What are the recommended postpartum management steps for a woman after cesarean delivery, including pain control, wound care, venous thromboembolism prophylaxis, anemia treatment, breastfeeding support, activity restrictions, urinary monitoring, contraception, and follow‑up?

Postpartum Care After Cesarean Delivery

All women undergoing cesarean delivery must receive sequential compression devices starting before surgery and continuing until fully ambulatory, with pharmacologic thromboprophylaxis (enoxaparin 40 mg subcutaneously once daily) added for those with one major or at least two minor VTE risk factors. 1, 2

Venous Thromboembolism Prophylaxis

Universal Mechanical Prophylaxis

• Sequential compression devices (SCDs) are mandatory for all cesarean deliveries, applied before skin incision and maintained continuously until the patient achieves full ambulation (GRADE 1C). 1, 2
• Pneumatic sequential compression devices are superior to static elastic stockings for preventing perioperative VTE. 2

Risk Stratification for Pharmacologic Prophylaxis

Major risk factors (any one triggers pharmacologic prophylaxis): 1

• Previous personal history of deep venous thrombosis or pulmonary embolism
• Inherited thrombophilia (high-risk or low-risk)
• Immobility ≥1 week antepartum
• Postpartum hemorrhage requiring surgery
• Preeclampsia with fetal growth restriction
• Antithrombin deficiency or Factor V Leiden mutations
• Blood transfusion
• Postpartum infection
• Systemic lupus erythematosus, heart disease, or sickle cell disease

Minor risk factors (two or more trigger pharmacologic prophylaxis): 1, 2

• Advanced maternal age (≥35 years)
• Obesity (BMI ≥30 kg/m²)
• Smoking
• Parity ≥3
• Family history of VTE
• Varicose veins
• Multiple pregnancy
• Prolonged labor >24 hours
• Operative vaginal delivery
• Postpartum hemorrhage

Pharmacologic Prophylaxis Regimen

Standard dosing: 1, 2

• Low-molecular-weight heparin (enoxaparin) is the preferred agent (GRADE 1C)
• Enoxaparin 40 mg subcutaneously once daily for patients with standard risk factors

Class III obesity (BMI ≥40) dosing: 2

• Intermediate-dose enoxaparin 40 mg subcutaneously every 12 hours (GRADE 2C)
• Initiate no earlier than 24 hours after neuraxial block and at least 4 hours after epidural catheter removal

Renal impairment: 2

• If creatinine clearance <30 mL/min, use unfractionated heparin 5,000-10,000 units subcutaneously every 8-12 hours instead of enoxaparin

Duration of Prophylaxis

• Mechanical prophylaxis continues until full ambulation 1, 2
• Pharmacologic prophylaxis extends for 6 weeks postpartum when risk factors persist (GRADE 2C) 1, 2
• For intermediate-risk patients (one major or two minor factors), minimum 10 days of pharmacologic prophylaxis is recommended 1

High-Risk Populations Requiring Combined Prophylaxis

• Women with previous VTE receive both mechanical and pharmacologic prophylaxis for 6 weeks postpartum (GRADE 2C) 1
• Women with inherited thrombophilia (with or without previous thrombosis) receive both mechanical and pharmacologic prophylaxis for 6 weeks postpartum (GRADE 2C) 1
• Very high-risk patients with multiple persistent risk factors should receive combined mechanical and pharmacologic prophylaxis rather than either alone (GRADE 2C) 2

Pain Management

Multimodal Analgesia Protocol

• Scheduled acetaminophen 650 mg orally every 6 hours 3
• Ketorolac 30 mg IV every 6 hours for 4 doses, then ibuprofen 600 mg orally every 6 hours 3
• Intraoperative administration of 1 g IV acetaminophen and 30 mg IV ketorolac optimizes postoperative pain control 3
• Reserve short-acting opioids for breakthrough pain only, with prescribing individualized based on inpatient requirements 3

Wound Care

• Leave surgical dressing in place for 48 hours if applied 3
• Closure of deep subcutaneous layer in patients with subcutaneous tissue >2 cm thickness significantly reduces seroma, hematoma, and wound disruption 4
• Use of chlorhexidine skin preparation and electric clippers (not razors) for hair removal reduces wound infection rates 4

Antibiotic Prophylaxis

Additional postoperative antibiotic doses are indicated for: 3

• Patients with obesity who did not receive preoperative azithromycin
• Cesarean delivery lasting ≥4 hours since prophylactic dose
• Blood loss >1,500 mL
• Intra-amniotic infection

Routine multi-dose prophylactic antibiotics are not recommended for all patients 3

Urinary Catheter Management

• Remove indwelling bladder catheter immediately postoperatively when placed for scheduled cesarean delivery 3

Gastrointestinal Recovery

• Chewing gum aids return of bowel function and should be encouraged 3
• Early oral intake of solid food can begin immediately after cesarean delivery and within 2 hours 3

Nausea and Vomiting Prevention

• Administer 5HT3 antagonists combined with either a dopamine antagonist or corticosteroid 3

Early Mobilization

• Ambulation should begin 4 hours postoperatively and be incentivized with pedometer use 3
• Early mobilization is the minimum requirement for low-risk patients without additional VTE risk factors 2, 5

Postpartum Hemorrhage Prevention

• Continue oxytocin infusion post-cesarean delivery for prevention of postpartum hemorrhage 3

Hospital Discharge Timing

• Low-risk patients may be discharged 24-28 hours postoperatively if close (1-2 days) outpatient neonatal follow-up is available for jaundice monitoring 3
• Otherwise, discharge at 48-72 hours postoperatively 3

Discharge Counseling and Contraception

Pain Management at Discharge

• Continue scheduled acetaminophen and ibuprofen 3
• Individualize short-acting opioid prescriptions based on inpatient requirements 3

Reproductive Health Counseling

• Optimal interpregnancy interval is 18-23 months 3
• Counsel on immediate postpartum intrauterine device insertion, intraoperative salpingectomy, or postpartum long-acting reversible contraception placement 3

Breastfeeding and Activity

• Encourage exclusive breastfeeding for at least 6 months 3
• Quick resumption of physical activity is recommended 3
• Vaginal intercourse may resume as tolerated 3

Institutional Implementation

• Each institution should develop a standardized patient safety bundle with a VTE prophylaxis protocol for cesarean delivery (Best Practice) 1, 2
• Implementation of evidence-based postoperative care protocols decreases length of stay, surgical site infection rates, and improves patient satisfaction and breastfeeding rates 3

Critical Pitfalls to Avoid

• Do not use standard-dose enoxaparin (40 mg once daily) in Class III obesity—this results in subtherapeutic anti-Xa levels; use 40 mg every 12 hours instead 2
• Do not initiate intermediate-dose enoxaparin before 24 hours post-neuraxial block—this increases spinal hematoma risk 2
• Do not use direct oral anticoagulants (DOACs) in the postpartum period—insufficient safety data exists 2
• Do not rely on early ambulation alone when two or more minor risk factors are present—pharmacologic prophylaxis is required 2
• The number needed to harm with pharmacologic VTE prophylaxis may be lower than the number needed to treat in low-risk scenarios, with increased rates of wound separation and hematomas 1