New Guidelines in Development for Enhanced Recovery After Surgery for C-Section Patients

Team will track patient and clinician compliance, as well as outcomes

Innovations in Obstetrics & Gynecology | Winter 2021

Enhanced Recovery after Surgery (ERAS) has been used to reduce the physiologic stress response to surgery and improve outcomes across multiple disciplines for years. The Department of Obstetrics & Gynecology has implemented ERAS protocols for major gynecological surgeries, such as hysterectomy, 2 years ago under the leadership of Megan Billow, MD. The OB team at University Hospitals Cleveland Medical Center is now preparing to bring the ERAS approach to patients undergoing cesarean birth.

“In other disciplines, it has been shown to reduce costs, decrease post-operative surgical complications and engage patients in self-care related to surgery and the recovery period,” says Marcie Niemi, MS, RNC-OB, Advanced Practice Nurse for Perinatal Research, Development and Quality at University Hospitals Cleveland Medical Center. “Our team is comprised of OB anesthesia, OB providers and nurses. This is a great way for a multidisciplinary team to engage the patient as the most important person on our team.”

In 2019, the American Journal of Obstetrics & Gynecology published a series providing guidelines for ERAS following cesarean birth. Niemi facilitates the UH obstetrics guideline committee and initiates literature reviews. With the release of these evidence-based guidelines, she has been working with a multidisciplinary team to develop and implement ERAS guidelines for patients undergoing scheduled cesarean birth.

“We will be speaking the same message to the patient from the outpatient setting through hospital discharge and then circling back as they follow up in the postpartum period,” she says. “Though we have a large team, we are promoting the same message: encouraging best outcomes and patient participation in her care as she prepares for and recovers from surgery and bonds with her newborn.”

UH Cleveland Medical Center has been steadily introducing some ERAS elements of care over the past 18 months. For example, the OB team has been working to maximize patient comfort in the postpartum period through a comfort bundle, including the administration of scheduled multimodal analgesics. The team has also adjusted their approach to preoperative skin and vaginal preparation and intraoperative fluid volume management.

The UH team is also planning to roll out a number of new elements in the coming months. As a part of the process, they are analyzing preoperative oral intake. Currently, patients who are scheduled to undergo a C-section are instructed to refrain from eating or drinking anything after midnight prior to the surgery.

Now, the team is planning to move to a policy of no solid food within the eight hours prior to surgery with clear liquids permissible up to two hours before surgery. Niemi and her team are hoping that this will improve patient satisfaction and reduce postoperative nausea and vomiting.

After surgery, the team is looking to implement ERAS guidelines to promote the quicker return of bowel motility and gut function in patients. The OB team will be offering patients chewing gum and introducing food and liquids much sooner in the postoperative period. Additionally, the OB team will be removing Foley catheters earlier to encourage ambulation, which can reduce pain levels we well as the risks of postoperative thromboembolism and ileus.

Niemi and the OB ERAS team are developing tools and engagement activities for nurses to help prepare patients for these changes on-site. They are collaborating with UH marketing experts in the development of patient education materials and checklists to promote understanding of the plan of care.

She is also involved in the process of updating order sets. “We want to ensure that our current and upcoming guidelines are consistent with our orders,” Niemi says. “This helps to promote standardization of care.”

The UH Cleveland Medical Center rolled out ERAS guidelines for cesarean birth in early 2021. The team is carefully tracking patient and clinician compliance, as well as outcomes, she says. “Were we able to encourage patients to get up and ambulate several hours after the recovery period? Did we experience any increased post-operative nausea and vomiting with our new protocols?”

Following the collection of initial outcomes data and patient feedback, UH hopes to expand its ERAS protocols for C-section patients to its community hospitals. Eventually, the health system would like to also implement these guidelines for unscheduled cesarean births.

UH as a whole has been making a concerted push to move to ERAS guidelines across multiple disciplines, not just OB. Team members from different departments have worked together to help make this happen. For example, a UH care liaison involved with the development of ERAS guidelines for colorectal surgery provided feedback on the work being done by Niemi and her OB colleagues.

“Whenever we develop new guidelines, everyone is always willing to get engaged and involved,” Niemi says. “We certainly value implementing evidence-based practice to promote best outcomes while utilizing innovative methods to optimize patient engagement and satisfaction.”

If you are interested in learning more about UH’s effort to bring ERAS to C-section patients, reach out to Marcie Niemi at Marcie.Niemi@UHhospitals.org.