The significance of enhanced recovery after surgery (ERAS) protocols has been well established in non-obstetric surgery patients and was described by Wilmore and Kehlet, 15 years ago (1). Soon after ERAS protocol successes in speeding patient recovery, decreasing times to discharge form the hospital and improving patient outcomes were described in colorectal surgery patients (2), successful application was reported in urological, breast, pancreatectomy, liver resection, and gynecologic surgery (3–9). The ERAS approach emphasizes optimization of the processes of patient care, so that enhanced patient recovery can occur without decreasing the quality of care or patient satisfaction. ERAS aims to return the patient to normal life quickly. The increased efficiencies have been demonstrated to reduce waste of scarce resources (10) and thus reduce the overall cost of care. While significant variations in ERAS protocols exist both within and between surgical specialties (11), common elements often include effective patient education and acceptance, good perioperative hydration and nutrition, use of surgical techniques associated with fastest patient recovery, maintenance of perioperative patient normothermia, early removal of urinary catheters, adequate pain relief that promotes early ambulation and minimal use of perioperative opioids (which helps the return of bowel function quickly). The multidisciplinary approach requires commitment from the patient, as well as all of the persons involved in their perioperative care: surgeons, anesthesiologists, pain specialists, nursing staff, physical and occupational therapists, social services, and hospital administration. Successful ERAS protocol implementation involves the creation of a core team of anesthesiologists, obstetricians, specialist nurses, and hospital managers (12). The large number of elements that are required for implementation of an ERAS protocol often requires significant culture change in the health organization (12).

A survey tool of 22 questions with multiple choice answers was sent by email to all hospitals in Serbia (4 university teaching hospitals and 45 general hospitals), which provide obstetric services (Table 1). This survey was approved by Ethical Committee at the Clinical Center of Vojvodina. The questionnaire was completed by either the Chief of Obstetrics or Chief of Anesthesiology who had knowledge of all aspects of perioperative care within the institution, and only one questionnaire per institution was returned. One of the authors (BP) followed up after distribution of the survey to answer all responder questions. The questionnaire asked for the presence of ERAS protocols for CD in the hospital, preoperative patient counseling of the elements within the protocol, time of admission to hospital and hospital stay, bowel preparation prior surgery, antibiotic prophylaxis prior to skin incision, prevention of deep venous thrombosis (DVT), percentage of neuraxial anesthesia (NA) for elective and emergency CD, use of intrathecal analgesia, medications for postoperative analgesia, oral intake after CD, use of chewing gum in the early postoperative period, duration of IV fluid therapy, urinary catheter removal, early mobilization of the parturient, skin-to-skin contact between mother and baby in the operating theater, monitoring of body temperature, and active maternal warming intraoperatively. Overall responses were recorded, and the responses between those hospitals with ERAS protocols in place were compared with those who did not report having them. Pearson’ chi square test was used where appropriate for comparisons between groups in this prospective observational study (R version 3.3.3, R Core Team, R Foundation for Statistical Computing). Differences of P ≤ 0.05 were considered significant.

Responses were obtained from 46 of 49 hospitals (3 university and 43 general hospitals; a 94% response rate). ERAS protocols were in use in 11 of 46 (24%) of surveyed hospitals and 63% of the time the responsibility for patients counseling was shared between the obstetrician and anesthesiologist (Table 2).

This is the first survey of ERAS use in obstetrics in a middle-income country. In Serbian hospitals, patients are not encouraged to eat solid food early after surgery, early mobilization is not encouraged, and a bowel preparation is mandatory in almost all hospitals. There is also a low percentage of NA for CD and a low rate of neuraxial narcotics use.

The low rate of skin-to-skin contact during CD may be due to a low rate of NA use and may interfere with successful breast feeding. Lack of successful breastfeeding is among those factors that have been associated with longer lengths of stay after CD in the UK (16).

A quarter of hospitals in Serbia reported having adopted ERAS protocols. A similar type survey conducted in the UK by Aluri and Wrench, showed that only 10 of 158 labor units in the UK were specifically following one (22). Despite this larger reported use, many elements in the ERAS protocols implemented elsewhere have not been routinely adopted by hospitals in Serbia. Most hospitals, both those with ERAS and those without ERAS, admit patients the night before elective CD, use a bowel preparation, do not allow oral intake up until a few hours before the procedure, do not routinely remove urinary catheters on the day of operation, do not monitor perioperative maternal temperature, and do not engage in active measures to avoid maternal hypothermia. These are practices that differ from hospitals outside Serbia that report using ERAS protocols. Although use of maternal temperature monitoring is routine in less than half of labor and delivery units in the UK, use of the other ERAS elements appears widespread among patients who undergo CD (21, 22).

In 2012, Abel et al. reported on a 2-month use of ERAS protocols for CD and compared two groups of 60 parturients who followed ERAS and non-ERAS pathways (19). Drinking in the recovery room was encouraged and patients were fed and mobilized early. The length of stay (LOS) decreased from 3.3 to 2.1 days, and the readmission rate was reduced from 8.3% to 3.3%. They showed that most of the patients in the ERAS group (97.8%) were satisfied and would recommend ERAS to others undergoing CD or would choose it for themselves in the future. We do not know if patient acceptance would be similar in Serbian mothers as we did not include measures of patient satisfaction in our survey.

Wrench et al. reported initiation of an ERAS for elective CD in 2012 and noted a decrease in LOS and patient satisfaction. Over 2 years, the maternal discharge rate on Day 1 increased from 1.6 to 25.2% (16). In Serbian hospitals, mothers are almost never discharged after CD on postoperative days 1 or 2, although many mothers express the desire to do so. Wrench et al. reported initiation of an ERAS for elective CD in 2012 and noted a decrease in LOS and patient satisfaction. Over 2 years, the maternal discharge rate on Day 1 increased from 1.6 to 25.2% (16). In Serbian hospitals, mothers are almost never discharged after CD on postoperative days 1 or 2, although many mothers express the desire to do so. One reason may be that the cost to the patient of in hospital care is low and patients may not feel an economic incentive to leave. Hospital administrators may also have little economic incentive to do so either. Finally, robust follow-up after patients are discharged may be necessary for patients discharged sooner after CD and the out of facility Serbian health-care system may not be able to assist parturients who are discharged home early.

We showed that Serbian hospitals that report ERAS use discharge patients home earlier than in non-ERAS groups. However, many ERAS hospitals reported a high number of discharges after 3 days compared to surveys of UK hospitals that show that a majority of women are eager go home and are discharged within 2 days of their CD. The elements of an ERAS program that are most associated with a greater chance for early discharge have not been determined. Although we showed that few elements of ERAS protocols reported elsewhere are routinely used in Serbian hospitals, adoption of an ERAS protocol lead to earlier patient discharges. We suggest that the adoption of an ERAS protocol leads to a greater effort on part of hospital staff and patients to achieve earlier maternal discharge, independent of the elements within the protocol. This change in organization and the re-setting of both staff and patient expectations may be the most important reason for reducing hospital stay, as has been suggested by others (12).

The lower rate of early ambulation in the ERAS group vs. the non-ERAS group may reflect the greater use of NA in the ERAS group. Practitioners in Serbia may discourage ambulation in patients for fear of post dural puncture headache (PDPH) after NA, despite substantial work that suggests that the rate of PDPH after NA is not influenced by patient activity.

The cost benefits of ERAS adoption for CD may be considerable. Pilkington et al. (16) reported a possible reduction of 200,000 euros in hospital expenses after implementation of ERAS protocol for CD in their hospital.

All patients may not be suitable candidates for ERAS. The factors suggesting which patients would benefit most from ERAS protocols have not been determined. However, Lucas and Gough suggested that a successful ERAS implementation for CD requires at a minimum good patient education, good in-hospital care, and good community out-of-hospital care for early discharged mothers and babies. Coates et al. showed how implementation of an ERAS program increased maternal satisfaction, primarily by increasing the number of earlier discharges (22). They also noted that a significant improvement in neonatal assessment and early determination of a neonate’s status was essential for safe early discharge of both mother and child.

Our survey study has many limitations. As noted earlier, we did not survey for patient satisfaction, which would help in deciding if ERAS protocol introduction would be appropriate. We asked either the Chief of Obstetrics or Chief of Anesthesiology to complete the survey and there may be differences between groups of respondents, although follow-up to ensure understanding of the elements of the survey tool by author BP was rigorous and should have removed this bias. We did not ask the respondents about what barriers prevent the adoption of ERAS protocols, and thus using our data to affect change only identifies those elements for improvement, not how best to implement them. We asked many questions to help to describe perioperative CD care. This may have lead to our finding differences between ERAS and non-ERAS groups that may not be real. Finally, the elements of ERAS protocols which lead to improved maternal and neonatal outcomes have not been determined.

We found that hospitals that have adopted ERAS protocols discharge patients earlier than those that have not, although they do not use many of the elements reported from the UK. We simply do not know which elements are the most important. Patient education and institutional culture change may be the vital change needed. We suggest that setting the patient’s expectation that they would be discharged home early and setting staff expectations for the same may be more important than other factors in determining time to discharge after CD; we cannot determine this from our study.

Enhanced recovery after surgery protocols are in use at some Serbian hospitals for surgical procedures (mostly colorectal procedures), and some report the use of some elements of ERAS protocols for have CD as well. The results showed uncommon use of antibiotic prophylaxis prior to skin incision but routine use of DVT prophylaxis, earlier oral intake, and earlier discharge from the hospital post CD compared to hospitals not reporting ERAS use. Successful ERAS protocol implementation for CD in Serbian hospitals will require the great efforts of a multidisciplinary medical staff team and the outside community.

BP, MK, MS, YS, and CB all made substantial contributions to the conceptual design of the work, in acquiring the data, and in its analysis. All helped draft the work and revised it critically. All the authors approved this copy for publication. All agreed to be accountable for all aspects of the work in ensuring its accuracy and integrity.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.