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01.12.2017 | Research article | Ausgabe 1/2017 Open Access

BMC Pregnancy and Childbirth 1/2017

Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews

BMC Pregnancy and Childbirth > Ausgabe 1/2017
Ellena Corso, Daniel Hind, Daniel Beever, Gordon Fuller, Matthew J. Wilson, Ian J. Wrench, Duncan Chambers
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s12884-017-1265-0) contains supplementary material, which is available to authorized users.



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.
Additional file 1: MEDLINE Search Strategy. This file provides a reproduction of the search strategy used in the MEDLINE search. (PDF 12 kb)
Additional file 2: Figure S1. Eligible studies for ERAS packages in elective caesarean. Flow diagram of the study selection process for ERAS packages in elective caesarean. (PDF 33 kb)
Additional file 3: Figure S2. Eligible systematic reviews for ERAS components and packages in any setting. Flow diagram of the study selection process for ERAS components and packages in any setting. (PDF 36 kb)
Additional file 4: Table S1. Excluded studies. Table listing the studies found to be ineligible at full reading (ERAS components and packages in any setting). (PDF 10 kb)
Additional file 5: Table S2. Components of pathways for enhanced recovery after elective CS. Table listing the various enhanced recovery components found in the included studies. (PDF 22 kb)
Additional file 6: Table S3. Outcomes reported by systematic reviews of components and pathways for ERAS. Table listing the various outcomes from the included studies, presented by category and in specific detail. (PDF 57 kb)
Additional file 7: Table S4. AGREE II criteria for assessing quality of studies of proposed ERAS packages in elective caesarean. Table presenting the results of the quality assessment undertaken in terms of risk of bias of the included studies (ERAS packages in elective caesarean). (PDF 22 kb)
Additional file 8: Table 5. Aggregate Summary of Findings table. Table presenting the summary of findings from the included studies (ERAS components and packages in any setting). (PDF 57 kb)
Additional file 9: Table 6. AMSTAR Assessment. Table presenting the results of the quality assessment undertaken in terms of risk of bias of the included studies (ERAS components and packages in any setting). (PDF 45 kb)
Additional file 10: Figure S3. Proposed mechanisms of action for broad categories of ERAS components. Figure illustrating how the proposed mechanisms of action may work in an enhanced recovery pathway. (PDF 212 kb)
Additional file 11: Table S7. Interventions, mechanisms and actions. Table detailing the theory of the proposed mechanisms of action in an enhanced recovery pathway. (PDF 22 kb)
Additional file 12: Table S8. Proposed barriers and facilitators of uptake. Table detailing the barriers and facilitators of adoption of healthcare innovations. (PDF 19 kb)
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