Enhanced Recovery after Caesarean Section

• Enhanced recovery after Caesarean section (ERAC) is an evidence-based, structured approach to perioperative care designed to optimise maternal and neonatal outcomes
• It spans the antenatal period through to the postpartum period and discharge
• Endorsed by the ERAS Society, NICE and the Society for Obstetric Anesthesia and Perinatology (SOAP)

• Reduce the physiological stress of surgery
• Promote faster recovery and return to normal function
• Enhance the maternal experience and maternal–neonatal bonding
• Improve the efficiency of healthcare delivery and reduce costs

• Two patients: care must address both maternal and neonatal needs; bonding, breastfeeding and neonatal health all influence length of stay
• Patients are typically young and fit, and perioperative mortality is extremely low
• There is a long, predictable antenatal period offering a unique window for optimisation
• Much of standard UK practice (spinal anaesthesia, minimal fasting, oral analgesia, early mobilisation) was already compatible with enhanced recovery before formal pathways were introduced

• Multidisciplinary team working: midwives, obstetricians, anaesthetists, neonatologists and management
• Patient-centred care and shared decision making
• Standardisation of care, often supported by checklists
• Measurement of outcomes and compliance to drive ongoing improvement

• Meta-analyses of ERAC implementation show:
  • Reduced pain scores and opioid consumption
  • Shorter time to mobilisation and urinary catheter removal
  • Reduced length of stay and lower healthcare costs
  • No increase in readmission or complication rates
• Improved maternal satisfaction; many women are positive about next day discharge when it is offered
• In the UK, approximately 40% of women having an elective Caesarean section now go home the day after surgery

Evidence for individual components is often limited or extrapolated from other specialties; much of the guidance is based on the assumption that best practice standard care should lead to a more timely recovery.

• Empowers women to take an active role in their care, sets expectations and supports shared decision making
• Improves engagement with the pathway, obstetric outcomes and maternal experience
• Discussion of the risks and benefits of each mode of delivery should begin around 16 weeks, with birth preference provisionally finalised by 28 weeks
• Information can be verbal, written or digital (accessible on mobile phones); educational videos appear most effective at reducing anxiety
• Women having a repeat Caesarean section are more likely to achieve next day discharge, suggesting that well-informed women recover more quickly

• Continuous education and checklists help maintain adherence and consistent practice
• Local champions from each discipline lead implementation and quality improvement
• Hospital management involvement secures organisational support and resources

• The WHO recommends exclusive breastfeeding for the first 6 months of life
• Benefits include fewer infections and reduced SIDS in infants, and long-term protection against diabetes and breast and ovarian cancer in mothers
• Support can be offered through prenatal classes, information leaflets and support groups

The extended antenatal period allows multidisciplinary optimisation of comorbidities associated with adverse obstetric and neonatal outcomes.

• Bathing or showering with 2% chlorhexidine before elective Caesarean section is recommended
• Evidence in obstetrics is limited (largely extrapolated from other specialties) but it is a low-risk intervention

• Pregnancy increases aspiration risk through delayed gastric emptying, raised intra-abdominal pressure and reduced lower oesophageal sphincter tone
• However, prolonged fasting causes hypovolaemia, hypoglycaemia, ketosis, thirst and anxiety
• Conventional guidance: light meal up to 6 h and clear fluids up to 2 h before surgery
• 'Sip til send': women are encouraged to sip water until called to theatre
  • Reduces nausea, light-headedness, thirst and anxiety
  • Gastric ultrasound studies show no difference in gastric antral cross-sectional area compared with standard fasting
  • Well suited to obstetric lists where delays and cancellations are common
• Scheduling first on the list makes next day discharge more likely

• A nonparticulate drink containing 45 g carbohydrate taken 2 h before surgery (e.g. pulp-free apple juice or sports drinks)
• Benefits:
  • Reduced insulin resistance
  • Shorter time to colostrum expression and breastfeeding, with longer and more frequent feeds
  • Reduced neonatal hypoglycaemia
• Effects on maternal ketosis and nausea and vomiting are inconsistent
• Use with caution in diabetic mothers

• Antacid prophylaxis (e.g. H₂ antagonist) is indicated given the risk of aspiration should general anaesthesia be required
• Sedative premedication is avoided due to the risk of neonatal depression
• Bowel preparation is not required

• A partner, relative, doula or midwife; reduces maternal anxiety and increases satisfaction

• Neuraxial anaesthesia is preferred over general anaesthesia:
  • Less blood loss and a reduced stress response
  • Less PONV and earlier return to oral intake
  • Allows long-acting neuraxial opioids for postoperative analgesia
• Spinal is faster in onset than epidural with less intraoperative pain; outcomes are otherwise similar

• Hypotension follows sympathetic blockade and systemic vasodilation, causing maternal nausea, vomiting and dizziness
• Uteroplacental blood flow is not autoregulated; prolonged hypotension risks fetal bradycardia and neonatal acidosis
• Aim to maintain systolic BP ≥ 90% of baseline, avoiding a fall below 80%
• Strategies:
  • Left lateral uterine displacement
  • Crystalloid coload at the time of neuraxial block
  • Prophylactic vasopressor infusion, titrated to heart rate and BP

• Aim for euvolaemia; pregnant women are more susceptible to fluid shifts
• Limit IV fluids to <3L for routine Caesarean section unless there is haemorrhage
• Even greater caution in pre-eclampsia and cardiac disease

• Hypothermia (core temperature <36°C) is common and mainly caused by neuraxial anaesthesia:
  • Vasodilation redistributes heat from core to periphery
  • Central thermoregulation is impaired, lowering the thresholds for shivering and vasoconstriction
  • Efferent nerves responsible for shivering and vasoconstriction are blocked
• Measure temperature before induction and every 30 minutes thereafter
• Methods: warm theatre (≥ 23°C), passive warming (a single blanket reduces skin heat loss by up to 30%), warmed IV fluids and forced air warming
• Combining warmed fluids with forced air warming has not been shown to be superior to either alone


• Consequences of hypothermia
• Maternal shivering and discomfort
• Increased blood loss and transfusion
• Surgical site infection
• Delayed PACU and hospital discharge
• Neonatal hypothermia, lower umbilical artery pH and a barrier to skin-to-skin contact

• Sepsis remains a leading cause of direct maternal death
• Single-dose IV antibiotics given within 60 minutes before skin incision (rather than after cord clamping) reduce endometritis and wound infection, without harm to the neonate
• Abdominal skin: chlorhexidine-alcohol is superior to povidone iodine for reducing surgical site infection
• Vaginal preparation (chlorhexidine or povidone iodine) reduces endometritis and postoperative pyrexia; evidence is strongest in labouring women

• Delay for at least 30–60 seconds to allow placental transfusion to the neonate
• Term neonates: higher haemoglobin, better iron stores and improved neurodevelopment
• Preterm neonates: improved transitional circulation and fewer transfusions, cases of necrotising enterocolitis and intraventricular haemorrhage
• No increased risk of postpartum haemorrhage; timing of oxytocin does not affect placental transfusion
• Increased risk of neonatal jaundice; local protocols should identify those needing phototherapy


• Contraindications:
• Compromised placental circulation
• Neonate requiring immediate resuscitation

• Uterine atony is the most common cause of postpartum haemorrhage
• The aim is adequate uterine tone using the lowest effective dose of a first-line agent, escalating promptly to second-line drugs when required
• Oxytocin should be given slowly (no faster than 1 IU every 10 seconds) to limit haemodynamic effects
• Ergometrine is probably the most effective second-line agent, but choice should follow local guidance and patient comorbidities

• Combination prophylaxis with a 5-HT₃ antagonist and dexamethasone is superior to monotherapy
• Dexamethasone is preferred as it also lowers pain scores and reduces opioid requirement
  • Raises blood glucose by up to ~1 mmol/L in the first 24 h; safe in diabetics with reasonable control
  • In diabetic mothers give after delivery to avoid neonatal hypoglycaemia
  • When compared to a standard 6.6mg dose, higher dose dexamethasone (25mg at delivery and 25mg 24hrs post-delivery) shows improvements in pain scores, opioid use, quality of recovery and satisfaction (BJA, 2026)
• Surgical factors: avoid uterine exteriorisation and intra-abdominal saline irrigation, which increase nausea without reducing blood loss

• Caesarean section causes moderate to severe pain; multimodal analgesia is commenced intraoperatively
• Long-acting neuraxial opioids are the gold standard, providing up to 26 h of analgesia

• Consider CSE where high analgesic requirements are expected (e.g. chronic pain), allowing repeat epidural dosing
• PROSPECT recommends preoperative or intraoperative paracetamol and an intraoperative NSAID, continued regularly afterwards
• Dexamethasone 8 mg IV contributes to analgesia as well as antiemesis
• Where long-acting neuraxial opioids have not been given (e.g. general anaesthesia), consider truncal blocks: TAP, quadratus lumborum, ilioinguinal-iliohypogastric or erector spinae plane; none is consistently superior
• Adding blocks to neuraxial opioids gives little additional benefit, except perhaps in selected women at risk of severe pain

• Maternal benefits: improved breastfeeding success, satisfaction, uterine tone and less blood loss and pain
• Neonatal benefits: more stable heart rate, earlier feeding behaviours and less crying

• Around one in five women experience severe acute pain after Caesarean section, which affects mental health, bonding, breastfeeding and the risk of chronic pain
• Regular paracetamol and NSAID (unless contraindicated), with oral opioids as required for breakthrough pain
• Scheduled analgesia is superior to analgesia on request
• The oral route is preferred; IV paracetamol and NSAIDs offer no advantage and cost more
• Opioids are rarely needed after discharge; avoid routinely sending women home with strong opioids

• Side-effects of neuraxial anaesthesia and opioids affect up to 80% of women, so rescue medication should be prescribed pre-emptively

• Fluids in PACU (ice chips or water) and a light diet within 1–2 h after regional anaesthesia
• Associated with earlier return of bowel function, mobilisation and catheter removal, without more nausea or ileus
• Chewing gum speeds return of bowel function if oral intake must be delayed
• Diabetes: insulin requirements fall sharply after delivery and breastfeeding increases hypoglycaemia risk; reduce or stop treatment and monitor glucose closely

• Reduces infection, thrombophlebitis and fluid overload while aiding mobility
• Stop once the patient is haemodynamically stable, tolerating oral fluids without nausea, passing adequate urine and the oxytocin infusion is complete

• Poor sleep after Caesarean section is linked with postnatal depression, worse pain and breastfeeding difficulty
• Cluster observations, drug rounds and investigations; tailor monitoring frequency to clinical status
• Treat pain and nausea effectively

• Improves bowel function and reduces deconditioning and VTE risk
• Sitting out or transferring to a chair within 6–8 h, once motor function has returned, under supervision
• Motor block persisting 6 h after neuraxial anaesthesia warrants urgent review to exclude complications such as epidural haematoma

• Reduces urinary tract infection and improves comfort, mobility and length of stay
• ERAS Society and SOAP recommend removal 6–12 h after delivery once mobile
• No increase in recatheterisation has been shown, though the optimal timing after long-acting neuraxial opioids is uncertain

• VTE risk is higher after Caesarean section than vaginal delivery
• Mechanical prophylaxis (e.g. pneumatic compression devices) until fully ambulatory
• Risk assess before surgery and again at the WHO checklist sign-out
• Pharmacological prophylaxis for those at high risk; LMWH is generally preferred, with unfractionated heparin reserved for those at high bleeding risk
• Heparins increase the risk of wound haematoma and dehiscence, so routine use in all women is not recommended

• Postpartum anaemia is common and causes fatigue, impaired wound healing, infection and depression
• Routine testing is unnecessary; check Hb on day 1 or 2 if at high risk (significant blood loss, pre-existing anaemia or symptoms)
• Treat with oral or IV iron; IV iron gives a greater rise in Hb at 6 weeks
• Consider transfusion on an individual basis if Hb < 70 g/L or symptomatic; liberal transfusion confers no benefit

• Breastfeeding difficulty is common and linked to poorer maternal mental health
• Early skin-to-skin contact, counselling, educational material and access to lactation specialists increase breastfeeding initiation and duration
• Intention to breastfeed may lengthen stay while feeding is established

• Planning starts before surgery: patient goals, neonatal care, contraception and lactation education, involving the support person
• The appropriate day of discharge is decided postoperatively; next day discharge is unsuitable for some (e.g. significant comorbidity)
• Early discharge does not increase readmission, pain or wound infection
• More than 80% of Caesarean wound infections present after discharge, so women need written and verbal information on normal recovery, warning signs and how to seek help
• Community midwifery support and outpatient follow-up within 6 weeks

• Maternal outcomes:
  • Length of stay
  • Readmission and unplanned reattendance within 30 days
  • Satisfaction with analgesia
  • Inpatient opioid consumption and the proportion requiring opioids
  • Postoperative nausea and vomiting
  • Obstetric Quality of Recovery 10 (ObsQoR-10) score at 24–48 h
• Process measures:
  • Compliance with the pathway
  • Preoperative fasting duration for liquids
  • Time to first drink, first food and first mobilisation
  • Time to urinary catheter removal
• Neonatal outcome: breastfeeding at discharge

• Standardised questionnaires capturing symptoms, function and quality of life; cheap and non-invasive
• Postpartum recovery covers many domains (physical, psychological, sleep, fatigue, infant feeding), but most PROMs assess only one
• ObsQoR-10: best validated measure of global inpatient recovery after any mode of delivery
• STORK (Stanford Obstetric Recovery ChecKlist): developed to assess all domains of outpatient postpartum recovery