Enhanced Recovery After Cesarean Section Improves Patient-Reported Outcomes Without Shortening Hospital Stay: RCT
Can We Make Cesarean Recovery Better Without Prolonging the Hospital Stay?
As cesarean section rates rise and fertility rates fall, physicians are seeking ways to improve postpartum recovery without increasing costs or length of stay (LOS). Enhanced Recovery After Cesarean Section (ERAC)—an adaptation of Enhanced Recovery After Surgery (ERAS) protocols—has gained attention. But does it truly deliver on its promise? A new randomized controlled trial in BMC Anesthesiology provides important insights.
ERAC vs. Standard Care: Study Design
Researchers randomized 140 women scheduled for elective cesarean section into two groups: ERAC or standard of care (SOC). The ERAC protocol included:
Reduced fasting intervals
Early mobilization and function training
Early urinary catheter removal
Multimodal analgesia (combining different pain medications)
Proactive nausea and vomiting prevention
Primary outcomes were hospital LOS and the Obstetric Quality-of-Recovery score (ObsQoR-11), a validated patient-reported outcome tool. Secondary outcomes included pain, time to first mobilization, bowel function, and complications.
Findings: Quality of Recovery Up, LOS Unchanged
Both groups had a similar average LOS (about 55 hours), with no significant difference between ERAC and SOC. However, patients in the ERAC group reported significantly higher ObsQoR-11 scores (median 77 vs. 60), indicating better overall recovery. The ERAC group also experienced:
Shorter time to first off-bed activity (22 vs. 24 hours)
Faster return of bowel function (13 vs. 18 hours to first flatulence)
Lower pain scores at 24 and 36 hours post-op
Comparable direct costs and complication rates compared to SOC
Why These Results Matter for Clinicians
The study demonstrates that ERAC protocols can improve patient-reported recovery quality after cesarean delivery—even when hospital stay and costs remain unchanged. Improvements included faster mobilization, better pain control, and earlier return of function, all without increasing adverse events.
Importantly, traditional metrics like LOS may not fully capture the patient experience. Incorporating validated tools such as ObsQoR-11 allows for a more patient-centered assessment of recovery.
Practical Considerations and Future Directions
Adopting ERAC elements—especially multimodal analgesia and early mobilization—is feasible and safe in busy tertiary hospitals. While LOS may be difficult to reduce further where high-quality care is already standard, focusing on patient-centered outcomes can meaningfully enhance recovery. Future studies should explore long-term outcomes, adaptation to local practice, and further integration of ERAC into routine obstetric care.
Conclusion
Enhanced Recovery After Cesarean Section protocols improve recovery quality without changing length of stay or costs. For clinicians, these findings support the shift toward patient-centered, evidence-based pathways in cesarean recovery.
Key points
ERAC protocols significantly improved ObsQoR-11 patient-reported recovery scores versus standard care.
Hospital length of stay and direct costs were unchanged between groups.
ERAC participants experienced better pain control and faster return to mobility and bowel function.
No increase in complications or readmissions was observed with ERAC protocol.
Patient-centered outcomes may better reflect recovery quality than LOS alone.
Citation:
Fan Y, Wang J, Xie H, Ding W, Song X, Huang J. Effects of enhanced recovery after cesarean section on hospital length of stay and Obstetric Quality-of-Recovery score (ObsQoR-11): a randomized controlled trial. BMC Anesthesiology. 2026;26:405. https://doi.org/10.1186/s12871-026-03890-0
