What are the appropriate first‑line postoperative orders for an adult woman in the recovery area after a routine obstetric‑gynecologic surgery (e.g., hysterectomy, myomectomy, or ovarian cystectomy)?

Postoperative Orders for Obstetric-Gynecologic Surgery

Implement an Enhanced Recovery After Surgery (ERAS) protocol with early feeding, multimodal analgesia, early mobilization, and thromboprophylaxis as the standard postoperative care pathway for routine gynecologic procedures. 1, 2, 3

Immediate Postoperative Care (Recovery Room)

Vital Signs and Monitoring

• Monitor vital signs every 15 minutes until stable, then every 30 minutes for 2 hours 1
• Assess surgical site, vaginal bleeding, and fundal height (if applicable) 1
• Monitor urine output if catheter remains in place 1

Pain Management: Multimodal Analgesia

Use a multimodal, opioid-sparing approach as first-line pain management to reduce narcotic requirements and side effects 1, 2, 4:

• Scheduled NSAIDs: Ibuprofen 600-800 mg PO every 6-8 hours or ketorolac 15-30 mg IV every 6 hours (if no contraindications) 1, 2
• Scheduled acetaminophen: 1000 mg PO/IV every 6 hours 1, 2, 4
• Opioids as rescue only: Oxycodone 5-10 mg PO or morphine 2-4 mg IV every 4 hours PRN for breakthrough pain 1, 2
• Avoid routine gabapentinoids due to FDA warnings about respiratory depression 2

Nausea and Vomiting Prevention

• Administer prophylactic antiemetics in recovery room 1
• Use multimodal approach: ondansetron 4-8 mg IV plus dexamethasone 4-8 mg IV 1, 2
• Provide rescue antiemetics PRN (metoclopramide, promethazine) 1

Early Oral Intake

Begin clear liquids immediately upon return to recovery room once patient is alert 1, 2, 4:

• Progress to regular diet as tolerated within 2-4 hours postoperatively 1, 2
• No need for traditional feeding trials or waiting for bowel sounds 1, 4
• Gum chewing may reduce time to flatus by 7 hours if early feeding is not implemented, though evidence is low quality 1

Floor/Ward Orders (First 24 Hours)

Activity and Mobilization

Mobilize patient out of bed within 4-6 hours of surgery 1, 2, 4:

• Ambulate in hallway at least 3 times on postoperative day 0 2, 4
• Early mobilization reduces thromboembolism risk and improves recovery 1, 2

Urinary Catheter Management

• Remove Foley catheter within 12-24 hours postoperatively for most procedures 1, 2
• Earlier removal (within 6 hours) is acceptable for minimally invasive procedures 2
• Prolonged catheterization increases infection risk 1

Thromboprophylaxis

Implement mechanical and/or pharmacologic VTE prophylaxis based on risk stratification 1, 2:

• Low risk (minimally invasive, <60 minutes, mobile): Early ambulation alone 2
• Moderate risk (open surgery, age >40, obesity): Sequential compression devices (SCDs) plus early ambulation 2
• High risk (cancer, prior VTE, prolonged surgery >2 hours): SCDs plus pharmacologic prophylaxis (enoxaparin 40 mg SC daily or heparin 5000 units SC every 8 hours) 2, 3

Fluid Management

• Goal-directed fluid therapy: maintain euvolemia, avoid fluid overload 2, 4, 3
• Discontinue IV fluids once patient tolerating oral intake (typically 4-12 hours postop) 2, 4
• Target urine output >0.5 mL/kg/hour 3

Glucose Control

• Monitor blood glucose every 6 hours if diabetic 1
• Target glucose <180 mg/dL using sliding scale insulin 1, 3

Nutritional Care

• Regular diet as tolerated starting postoperative day 0 1, 2, 4
• Protein supplementation if malnourished 3
• No bowel preparation required preoperatively, and no need to wait for bowel function return 2, 4

Antibiotic Considerations

Routine Gynecologic Surgery

• No routine postoperative antibiotics needed after clean gynecologic procedures (hysterectomy, myomectomy, cystectomy) if appropriate preoperative prophylaxis was given 5, 2
• Single preoperative dose is sufficient for most procedures 2

Special Circumstances Requiring Postoperative Antibiotics

• Third/fourth-degree perineal lacerations (OASIS): Continue second- or third-generation cephalosporin plus metronidazole for 24 hours postoperatively 6
• Contaminated wounds: Continue antibiotics for 3-5 days depending on severity 6

Discharge Planning

Discharge Criteria

Target same-day or next-day discharge for minimally invasive procedures 2, 4:

• Adequate pain control on oral medications 2, 4
• Tolerating regular diet 2, 4
• Ambulating independently 2, 4
• No signs of complications (fever, excessive bleeding, urinary retention) 2

Discharge Instructions

• Pain management: Continue scheduled NSAIDs and acetaminophen with opioids PRN only 2, 4
• Activity: Gradual return to normal activities over 2-6 weeks depending on procedure 2
• Warning signs: Fever >38.5°C, heavy bleeding, severe pain, leg swelling, shortness of breath 2, 3
• Follow-up appointment in 2-6 weeks 2, 3

Common Pitfalls to Avoid

• Delaying oral intake: Traditional NPO orders until bowel function returns are outdated and delay recovery 1, 2, 4
• Opioid-only analgesia: Leads to increased side effects (nausea, ileus, sedation) without superior pain control compared to multimodal approach 1, 2, 4
• Prolonged bed rest: Increases VTE risk and delays recovery; mobilize early even if uncomfortable 1, 2
• Routine IV fluids beyond 12 hours: Causes fluid overload and delays discharge 2, 4
• Unnecessary postoperative antibiotics: No benefit for clean procedures and increases resistance risk 5, 2
• Keeping Foley catheter >24 hours: Increases UTI risk without benefit for most procedures 1, 2