Journal of Obstetric Anaesthesia and Critical Care

: 2020  |  Volume : 10  |  Issue : 1  |  Page : 1--3

Enhanced recovery after surgery in obstetric patients – Are we ready?

Anjan Trikha, Manpreet Kaur 
 Department of Anaesthesiology Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Prof. Anjan Trikha
Department of Anaesthesiology Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi

How to cite this article:
Trikha A, Kaur M. Enhanced recovery after surgery in obstetric patients – Are we ready?.J Obstet Anaesth Crit Care 2020;10:1-3

How to cite this URL:
Trikha A, Kaur M. Enhanced recovery after surgery in obstetric patients – Are we ready?. J Obstet Anaesth Crit Care [serial online] 2020 [cited 2020 Aug 6 ];10:1-3
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Full Text

Enhanced recovery after surgery (ERAS) for various surgical procedures has been embraced by many developed countries. Obstetric surgeons and anaesthesiologists are not far behind. However, a lot needs to be ensured before the developing countries like India can follow the developed nation. ERAS protocols were first published for colorectal surgeries by Henrik Kehlet in 1997.[1] Later, these protocols have been modified and have proliferated across different specialities which include bariatric, breast, plastic, cardiac, colorectal, oesophageal, head and neck, hepatic, gynaecologic oncology, neurosurgical, orthopaedic, pancreatic, thoracic and urologic surgery.[2],[3],[4],[5],[6],[7] However, fast track adoption in obstetric surgeries is a less travelled ground. Recently, in August 2019, the guidelines for perioperative care in caesarean delivery (ERAS society) recommendations have been published.[8] But its applicability in developing countries like India, especially in a low resource setting, is itself a challenge.

The core tenants of ERAS pathways include efficient perioperative management for early recovery (euvolemia, adequate perioperative pain relief, use of minimally invasive surgical techniques, early feeding, early removal of urinary catheters, effective postoperative analgesia, prevention of postoperative complications like nausea and vomiting, early oral intake) which have been modified depending upon the type of surgeries.[9] Different systematic reviews have assessed components of ERAS and there is significant variability of components being employed.[10] A few modifications incorporated include the provision of preadmission information to parturient, delayed umbilical cord clamping, postoperative antibiotic prophylaxis, breastfeeding education, discharging the parturient with caution for warning signs and care of the new-born.[8],[11]

Applying ERAS in obstetric patients needs to cover a vast horizon and a different subset of parturient. Obstetric patients can present for surgeries other than the cesarean section. These include cervical encirclage, ovarian cysts, etc., and often require hospital admission for 2-3 days. The implementation of ERAS in them is rather simple, and once they meet the discharge criteria, they are discharged as soon as possible.

The goal of implementing these protocols after caesarean section would be a rapid return to normal physiological activities, reduction of the duration of parturient stay, cost-saving for obstetric units and earlier discharge. This, in turn, can provide increased maternal satisfaction and enhanced maternal-neonatal bonding Thus, there is widespread interest in introducing ERAS protocols in obstetric patients. Also, National institute for health and care excellence (NICE) guidelines recommends “women who are recovering well, are apyrexial and do not have complications following Caesarean Section should be offered early discharge (after 24 hours) from hospital and follow-up at home”.[12] Reviewing the literature indicates that ERAS protocols after caesarean are being published mainly from high resource countries but its implementation in developing countries pose unique challenges.[10],[11],[13],[14],[15]

The prime barriers for introducing ERAS in obstetric patients in developing countries are illiteracy, big rural and urban divide inability to recognise early warning signs and poor infrastructure, lack of trained staff for ERAS protocols, lack of strong telecommunication and networking.

In developing countries like India, illiteracy is a major impediment. ERAS has the potential for early discharge if parturient is literate enough to recognize the warning signs and if there is a provision of a good telephonic communication system to report such complications. Hence, patient education is essential for assessing early warning signs of impending complications. This might not be practicable in developing countries where illiteracy is a major setback.

There are glaring disparities between rural and urban sectors in developing countries. Maternal mortality in rural women is high,[16] wherein the provision of modern amenities and healthcare facilities is lacking. These rural women often do not have access to large public or private referral centres where the implementation of ERAS is possible. For bridging the rural-urban divide and to reduce maternal mortality, the Indian government started schemes like Janani Suraksha Yojana (JSY) (2005) for safe motherhood and to promote institutional deliveries. It integrates cash assistance with delivery and post-delivery care parturient below poverty line as decided by government of india. In an attempt to bridge the social gap, cash assistance in the rural area is higher than in urban area for facilitating institutional delivery. But the implementation of ERAS would mean early discharge, which might result in neglecting a few warning signs in a setting of lack of optimal training. These programmes do not provide incentives for readmission for any postoperative complications. So, readmission would mean a heavy financial burden upon the low-income families, and besides, they will only get admitted once they are extremely sick. Besides, the communication system might not be that robust in rural areas to report mishaps at the earliest due to poor infrastructure. Teaching and training woman health volunteers ASHA (Accredited Social Health Activist) for post-caesarean care requires substantial financial investment by the government. In order to promote readmission, cash incentive for both peripartum women and ASHA for readmission has to be introduced by the government, which in turn will cause health care economic pressure. Our system of training ASHA workers is still deficient as they are not very efficient in early detection of red flags for post-surgical obstetric complications and neonatal complications.

FIGO (International Federation of Gynaecology and Obstetrics) has suggested 6–12 weeks follow-up after birth in complicated pregnancies (Preeclampsia, gestational diabetes mellites and placental complications) to limit the chronic morbidity due to gestational adverse events.[13] With limited health system resources ERAS implementation in such high-risk pregnancies is not realistic in India in the present time. Besides, anaemia in pregnancy prevalence in India is among the highest in the world,[14] and it might not be practically possible to early discharge such parturients with low haemoglobin.

Parturient in developed countries is sent back home with discharge summary, parturient and child care information booklet, telephonic contact networking and midwives home visit the parturient home twice or thrice during the first 10 days.[11],[15],[17] Such a strong telecommunication system, well-trained health visitors is practically not possible in vast country like India due to economic constraints. Hence, there is need for the allocation of resources for patient education, training staff for ERAS protocols, initiation and strict implementation of a follow up system for all institutional deliveries - caesarean or otherwise.

To complement the ERAS pathway, the concept of the perioperative surgical home (PSH) has developed which extends beyond the immediate perioperative period as an external outpatient setting.[7],[18],[19] Wherein an anaesthesiologist-intensivist together with a nurse practitioner provides and integrates perioperative care including post-discharge plans (home or step-down recovery or outpatient medical home). This concept is coming up in developed countries and is still not part of developing nations. Future integration of PSH (in the form of stepdown recoveries, accountable care organizations) with centres practising ERAS in developing nations is needed for successful ERAS implementation. Hence, in our opinion, all obstetric anaesthesiologists can play a very important role in this area and can be lead physicians in the perioperative care of Obstetric ERAS parturient.

The appropriate time for a maternal discharge not only depends upon the maternal wellbeing but also neonatal wellbeing. An infant is discharged once he/she has attained necessary physiologic maturity, parents have received the necessary teaching for neonatal care, established competent feeding by breast or bottle and the child has been immunised.[20] In Indian set up, a healthy newborn is usually discharged within 48-72 hrs unless there is a specific indication for prolonged admission.[20] If the neonate has some special health care needs or concerns, the mother is often not discharged from the hospital. Hence, the implementation of ERAS is unlikely to be possible in this group of parturient. To alleviate this problem, an appropriate solution would be to have a step-down area like Dharamshala (hospital-like areas) wherein the mother can be shifted and would have close monitoring of warning signs in her as well as in baby.

An efficient telecommunication system to facilitate smooth recovery is needed to prevent any complications postoperatively. Technology advancements in the form of telemedicine and wearable monitoring sensors can complement the ERAS protocols.[7] However, these advancements are at the present time out of reach for the rural population though not impossible to initiate and implement in a phased manner.

One of the targets of ERAS protocols is reducing cost without causing any increase in morbidity and ensuring patient safety and comfort. Hence, though the adoption of ERAS is gaining popularity in western countries[21] which is well supported by strong networking and infrastructure, there is still a long way for the implementation of ERAS in obstetric patients in India and other such developing countries. It is suggested that the government should initiate programs in this respect in phased manner, though it is unlikely that at the present time this would happen as all the efforts are directed to achieve the Fifth Millennium Development Goal (i.e. 75% reduction in maternal mortality ratio [MMR] from 1990 by 2015) which has not yet been achieved,[22],[23] and meeting these goals would be first targeted by the government.


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