Recovery after operative birth and enhanced recovery after caesarean

It is 07:30 on the postnatal ward. Six women are recovering from caesareans overnight; one had a forceps with a third-degree tear; one is in pain because nobody wrote the paracetamol regularly. The difference between a ward that runs the bundle and a ward that runs on habit is the difference between women who walk to the bathroom at 6 hours and women who lie in bed until tomorrow. This topic is the bundle, element by element, with the doses examiners want to hear.[2][3]

Overview and definition

Enhanced recovery after surgery (ERAS) is a perioperative care bundle — a set of evidence-based elements that work together to blunt the surgical stress response, preserve physiology, and accelerate recovery. A bundle is more than a list; the elements are interdependent, and dropping one degrades the others.[1]

Enhanced recovery after caesarean (ERAC) adapts the ERAS framework to the unique physiology of caesarean: the patient is awake, pregnant, about to breastfeed, and at uniquely high venous thromboembolism (VTE) risk. The ERAS Society published caesarean guidance in three parts — antenatal and preoperative (Wilson and colleagues, 2018), postoperative (Macones and Wilson, 2019), and intraoperative (Caughey and colleagues, 2025 update).[1][2][3]

Operative vaginal birth recovery shares the analgesia, bladder-care, thromboprophylaxis and antibiotic principles, with the addition of perineal care. The ANODE trial in 2019 settled the antibiotic question for forceps and ventouse: a single dose of co-amoxiclav reduced confirmed or suspected perineal infection from 7.0% to 5.3% at 6 weeks.[6]

References15Show ledgerHide ledger

1. [1]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.PMID 30240657
2. [2]Macones GA, Caughey AB, Wood SL, et al. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (Part 2) Am J Obstet Gynecol, 2019.PMID 30995461
3. [3]Caughey AB, Wood SL, Macones GA, et al. Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society recommendations (Part 3) Am J Obstet Gynecol, 2026.PMID 40335352
4. [4]Mackeen AD, Packard RE, Ota E, Berghella V, Baxter JK Timing of intravenous prophylactic antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery Cochrane Database Syst Rev, 2014.PMID 25479008
5. [5]Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial Am J Obstet Gynecol, 2007.PMID 17466699
6. [6]Knight M, Chiocchia V, Partlett C, et al. Prophylactic antibiotics in the prevention of infection after operative vaginal delivery (ANODE): a multicentre randomised controlled trial Lancet, 2019.PMID 31097213
7. [7]Sentilhes L, Sénat MV, Le Lous M, et al. Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery N Engl J Med, 2021.PMID 33913639
8. [8]Sentilhes L, Winer N, Azria E, et al. Tranexamic Acid for the Prevention of Blood Loss after Vaginal Delivery N Engl J Med, 2018.PMID 30134136
9. [9]Guo J, Long S, Li H, Luo J, He T Early versus delayed oral feeding for patients after cesarean Int J Gynaecol Obstet, 2015.PMID 25457588
10. [10]Bauchat JR, Habib AS, Carvalho B, et al. Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia Anesth Analg, 2019.PMID 31082964
11. [11]Committee on Practice Bulletins-Obstetrics Practice Bulletin No. 183: Postpartum Hemorrhage Obstet Gynecol, 2017.PMID 28937571
12. [12]Royal College of Obstetricians and Gynaecologists (RCOG) Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52 BJOG, 2017.PMID 27981719
13. [13]Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial Obstet Gynecol, 2008.PMID 18515507
14. [14]Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O'Brien PM Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial Obstet Gynecol, 2006.PMID 16738150
15. [15]Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth Cochrane Database Syst Rev, 2014.PMID 25289960