Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2026.844817
Brazilian Journal of Anesthesiology
Review Article

Enhanced recovery after surgery for cesarean delivery: a systematic review and meta-analysis of randomized trials with trial sequential analysis

Recuperação otimizada após cirurgia para parto cesárea: uma revisão sistemática e metanálise de ensaios clínicos randomizados com análise sequencial de ensaios

Tauãna Terra Cordeiro de Oliveira, Vanessa Tapioca, Eduardo Pereira, Bruna Ferreira, Tamiris Soares, Sara Amaral, Maria Luisa Assis, Gabriel Carvalho, Julio S. Curi, Kamal Kumar

http://dx.doi.org/10.1016/j.bjane.2026.844817 Braz J Anesthesiol, vol.76, n5, 844817, 2026
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Abstract

Background

Enhanced Recovery After Surgery (ERAS) protocols have improved perioperative care across multiple surgical specialties. In obstetrics, ERAS pathways for cesarean delivery have been increasingly adopted; however, their comparative effectiveness versus standard care remains uncertain. Therefore, we conducted a systematic review and meta-analysis with trial sequential analysis to compare ERAS protocols with standard perioperative care in cesarean delivery.

Methods

We systematically searched MEDLINE, Embase, Web of Science, and Cochrane databases for Randomized Clinical Trials (RCTs) comparing ERAS and standard care in parturient undergoing cesarean delivery. Statistical analyses were performed using R software (version 4.2.2). We conducted subgroup analyses based on cesarean category (elective vs. emergency) and national income level. A Trial Sequential Analysis (TSA) was also performed.

Results

We included 13 RCTs comprising 1,809 parturient. ERAS was associated with a significant reduction in hospital Length of Stay (LOS) compared with standard care (MD = -17.05 hours, 95% CI -25.08 to -9.02 hours, I2 = 98.2%, n = 1,128, p < 0.01), with similar effects across elective and emergency cesarean deliveries. Greater reductions were observed in low- and middle-income countries, whereas no significant difference was identified in upper-middle-income settings, albeit formal subgroup test was not significant. ERAS was associated with lower postoperative pain at 24 and 48 hours, reduced wound infection, and higher maternal satisfaction, with no differences in readmission and postoperative nausea and vomiting. TSA suggested that the accrued sample size was adequate for hospital LOS; however, this should be interpreted cautiously given the substantial clinical and methodological heterogeneity.

Conclusion

This systematic review and meta-analysis suggest that ERAS protocols may be associated with reduced hospital stay and improved maternal recovery after cesarean delivery.

Keywords

Cesarean section; Enhanced recovery after surgery; Length of stay; Maternal health; Perioperative care; Postoperative care

Resumo

Introdução

Os protocolos de recuperação otimizada após cirurgia (ERAS, do inglês Enhanced Recovery After Surgery) têm melhorado a assistência perioperatória em múltiplas especialidades cirúrgicas. Na obstetrícia, as diretrizes de ERAS para o parto cesárea têm sido cada vez mais adotadas; no entanto, sua eficácia comparativa em relação aos cuidados convencionais permanece incerta. Portanto, conduzimos uma revisão sistemática e metanálise com análise sequencial de ensaios para comparar os protocolos ERAS com os cuidados perioperatórios convencionais no parto cesárea.

Métodos

Realizamos buscas sistemáticas nas bases de dados MEDLINE, Embase, Web of Science e Cochrane para ensaios clínicos randomizados (ECRs) que comparassem o ERAS e os cuidados convencionais em parturientes submetidas a parto cesárea. As análises estatísticas foram realizadas no software R (versão 4.2.2). Realizamos análises de subgrupos com base na categoria da cesárea (eletiva vs. urgência/emergência) e no nível de renda nacional. Uma análise sequencial de ensaios (TSA, do inglês Trial Sequential Analysis) também foi realizada.

Resultados

Foram incluídos 13 ECRs totalizando 1.809 parturientes. O ERAS foi associado a uma redução significativa no tempo de internação hospitalar em comparação com os cuidados convencionais (DM = -17,05 horas, IC 95% -25,08 a -9,02 horas, I² = 98,2%, n = 1.128, p < 0,01), com efeitos semelhantes em partos cesáreos eletivos e de urgência/emergência. Reduções maiores foram observadas em países de baixa e média renda, ao passo que nenhuma diferença significativa foi identificada em cenários de alta-média renda, embora o teste formal de subgrupo não tenha sido significativo. O ERAS foi associado a menor dor pós-operatória em 24 e 48 horas, redução de infecção de ferida operatória e maior satisfação materna, sem diferenças na readmissão e em náuseas e vômitos pós-operatórios. A TSA sugeriu que o tamanho amostral acumulado foi adequado para o tempo de internação hospitalar; contudo, isso deve ser interpretado com cautela devido à substancial heterogeneidade clínica e metodológica.

Conclusão

Esta revisão sistemática e metanálise sugere que os protocolos ERAS podem estar associados à redução do tempo de internação hospitalar e à melhora da recuperação materna após o parto cesárea.

Palavras-chave

Cesárea; Recuperação otimizada após cirurgia; Tempo de internação; Saúde materna; Assistência perioperatória; Cuidados pós-operatórios

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Submitted date:
02/18/2026

Accepted date:
07/31/2026

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