Recovery after operative birth — structured SAQ (15 marks)

(a) The day-0 bundle (6 marks)

One mark per element with a specific action or timing. ^[2]

• Early oral intake — free fluids and a light diet within 2 hours of recovery from anaesthesia; the Guo systematic review supports early feeding without increased complications.^[6]
• Early urinary catheter removal — remove the indwelling catheter within 6 to 12 hours, once the neuraxial motor block has resolved and the woman can mobilise; document the first void and check a residual if symptomatic.
• Early mobilisation — first assisted ambulation within 12 hours; full independent mobility by day 1; the largest single determinant of recovery quality.
• Scheduled multimodal analgesia — paracetamol plus NSAID scheduled, opioid rescue (see part b).
• Neuraxial opioid monitoring — respiratory rate and sedation score hourly for 24 hours; naloxone available; per the SOAP consensus statement.^[7]
• Thromboprophylaxis — enoxaparin prescribed and documented, first dose timed to neuraxial block (see part c).
• Discharge planning begun on day 0 — social, transport, neonatal, feeding, contraception plans in motion.

(b) Multimodal analgesia chart (4 marks)

Two marks for the scheduled agents with doses; one for opioid rescue with dose; one for the rationale. ^[2]

• Reasoning: scheduled paracetamol plus NSAID outperforms opioid-first dosing because it pre-empts central sensitisation. Opioid is rescue, never foundation. The intrathecal morphine (100 micrograms) provides 18 to 24 hours of baseline analgesia and is supplemented by this regimen.^[2]

(c) VTE risk and enoxaparin (3 marks)

One mark for risk category; one for dose and first-dose timing; one for duration. ^[2]

• Risk category: high — body mass index over 30 plus caesarean birth.^[2]
• Regimen: enoxaparin 40 mg SC daily (the BMI threshold for higher weight-banding is 50; at BMI 41 she remains on 40 mg daily).
• First-dose timing: at least 4 hours after spinal catheter removal (or 6 to 8 hours after epidural catheter removal) to minimise neuraxial haematoma risk.
• Duration: 10 days post-caesarean for high-risk women. Extended to 6 weeks only for the highest-risk categories (prior VTE, high-risk thrombophilia, or multiple additional risk factors), which she does not have.

(d) Discharge criteria (2 marks)

One mark for naming at least four clinical criteria; one for the safety-net and follow-up elements. ^[2]

• Clinical: vital signs stable and afebrile for over 24 hours; pain controlled on oral analgesia; mobilising independently; voiding spontaneously and passing flatus; wound clean and dry; lochia normal.^[2]
• Safety-net and follow-up: thromboprophylaxis prescribed with the woman taught to self-inject; contraception plan documented; neonatal plan in place; follow-up booked; safety-net advice explained (return for fever, wound redness, heavy bleeding, calf pain, shortness of breath); adequate social supports confirmed.