In Cesarean Surgery
cesarean mom with new baby

In a recent post, we discussed evidence-based practices that maximize your chances of avoiding an avoidable cesarean, but not all cesareans can or should be avoided. This post covers evidence-based practices that enhance cesarean recovery. They come from a set of guidelines issued by the American College of Obstetricians & Gynecologists (ACOG) that lay out the elements of “Enhanced Recovery after Surgery” as they apply to cesarean surgery.

Unfortunately, as with practices to avoid a cesarean, while they are backed by the U.S. ObGyn’s professional organization, they may not be your obstetrician’s or hospital’s standard practice, which means you would be wise to explore ahead of time whether they would be provided to you. I recommend doing this even if you are planning vaginal birth because life doesn’t always go as planned.

Care before Surgery

Women planning cesarean surgery should be instructed to shower with an antibacterial soap the night before surgery or supplied with pads soaked in an antibacterial solution and instructed to wipe themselves down or both. This has been shown to reduce wound infections.

Anti-nausea medication should be administered to reduce the possibility of vomiting during surgery. This is recommended even if epidural or spinal (regional) anesthesia is planned for the surgery. Pre-op anti-nausea medication also helps prevent post-operative nausea.

Sedatives should not be administered pre-operatively. It can have adverse effects on the baby, and it impairs maternal mental and physical functioning for several hours after the operation, which could interfere with interacting with the baby.

Women planning cesarean surgery should be permitted clear fluids (pulp-free juice or coffee or tea without milk) up to 2 hours before surgery, and a light meal is permissible up to 6 hours before surgery. This is a significant relaxation of previous pre-surgical guidelines, but it only applies to women planning a cesarean. Laboring women are usually prohibited from eating on the grounds that need for a cesarean cannot be predicted; however, you should know that the evidence does not support this policy.

Care during Surgery

I.V. fluid volume should be carefully monitored. Both too little and too much I.V. fluid are equally problematic.

Measures should be taken to keep women warm during the operation. Chilling is a not uncommon problem during surgery that not only increases discomfort but has adverse effects. It can be avoided by strategies such as keeping the operating room temperature at 73 degrees instead of 68 degrees, by forced air warming, or by warming I.V. fluid.

Umbilical cord clamping should be delayed. Immediate cord clamping deprives the baby of a substantial proportion of its blood volume, which has several potential adverse consequences. ACOG recommends waiting at least 1 minute before clamping the cord, which is better than immediate clamping, but much better still is to wait until the cord stops pulsing, the physiologic indicator that placental drainage is complete. (For more on this, see “Just Say ‘No’ to Immediate Umbilical Cord Clamping.”)

Babies not in need of medical attention should be placed skin-to-skin with their mothers. This keeps the baby warm and starts the mother-baby bonding process.

Babies should not have routine suctioning of their airway or stomach contents. The only time suctioning is indicated—and this includes when meconium, the baby’s first stool, is present in the amniotic fluid—is when the airway is obstructed by secretions.

The skin should be closed with sutures, not staples. The wound is more likely to reopen when the staples are removed. In addition, women having stitches rated them higher than women having staples.

For early post-operative pain control, at the end of the operation, either administer a dose of opioid through the epidural catheter or inject anesthetic locally to block the abdominal nerve. The guideline notes that the opioid has side effects, including nausea, vomiting, and itching, but does not mention any for the abdominal nerve block.

Care during the Postpartum Stay

If a urinary catheter was inserted for the surgery, it should be removed immediately afterward. This reduces likelihood of infection and decreases experience of other urinary symptoms such as burning when urinating, urinary frequency, and urgency.

Pneumatic compression stockings should be used. They have been shown to reduce deep venous clots. Clots in the deep leg veins are especially dangerous because they can detach and end up blocking a blood vessel in the lungs (pulmonary embolism).

Normal diet should be resumed within 2 hours after surgery. It was thought that because bowel function ceases during surgery, early feeding post-surgery could lead to gastrointestinal complications. It turns out that it doesn’t. On the contrary, early resumption of normal eating results in a faster return of bowel activity as well as increased maternal satisfaction, among other benefits.

Mobility should be encouraged as soon as possible. While this strategy hasn’t been studied specifically in women recovering from cesarean surgery, studies of surgery patients in general find that deep venous blood clots are less likely and bowel function resumes more quickly when patients are up and about.

Post-operative pain should be controlled by non-opioid medications, e.g., ibuprofen, acetaminophen. No mention is made of opioid medication, which used to be the norm for controlling cesarean post-operative pain. If non-opioid medications give you adequate pain relief, well and good, but if they don’t, speak up and ask for something stronger. It is vital that you feel comfortable enough to hold, breastfeed, and care for your baby.

Staff should provide comprehensive discharge counseling. At a minimum, you should be instructed on what is normal to expect, managing your pain medication, signs and symptoms of infection, activity restrictions, and when to seek medical attention.

Care Missing from ACOG’s Enhanced Cesarean Recovery Guidelines

By focusing on modifying generalized enhanced surgical recovery guidelines to apply to cesarean surgery, ACOG’s guidelines omit important elements specific to optimal cesarean recovery. I’ve filled in that gap here:

Doulas should be permitted to accompany women during the surgical prep and the operation in addition to women’s partners. It has become routine to allow women’s partners to be present during the operation but much less common to also allow doulas. Separating women from this important source of emotional support can increase anxiety and mental distress. And while admission to the operating room has become common, permitting her support team to accompany her during the surgical prep process is less so, yet preparation for surgery may be a more anxious time than the operation itself.

A member of the operating room staff should be designated to keep the woman and her support person(s) informed of what is happening and answer any questions and address any concerns that she or they may have. As you may imagine, cesarean surgery can be a stressful event, and it isn’t uncommon for operating room staff to behave as if the woman isn’t present. Childbirth-related post-traumatic distress is strongly associated with feeling endangered and helpless, which having informational and emotional support can avert.

Breastfeeding advice and assistance should be provided by staff with specialized expertise. All new breastfeeding mothers need this, but women recovering from surgery face additional challenges such as finding comfortable nursing positions. Challenges may also include a baby who is sleepy from meds, engorged breasts due to excess I.V. fluid, and delay in the milk coming in. Women with cesarean delivery are less likely to be exclusively breastfeeding at 1 week after delivery than women with vaginal births (Declercq 2008). The extra need for help with breastfeeding may be one reason why.

The Take-Away

As I wrote at the beginning of this post, you would be wise to discuss your doctor’s and hospital’s cesarean care practices even if you aren’t planning a cesarean. Here are some tips for having that conversation:

  • Make a conference appointment. This ensures adequate time for discussion, which may not be the case during routine prenatal visits.
  • Take notes. You don’t want to depend on recall.
  • If an option is not available, explore further. Ask why it isn’t available, whether it could be made available, and is there something available that would accomplish the same goal.

I’ve included the citations to ACOG’S guidelines in the reference list below in case you and your doctor would find that helpful.

One final note:  It is possible that your doctor will be angered by your asserting your right to have a say in your care. I would take that as a bad sign. Above all else, you want your doctor to view you as a full participant in making decisions about your care.

References

American College of Obstetricians & Gynecologists’ Enhanced Recovery after Surgery Guidelines

Caughey AB, Wood SL, Macones GA, et al. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2). Am J Obstet Gynecol 2018;219(6):533-44.

Macones GA, Caughey AB, Wood SL, et al. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). Am J Obstet Gynecol 2019;221(3):247 e1- e9.

Wilson RD, Caughey AB, Wood SL, et al. Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1). Am J Obstet Gynecol 2018;219(6):523 e1- e15.

Additional References

Declercq E, Sakala C, Corry MP, et al. New Mothers Speak Out:. National Survey Results Highlight Women’s Postpartum Experiences. . New York: Childbirth Connection; 2008.

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