Enhanced Recovery After Caesarean
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Direct answer
Enhanced recovery after caesarean is a multimodal care pathway built from evidence-based steps that shorten hospital stay and speed return to normal function after surgery. Its core elements are counselling, shorter preoperative fasting, antibiotic prophylaxis, opioid-sparing analgesia, early feeding, early mobilisation, early catheter removal and risk-based thromboprophylaxis. Each element reinforces the others, so the benefit comes from applying the whole pathway rather than any single step.
What you must remember
- Core principle: a multimodal pathway in which each evidence-based element reinforces the others, rather than relying on a single intervention.
- Preoperative care: counselling, clear fluids allowed up to about two hours before surgery, no routine mechanical bowel preparation, and antibiotic prophylaxis before the incision.
- Anaesthesia: spinal anaesthesia with intrathecal morphine, which gives prolonged postoperative analgesia and reduces systemic opioid requirement.
- Analgesia: regular paracetamol and NSAIDs where not contraindicated, with a transversus abdominis plane block as an adjunct and opioids kept for breakthrough pain.
- Feeding and gut recovery: early oral intake once the woman has recovered from spinal anaesthesia, and chewing gum may help return of bowel function.
- Mobilisation and catheter: walking on the day of surgery and early removal of the urinary catheter, to reduce infection and immobility.
- Thromboprophylaxis: early mobilisation first, with low-molecular-weight heparin for women at higher risk on the basis of their individual risk factors.
- Outcomes: shorter hospital stay, earlier bowel function and mobilisation, and fewer complications when the pathway is applied as a whole.
Building the pathway on the ward
Enhanced recovery works only when each step is delivered reliably, so the team plans the sequence before surgery begins. The steps below set out a usual order.
- Prepare before surgery: counsel the woman on the plan, limit fasting to clear fluids up to two hours before surgery, and give antibiotic prophylaxis before the skin incision.
- Choose the anaesthetic: use spinal anaesthesia with intrathecal morphine so that systemic opioid requirement stays low.
- Layer the analgesia: combine regular paracetamol, NSAIDs where there is no contraindication and a regional block, reserving opioids for breakthrough pain.
- Start feeding early: begin oral fluids and diet soon after recovery from spinal anaesthesia rather than waiting for flatus.
- Remove the catheter and mobilise: take out the urinary catheter early and help the woman to walk on the day of surgery.
- Assess thromboprophylaxis: review each woman's risk factors and give heparin prophylaxis to those at higher risk, with early mobilisation as the base measure.
Where the exam tries to catch you
Questions here reward recognising that the pathway is a package, and that old habits delay recovery.
- Trap: Withholding oral fluids until flatus appears. Correct: Early feeding is part of the pathway and does not impair recovery, whereas waiting for flatus delays it.
- Trap: Using opioid-heavy analgesia as the default. Correct: The pathway depends on opioid-sparing multimodal analgesia, so a regional block with paracetamol and NSAIDs replaces routine high-dose opioids.
- Trap: Keeping the urinary catheter in for a day or more by routine. Correct: Early catheter removal is an aim of the pathway because prolonged catheterisation raises infection risk.
Frequently asked questions
What are the main components of an enhanced recovery pathway after caesarean?
Components include counselling, shorter fasting, antibiotic prophylaxis, opioid-sparing multimodal analgesia, early feeding, early mobilisation, early catheter removal and risk-based thromboprophylaxis. They are used together because each one supports the others.
Is routine bowel preparation part of enhanced recovery after caesarean?
Routine mechanical bowel preparation is not part of enhanced recovery after caesarean, since it adds discomfort without clear benefit. The pathway favours shorter fasting and early oral intake after surgery instead.
Why is opioid-sparing analgesia important in enhanced recovery after caesarean?
Opioid-sparing analgesia reduces nausea, sedation and ileus, which otherwise delay feeding and mobilisation. Regional anaesthesia combined with paracetamol and NSAIDs is the usual foundation of enhanced recovery after caesarean.
Which antibiotic is given before caesarean for infection prophylaxis?
A single dose of a cephalosporin, typically cefazolin, is given before the skin incision in standard practice. It is timed so that it is active at the moment of incision, and local protocols specify the exact agent and dose.