Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial

ABSTRACT OBJECTIVE Our objective was to determine whether an enhanced recovery after surgery (ERAS) pathway at the time of cesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction compared to standard perioperative care (SC). STUDY DESIGN Patients undergoing nonemergent cesarean delivery at ≥ 37 weeks of gestation were randomized to ERAS or SC. ERAS involved multiple evidence-based interventions bundled into one protocol. The primary outcome was discharge on postoperative day 2 (POD#2). Secondary outcome variables included pain medication requirements, breastfeeding rates and various measures of patient satisfaction. RESULTS From September 27, 2017 to May 2, 2018, 58 women were randomized to ERAS and 60 to SC. The groups were similar in medical comorbidities, demographic and perioperative characteristics. ERAS was not associated with a significantly increased rate of POD#2 discharges when compared with SC, 8.6% vs. 3.3%, respectively (OR: 2.74, 95% CI 0.51-14.70), but it was associated with a significantly reduced postoperative length of stay (LOS) when compared with standard care, with median LOS of 73.5 [(IQR): 71.08-76.62)] v. 75.5 [(IQR: 72.86-76.84)] hours from surgery, difference in median LOS: (-1.92, 95% CI -3.80 - -0.29). ERAS was not associated with a reduction in postoperative narcotic use, 117.16 ± 54.17 vs. 119.38 ± 47.98 morphine milligram equivalents (Mean difference: -2.22, 95% CI -20.86-16.42). More subjects randomized to the ERAS protocol reported breastfeeding at discharge, 67.2% vs. 48.3% (p=0.046). When patients were surveyed 6 weeks postpartum, those in the ERAS group were more likely to feel that their expectations were met, they achieved their postoperative milestones earlier and to report continued breastfeeding. CONCLUSION ERAS after cesarean was not associated with an increase in the number of women discharged on POD#2, but that may have been related to factors other than patients’ medical readiness for discharge. Evidence that ERAS after cesarean may have the potential to improve outcomes such as day of discharge are suggested by the observed reduction in overall postoperative LOS, improved patient satisfaction and an increase in breastfeeding rates. Even better results may accrue with more provider and patient experience with ERAS.