Comparison of Enhanced Recovery After Cesarean protocol versus Traditional approach in elective lower segment cesarean section under spinal anaesthesia : A Prospective Observational Study.

It is a hospital based prospective randomised observational study to be conducted by the Department Of Anaesthesiology, Mahatma Gandhi Medical College & Hospital.

The initiation of this study is contingent upon obtaining ethical clearance from the Institutional Ethics Committee (IEC). Comprehensive written and informed consent will be diligently obtained from all participating patients.

The sample size was estimated by using the formula for comparison of two independent mean. Anticipating a medium effect size of 0.5 in the day of readiness for discharge between the two groups, the minimum sample size required is 172 i.e., 86 in each group at 5 % level of significance and 90% power.

A multi disciplinary team comprising anaesthesiologists, obstetricians, neonatologists, and nursing professional, will gather to discuss the change in peri partum management of patient undergoing elective cesarean section. After going through various guidelines proposed by Society of Obstetric Anaesthesia and Perinatology, American College of Obstetrics and Gynaecology, and ERAC society and extensive discussion, strategies for standardization of care was decided. Broadly major components, which will be key to improved outcome according to previous research and found feasible to implement in our hospital will be included in the revised ERAC protocol.

Parturients undergoing traditional protocol will continue the routine practice of admission a day prior to surgery, with scheduled preoperative counselling, overnight fasting, and liberal fluid administration along with use of povidone iodine as a standard antiseptic for all aseptic procedures. Standard practice of day 2 mobilization and delayed catheter removal will be continued for them. In the ERAC protocol, parturients will be counselled in detail on antenatal visit about risks and complications associated with the procedure and will  also be sensitized about the ERAC program and its benefits. After thorough understanding of the ERAC components and approval, parturients will be asked to get admitted a day prior to surgery or on the day of surgery with advice to be followed at home for prior day. Alcohol based chlorhexidine solution will be used for asepsis except for vaginal toileting.

Pre-operative fasting will be reduced to 2 hrs for clear liquids and carbohydrate rich drinks will be given a night before and on the day of surgery to avoid hypoglycaemia. Neuraxial anaesthesia  (Sub-arachnoid Block; SAB) will be administered in both the protocols. In ERAC Protocol, USG guided Transversus Abdominis Plane block will be given for post-operative pain relief. In ERAC protocol, patients will receive fluid administration @15–20 ml/hr  and early feeding (within 2 hrs sips of water) early mobilization and de-catheterization within 6–10 hrs with multimodal analgesia to cover postoperative pain.