ERAS Society Updates 2025 Guidelines for Safer Cesarean Delivery Recovery
New evidence-based recommendations target antenatal and preoperative care to boost recovery outcomes for cesarean patients and their newborns.
Summary
The Enhanced Recovery After Surgery (ERAS) Society issued its first update since 2018 to guidelines covering antenatal and preoperative care for cesarean delivery. Using a rigorous Delphi consensus process and GRADE evidence grading, the panel identified six key interventions: patient education during pregnancy, multidisciplinary staff training, optimization of comorbidities like anemia and diabetes, chlorhexidine skin preparation the night before surgery, updated preoperative fasting guidance, and preoperative carbohydrate drinks. The first three apply during the antenatal period (10–38 weeks), while the last three are implemented directly before surgery. Together, these recommendations aim to improve patient experience, reduce complications, and enhance neonatal outcomes while lowering healthcare costs.
Detailed Summary
Cesarean delivery is one of the most commonly performed surgeries worldwide, yet recovery protocols have historically lacked standardization. Enhanced Recovery After Surgery (ERAS) protocols—originally developed for general surgery—have been adapted for obstetrics to close this gap. This 2025 update from the ERAS Society represents the first revision of its cesarean-specific antenatal and preoperative guidelines since 2018, reflecting nearly seven years of new evidence.
The research team used the Delphi method for expert consensus and conducted a comprehensive literature search through September 2024 across six major databases. Evidence quality and recommendation strength were graded using the GRADE system, ensuring transparency about the certainty behind each recommendation.
Six interventions earned formal recommendations. Antenatal patient education and multidisciplinary staff training both received strong recommendations despite low-quality evidence, reflecting expert consensus on their foundational importance. Comorbidity optimization—addressing conditions such as anemia, obesity, gestational diabetes, hypertension, and smoking—earned a strong recommendation supported by moderate evidence, underscoring that medical preparation well before surgery meaningfully impacts outcomes.
On the preoperative side, chlorhexidine gluconate skin preparation the night before surgery received a weak recommendation based on moderate evidence. Updated fasting duration guidance and the use of preoperative carbohydrate drinks also featured prominently, with the carbohydrate drink earning a strong recommendation despite mixed evidence quality, given its potential to reduce insulin resistance and improve patient comfort.
The guidelines highlight that while these practices are often considered routine, their implementation and measurable impact vary considerably across clinical settings. The authors call for better-designed shared decision-making tools that integrate comorbidity management into obstetric care pathways, with the ultimate goal of maximizing maternal recovery quality and neonatal outcomes for all scheduled cesarean deliveries.
Key Findings
- Comorbidity optimization (anemia, obesity, diabetes, hypertension) during pregnancy strongly recommended with moderate evidence.
- Preoperative carbohydrate drinks earned a strong recommendation to reduce insulin resistance and improve patient comfort.
- Chlorhexidine gluconate skin prep the evening before surgery received a weak recommendation based on moderate evidence.
- Multidisciplinary staff education on ERAS protocols strongly recommended despite only low-quality supporting evidence.
- Antenatal patient education for scheduled cesarean delivery carries a strong recommendation despite low to very low evidence quality.
Methodology
Expert consensus was established via the Delphi method, with a systematic literature search across six databases through September 2024 targeting RCTs and large observational studies (≥800 patients). Evidence quality and recommendation strength were graded using the GRADE framework.
Study Limitations
Several recommendations rest on low or very low quality evidence, reflecting gaps in rigorous RCT data for obstetric ERAS interventions. The guidelines are based on the abstract only, limiting full appraisal of individual study quality and effect sizes. Implementation fidelity varies widely across healthcare settings, which may limit real-world generalizability.
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