Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews.
The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting.



Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS).



Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate.



Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.
School of Medicine and Dentistry, University of Sheffield, Sheffield, UK.
Ellena
E
Corso
Clinical Trials Research Unit, Regent Court, 30 Regent St, Sheffield, S1 4DA, UK. d.hind@sheffield.ac.uk.
Daniel
D
Hind
Clinical Trials Research Unit, Regent Court, 30 Regent St, Sheffield, S1 4DA, UK.
Daniel
D
Beever
School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA, UK.
Gordon
G
Fuller
School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA, UK.
Matthew J
MJ
Wilson
Sheffield Teaching Hospitals Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
Ian J
IJ
Wrench
School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent St, Sheffield, S1 4DA, UK.
Duncan
D
Chambers
D000359:Aftercare / Q000379:methods / Q000592:standards*; D002585:Cesarean Section / Q000379:methods / Q000592:standards*; D002985:Clinical Protocols; D017558:Elective Surgical Procedures / Q000379:methods / Q000592:standards*; D005260:Female; D006801:Humans; D007902:Length of Stay; D011181:Postnatal Care / Q000379:methods / Q000592:standards*; D011247:Pregnancy; D000078202:Systematic Reviews as Topic
Elective caesarean; Enhanced recovery; Length of stay