Bupivacaine heavy 0.5% (10-12.5 mg) + intrathecal fentanyl (15-25 mcg) + intrathecal morphine (100-150 mcg)
• General anaesthesia reserved for: failed regional, coagulopathy, severe fetal distress, patient refusal of regional

Spinal Anaesthesia Technique Considerations in ERAC

Multimodal Analgesia Ladder (ERAC)

TIER 1 (All patients):
  Intrathecal morphine 100-150 mcg
  + Intrathecal fentanyl 15-25 mcg
  + Regular paracetamol 1g q6h
  + Regular ibuprofen/diclofenac

TIER 2 (If tier 1 insufficient):
  + Oral opioid PRN (oxycodone 5mg, max 30mg/day)
  + Dexamethasone 4-8 mg IV (intraoperative)

TIER 3 (If no intrathecal morphine / GA cases):
  + TAP block / QL block / wound infiltration
  + IV paracetamol + IV ketorolac
  + Oral opioid PRN rescue

Key Drugs and Doses for Exam

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7. OUTCOMES OF ERAC IMPLEMENTATION

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8. BARRIERS TO ERAS IMPLEMENTATION & AUDIT

• Staff resistance to change
• Lack of trained personnel
• Limited resources (IV iron, vasopressor infusions, warmers)
• Patient/cultural beliefs (e.g., fasting)
• Poor documentation and audit infrastructure

• Protocol compliance rate
• Hospital LOS
• VTE event rate
• Opioid consumption (mg morphine equivalents)
• Patient satisfaction scores
• SSI rate
• Breastfeeding initiation rate

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9. SUMMARY TABLE - ERAC 2025 (All 22 Interventions)

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10. EXAM HIGH-YIELD POINTS

1. ERAC has 3 phases (Parts 1, 2, 3) with 6, 10, and 13 interventions respectively (total 29 across all three guideline parts; summary table above consolidates 22 discrete items by category)
2. Spinal hypotension - phenylephrine infusion is first-line (not ephedrine alone); norepinephrine preserves maternal HR better
3. Intrathecal morphine 100-150 mcg = standard low-dose; monitor for delayed respiratory depression (6-12 hrs), manage pruritus
4. Carbetocin is preferred uterotonic for PPH prevention in elective CS (single dose, no need for infusion)
5. Prophylactic antibiotics before skin incision (not after cord clamping) - strong/high evidence
6. NSAIDs are the only High-evidence intervention in ERAC
7. TAP / QL block used if intrathecal morphine unavailable (GA cases)
8. CHG prep evening before surgery - moderate evidence but only weak recommendation (due to inconsistent study designs)
9. Carbohydrate drink up to 2 hours before - reduces insulin resistance (strong recommendation)
10. Early catheter removal (6-12 hours) facilitates earlier mobilization - both prevent VTE
11. Cluster care = group nursing/medical interventions to protect sleep
12. LMWH starts 4-6 hours post-operatively - not immediately (haemostasis must be ensured)

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11. REFERENCES

1. Wilson RD et al. Guidelines for antenatal and preoperative care in cesarean delivery: ERAS Society recommendations (Part 1) - 2025 update. Am J Obstet Gynecol. 2026. PMID: 40335350
2. Caughey AB et al. Guidelines for intraoperative care in cesarean delivery: ERAS Society recommendations (Part 2) - 2025 update. Am J Obstet Gynecol. 2026. PMID: 40335352
3. Sultan P et al. Guidelines for postoperative care in cesarean delivery: ERAS Society recommendations (Part 3) - 2025 update. Am J Obstet Gynecol. 2026. PMID: 40335351
4. Pinho B, Costa A. Impact of ERAS guidelines implementation in cesarean delivery: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2024. PMID: 38042118
5. Barash, Cullen & Stoelting's Clinical Anesthesia, 9th Ed. - Chapter on Perioperative Care/ERAS

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