This chapter should be cited as follows:
Cordioli E, Glob Libr Women's Med
ISSN: 1756-2228; DOI 10.3843/GLOWM.422223

The Continuous Textbook of Women’s Medicine Series – Obstetrics Module

Volume 20

Surgical Techniques in Obstetrics

Volume Editors: Professor Michael Stark, New European Surgical Academy (NESA) and Charité University Hospital, Berlin, Germany
Professor Sergej Barinov, Omsk State Medical University, Ministry of Health of Russia
Professor Gian Carlo Di Renzo, PREIS International School, Florence, Italy

Chapter

Perioperative Care for Cesarean Delivery and Other Obstetric Surgical Procedures

First published: October 2026

AUTHOR(S)

Eduardo Cordioli, MD, MBA, MSCE, PhD

Medical Director of Obstetrics, Grupo Santa Joana, São Paulo; Brazil Director of Innovation, Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO), Brazil

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INTRODUCTION

The outcome of surgery depends on much more than what happens in the operating room. In obstetrics, we too often focus on the procedure itself, rather than on the care that comes before and after it. Cesarean birth is the most frequent major operation performed on women worldwide, and uterine evacuation for early pregnancy loss is among the most common gynecological procedures; both are performed, in the overwhelming majority of cases, on otherwise healthy patients whose recovery timeline is dictated by a newborn or by a grieving family. In that context, standardized perioperative care is not administrative housekeeping. It can make the difference between a patient returning home promptly and facing an unnecessarily prolonged recovery at a difficult time in her life.

Twentieth-century obstetric practice was built on custom: overnight fasting regardless of the anesthetic plan, antibiotics withheld until cord clamping, prolonged bed rest, days of urinary catheterization. These habits were passed from one generation of clinicians to the next, with the authority of tradition rather than evidence. The enhanced-recovery movement, which emerged from Copenhagen colorectal wards in the 1990s under the name of fast-track surgery, eventually reached obstetrics and prompted a reappraisal of each of those rituals. The Enhanced Recovery After Surgery (ERAS) Society published a three-part cesarean guideline series between 2018 and 2019¹^,²^,³ and delivered a full update in 2025.⁴^,⁵^,⁶ The Society for Obstetric Anesthesia and Perinatology (SOAP) subsequently issued a complementary consensus statement,⁷ and the American Society of Anesthesiologists (ASA) modernized both preoperative fasting guidance and the obstetric preanesthetic assessment.⁸^,⁹

The sections that follow trace the patient through the perioperative period. A worked example from Hospital e Maternidade Santa Joana, in São Paulo, illustrates how the evidence can be distilled into a one-page instruction sheet that patients can readily understand and follow.

PREOPERATIVE CARE

Much of the groundwork for a successful outcome of obstetric surgery is laid before the skin is opened. Risk assessment, shared decision-making, physiological optimization and preventive interventions each contribute to maternal and neonatal outcomes. Preoperative care offers the clinician what the intraoperative period rarely allows: time.

Preoperative assessment and risk stratification

Women scheduled for obstetric procedures should undergo a structured assessment: focused history, physical examination, review of the antenatal record and investigations ordered by indication. The ASA advisory on pre-anesthesia evaluation states clearly that testing should be guided by the history, examination and invasiveness of the planned procedure, rather than performed routinely.¹⁰ The joint ASA–SOAP obstetric guideline defines the essential elements of the obstetric pre-anesthetic assessment: pertinent comorbidities, prior anesthetic complications, obstetric history, airway examination, baseline vital signs, and an explicit plan communicated between obstetric and anesthesia teams.⁹

For scheduled cesarean section, blood group and antibody screening are sufficient in uncomplicated patients; crossmatching is reserved for those at elevated risk of needing transfusion, such as those with placenta previa, suspected placenta accreta spectrum or severe anemia.⁹ Universal preoperative hemoglobin screening is now recommended by ERAS.¹^,⁴ Beyond that, testing is individualized: renal function and proteinuria in hypertensive disorders, glycemic markers in diabetes, and coagulation studies only when there is a clinical reason to order them. Early anesthesiology consultation is warranted for an anticipated difficult airway, significant cardiopulmonary disease, morbid obesity, bleeding diatheses or a history of anesthetic complications.¹^,⁹

Scheduling, informed consent and shared decision-making

Informed consent for obstetric surgery is a conversation that develops over weeks; it is not a signature captured on the morning of surgery. ACOG defines adequate disclosure as including the nature of the procedure, its material risks and benefits, and the reasonable alternatives, with explicit attention to decision-making capacity and to the particular pressures of obstetric emergencies.¹¹ For elective procedures the conversation should begin in the antenatal clinic, allowing space for questions and for reflection.¹^,¹¹

Counseling before a first cesarean section should include a candid discussion of what a uterine scar means for future pregnancies. In the NICHD Maternal-Fetal Medicine Units Network cohort of 30 132 women delivered by cesarean without labor, the risk of placenta accreta rose from 0.24% at the first cesarean to 6.74% at the sixth or subsequent operation, with parallel increases in hysterectomy, transfusion and cystotomy; in women with placenta previa and three or more prior cesareans, accreta occurred in approximately 40% of cases.¹² These figures belong in the consent discussion because they bear directly on decisions about family size and about the trade-offs between elective repeat cesarean and a trial of labor after cesarean.¹^,¹²

Preoperative fasting and aspiration prophylaxis

The overnight fast is one of the most durable rituals in surgery, and one of the least defensible. Current ASA guidance permits clear liquids up to 2 hours before an elective procedure and mandates longer fasting only for solids: 6 hours after a light meal, 8 hours or more after fried or fatty food.⁸ The ASA–SOAP obstetric guideline applies these principles to the parturient, individualizing restriction for women in labor and for those at risk of urgent operative delivery.⁹ Universal nil-by-mouth in labor is not defensible: a Cochrane review of five randomized trials involving 3130 women found neither benefit nor harm from restricting oral intake in women at low risk of general anesthesia.¹³ Preoperative carbohydrate loading with clear fluids is now a component of ERAS cesarean pathways.¹^,⁴

Because pregnancy increases the risk of pulmonary aspiration, pharmacological prophylaxis before cesarean section remains standard. A Cochrane review of 22 studies with 2658 women found that non-particulate antacids (such as sodium citrate), H₂-receptor antagonists, proton pump inhibitors and prokinetics all reduce gastric acidity or volume, and that the combination of an antacid with an H₂ antagonist outperformed either strategy alone; no trial was powered to assess aspiration pneumonitis or maternal death, so the practice rests on surrogate endpoints.¹⁴ A pragmatic regimen is a non-particulate antacid for all patients, with an H₂ antagonist added for those at higher risk.⁹^,¹⁴

Optimization of comorbidities: anemia, glycemia and hypertensive disorders

Anemia

Antenatal anemia is common, closely tied to peripartum transfusion and eminently modifiable. ACOG recommends routine hemoglobin screening supplemented by ferritin and iron studies, with oral iron as first-line therapy.¹⁵ For women scheduled for cesarean who cannot tolerate oral iron, fail to respond or present late in gestation, parenteral iron has solid support: a Cochrane review of 23 trials (approximately 3200 women) confirmed that all routes improve hematologic indices, with intravenous iron producing faster hemoglobin and ferritin responses; transfusion data remain limited.¹⁶ ERAS incorporates preoperative hemoglobin screening and active correction of anemia, including intravenous iron, as core elements.¹^,⁴ Ideally, assessment takes place 4–8 weeks before a scheduled procedure, which is the interval iron needs to work.

Glycemia

Hyperglycemia is a recognized risk factor for surgical site infection (SSI) after cesarean section.¹⁷ Practical measures include scheduling women with diabetes early in the operating day, continuing basal insulin where appropriate, monitoring glucose and using dextrose-containing fluids during any prolonged fast, and writing explicit glycemic thresholds into the preoperative orders.

Hypertensive disorders

Blood pressure should be brought under control before elective surgery, severe-range readings treated acutely, and magnesium sulfate seizure prophylaxis continued perioperatively where indicated. Pre-eclampsia and chronic hypertension are themselves independent risk factors for post-cesarean surgical site infection.¹⁷ The anesthetic plan must anticipate both the hemodynamic effects of neuraxial blockade and the interactions between antihypertensive drugs and uterotonics.⁹

Perioperative medication management and neuraxial timing

Medication reconciliation must be systematic and drug-by-drug, with explicit written guidance on what to continue, what to suspend, and when. Low-dose aspirin for pre-eclampsia prophylaxis has a reassuring safety profile and is generally not withheld for neuraxial anesthesia or cesarean section.¹⁸ Antihypertensives are usually continued through the morning of surgery; oral glucose-lowering medications are managed according to the specific drug and fasting requirements, while herbal supplements with antiplatelet effects are discontinued.

Low-molecular-weight heparin (LMWH) demands closer attention, because the feared complication of miscalibrated timing is spinal-epidural hematoma. The SOAP consensus statement specifies a minimum interval of 12 hours after a prophylactic dose and 24 hours after a therapeutic dose before placement of a neuraxial block or removal of a catheter, with corresponding guidance on postoperative resumption;¹⁹ ACOG offers complementary recommendations stratified by dosing intensity.²⁰ Women on full therapeutic anticoagulation require an individualized, documented peripartum plan, commonly a switch to unfractionated heparin near term, agreed among obstetric, anesthesia and hematology teams.²⁰^,²¹ A written medication checklist completed in advance reduces omission errors.

Prevention of surgical site infection

When Ignaz Semmelweis argued in 1847 that physicians should wash their hands before entering the maternity ward, he was ridiculed, and puerperal fever went on killing. Nearly two centuries later, infection prevention in obstetric surgery still rests on doing simple things reliably. Recognized risk factors for post-cesarean SSI include obesity and subcutaneous tissue thickness ≥ 3 cm, chorioamnionitis, pre-eclampsia and hypertension, greater operative blood loss, and subcutaneous hematoma.¹⁷

Antibiotic prophylaxis and timing

A single dose of cefazolin is recommended for every cesarean section, administered within 60 min before skin incision. The usual dose is 2 g; a dose of 3 g may be considered for women weighing more than 120 kg, although the benefit of this higher dose in obstetric patients has not been established.²² Timing is not merely a procedural detail. In a randomized trial of 357 women, cefazolin given before incision reduced total infectious morbidity by roughly 60% compared with dosing at cord clamping (RR 0.40), with no increase in neonatal sepsis evaluations.²³ Three subsequent meta-analyses confirmed reduced endometritis and overall infectious morbidity with pre-incision timing and no neonatal harm.²⁴^,²⁵^,²⁶

Adjunctive azithromycin

For non-elective cesarean section (that is, in labor or after ruptured membranes), the multicenter C/SOAP trial of 2013 women showed that intravenous azithromycin 500 mg added to cefazolin halved the composite endpoint of endometritis, wound infection or other infection (12.0% vs 6.1%; RR, 0.51), with no adverse neonatal effects.²⁷ ACOG endorses adjunctive azithromycin in this setting.²²

Vaginal preparation

Vaginal cleansing with povidone-iodine immediately before cesarean section reduces postoperative endometritis, with the greatest benefit in women in labor or with ruptured membranes.²²^,²⁸

Skin antisepsis

In a randomized trial of 1147 cesarean deliveries, chlorhexidine-alcohol skin preparation reduced 30-day SSI compared with povidone-iodine (7.3% vs 4.0%; RR, 0.55);²⁹ a Cochrane review classified this as moderate-certainty evidence in favor of chlorhexidine-alcohol.³⁰ Whichever alcohol-based preparation is chosen, it must be allowed to dry fully before draping when electrocautery is due to be used.

Hair removal

Routine shaving should be abandoned. Razor shaving probably increases SSI; clipping or depilatory cream results in fewer infections. If hair removal is truly necessary, clipping should be carried out on the day of surgery.³¹

Venous thromboembolism risk assessment and prophylaxis

Cesarean delivery approximately doubles the risk of venous thromboembolism (VTE) compared with vaginal birth, and every woman undergoing cesarean section should have a documented VTE risk assessment. ACOG recommends pneumatic compression devices for all cesarean patients, applied before or at induction of anesthesia and continued until the woman is fully ambulatory, with risk-stratified pharmacological prophylaxis (LMWH or unfractionated heparin) added when factors such as prior VTE, thrombophilia, obesity or emergency surgery are present.²⁰ The American Society of Hematology guideline stratifies similarly by personal and family history and by thrombophilia status, prefers LMWH, and reserves mechanical methods for women in whom anticoagulants are contraindicated.²¹ The randomized-trial base is admittedly thin: a Cochrane review found few trials and low-quality evidence for both mechanical and pharmacological methods, with a possible bleeding signal from heparins.³² Pharmacological prophylaxis should be coordinated with the neuraxial timing intervals described above.¹⁹

Antenatal corticosteroids before scheduled late-preterm and early-term cesarean section

Cesarean birth without labor increases neonatal respiratory morbidity, because the fetal lung fluid has not been cleared by the hormonal cascade of labor. In women at risk of late-preterm delivery (34+0 to 36+6 weeks) who have not received antenatal steroids, the ALPS trial of 2831 women showed that betamethasone reduced the primary composite of need for neonatal respiratory treatment (11.6% vs 14.4%) and, more strikingly, severe respiratory complications (8.1% vs 12.1%; RR, 0.67), at the cost of a higher rate of neonatal hypoglycemia, which warrants monitoring but is largely manageable.³³ At term, the pragmatic ASTECS trial of 998 women delivered by elective cesarean at ≥ 37 weeks found that betamethasone reduced admission to special care for respiratory distress from 5.1% to 2.4% (RR, 0.46), with the largest absolute benefit before 39 weeks.³⁴ Given ongoing uncertainty about long-term neurodevelopmental effects of late steroid exposure, administration before elective cesarean at 37+0 to 38+6 weeks should be individualized; it is generally not indicated at ≥ 39 weeks.¹^,³⁴

Uterine evacuation in early pregnancy loss

Surgical management of early pregnancy loss, by manual or electric vacuum aspiration rather than sharp curettage, succeeds in more than 95% of cases; the choice between expectant, medical and surgical management is best reached through shared decision-making.³⁵ Preoperative assessment confirms diagnosis and gestational age, quantifies bleeding, verifies hemodynamic stability and hemoglobin, and establishes RhD status so that immune globulin can be given when indicated.³⁵

Antibiotic prophylaxis deserves emphasis because it is so often overlooked in a procedure that we tend to regard as minor. The AIMS trial, a double-blind randomized study of 3412 women undergoing evacuation for incomplete miscarriage in Malawi, Pakistan and Uganda, showed that a single preoperative dose of doxycycline plus metronidazole reduced pelvic infection within 14 days from 5.3% to 4.1% (RR, 0.77; NNT approximately 84).³⁶ Fasting and anesthesia follow the same principles as any other elective uterine surgery. Written orientation, an adult companion and clear post-procedure contact information are essential, because these women are almost always discharged the same day.

Standardized written preoperative orientation: a worked example from Grupo Santa Joana, São Paulo

The ERAS Society identifies structured preoperative education as a core element,¹^,⁴ but evidence is useful only insofar as the patient understands and acts on it. At Hospital e Maternidade Santa Joana we have operationalized this recommendation as four procedure-specific, one-page instruction sheets: uterine curettage or manual vacuum aspiration, elective cesarean delivery, elective induction of labor, and other elective obstetric surgery (Table 1).

Fasting instructions state the exact clock time at which fasting begins, and are tailored to procedure and anesthetic plan (Table 1). The cesarean sheet permits water, gelatin and isotonic drinks until the woman leaves home, mirroring ASA clear-fluid guidance;⁸ the curettage and other elective obstetric surgery sheets require a full 8-hour fast including water, reflecting the more frequent use of general anesthesia or deep sedation; the elective induction sheet imposes no fasting, in line with the evidence on oral intake during labor.¹³ Each sheet incorporates a medication checklist, completed by the responsible clinician, that specifies for every continuous medication whether it should be suspended and for how long (24, 48 or 72 hours, or other).¹⁹

Personal-care rules, often absent from formal protocols, safeguard the reliability of pulse oximetry and clinical assessment: light-colored nail polish only, no gel or fiberglass nails, no eyelash extensions, no jewelry, no creams or oils on the skin (Box 1). The cesarean sheet makes surgical-site hair removal optional and patient-performed; institutions adapting the model should specify clipping rather than shaving.³¹

Box 1 Core elements of a standardized written preoperative orientation for obstetric procedures

Procedure, date, scheduled time, and admission time and location, all stated explicitly
Fasting instructions with the exact clock time at which fasting begins; separate rules for solids and clear fluids, tailored to procedure and anesthetic plan
Documents to bring: identification, insurance, prenatal card, recent examinations (ultrasound, laboratory)
Allergy disclosure (medications, foods, other)
Continuous-medication checklist with an explicit, professionally completed suspension interval per drug (24, 48 or 72 hours, or other)
Adult companion requirement and custody of valuables
Personal-care rules: light-colored nail polish only; no glitter, gel or fiberglass nails or eyelash extensions; jewelry and piercings removed; dry hair, no extensions; no skin creams or oils; clipping (not shaving) where hair removal is relevant
Contingency statement and clear instructions on where to present for intercurrences before the scheduled date
Name of the professional responsible for the orientation; reference to institutional resources such as the maternity bag list

Comparison of the four procedure-specific preoperative orientation sheets (Hospital e Maternidade Santa Joana, São Paulo).

	Orientation sheet
Instruction domain	Curettage/vacuum aspiration	Elective cesarean section	Elective induction of labor	Other elective obstetric surgery*
Fasting	8 h, including water; start time stated	8 h for solids; water, gelatin and isotonic drinks permitted until leaving home	No fasting (unless physician advises otherwise)	8 h, including water; start time stated
Documents and exams	ID, insurance; recent ultrasound and laboratory results	ID, insurance, marriage certificate if any; prenatal card and exams	As for elective cesarean	ID, insurance; recent ultrasound and laboratory results
Admission	Emergency unit at stated time	Hospital at stated admission time	Hospital at stated admission time	Emergency unit at stated time
Allergy disclosure	Required	Required	Required	Required
Adult companion	Required	Required	Required	Required
Medication checklist	Yes (24, 48 or 72 h suspension options)	Yes (24, 48 or 72 h suspension options)	Yes (24, 48 or 72 h suspension options)	Yes (24, 48 or 72 h suspension options)
Personal-care rules	Nail, jewelry and hair rules	Nail, jewelry and hair rules; optional site hair removal; no creams or oils	Nail, jewelry and hair rules; no creams or oils	Nail, jewelry and hair rules
Contingency guidance	Rescheduling statement	Rescheduling statement; attend emergency unit for intercurrences	As for elective cesarean	Rescheduling statement
Named responsible professional	Yes	Yes	Yes	Yes

*'Other elective obstetric surgery' refers to planned procedures, other than cesarean delivery, performed under anesthesia or deep sedation in the obstetric unit, such as cervical cerclage (placement or removal), hysteroscopic resection of retained products of conception, surgical revision or secondary closure of a cesarean or perineal wound, and drainage of a postpartum hematoma. The orientation sheet for these procedures is identical in content to that for curettage/vacuum aspiration and is kept separate so that the procedure, date and responsible professional can be named on the sheet itself.

The strength of the model is its specificity: exact times rather than vague ones, tailoring to procedure and anesthetic technique, embedded medication reconciliation, explicit contingency guidance. Services adapting it should ensure that medication-suspension intervals align with anticoagulant-neuraxial timing standards.¹⁹ Written orientation complements verbal counseling and formal informed consent; it does not replace either.¹^,¹¹

POSTOPERATIVE CARE

The woman who leaves the operating theater after a cesarean delivery is not a surgical patient who happens to have a baby. She is a mother who happens to have a wound. That inversion of priorities is the philosophical core of enhanced recovery after cesarean section: every postoperative intervention aims to help her recover, as soon as safely possible, so that she can care for herself and her newborn. Drawing on the ERAS cesarean series³^,⁶ and the SOAP consensus,⁷ this section follows the patient from the recovery area through discharge, and closes with the aftercare of uterine evacuation.

Immediate recovery, monitoring and prevention of nausea and vomiting

After cesarean birth the patient should be observed in a recovery area with regular assessment of blood pressure, heart rate, oxygen saturation, temperature, uterine tone, vaginal bleeding, the wound dressing and regression of the neuraxial block.²^,³ Vital signs should be interpreted against institutional early-warning criteria, because postpartum hemorrhage is easily underestimated in young women who compensate physiologically until very late. Patients who have received neuraxial morphine require extended respiratory and sedation monitoring in accordance with local policy.

Postoperative nausea and vomiting (PONV) is common after neuraxial cesarean and delays feeding, mobilization and maternal-infant bonding. A Cochrane review supports multimodal prophylaxis: 5-HT3 antagonists such as ondansetron, dopamine antagonists and dexamethasone each reduce PONV, and the prevention and prompt treatment of spinal hypotension with vasopressors is itself antiemetic.³⁷ Keeping the neuraxial opioid dose low and avoiding unnecessary uterine exteriorization also reduce nausea.³⁷^,³⁸ Both ERAS and SOAP recommend routine pharmacological PONV prophylaxis.⁵^,⁷

Multimodal postoperative analgesia

Poorly controlled pain does more than hurt: it delays mobilization, impairs the mother's ability to care for her infant, and heightens the risk of persistent opioid use. The approach should be stepwise and opioid-sparing. Under neuraxial anesthesia, intrathecal morphine at 50–100 μg is a cornerstone of post-cesarean analgesia. A meta-analysis of 11 randomized trials showed that higher doses (> 100 μg up to 250 μg) prolong analgesia by roughly 4.5 hours, but at the price of substantially more nausea, vomiting and pruritus, supporting the lower dose as a balance between analgesic duration and adverse effects.³⁸ ACOG and ERAS endorse scheduled acetaminophen combined with a scheduled non-steroidal anti-inflammatory drug (NSAID), with oral opioids reserved for breakthrough pain at the lowest effective dose;⁶^,³⁹ scheduled (rather than as-needed) acetaminophen reduces opioid consumption in the first 48 hours without worsening pain scores.⁴⁰ NSAIDs are compatible with breastfeeding and are withheld only when contraindicated, for instance in women with renal impairment, severe pre-eclampsia with thrombocytopenia, or documented NSAID sensitivity.

The transversus abdominis plane (TAP) block is a useful adjunct when neuraxial morphine has not been given (as after general anesthesia), but a systematic review found that it adds little to intrathecal morphine and is best used selectively, or as rescue.⁴¹ Rescue opioids should be prescribed in defined, limited quantities, and unexpectedly uncontrolled pain should prompt a search for a surgical cause before doses are escalated.⁷^,³⁹ Table 2 summarizes the regimen.

Multimodal analgesia after cesarean birth.

Agent or technique	Typical regimen	Evidence and guideline basis
Intrathecal morphine	50–100 μg once with the spinal; low dose preferred	Higher doses prolong analgesia modestly but increase PONV and pruritus;³⁸ first-line under neuraxial anesthesia³⁹
Acetaminophen (paracetamol) or Dipirone	1 g orally or intravenously every 6 h, scheduled	Scheduled dosing reduces opioid consumption;⁴⁰ ACOG, ERAS and SOAP endorsement⁶^,⁷^,³⁹
NSAID (ibuprofen, ketorolac)	Ibuprofen 600–800 mg orally every 6–8 h; ketorolac intravenously while fasting, scheduled	Core of the stepwise multimodal regimen⁶^,³⁹
TAP block, ultrasound-guided	Bilateral ropivacaine or bupivacaine	Reduces opioid use when neuraxial morphine was not given; minimal additive effect with intrathecal morphine⁴¹
Rescue opioid (oral oxycodone)	Lowest effective dose, short course, defined quantity	Reserved for breakthrough pain; opioid stewardship with shared decision-making⁷^,³⁹

ACOG, American College of Obstetricians and Gynecologists; ERAS, Enhanced Recovery After Surgery society; NSAID, non-steroidal anti-inflammatory drug; PONV, postoperative nausea and vomiting; SOAP, Society for Obstetric Anesthesia and Perinatology; TAP, transversus abdominis plane.

Early oral intake, mobilization and catheter removal

Early oral intake is a pillar of enhanced recovery. A Cochrane review found that early postoperative fluids and food after cesarean hastened the return of bowel sounds and shortened hospital stay, without increasing ileus or other gastrointestinal complications.⁴² ERAS accordingly recommends a regular diet within 2 hours of surgery, as tolerated.³^,⁶ Chewing gum two or three times a day, a form of sham feeding, is a cheap, safe adjunct that accelerates first flatus, bowel sounds and defecation, and reduces ileus.⁴³

Mobilization should begin as soon as the neuraxial block has regressed, ideally within the first postoperative day; it reduces thromboembolic risk, hastens gastrointestinal recovery, and shortens hospital stay.³^,⁴⁴ The urinary catheter should be removed immediately after surgery when neuraxial morphine has been given, or as early as feasible thereafter. A meta-analysis of randomized trials showed that early removal reduces urinary tract infection, recatheterization, patient discomfort and time to first ambulation, without increasing retention.⁴⁵ Early catheter removal and early ambulation reinforce one another, and both are recommended by ERAS and SOAP.³^,⁷ A woman who can eat, walk and go to the bathroom unassisted is, in every practical sense, already on her way home.

Prevention and recognition of postpartum hemorrhage

Uterine atony remains the leading cause of postpartum hemorrhage (PPH), and cesarean is itself a risk factor. Active management with a prophylactic uterotonic is now the universal standard: ACOG recommends oxytocin as first-line prophylaxis at both vaginal and cesarean delivery, with stepwise escalation to additional uterotonics, balloon tamponade, operative interventions and transfusion when bleeding persists.⁴⁶ A Cochrane network meta-analysis of 140 trials confirmed that all uterotonic agents outperform placebo; carbetocin ranked among the most effective for preventing blood loss of ≥ 500 mL, and its heat-stable formulation offers a valuable alternative where cold-chain storage is unreliable.⁴⁷

Tranexamic acid (TXA) has become integral to the treatment of PPH. The WOMAN trial, enrolling 20 060 women, showed that intravenous TXA (1 g, repeatable once) reduced death from bleeding, with the greatest benefit when given within 3 hours of birth, and without any increase in thromboembolic events.⁴⁸ Prophylaxis is a separate question. In the French TRAAP2 trial, TXA added to prophylactic uterotonics at cesarean reduced calculated blood loss above 1000 mL or transfusion by day 2 (26.7% vs 31.6%), but clinically significant hemorrhage as judged by the provider was not reduced.⁴⁹ The US Maternal-Fetal Medicine Units trial of about 11 000 women found no reduction in the composite of maternal death or transfusion (3.6% vs 4.3%),⁵⁰ and the earlier TRAAP trial had shown no significant benefit after vaginal delivery.⁵¹ The message is clear: TXA is a treatment for hemorrhage, given early, and not a routine prophylactic. Quantitative blood-loss assessment, serial fundal examination and vital-sign trends, with a low threshold for reassessment, remain the cornerstones of management.⁴⁶

Surveillance for postoperative complications

Systematic surveillance in the first postoperative days permits early detection of the principal complications: infection, hemorrhage, urinary tract injury and thromboembolism. Postpartum endometritis presents with fever, uterine tenderness and foul lochia, most often after cesarean following labor or ruptured membranes. First-line therapy is intravenous clindamycin plus gentamicin, which a Cochrane review found superior to penicillin-based regimens; once-daily aminoglycoside dosing is as effective as divided dosing, and oral antibiotics after intravenous response are unnecessary in uncomplicated cases.⁵²

SSI complicates roughly 3–15% of cesareans, depending on population and definitions, with obesity, diabetes, emergency surgery and chorioamnionitis increasing the risk.⁵³ In women with a body mass index ≥ 30 kg/m², prophylactic incisional negative-pressure wound therapy reduced SSI requiring antibiotics within 30 days from 9.2% to 4.6% in a multicenter randomized trial of 876 women (RR, 0.50; NNT, 22).⁵⁴ Wounds should be inspected for erythema, discharge and dehiscence before leaving hospital and again at follow-up.

Iatrogenic bladder injury occurs in well under 1% of cesareans; prior cesarean, emergency surgery and adhesions raise the risk, and most dome injuries are recognized intraoperatively and repaired primarily with good outcomes.⁵⁵ Unrecognized injury presents with hematuria, abdominal pain, ileus or urinary ascites, and warrants prompt imaging and urological consultation. Thromboprophylaxis follows the risk-stratified approach described above, continued for up to 6 weeks in high-risk women.²⁰ Box 2 lists the findings that should bring a postoperative woman back for urgent evaluation.

Box 2 Red flags in the postoperative period after obstetric surgery

Heavy vaginal bleeding, passage of large clots, or signs of hypovolemia (tachycardia, hypotension, pallor)
Fever ≥ 38.0°C, particularly with uterine tenderness, foul lochia or chills
Wound erythema, purulent discharge, escalating pain or dehiscence
Unilateral leg pain or swelling (possible deep vein thrombosis)
Dyspnea, chest pain or hemoptysis (possible pulmonary embolism)
Severe or persistent headache, visual disturbance or epigastric pain (possible postpartum pre-eclampsia; consider also post-dural puncture headache)
Inability to void, suprapubic pain, hematuria or recurrent urinary symptoms after catheter removal
Increasing abdominal pain, distension, absent bowel sounds or persistent vomiting (possible ileus or bowel injury)

Skin-to-skin contact and breastfeeding support

Once mother and infant are stable, uninterrupted skin-to-skin contact should begin, in the operating room or the recovery area. A Cochrane review of 46 trials demonstrated that early skin-to-skin contact improves breastfeeding rates at 1–4 months (RR, 1.24) and breastfeeding duration, as well as infant cardiorespiratory stability and blood glucose, with no evidence of harm; several of the included trials were conducted in the setting of cesarean birth.⁵⁶ ERAS and SOAP both list early skin-to-skin contact and breastfeeding among the core postoperative elements.⁵^,⁶^,⁷ Practical support includes positioning that avoids pressure on the incision, analgesia timed to facilitate feeding, and reassurance that neuraxial morphine and scheduled NSAIDs are compatible with breastfeeding.³⁹

Blood pressure surveillance after discharge

Postpartum pre-eclampsia, including de-novo disease arising after a normotensive pregnancy, most often presents within the first week and may first become apparent after discharge, when routine postpartum monitoring has ended. Women with antenatal hypertensive disorders should have blood-pressure surveillance arranged before they leave the hospital, with clinical review within 3 days for severe-range readings.⁵⁷ Technology has proved unusually useful here. In a randomized trial, text-based remote monitoring achieved blood-pressure ascertainment within 10 days of discharge in 92% of women, compared with 44% under office-based follow-up;⁵⁸ a telehealth program with remote monitoring was associated with fewer hypertension-related readmissions.⁵⁹ Every postpartum woman, regardless of hypertensive history, should leave with clear instructions that severe headache, visual symptoms, epigastric pain or new-onset swelling after hospital discharge require urgent blood-pressure evaluation.

Discharge planning, the fourth trimester and counseling for future pregnancies

Discharge after cesarean in enhanced-recovery programs typically occurs at 24–48 hours, contingent on adequate oral analgesia, tolerance of diet, ambulation, spontaneous voiding after catheter removal, stable vital signs and arranged follow-up.⁶^,⁷ ACOG has reframed postpartum care as an ongoing process, the fourth trimester, with contact for every woman within 3 weeks of birth (within 3 days for those affected by severe hypertension) and a comprehensive visit by 12 weeks that addresses wound healing, pain, mood, contraception, infant feeding, and transition to ongoing primary care.⁵⁷ Discharge instructions, both written and verbal, should cover wound care, activity, any limited-quantity opioid prescription (with guidance on safe storage), and the red flags of Box 2.³⁹

Counseling for future pregnancies begins before discharge, revisiting the cumulative risks of uterine scarring outlined above.¹² Women with a single previous low-transverse cesarean should know that a trial of labor is an option for many of them, and that early ultrasound in any subsequent pregnancy should assess placental location relative to the scar in order to exclude cesarean scar implantation and screen for placenta accreta spectrum.¹²

Care after uterine evacuation for early pregnancy loss

Vacuum aspiration for early pregnancy loss is typically a day-case procedure.³⁵ Before discharge, the clinician confirms hemodynamic stability, diminishing bleeding, and tolerance of oral intake. Instructions must specify warning signs (heavy bleeding, fever, worsening abdominal pain, foul discharge), with a clear route for urgent review. RhD-negative women receive anti-D immunoglobulin according to protocol.³⁵ Contraception should be discussed before the woman leaves, because ovulation can resume within weeks and every method may be initiated immediately if desired.³⁵ Finally, the clinician should acknowledge the emotional weight of pregnancy loss, screen for grief, anxiety and depression at follow-up, and offer support: psychological sequelae are common even when physical recovery is uneventful.³⁵ A miscarriage is a small operation but a large event, and the aftercare must be proportionate to the latter, not the former.

CONCLUSION

Perioperative care in obstetrics has migrated decisively from custom to evidence. The literature reviewed here supports a coherent bundle: structured assessment and written orientation; individualized fasting; correction of anemia; a documented VTE risk assessment for every cesarean section; pre-incision antibiotic prophylaxis with adjunctive azithromycin when indicated; multimodal opioid-sparing analgesia; early feeding, mobilization and catheter removal; active prevention and early recognition of hemorrhage; surveillance for infection, thromboembolism and postpartum hypertension; and support for skin-to-skin contact, breastfeeding, and fourth-trimester follow-up. None of these interventions is individually spectacular. What is spectacular is their aggregate effect when they are delivered reliably, every time, by every team.

What remains, therefore, is not discovery but implementation. The evidence exists; what varies from one maternity to the next is the discipline to apply it consistently. Semmelweis learned, at considerable personal cost, that being right is not enough. The clinician who reads this chapter is invited to do something harder than agree with it: to translate it into a checklist, a sheet of paper, and, in time, a habit of the team.

PRACTICE RECOMMENDATIONS

Permit clear liquids up to 2 hours before elective procedures; require 6 hours of fasting after a light meal and 8 hours after fatty food; do not impose nil-by-mouth on low-risk women in labor.
Give cefazolin within 60 min before skin incision at every cesarean section (2 g, or 3 g in patients weighing ≥ 120 kg); add azithromycin 500 mg for non-elective cesarean; combine with vaginal preparation, chlorhexidine-alcohol skin antisepsis, and clipping rather than shaving where hair removal is needed.
Screen for anemia before scheduled surgery, ideally 4–8 weeks in advance, and treat with oral or intravenous iron.
Document a VTE risk assessment for every cesarean; apply pneumatic compression universally, and add risk-stratified pharmacological prophylaxis while respecting neuraxial timing intervals after heparin.
Use multimodal analgesia: low-dose intrathecal morphine (50–100 μg), scheduled acetaminophen plus an NSAID, and opioids only for breakthrough pain.
Offer a regular diet within 2 hours of surgery, mobilize early, and remove the urinary catheter early.
Give a prophylactic uterotonic (oxytocin first line) at every birth; treat hemorrhage with stepwise escalation including intravenous tranexamic acid (TXA) 1 g within 3 hours. Routine prophylactic TXA is not supported by the largest trials.
Monitor for hemorrhage, infection, urinary tract injury, thromboembolism and postpartum pre-eclampsia, with explicit red-flag instructions provided at hospital discharge.
Initiate skin-to-skin contact and breastfeeding support in the operating room or recovery area when clinically feasible; neuraxial morphine and scheduled NSAIDs are compatible with breastfeeding.
Arrange fourth-trimester follow-up (contact within 3 weeks; comprehensive visit by 12 weeks), and counsel on contraception and future pregnancy before discharge.

CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

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