Postoperative Orders for Uncomplicated Cesarean Section
For an uncomplicated cesarean delivery, implement the following evidence-based postoperative orders: continue oxytocin infusion for hemorrhage prevention, remove urinary catheter at 6-12 hours after ambulation, start scheduled acetaminophen 650mg PO every 6 hours plus ibuprofen 600mg PO every 6 hours (after initial ketorolac 30mg IV every 6 hours for 4 doses), begin clear liquids immediately and advance to regular diet within 2 hours, ambulate starting at 4-6 hours postoperatively, apply mechanical thromboprophylaxis until ambulation, and plan discharge at 24-48 hours if appropriate neonatal follow-up is available. 1, 2
Immediate Postoperative Care
Monitoring & Location
- Recovery room monitoring is standard; delivery unit monitoring acceptable only with proper safety protocols and regulatory notification 3
- Routine immediate postoperative blood count is not recommended for uncomplicated cases 3
Hemorrhage Prevention
- Continue oxytocin infusion postoperatively for postpartum hemorrhage prevention 2
Pain Management Protocol
Multimodal Analgesia (Scheduled, Not PRN)
The cornerstone is scheduled non-opioid medications with opioids reserved only for breakthrough pain 1, 2:
- Ketorolac 30mg IV every 6 hours for 4 doses (started intraoperatively if not already given)
- Then transition to ibuprofen 600mg PO every 6 hours
- Acetaminophen 650mg PO every 6 hours (continue throughout hospitalization)
- Short-acting opioids for breakthrough pain only - prescribe based on inpatient requirements 2
This approach is supported by ERAS Society, ACOG, and SOAP consensus recommendations 1.
Urinary Catheter Management
Remove catheter at 6-12 hours postoperatively, after the patient is walking 1, 2. This timing applies even with neuraxial morphine administration and increases patient satisfaction without compromising bladder function.
Exclusion criteria for early removal:
- Excessive bleeding
- Magnesium infusions
- Unsteadiness on feet 1
Critical follow-up: Verify spontaneous voiding within 4-6 hours after catheter removal; alert physician if no void by 6 hours 3.
Nutrition & Bowel Function
- Clear liquids immediately postoperatively
- Regular diet within 2 hours of surgery 2, 4
- Chewing gum recommended to facilitate return of bowel function 2
This applies to both elective and emergency cesareans, regardless of anesthesia type 3.
Mobilization Protocol
Begin ambulation at 4-6 hours postoperatively with assistance 2, 3. Early mobilization is strongly recommended despite low-quality evidence because immobilization is a proven risk factor for thromboembolism 1.
Structured Ambulation Targets 1:
- 0-8 hours: Sit on bed edge, transfer to chair, wheelchair ambulation as tolerated
- 8-24 hours: Walk in hallway 1-2 times
- 24-48 hours: Walk in hallway 3-4 times, aim for 8 hours out of bed daily
Consider pedometer use to incentivize early ambulation 2.
Thromboprophylaxis
Low-Risk Patients
- Mechanical prophylaxis (compression stockings) until ambulation 2, 4
- Apply on morning of surgery, continue for at least 7 days 3
- No routine pharmacologic prophylaxis 4
Higher-Risk Patients
Antiemetic Prophylaxis
Administer two antiemetic medications during cesarean delivery 3:
- 5HT3 antagonist (ondansetron) PLUS
- Either dopamine antagonist OR corticosteroid 2
Wound Care
Leave surgical dressing in place for 48 hours if applied 2.
Antibiotic Considerations
Routine multi-dose prophylactic antibiotics are NOT recommended for all patients 2.
Additional Antibiotic Doses Indicated For:
- Obesity without preoperative azithromycin
- Surgery duration ≥4 hours since prophylactic dose
- Blood loss >1500 mL
- Intra-amniotic infection 2
Discharge Planning
Timing
- 24-28 hours: Acceptable for low-risk patients IF close outpatient neonatal follow-up (1-2 days) is available due to jaundice risk 2, 5
- 48-72 hours: Standard discharge timing otherwise 2
The short-stay protocol (discharge at 3 days vs. 5 days) has been shown safe with lower pain scores and costs 5.
Discharge Medications
- Continue acetaminophen and ibuprofen on same schedule 2
- Short-acting opioids if needed, individualized to inpatient requirements
Discharge Counseling
- Optimal interpregnancy interval: 18-23 months 2
- Encourage exclusive breastfeeding for ≥6 months
- Resume physical activity quickly
- Vaginal intercourse as tolerated
- Contraception options (immediate postpartum IUD, intraoperative salpingectomy, or postpartum LARC) 2
Common Pitfalls to Avoid
- Do not use PRN-only pain medications - scheduled multimodal analgesia is superior 1
- Do not delay catheter removal beyond 12 hours in uncomplicated cases - increases infection risk 1
- Do not keep patients NPO - early feeding is safe and beneficial 4
- Do not delay ambulation - increases thromboembolism risk 1
- Do not routinely prescribe prophylactic antibiotics beyond single preoperative dose 2
Implementation of these evidence-based protocols decreases length of stay, reduces surgical site infections, and improves patient satisfaction and breastfeeding rates 2.