Evidence-based Cesarean Delivery: Postoperative Care (Part 10).

Abstract

The following review focuses on routine postoperative care after cesarean delivery (CD), including specific Enhanced Recovery After Cesarean (ERAS) recommendations as well as important postpartum counseling points. Following CD, there is insufficient evidence to support administration of prophylactic multi-dose antibiotics to all patients. Additional antibiotic doses are indicated for the following scenarios: patients with obesity, CD lasting ≥ 4 hours since prophylactic dose, blood loss >1,500 mL, or those with an intra-amniotic infection. An oxytocin infusion for prevention of postpartum hemorrhage should be continued post-CD. While initial measures to prevent postoperative pain occur in the intraoperative period, with the consideration of 1g intravenous (IV) acetaminophen and IV or intramuscular (IM) non-steroidal anti-inflammatory medications (e.g., 30mg IV ketorolac), the focus postoperatively continues with this multimodal approach with scheduled acetaminophen per os (PO, 650mg every 6 hours) and non-steroidal agents (ketorolac 30mg IV every 6 hours for 4 doses followed by ibuprofen 600mg PO every 6 hours) being recommended. Short-acting opioids should be reserved for breakthrough pain. Low-risk patients should receive mechanical thromboprophylaxis until ambulation with chemoprophylaxis being reserved for patients with additional risk factors. When an indwelling bladder catheter was placed intraoperatively for scheduled CD, it should be removed immediately postoperatively. Chewing gum to aid in return of bowel function and early oral intake of solid food can occur immediately after CD and within 2 hours, respectively. For prevention of postoperative nausea and vomiting, administration of 5HT₃ antagonists in recommended with the addition of either a dopamine antagonist or a corticosteroid as needed based on non-cesarean data. Early ambulation after CD starting 4 hours postoperatively is encouraged and should be incentivized by pedometer. For patients that receive a dressing over the CD skin incision, there is limited evidence regarding when best to remove it. Adjunct non-pharmacologic interventions for postoperative recovery discussed in this review are acupressure, acupuncture, aromatherapy, coffee, ginger, massage, reiki and TENS. In the low-risk patient, hospital discharge may occur as early as 24-28 hours if close (i.e., 1-2 days) outpatient neonatal follow up is available due to the potential for neonatal jaundice; otherwise, patients should be discharged at 48-72 hours postoperatively. Upon discharge, the multimodal pain control recommendations of acetaminophen and ibuprofen should be continued. If short-acting opioids are necessary, the prescribing practices should be individualized based upon the inpatient opioid requirements. Other portions of postoperative/postpartum counseling during the inpatient stay include the optimal interpregnancy interval of 18 to 23 months, encouraging exclusive breastfeeding for at least 6 months, quick resumption of physical activity and vaginal intercourse guidance as tolerated. Patients should also be counseled pre-CD on the option of immediate postpartum IUD insertion, intraoperative salpingectomy or placement of long acting reversible contraception in the postpartum period. Implementation of such evidence-based postoperative care protocols decrease length of stay, surgical site infection rates, and improve patient satisfaction and breastfeeding rates.