Walker Melissa, Sobel Mara, Siddiqi Naveed, Carvalho Jose C A, Jahan Nighat, Santini Sara, Watts Nancy, Dart Kim, Wang Stella, Huszti Ella, Thomas Jackie
Obstetrics and Gynecology, Sinai Health System, Toronto, Ontario, Canada.
Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.
BMJ Open Qual. 2025 Jul 30;14(3):e003391. doi: 10.1136/bmjoq-2025-003391.
Enhanced recovery after caesarean delivery (ERAC) is a multidisciplinary, evidence-based bundle of interventions developed from Enhanced Recovery After Surgery principles, designed to improve patient outcomes, reduce complications and save healthcare resources. Despite these benefits, the implementation of ERAC within the Canadian healthcare context is unknown. In addition, previous ERAC studies typically excluded patients undergoing unplanned caesarean deliveries (CD). The objective of our study was to evaluate the results of a quality improvement initiative that implemented a comprehensive ERAC pathway for both planned and unplanned CD in a large Canadian obstetric unit, with a specific focus on patient-reported outcomes.
A pre-implementation post implementation design was used. The primary outcomes were Obstetric Quality of Recovery Score (ObsQoR-10) and patient satisfaction at 6 weeks postpartum. Secondary outcomes included postpartum length of stay, postoperative pain and maternal infectious morbidity.
Antenatal, intraoperative and postoperative ERAC bundles were developed with multidisciplinary input.
513 patients were included: 290 pre-implementation (149 planned CD, 141 unplanned CD) and 223 post- implementation (128 planned CD, 95 unplanned CD). Baseline demographics were similar, except the post implementation groups had significantly higher median Body Mass Index (BMI). In planned CD, ObsQoR-10 scores were on average 3.4 points higher in the post-implementation group (95% CI (-0.19 to 6.99); p-value=0.063). Patient satisfaction assessed at 6 weeks postpartum was significantly improved by 12 points in the post-implementation group (95% CI (5.58 to 18.62); p-value<0.001). In unplanned CD, implementation was not associated with ObsQoR-10 (p-value=0.92) or patient satisfaction assessed at 6 weeks postpartum (p-value=0.43). Pain scores were higher in both post-implementation groups, but there were no differences in morphine milliequivalents or requirement for breakthrough opioids. Length of stay and maternal infectious morbidity were similar.
Implementation of ERAC in a large Canadian tertiary care obstetrics unit was feasible and resulted in improved recovery and increased satisfaction in patients undergoing planned CD. There were no differences in other outcomes, including infectious morbidity; however, the contribution of BMI needs to be explored. Patients undergoing unplanned CD face additional challenges related to outcomes, recovery and satisfaction and should be targeted in future studies.
剖宫产术后加速康复（ERAC）是基于外科手术后加速康复原则制定的多学科、循证干预措施组合，旨在改善患者预后、减少并发症并节省医疗资源。尽管有这些益处，但在加拿大医疗环境中ERAC的实施情况尚不清楚。此外，以往的ERAC研究通常排除了接受非计划剖宫产（CD）的患者。我们研究的目的是评估一项质量改进举措的结果，该举措在加拿大一个大型产科单位为计划内和非计划内剖宫产实施了全面的ERAC路径，特别关注患者报告的结局。
采用实施前-实施后设计。主要结局是产科康复质量评分（ObsQoR-10）和产后6周时的患者满意度。次要结局包括产后住院时间、术后疼痛和产妇感染发病率。
在多学科参与下制定了产前、术中和术后的ERAC干预措施组合。
纳入513例患者：290例实施前（149例计划剖宫产，141例非计划剖宫产）和223例实施后（128例计划剖宫产，95例非计划剖宫产）。除实施后组的中位体重指数（BMI）显著较高外，基线人口统计学特征相似。在计划剖宫产中，实施后组的ObsQoR-10评分平均高出3.4分（95%CI（-0.19至6.99）；p值=0.063）。实施后组产后6周评估的患者满意度显著提高了12分（95%CI（5.58至18.62）；p值<0.001）。在非计划剖宫产中，实施与ObsQoR-10（p值=0.92）或产后6周评估的患者满意度（p值=0.43）无关。两个实施后组的疼痛评分均较高，但吗啡毫克当量或突破性阿片类药物需求无差异。住院时间和产妇感染发病率相似。
在加拿大一个大型三级护理产科单位实施ERAC是可行的，并改善了计划剖宫产患者的康复情况并提高了满意度。在包括感染发病率在内的其他结局方面没有差异；然而，需要探讨BMI的影响。接受非计划剖宫产的患者在结局、康复和满意度方面面临额外挑战，未来研究应将其作为目标。
