The efficacy and safety of enhanced recovery after surgery (ERAS) protocols in cesarean delivery: a meta-analysis of randomized controlled trials

BACKGROUND: Given the concerns regarding maternal and neonatal safety, the application of enhanced recovery after surgery (ERAS) in cesarean delivery remains controversial and has not been adopted in some regions. This study aims to conduct a meta-analysis to compare the ERAS pathway with conventional postoperative care, in order to provide evidence on the safety and efficacy of the ERAS protocols. METHODS: PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, and CBM were searched from their inception until February 2025. Randomized controlled trials (RCTs) published in English or Chinese that compared the ERAS and standard care in cesarean section were eligible for inclusion. Two reviewers independently extracted the data and assessed the risk of bias using the Cochrane risk-of-bias tool. The analyses were conducted using RevMan 5.4 software, and the results were presented as forest plots. RESULTS: Out of 2817 records screened, 10 RCTs comprising 1934 participants met the inclusion criteria. The pooled analyses indicated that ERAS protocols significantly reduced the length of hospital stay (MD -14.13, 95% CI -25.36 to -2.90; p = 0.01), hospitalization costs (MD -447.85, 95% CI -687.04 to -208.66; p = 0.0002), time to first flatus (MD -9.82, 95% CI -13.54 to -6.10; p < 0.00001), time to first stool (MD -15.35, 95% CI -19.10 to -11.60; p < 0.00001), pain sores (MD -1.54, 95% CI -2.10 to -0.99; p < 0.00001), and postpartum hemorrhage (MD -47.75, 95% CI -69.94 to -25.55; p < 0.0001). No statistically significant differences were observed between ERAS and conventional standard recovery in terms of postoperative nausea and vomiting (PONV), urinary retention, postoperative infection, deep venous thrombosis (DVT), 30 days readmission rates, and NICU admission rates. CONCLUSIONS: The adoption of ERAS protocols in cesarean delivery is associated with accelerated postoperative recovery without compromising maternal or neonatal safety. Nevertheless, these findings should be approached with caution due to the limited number and heterogeneity of the studies included.