Abstract
Objective
To determine the role of regular diet recovery after restoration of normal muscle strength of both lower extremities in promoting postoperative recovery in women undergoing elective cesarean section.
Methods
This was a prospective observational cohort study. Patients who underwent elective cesarean section at Xiangya Hospital, Central South University, from October 2022 to December 2022, were categorized into two groups based on the duration of postoperative fasting: the observation group resumed eating after regaining lower extremity muscle strength, while the control group adhered to traditional postoperative fasting guidelines, waiting 6 hours before eating. Primary outcomes included postoperative pain levels assessed by visual analog scale (VAS) pain scores and time to first flatus. Demographic characteristics, time to first lactation, hospital stay length, and patient satisfaction were also assessed. Statistical analysis was conducted using Student’s t test and Chi-squared test, with significance set at P < 0.05.
Results
Out of a total of 300 patients, 240 were included in the analysis, comprising 112 in the control group and 128 in the observation group. There were no significant differences in baseline demographic characteristics. The median values of the first flatus time and the first lactation time were 33.37 ± 1.22 vs. 18.06 ± 6.34 hours (P = 0.003) and 26.34 ± 8.21 vs. 7.05 ± 1.26 hours (P = 0.001) in the control and observation groups, respectively. The median hospital stay duration in the control and observation groups was 6.54 ± 0.53 vs. 4.84 ± 0.18 days (P = 0.000), respectively. Median postoperative VAS pain scores and patient satisfaction values were 8.57 ± 0.11 vs. 4.91 ± 0.27 (P = 0.000) and 9.36 ± 0.16 vs. 9.72 ± 0.08 (P = 0.005) in the control and observation groups, respectively. There were no statistically significant differences in other postoperative outcomes, such as intestinal obstruction, infection, and readmission within 42 days (P > 0.05).
Conclusion
Food intake after restoration of lower extremity muscle strength improves first flatus, relieves postoperative pain, shortens hospital stay, and enhances satisfaction after elective cesarean section, without adverse effects. It is crucial for postoperative rehabilitation and should be encouraged.
Keywords: Obstetrics, Cesarean section, Early food intake
Introduction
A cesarean section (CS) is one of the most commonly performed procedures in obstetrics. In the past 30 years, the development of medicine has resulted in a continuous increase in the CS rate globally. From 2008 to 2014, the CS rate in China increased from 28.8% to 34.9% and further increased to 36.7% in 2018.1 Traditionally, patients were advised to refrain from eating until the passage of flatus following surgery, aiming to mitigate potential complications such as flatulence and intestinal obstruction. However, Enhanced Recovery After Surgery (ERAS), proposed in 1997,2 suggests that patients should eat as early as possible after surgery, as it could promote postoperative recovery and shorten the length of the hospital stay. Several updated guidelines now advocate for earlier food intake and strongly recommend that patients follow a stepwise dietary approach.3,4 Accumulating evidence suggests that reducing the interval between food intake does not lead to postoperative complications. Additionally, it may alleviate postoperative discomfort, such as incision pain, and shorten hospital stays.5,6 A well-balanced nutrient supply can offer sufficient energy to promote gastrointestinal recovery, decrease insulin resistance, and facilitate overall rapid recovery. Lower insulin resistance was noted in patients who consumed food earlier rather than later.7 The ERAS protocols are rapidly becoming the standard of care for patients undergoing elective CS, as they accelerate recovery and reduce postoperative length of stay and morbidity.3,4
Nevertheless, despite the recognition of its safety, some pregnant women and obstetricians remain concerned that early feeding might result in adverse complications. Moreover, while current guidelines suggest that a small volume of liquid can be consumed 2 hours postoperatively, the resumption of the regular diet is still contingent upon the occurrence of flatus. Therefore, early postoperative feeding is still not widely encouraged in women undergoing CS. However, because CS primarily affects gastrointestinal function through anesthesia factors rather than direct gastrointestinal manipulation, we hypothesize that resuming a regular diet after the restoration of normal muscle strength in both lower limbs could be feasible. Hence, our study aims to investigate the impact of resuming the regular diet following the restoration of normal muscle strength in both lower extremities on postoperative recovery in patients undergoing elective CS.
Materials and methods
This prospective observational cohort study aimed to evaluate the effects of postpartum dietary rehabilitation, initiated after the restoration of normal muscle strength in both lower extremities, on several outcomes. Primary outcomes included the time to first flatus and postoperative pain levels, while secondary outcomes encompassed the initiation of lactation, duration of hospitalization, and patient satisfaction.
Participants
Singleton pregnant women scheduled for elective CS between October 2022 and December 2022 at Xiangya Hospital, Central South University, were included in the study. Elective CS cases with a procedure duration of less than 2 hours and no severe pregnancy complications were eligible. Exclusions comprised women undergoing emergency CS and those with severe pregnancy complications such as acute fatty liver of pregnancy and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count).
Our medical team possesses extensive expertise in performing CSs and managing complex conditions and complications. Since October 2022, we have been implementing early postoperative oral intake strategies in line with the ERAS guidelines.3,4 However, during the early stage of implementation, because of the different acceptance rates of patients, some patients were still reluctant to eat earlier compared to traditional measures after surgery. Postoperative fasting time was defined as the duration between the moment of arrival at the postanesthesia care unit and first postoperative intake. Based on the duration of postoperative fasting and considering participants’ preferences in accordance with ethical guidelines, participants were categorized into two groups: the observation group (comprising individuals who resumed eating after the restoration of normal muscle tension in the lower limbs) and the control group (consisting of individuals who resumed eating after 6 hours, adhered to traditional postoperative fasting guidelines). The management protocol for both groups is outlined in Figure 1.
Figure 1.
Comparison of postoperative management measures between the control (A) and the observation group (B).
Data collection
Patient demographic characteristics, including age, gravidity, parity, number of previous cesarean deliveries, prenatal body mass index (BMI), delivery gestation, status of in vitro fertilization and embryo transfer, and abortion history, were recorded. Primary outcomes included the pain score and time to first flatus. Postoperative pain and VAS were recorded by nurses each day. Secondary outcomes included the time to first lactation; fasting time, fluid intake time, time to mobilization; postoperative complications based on clinical experiences, such as flatulence and intestinal obstruction; length of hospital stay; satisfaction with hospital services evaluated by filling out a questionnaire; hospitalization cost; and postoperative 42-day readmission rate.
Statistical analysis
Statistical Product and Service Solutions (SPSS) software (version 26.0; IBM Corporation, Armonk, NY, USA) was used for statistical analysis. Measurement data were expressed as the mean ± standard deviation values, and the t test was performed for comparison between the two groups. The enumeration data were expressed as the rate (%), and the Chi-squared (χ2) test was performed to compare the two groups. P < 0.05 was considered to indicate statistically significant differences.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institution, and written consent was obtained before the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the medical ethics committee of the Xiangya Hospital Central South University (clinical ethical approval no. 202304081).
Results
A total of 300 patients underwent CS surgery during the study period; of these, 240 patients were enrolled. Patients subjected to interventions were classified into the observation group (128 patients) and control group (112 patients) based on the length of the postoperative fasting duration (Fig. 2).
Figure 2.
Flow chart for inclusion, exclusion, and subgrouping of patients undergoing elective cesarean delivery.
Baseline demographic characteristics
The baseline demographic characteristics of the study population were compared. There were no significant differences in the demographic characteristics of 240 patients between subcharacteristics groups (Table 1).
Table 1.
Demographic characteristics for control and observation groups.
| Characteristic | Total n (%) | Control group (n = 112) | Observation group (n = 128) | P* | χ2 (P†) | ||
|---|---|---|---|---|---|---|---|
| Mean ± SD | n | Mean ± SD | n | ||||
| Age (years) | |||||||
| <35 | 172 (71.67%) | 32.39 ± 0.77 | 88 | 32.75 ± 0.68 | 84 | 0.679 | 4.931 (0.026) |
| ≥35 | 68 (28.33%) | 24 | 44 | ||||
| Gravidity | |||||||
| 1–2 | 144 (60%) | 2.50 ± 0.22 | 52 | 2.16 ± 0.21 | 92 | 0.554 | 16.116 (0.000) |
| ≥3 | 96 (40%) | 60 | 36 | ||||
| Parity | |||||||
| 0 | 120 (50%) | 0.57 ± 0.11 | 52 | 0.50 ± 0.10 | 68 | 0.989 | 1.070 (0.301) |
| ≥1 | 120 (50%) | 60 | 60 | ||||
| Number of cesarean sections | |||||||
| 0 | 168 (70%) | 0.39 ± 0.12 | 68 | 0.25 ± 0.13 | 100 | 0.277 | 8.622 (0.003) |
| ≥1 | 72 (30%) | 44 | 28 | ||||
| Prenatal BMI (kg/m2) | |||||||
| ≤24 | 56 (23.33%) | 28.05 ± 0.73 | 16 | 26.27 ± 0.76 | 40 | 0.839 | 9.610 (0.002) |
| >24 | 184 (76.67%) | 96 | 88 | ||||
| Delivery gestation (weeks) | 36.36 ± 0.51 | 37.88 ± 0.29 | 0.063 | ||||
| IVF-ET | 20 (18%) | 28 (22%) | 0.445 | ||||
| Abortion history | 0.89 ± 0.22 | 0.72 ± 0.19 | 0.820 | ||||
*P value among subcharacteristic groups.
†P value between the control and the observation groups.
BMI: Body mass index; IVF-ET: In vitro fertilization and embryo transfer; SD: Standard deviation.
First flatus time, pain scores, fasting, fluid intake, and mobilization time after surgery
The primary outcomes in the observation group, including the time to first flatus and pain scores (18.06 ± 6.34, 4.91 ± 0.27), were notably lower compared to those in the control group (33.37 ± 1.22, 8.57 ± 0.11), with statistically significant differences observed (P = 0.003, 0.000) (Table 2). The fasting time in the observation group (11.85 ± 0.77) was significantly lower than that of the control group (25.95 ± 2.37), and differences were statistically significant (P < 0.05 = 0.018). The fluid intake and mobilization time after surgery were not significantly different between the two groups (P = 0.534, 0.625) (Table 3).
Table 2.
Comparison of primary outcomes between control and observation groups.
| Project Group | Mean ± SD | P | |
|---|---|---|---|
| Control group (n = 112) |
Observation group (n = 128) |
||
| Time to first flatus (hours) | 33.37 ± 1.22 | 18.06 ± 6.34 | 0.003 |
| Pain score | 8.57 ± 0.11 | 4.91 ± 0.27 | 0.000 |
SD: Standard deviation.
Table 3.
Comparison of secondary outcomes between control and observation groups.
| Project Group | Mean ± SD | P | |
|---|---|---|---|
| Control group (n = 112) |
Observation group (n = 128) |
||
| Time to first lactation (hours) | 26.34 ± 8.21 | 7.05 ± 1.26 | 0.001 |
| Fluid intake (hours) | 7.62 ± 1.22 | 6.44 ± 1.10 | 0.534 |
| Fasting (hours) | 25.95 ± 2.37 | 11.85 ± 0.77 | 0.018 |
| Mobilization (hours) | 24.24 ± 1.49 | 21.57 ± 1.47 | 0.625 |
| Hospital stays (days) | 6.54 ± 0.53 | 4.84 ± 0.18 | 0.000 |
| Patient satisfaction | 9.36 ± 0.16 | 9.72 ± 0.08 | 0.005 |
| Hospital cost (CNY) | 14859 ± 936 | 12493 ± 644 | 0.050 |
| 42-Day readmission rate | 0 | 0 | - |
CNY: Chinese Yuan; SD: Standard deviation.
Postoperative complications, hospital stays, patient satisfaction, hospital cost, and 42-day readmission
The hospital stay days and patient satisfaction in the observation group were statistically significant (P = 0.000). The hospitalization cost and postoperative complications in the observation group were lower than those in the control group, but the differences were not statistically significant (P ≥ 0.05) (Table 3). Regarding postoperative complications, two patients in the control group had incomplete intestinal obstruction, which resolved with conservative treatment, and no postoperative complications were observed in the observation group (P > 0.05). No 42-day readmissions were observed in any of the groups (Table 3).
During the investigation into breastfeeding, 65 patients refused to breastfeed due to limitations related to mental and physical health, finances, practicality, or information, while 43 patients were primarily concerned about adherence to medication during breastfeeding. Thus, they were excluded from the study. Finally, 132 patients were included, of which 68 patients were in the observation group, and 64 patients were in the control group. In comparison to the control group (26.34 ± 8.21), the time until the first lactation was shorter in the observation group (7.05 ± 1.26) (P = 0.001).
Correlation analysis among primary and secondary outcomes
After correlation analysis, fasting time was positively correlated with pain score, time to first flatus, length of hospital stays, and hospital cost (P < 0.05). Pain score was positively correlated with time to first flatus and hospital stay (Table 4).
Table 4.
Correlation analysis among primary and secondary outcomes.
| Fasting | Mobilization | First lactation | Pain score | Time to first flatus | Hospital stay | Hospital cost | Patient satisfaction | |
|---|---|---|---|---|---|---|---|---|
| Fasting | 1 | |||||||
| Mobilization | 0.153 | 1 | ||||||
| First lactation | 0.142 | −0.049 | 1 | |||||
| Pain score | 0.536* | 0.192 | 0.229 | 1 | ||||
| Time to first flatus | 0.627* | 0.231 | 0.192 | 0.584* | 1 | |||
| Hospital stay | 0.415* | 0.222 | 0.623* | 0.356* | 0.404* | 1 | ||
| Hospital cost | 0.267* | 0.188 | 0.734* | 0.24 | 0.21 | 0.695* | 1 | |
| Patient satisfaction | −0.115 | −0.049 | 0.098 | −0.17 | −0.175 | −0.043 | 0.071 | 1 |
*P < 0.05.
Discussion
The adoption of ERAS protocols has improved in the past few decades in the fields of urological,8 gastrointestinal, oncologic,9 pancreatic,10 and thoracic and cardiac surgeries11 and hip and knee arthroplasty.12 A series of issues such as postoperative rehabilitation, postoperative complications, and postoperative neonatal feeding and nursing are associated with obstetric procedures. Eventually, obstetricians realized that ERAS protocols could be implemented successfully for the CS procedure, which is by far the most common surgical procedure performed in obstetrics.13 The early postoperative food intake strategy aims to promote patient recovery and reduce surgical stress and complications. This measure has been applied to various clinical fields to achieve good results.
Growing evidence has shown that the early food intake protocol for CS is safe, feasible, and effective. Recently, a consensus and recommendations were provided by the Society for Obstetric Anesthesia and Perinatology.14 Positive changes included the recommendation of a regular diet within 2 hours after cesarean delivery,4 encouragement of breastfeeding as early as possible, and earlier discharge. Protocol implementation is associated with several improved maternal outcomes, which were described effectively in earlier studies.4,15
The application of the early postoperative food intake strategy has become a routine procedure for managing CS in our department since October 2022. In our study, the early postoperative food intake strategy reduced the hospital stay duration. This also resulted in better clinical outcomes such as earlier flatus and lactation times, without increasing the rate of complications or readmission.
The implementation of the early postoperative feeding strategy is a multidisciplinary process and requires a team leader to coordinate between different team members and hospital management. Team members included an obstetrician, nurse, anesthesiologist, and patient. Our observations showed that the patient was the most important member of this team. Patient compliance has a positive role in the healing process and results in faster recovery.16 Our findings showed that the first flatus time and hospital stay length were shorter than those of the control group, which is consistent with the findings of previous studies,17–20 thus demonstrating that the time to first anal flatus and postoperative in-hospital time were significantly shorter than those of the control group (P < 0.001).
Because of a shorter hospital stay, a decrease should have been observed in hospital-associated costs.21,22 However, in our study, there were no significant differences in the costs associated with the two groups. This could be attributable to the fact of the management mode of direct rooming-in, and the costs of postpartum examinations for the newborn were also included in maternal hospitalization costs, resulting in the maternal hospitalization costs being higher than the actual cost. Surprisingly, our data showed that the early postoperative food intake strategy can largely reduce postoperative pain scores, which was consistent with the findings of McCoy et al.23
Early mobilization can improve numerous short-term outcomes after surgery, including the promotion of return of bowel function and a decrease in the length of hospital stays. In our study, although the mobilization time was shorter in the observation group than in the control group, this difference was not significant. The possible reasons are: first, postoperative analgesia was sufficient in the two groups. Hence, patients’ fear of pain could be eliminated, and their mobilization after surgery could be enhanced. Second, sample sizes were limited. Hence, more patients need to be included in future analyses.
All patients were successfully discharged after surgery without readmission. Our data showed that the difference in complication rates in both groups was insignificant. Only two patients (2/112) in the control group had postoperative incomplete intestinal obstructions; no postoperative complications occurred in the observation group (P > 0.05). A previous meta-analysis found that rapid recovery after CS relieved pain without increasing the risk of postoperative complications and readmission, which is consistent with the results of this study.24
After correlation analysis, we found that fasting time was positively correlated with pain score, flatus time, hospital stay, and hospital cost (P < 0.05). The pain score seemed mainly influenced by the duration of fasting. The length of hospital stay was positively correlated with the duration of fasting, which is consistent with the research conclusion of Tamang et al.18 The hospital cost is mainly influenced by the length of hospitalization. Therefore, early postoperative eating plays an important role in promoting rapid postoperative recovery for patients undergoing elective CS. Early postoperative eating promotes the recovery of gastrointestinal function, manifested as flatus in behavior. The recovery of gastrointestinal function can alleviate postoperative discomfort to a certain extent and promote early activity, which can further promote early discharge and reduce hospitalization costs.4
This study has some limitations. First, this study is a retrospective single-center study with a small sample size. Prospective multicenter studies need to be performed in the future to verify and validate these findings. Second, the patients were classified into the control and observation groups based on the time of food intake after surgery. However, the Enhanced Recovery After Cesarean section (ERAC) guidelines recommend that food intake be started as early as 2 hours after surgery, which contrasts with the findings of our study. To a certain extent, pregnant women undergoing CS still show poor acceptance of our hospital’s early postoperative feeding management measures. Moreover, because some patients were injected with sedative drugs during surgery, this may have resulted in drowsiness up to 2 hours after surgery. Third, there are intergroup differences in the age, gravidity, number of CS, and BMI of the subjects included in this study. Therefore, subsequent research should consider the existence of component differences and conduct a hierarchical analysis of relevant factors. Hence, some obstacles are still associated with ERAC strategy implementation. Propaganda and education should be strengthened to lay a foundation for implementing rapid rehabilitation measures in the future.
To our knowledge, this is the first study to consider the recovery of lower limb muscle strength as a key factor for postoperative dietary recovery, providing a basis for more efficient recovery research after CS in the future. Meanwhile, this study explored the correlation analysis between regular diet recovery after normal muscle strength restoration and relevant factors and confirmed the value of regular diet recovery after normal muscle strength restoration post CS in promoting gastrointestinal function recovery, thereby improving postoperative pain and early discharge without the occurrence of intestinal obstruction.
Conclusion
The implementation of the early food intake protocol can significantly decrease the flatus time, lactation time, and length of hospital stay, while improving patient satisfaction without increasing complications and readmission rates. Such quality improvement initiatives and evidence-based practices should be adopted in postoperative management to improve the outcomes of elective CS patients.
Funding
This work was supported by grants from National Natural Science Foundation of China (grant no. 82101789), Changsha Natural Science Foundation (grant no. Kq2202369), General project of Hunan Provincial Health Commission (grant no. B202305026242).
Author Contributions
Ping Li, Caihong Hu, Kuiling Fei, Yuelan Liu, Xiao’e Jiang, Wenjing Yong, and Weishe Zhang have full access to all the data in the study. Ping Li and Caihong Hu take responsibility for the integrity of the data and the accuracy of the data analysis, conceptualized the study, and wrote the manuscript. Caihong Hu performed the statistical analysis. All the authors contributed to the interpretation of the data, revised the manuscript critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Data Availability
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
Footnotes
First online publication: 4 April 2024
How to cite this article: Hu C, Fei K, Liu Y, Jiang X, Yong W, Zhang W, Li P. The Impact of Regular Diet Recovery on Postoperative Rehabilitation After Elective Cesarean Section. Maternal Fetal Med 2024;6(2):78–83. doi: 10.1097/FM9.0000000000000224.
Contributor Information
Caihong Hu, Email: 2645840648@qq.com.
Kuilin Fei, Email: 63738003@qq.com.
Yuelan Liu, Email: lanlyliu1988@126.com.
Xiaoe Jiang, Email: 252420278@qq.com.
Wenjing Yong, Email: chrispaper@sina.com.
Weishe Zhang, Email: caihong__hu@163.com.
Yang Pan, Email: 269330035@qq.com.
Conflicts of Interest
None.
References
- 1.Qiao J Wang Y Li X, et al. A lancet commission on 70 years of women's reproductive, maternal, newborn, child, and adolescent health in China. Lancet 2021;397(10293):2497–2536. 10.1016/S0140-6736(20)32708-2. [DOI] [PubMed] [Google Scholar]
- 2.Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78(5):606–617. 10.1093/bja/78.5.606. [DOI] [PubMed] [Google Scholar]
- 3.Caughey AB Wood SL Macones GA, et al. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (part 2). Am J Obstet Gynecol 2018;219(6):533–544. 10.1016/j.ajog.2018.08.006. [DOI] [PubMed] [Google Scholar]
- 4.Macones GA Caughey AB Wood SL, et al. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). Am J Obstet Gynecol 2019;221(3):247.e1–247.e9. 10.1016/j.ajog.2019.04.012. [DOI] [PubMed] [Google Scholar]
- 5.Bowden SJ Dooley W Hanrahan J, et al. Fast-track pathway for elective caesarean section: a quality improvement initiative to promote day 1 discharge. BMJ Open Qual 2019;8(2):e000465. 10.1136/bmjoq-2018-000465. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Fay EE Hitti JE Delgado CM, et al. An Enhanced Recovery After Surgery pathway for cesarean delivery decreases hospital stay and cost. Am J Obstet Gynecol 2019;221(4):349.e1–349.e9. 10.1016/j.ajog.2019.06.041. [DOI] [PubMed] [Google Scholar]
- 7.Wendler E Nassif P Malafaia O, et al. Shorten preoperative fasting and introducing early eating assistance in recovery after gastrojejunal bypass? Arq Bras Cir Dig 2022;34(3):e1606. 10.1590/0102-672020210003e1606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Prionas A, Craddock C, Papalois V. Enhanced recovery after renal transplantation decreases recipients' urological complications and hospital stay: a systematic review and meta-analysis. J Clin Med 2021;10(11):2286. 10.3390/jcm10112286. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Brown ML Simpson V Clark AB, et al. ERAS implementation in an urban patient population undergoing gynecologic surgery. Best Pract Res Clin Obstet Gynaecol 2022;85(Pt B):1–11. 10.1016/j.bpobgyn.2022.07.009. [DOI] [PubMed] [Google Scholar]
- 10.Melloul E Lassen K Roulin D, et al. Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg 2020;44(7):2056–2084. 10.1007/s00268-020-05462-w. [DOI] [PubMed] [Google Scholar]
- 11.Salenger R Morton-Bailey V Grant M, et al. Cardiac enhanced recovery after surgery: a guide to team building and successful implementation. Semin Thorac Cardiovasc Surg 2020;32(2):187–196. 10.1053/j.semtcvs.2020.02.029. [DOI] [PubMed] [Google Scholar]
- 12.Li J, Zhu H, Liao R. Enhanced Recovery After Surgery (ERAS) pathway for primary hip and knee arthroplasty: study protocol for a randomized controlled trial. Trials 2019;20(1):599. 10.1186/s13063-019-3706-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Sordia Pineyro MO Villegas-Cruz C Hernandez-Bazaldua M, et al. Effect of the implementation of an Enhanced Recovery After Surgery protocol (ERAS) in patients undergoing an elective cesarean section. Ginekol Pol 2023;94(2):141–145. 10.5603/GP.a2023.0003. [DOI] [PubMed] [Google Scholar]
- 14.Bollag L Lim G Sultan P, et al. Society for Obstetric Anesthesia and Perinatology: consensus statement and recommendations for enhanced recovery after cesarean. Anesth Analg 2021;132(5):1362–1377. 10.1213/ANE.0000000000005257. [DOI] [PubMed] [Google Scholar]
- 15.Huang J Cao C Nelson G, et al. A review of Enhanced Recovery After Surgery principles used for scheduled caesarean delivery. J Obstet Gynaecol Can 2019;41(12):1775–1788. 10.1016/j.jogc.2018.05.043. [DOI] [PubMed] [Google Scholar]
- 16.Mullman L Hilden P Goral J, et al. Improved outcomes with an enhanced recovery approach to cesarean delivery. Obstet Gynecol 2020;136(4):685–691. 10.1097/AOG.0000000000004023. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Zhang S Chen J Li H, et al. Clinical application of enhanced recovery after surgery concept in laparoscopic treatment of pediatric acute appendicitis. Pediatr Surg Int 2023;39(1):178. 10.1007/s00383-023-05439-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Tamang T Wangchuk T Zangmo C, et al. The successful implementation of the Enhanced Recovery After Surgery (ERAS) program among caesarean deliveries in Bhutan to reduce the postoperative length of hospital stay. BMC Pregnancy Childbirth 2021;21(1):637. 10.1186/s12884-021-04105-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Teigen NC Sahasrabudhe N Doulaveris G, et al. Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial. Am J Obstet Gynecol 2020;222(4):372.e1–372.e10. 10.1016/j.ajog.2019.10.009. [DOI] [PubMed] [Google Scholar]
- 20.Zhu T Lu W Wang W, et al. Effect of patient-controlled epidural analgesia (PCEA) based on ERAS on postoperative recovery of patients undergoing gynecological laparoscopic surgery. Evid Based Complement Alternat Med 2022;2022:6458525. 10.1155/2022/6458525. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Pujić B Vejnović T Jovanović L, et al. Implementation of ERAS protocol for cesarean section. Acta Clin Croat 2022;61(suppl 2):151–154. 10.20471/acc.2022.61.s2.20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Pujic B Kendrisic M Shotwell M, et al. A survey of Enhanced Recovery After Surgery protocols for cesarean delivery in Serbia. Front Med (Lausanne) 2018;5:100. 10.3389/fmed.2018.00100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.McCoy JA Gutman S Hamm RF, et al. The association between implementation of an enhanced recovery after cesarean pathway with standardized discharge prescriptions and opioid use and pain experience after cesarean delivery. Am J Perinatol 2021;38(13):1341–1347. 10.1055/s-0041-1732378. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Sultan P Sharawi N Blake L, et al. Impact of enhanced recovery after cesarean delivery on maternal outcomes: a systematic review and meta-analysis. Anaesth Crit Care Pain Med 2021;40(5):100935. 10.1016/j.accpm.2021.100935. [DOI] [PubMed] [Google Scholar]