What is enhanced recovery?

Enhanced recovery is an approach that is aimed at helping people recover more quickly after having planned or elective major surgery; this includes caesarean section. It is sometimes known as “accelerated or rapid recovery”. The aim is to improve the care that you receive and to reduce the time you will need to stay in hospital after the birth. With enhanced recovery, it is anticipated that you will be well and ready to go home the day after the caesarean section.

What are the advantages of enhanced recovery?

Enhanced recovery helps patients:

• To be as healthy as possible before surgery.
• Receive the best possible care during the operation
• Receive the best possible care after surgery.

Having a major operation like a caesarean can be both emotionally and physically stressful. However, enhanced recovery programmes aim to minimise this by getting you back to full health as quickly as possible. Research has shown that the earlier a person gets out of bed and starts walking, eating and drinking after an operation, the shorter their recovery time will be. With enhanced recovery, it is expected that you and your baby will be ready to go home within 24 hours of the birth of your baby by caesarean section. The risk of hospital acquired infection, and the risk of developing blood clots will be reduced. It is important for you to play an active part in your own recovery.

What to expect before the operation

If you have a planned caesarean section, before your operation, you will be encouraged to:

• Eat well: Ensure that you eat a healthy diet, high in protein (e.g. meat, fish, cheese, beans and pulses) with plenty of fruit and vegetables. This is important as your body will need energy for repairing itself following surgery.
• Exercise: Try to stay active and do daily physical exercise as this will help with the recovery process. Remember that exercise does not have to be strenuous to be beneficial (e.g. 30 minutes of brisk walking each day can be enough). If you cannot manage this, any physical activity is better than nothing.
• Reduce or stop smoking: This will reduce the risk of complications after surgery, will help with the healing process and will improve the general health or you and your baby. Speak to a health professional or your GP if you would like to be referred to the smoking cessation services. You can also find support by calling the free Smokefree National Helpline on 0300 123 1044.
• Stabilise any pre-existing health conditions: Particularly any that may affect the surgery or recovery process. Your GP and medical doctor should talk to you about how to optimise your health so that you are in the best possible condition for surgery.
• Relax as much as possible: It may not always be easy, but you will be encouraged to relax as much as you are able.

What happens at the pre-assessment appointment?

In the days before your admission date, you will be seen in a pre-assessment clinic. It is important for you to attend the pre-assessment appointment because you will see a specialist midwife and anaesthetist, who will make an individual plan for your caesarean section. The midwife will discuss your feeding choices; if you wish to breastfeed you may be encouraged to start expressing and storing colostrum (early breastmilk).

When you see the anaesthetist, they will assess you and discuss with you what happens during your caesarean section as well as the pain relief that you will receive after the operation. The anaesthetist will also gain consent for your anaesthetic.

Bloods will be taken to check for your blood count and your blood group to make sure that you are fit for surgery. You will also be provided with pre-op medications that are designed to help ready you for surgery.

What to expect after the operation

After your caesarean section you will be transferred to the recovery unit. You will be monitored for a minimum of 2 hours to ensure that your observations indicate that you are stable and in good health. If all is well, you will be offered a light snack and a drink and you will be given feeding support for the baby. You will then be moved to the postnatal ward until you are ready to go home. Once you are fit for discharge, you will need to make arrangements to be picked up from the hospital as you will not be fit to drive. In fact, following the operation you may experience a number of symptoms, including the following:

Vaginal discharge/bleeding

It is normal to experience some vaginal discharge/bleeding after surgery. This may be like a light period, may be red or brown in colour or may have small blood clots. You should use maternity pads/towels and not tampons as this reduces the risk of infection. If the vaginal discharge/bleeding is heavy, you should seek medical advice.

Pain

Most women experience some pain and discomfort for the first few days after a caesarean section. This can last a few weeks in some women. You should take painkillers while at home if you are in pain; paracetamol and ibuprofen are safe to take in the postnatal period. Other stronger painkillers such as codeine can be taken, but may cause constipation and are not usually recommended in breastfeeding mothers.

Your wound

Your wound will be covered with a dressing for at least 24 hours. Your midwife will advise you on how to look after your wound. It may be slightly red and uncomfortable. If it becomes inflamed, excessively painful, swollen or starts to discharge fluid, you must let your midwife know as this may be a sign of infection. You should keep your wound clean and dry, wear loose fitted clothing/underwear and take painkillers if the wound is sore.

Problems passing urine

All being well, the flexible tube draining your bladder (catheter) will be removed 6 hours after the caesarean section. A midwife will ensure that you are passing good amounts of urine by yourself before considering discharge home. It is not uncommon to feel as though your bladder is not emptying fully after a caesarean section, and this usually improves with time. If it does not, you feel that you are not passing normal volumes of urine or you have excessive stinging when passing urine, you should see your GP.

Loose bowels or constipation

Your stools may change temporarily, as you may experience constipation or loose bowels. Make sure you stay hydrated, eat regular meals and have regular walks.

How to prepare for enhanced recovery after a c-section

You will be encouraged to mobilise (stand up and walk around); the sooner you mobilise, the quicker the recovery process. Staying mobile and doing gentle exercises, such as going for a daily walk will reduce the risk of blood clots and will help with your bowels. However, take care not to over-exert yourself.

You should be able to hold you baby once you are discharged. However, there are some activities that you should avoid until you feel ready and are pain-free — these include driving, exercising, carrying anything heavier than your baby or having sex. It may not be for 6 weeks or so until you feel ready or able to perform these activities.

You will be allowed to eat and drink as soon as possible after surgery. This is important as you will need the calories (energy) from your diet to help your body to heal and get back its strength. Some women find that eating ‘little and often’ is best.

What support is available post-operatively (including at home)?

Make sure you have someone with you at home for the first few days. Your midwife and health visitor will visit you at home for the first few weeks to ensure that you and your baby are doing well. After that you will see your health visitor in a local clinic where you can talk about any problems you are experiencing or ask any questions.

You will need to book an appointment with your GP for a check-up 6 weeks after your caesarean section. During this appointment, your GP will assess you and your baby’s wellbeing and make sure that you are recovering well.

Driving after a caesarean section

After a caesarean section, most insurance companies will not insure you to drive until 6 weeks afterwards. Therefore, it is advisable to check with your own insurance company if you wish to drive before this time.

Main points

• Enhanced recovery aims to get women feeling better faster and able to care for themselves and their baby independently, so that they heal better and can get home more quickly.
• Being in the optimal physical condition before surgery (moderate exercise, good diet, avoiding smoking) will mean that wound healing following surgery is improved.
• The process of having a C-section is streamlined so that a plan is made days in advance of the operation, and time spent on the recovery unit and post-natal ward is minimised.
• After your c-section you will be transferred to a recovery unit and monitored. Once you are stable and in good health you will be able to go home accompanied by a friend or relative.
• you will be encouraged to stand up and walk around fairly quickly after the c-section as this helps the recovery process.
• The symptoms you may experience after a c-section include; vaginal discharge or bleeding, pain, problems passing urine, loose bowels or constipation
• You will need to book an appointment with your GP six weeks after the c-section so that your recovery can be checked.
• You should not drive after a c-section for six weeks