Enhanced Recovery after Surgery


Having a planned caesarean section can be an exciting yet stressful situation for parents. As healthcare professionals, we understand your concerns and have developed this information leaflet for you to explain step-by-step how you will be involved in the preparation for your surgery and recovery following your caesarean section.

For most women a planned caesarean section takes place at or around 39 weeks. Once it has been agreed that you are having a caesarean section, the doctor will explain the risks and benefits of the surgery and give you the opportunity to ask any questions. You will then sign your consent form which will be uploaded to your healthcare record. Your doctor will give you a planned date for surgery. However, you should be aware that due to the unpredictable nature of the workload in the Delivery Suite, this date may occasionally need to be changed due to emergency activity.


What is Enhanced Recovery?

At the Rotunda Hospital we aim to follow an Enhanced Recovery After Surgery pathway for women undergoing elective caesarean section. Enhanced recovery is a modern, evidence-based approach that helps people to recover from surgery more quickly. It aims to optimise your experience and facilitate your recovery after surgery, so that you return to your normal level of function as soon as possible, allowing you to be independent sooner.

The enhanced recovery programme focuses on:

  • Being well prepared for your surgery through information and education
  • An early step-wise introduction of oral fluids and foods after your surgery
  • Moving early after surgery (getting out of bed and walking)
  • Optimum pain control which allows you to move more freely

The enhanced recovery pathway is a general guide. However, during your stay, your circumstances may change and we may have to modify the pathway, so you may not be able to complete all of it. This is nothing to worry about, everyone is different and you will achieve the goals at your own pace. 

The main points in the programme are:

  • Making sure you are not fasting for too long before your operation 
  • Encouraging oral fluids in the recovery room and a light snack when you are back on the postnatal ward
  • Good control of nausea with anti-sickness medication as required during the operation and afterwards in recovery and the postnatal ward
  • Good pain relief to allow for early mobilisation on the postnatal ward
  • An assessment after your surgery to enable you to start walking sooner
  • Early bladder catheter removal so that you can go to the toilet to pass urine
  • Discharge planning so that you can go home as early as possible

Before your operation

At the antenatal visit prior to your planned surgery, you will be given two tablets (called Omeprazole) which reduce the amount of acid in your stomach. One tablet should be taken the night before your operation (10pm) and one on the morning of the operation (6am). You will also be given two pre-operative carbohydrate drinks to bring home and take on the morning of your surgery. Store these in the fridge the night before your operation. If circumstances change, and you do not use these drinks, please bring them back to reception unopened on your admission to hospital.

The day before your caesarean section, you will receive a phone call from a member of theatre staff telling you what time you should come to the hospital the following day. The person contacting you will remind you the time to stop eating and drinking before surgery depending on whether your operation is scheduled for the morning or afternoon.

Please check that we have your correct phone number and that of your partner, so that we can make contact with you to give you these details. Please also ensure your phone is not on silent so you are aware we are calling you.

At the antenatal visit prior to your planned surgery, you will be given tablets (called Omeprazole) which reduce the amount of acid in your stomach. One tablet should be taken the night before your operation (10pm) and one on the morning of the operation (6am).

You should have a shower or bath every day for seven days prior to your caesarean section. Please pay particular attention to the groin and skin fold sites. No routine hair removal at the incision site is needed before your operation and most importantly this should not be undertaken in the 7 days before your caesarean section to reduce the risk of wound infection.


The day of your operation

To reduce the risk of infection, you should have a shower on the morning of surgery. Remove all make up, body piercings, jewellery and nail varnish including acrylic nails.

Fasting guidelines
You will need to fast for 6 hours for solid foods before your operation. Solid foods include milk and milk products. You are allowed clear fluids up to 2 hours before your operation. Clear fluids include water, cordial e.g. MiWadi, isotonic sports drinks, black tea or black coffee. Drinks that are fizzy, contain ‘bits’ or are cloudy are not suitable. If you are a diabetic, it is best to just drink water.

If your caesarean section is planned for the morning:
You should not eat solid foods after 2am. You can drink clear fluids up until 6am. Take the Omeprazole tablet with a sip of water at or before 6am.

If your caesarean section is planned for the afternoon:
You are strongly advised to eat a light breakfast at or before 6am so that you will not be fasting for too long. A light breakfast would be tea, toast, cereal and/or fruit. No solid foods are allowed from 6am onwards but you can continue to drink clear fluids until 10am. Take the tablet Omeprazole with a sip of water at or before 10am.

What to bring to the hospital?
Please bring some chewing gum with you to use AFTER your operation. Chewing gum has been shown to improve gut function after an operation.

For you: dressing gown, slippers, disposable underwear, sanitary towels, bath towel, pyjamas, general toiletries.

For baby: nappies, cotton wool, bath towel, baby-grows, vests, cardigans, baby hats and water-based baby wipes.

In a separate bag specific for theatre – two cotton hats or one knitted hat and a nappy. If you wear contact lens please bring a case to place the lens.

Please do not bring: a large amount of money, valuables such as a laptop or jewellery. The hospital will not be responsible for any valuables that are lost during your stay.

What happens in the hospital on the day of surgery?
You should attend the admissions office in the main reception at the time given to you. You will be admitted to a ward area where a midwife will prepare you for theatre. Unfortunately, it is not possible to give you an exact time for surgery as we are unable to predict how busy the Delivery Suite and the operating theatre will be on the day.

If your operation is delayed for any reason for more than 2 hours, you may be offered a carbohydrate drink. The staff looking after you on the ward will let you know if you can have this drink and provide you with it.

The midwife will ask you questions regarding allergies and your general health. Please let the midwife know if you are allergic to any medications, to fish or dairy products or if you have a latex allergy. If you have an allergy, you will be given an allergy band for your wrist to highlight the allergy.

The midwife will perform a full set of observations including listening to your baby’s heart beat. Occasionally an ultrasound scan may be done to confirm what way your baby is lying in the womb. You will be asked to put on a theatre gown and to wear surgical stockings which help to prevent a blood clot in your leg. A blood sample will be taken to check your blood group. The midwife will check that you have signed the consent form for surgery. You will get an identification armband with your name, date of birth, and hospital number. When it is time for surgery, you will walk to theatre with a member of staff from the ward and your partner.


During your operation

On arrival in theatre

  • You and your partner will be brought to one of our theatre reception areas.
  • A member of staff will check you in to theatre. They will check your medical/obstetric history and consent for your operation.
  • You will be given a small drink to take which neutralises the acid in your stomach.
  • The anaesthetist will speak to you about the anaesthetic and your choices. They will check your medical history, previous anaesthetics and that you have fasted for long enough
  • You will be guided by your midwife/nurse into theatre, while your partner will be shown to the change area to change into scrubs.
  • Preparation for your operation will take about 20 minutes. Your partner will wait in the reception area while the preparation takes place. A nurse and anaesthetist will be with you during this time. A drip or intravenous cannula will be placed in your arm/hand. You will be given fluids and antibiotics through this drip. The theatre team will attach some routine monitoring devices to your arm, finger and chest to check your blood pressure, heart rate and rhythm – these devices do not hurt. The team will also run through a routine safety checklist recommended by WHO (World Health Organisation) prior to starting.
  • Following the anaesthetic, a nurse will place a catheter (plastic tube) in your bladder to drain urineA protection screen will be placed on top of your tummy so that you and your partner do not see the surgery. Just prior to commencing surgery, once the anaesthetic has been checked and working effectively, your partner will be brought into theatre and given a seat next to you, opposite the anaesthetist.

Anaesthesia (pain relief) for your caesarean section
The most common anaesthetic for a caesarean section is a regional anaesthetic. This is often called a ‘spinal anaesthetic’ and means you will be awake for the birth. In some circumstances however, women may be offered a general anaesthetic and will therefore be asleep. This happens if a regional anaesthetic is not suitable (due to blood clotting disorders or abnormalities of the back/spine for example) or rarely, if you experience pain during the surgery.

A spinal anaesthetic involves an injection of local anaesthetic and strong painkillers into the back using a very fine needle. The medicine goes into the fluid around your spine that contains your nerves which normally gives sensation to your tummy and legs.

What to expect from regional anaesthesia?

  • Once in the operating theatre, you will be asked to either sit, slouching over a pillow or lie on your side, curling your back
  • A nurse will spray your back with a cold antiseptic cleaning solution
  • The anaesthetist will inject local anaesthetic into the skin of your lower back to numb your skin
  • From this point onwards, you should just feel pressure or pushing on your back
  • When the anaesthetic medication is being injected, you may feel a tingling sensation going down one leg. It is usually nothing to worry about, but you should tell the anaesthetist if this happens
  • The procedure will take a few minutes but if it is difficult to find the right position for the needle, it may take longer
  • Your bottom and legs will begin to feel warm and heavy or may start to tingle
  • After approximately 5 minutes, the anaesthetist will check that the anaesthetic is working correctly before the operation starts. They do this by checking your ability to feel cold sensation over your legs and tummy with ice.
  • Sometimes your blood pressure can fall after a spinal anaesthetic. This may make you feel nauseous or sick. Please mention this to the anaesthetist as it can be treated very easily with medication.


What happens during the operation and how long will it take?
If you are awake for your operation, it is normal to feel pulling and pressure but you should not feel any pain. If you do feel pain, tell the anaesthetist who will be by your side. They can give you more pain relief, which can include a general anaesthetic if required. Birth of the baby can take only minutes but it will take longer if you have had previous operations.

The baby will be held up so that you and your partner can see them and find out if you have had a boy or girl. The midwife will then place the baby on a warm bed close to the operating table. The baby will be dried and examined from head to toe by the midwife and/or a paediatrician, if necessary.

If all is well, we encourage skin to skin with your baby; the midwife will place your baby on your chest while surgery continues. Skin to skin is encouraged for as long as possible provided there are no health problems with you or your baby. Sometimes we may have to delay skin to skin contact and or feeding your baby. The most common reasons are:


  • nausea/vomiting
  • bleeding
  • general weakness or tiredness
  • low temperature


  • need for oxygen, suctioning
    and observations
  • requires admission to the NICU
  • low temperature

The midwife will put an identification bracelet and security tag on the baby’s arm and leg and with your consent will give the baby an injection of vitamin K.

After the birth, the obstetrician will remove the placenta and close the wound. This can take about another 30 minutes or more to complete. When the surgery is about to finish, your partner will be taken to the reception area of theatre with your baby. Your partner may continue skin to skin contact with your baby until you get to the recovery room. If your plan is to bottle feed, your partner can feed the baby. We ask partners not to walk around the reception area of theatre with the baby or use their mobile phone as these can interfere with theatre equipment. It is ok to use your phone to take pictures of the baby.


After the caesarean section and pain relief

You may be given a suppository at the end of the operation to relieve pain when the anaesthetic wears off. If you have had a regional anaesthetic (spinal), the medicines you received in your spinal anaesthetic will last for approximately 4 to 6 hours. The anaesthetist will prescribe regular pain relief for the postnatal ward – usually Paracetamol and a non-steroidal anti-inflammatory such a Diclofenac or Ibuprofen, if there are no contraindications. These painkillers when taken at regular intervals are very good at limiting the level of discomfort after surgery. Should you still have pain despite these medications, an additional painkiller tablet is available to you on request. This is a medication called Oxynorm and is similar to Morphine. It is very important to ask for Oxynorm if you are starting to feel pain. All medications prescribed are suitable during breastfeeding.

Recovery room

Once you arrive to the recovery room you will be closely monitored for approximately 30 minutes prior to being transferred to the postnatal ward. Once you are comfortable in recovery, you will be reunited with your baby and partner. You will be able to continue skin to skin contact with baby and you will be assisted with breastfeeding if you choose to do so. Early suckling on the breast provides colostrum to nourish your baby and it also helps develop the baby’s immune system. Early feeding (or early hand expressing where feeding is not possible) within the first hour has been proven to enhance milk supply.
The nurse will give you some water to drink. It is important to control any nausea or sickness and pain with medication, so be sure and tell your nurse if you are experiencing any of these symptoms.


The postnatal ward
Once on the postnatal ward, a member of the postnatal staff will perform routine observations. If you are feeling ok after drinking some water, we recommend you have something light to eat. The staff on the ward will organise this for you. A light diet can consist of tea, toast, low fat yogurt, fruit, crackers and/or biscuits. We also recommend you chew some chewing gum as it has been shown to promote return of gut function. Please put chewing gum in the medication cup provided when you are finished chewing it.
As your spinal anaesthetic wears off you will gradually be able to move your legs over a few hours. (This will not apply to you if you have had a general anaesthetic). You may begin to experience some discomfort or pain. You will be given regular painkillers by the midwife looking after you. These painkillers, when taken regularly, are very good at limiting the discomfort you may feel after surgery. Ask for the additional painkiller, Oxynorm, at any time if you have pain between your regular painkillers. Being pain free will allow you to start walking earlier and this will help your recovery. Two out of three women will require this extra pain relief on the day of or after surgery.
If you experience any nausea, please ask your midwife for anti-sickness medication. Controlling nausea will help make you feel more comfortable and help your recovery. All medications offered are safe if you are breastfeeding.


Aims for the first 6 hours post-surgery

  • Enjoy your baby and try breastfeeding if that is your preference
  • Continue to drink more and eat some food
  • Control nausea – ask your midwife for anti-sickness medications if needed
  • Control any pain – ask your midwife for additional painkillers if your pain is not controlled with the regular painkillers
  • Start to move around in the bed as your legs gradually recover from the spinal anaesthetic. Movement reduces your risk of developing a clot (DVT) by working your calf muscles. You will wear the surgical stockings while you are in the hospital. At 6 hours after your spinal anaesthetic, your midwife will assess whether or not you are ready to get out of bed. Do not worry if you are not quite ready, the staff will check again at 8 hours.

The assessment to get you walking
The midwife/nurse will do an assessment 6 hours after your spinal anaesthetic, or approximately 4 hours after your arrival on to the postnatal ward.

The assessment consists of the following:

  1. Getting you to raise each of your legs straight up in the air while you are lying on your bed
  2. Standing for a minute beside the bed to check for balance
  3. Supervised walk to the toilet

Once you have passed this assessment, you will be allowed and encouraged to walk on your own.

Removing your urinary catheter
It may be safe to remove your urinary catheter 6 hours after your spinal anaesthetic particularly if the caesarean section was done early in the day and you are able to walk to the toilet safely. If you do not wish to have your urinary catheter removed 6 hours after your spinal anaesthetic, it can be removed the next morning at 6am.

Before removing the catheter, we must ensure that:

  • Your observations are normal i.e. blood pressure, heart rate etc
  • Your pain is reasonably well controlled
  • Your nausea is well controlled
  • You are able to drink water and will monitor your fluid intake and urine output once the catheter is removed from your bladder
  • You have passed the assessment and are able to walk to the toilet independently

Once the catheter is removed
It is important that you manage to pass urine by yourself within 4 to 6 hours after the catheter is removed. To help with this, we advise you to drink to thirst. Keep a note of how much you have drank and communicate this to the midwife looking after you. Let your midwife know if you have not passed any urine by 4 hours so you can be monitored more closely for the next 2 hours.

  • You will be asked to pass urine into a jug for the first couple of times you go to the toilet so that we can measure how much you pass – it should be at least 200mls each time.
  • Let the midwife know if your bladder does not feel empty after passing urine, you are incontinent of urine or if the stream of urine feels irregular.

Day 1 after Surgery

Pain control; Take your regular pain relief as prescribed. Please feel free to request additional pain relief if you are still in discomfort.

Activity; We encourage you to walk as much as possible. Aim to walk at least 4 times during the day. Don’t lift anything heavier than your baby. Have a shower every day and as the wound dressing is shower-proof there is no need to remove or cover it.
It is important to change sanitary pads frequently.

Eating and drinking; We hope that you will be enjoying a normal diet. Make sure to stay well hydrated; aim to drink 8-10 glasses of water per day.

Baby check; The paediatrician (baby doctor) will examine your baby to make sure they are well and able to go home.

Obstetric review; Blood tests may be performed to check your haemoglobin level after your caesarean section to ensure your recovery. You will also be reviewed by a member of the obstetric team, which will give you the opportunity to discuss any concerns you may have.

Breastfeeding; Breastfeeding provides many benefits for both mother and baby. The midwives will help you with breastfeeding, as required. Additional support from lactation consultants is available if required.


Discharge Checklist

Before you go home, we want to ensure that:

  • Your pain is under control
  • You can walk and move around easily
  • You are drinking plenty and eating healthy meals
  • You can pass urine
  • Your baby has been examined by the paediatrician
  • Your doctor or midwife say you are well enough to go home
  • You have a prescription for painkillers and understand when and how to take your medication at home

Early discharge
If both you and your baby are well, you may be eligible for early discharge. Early discharge is dependent on the above criteria being met and your home address being in the geographical catchment area for our community midwifery led follow up. For some women, early discharge may still be possible despite not living in the right catchment area for community midwifery care follow up, provided they have adequate support at home from family or friends.

Wound care
It is important not to touch your wound unless absolutely necessary and to ensure your hands are washed regularly, particularly before and after toilet use. The dressing should stay in place for 72 hours unless it is soiled. If you have a PICO (vacuum-type) dressing this will be removed after 5-7 days. Light showering is allowed with the PICO dressing, but the pump must be disconnected first as it cannot get wet. Ensure that the end of the tubing attached to the dressing does not get wet – keep it facing down so that the water does not get into the tube. Our midwives will explain this again at the time.

You will be told if your wound was closed with sutures or clips, and when these need to be removed.

At home
Recovery from a caesarean section is a gradual process over a period of about six weeks. Your public health nurse will visit you at home following your discharge from hospital or from the community midwifery team.

Pain management
It is important you take the painkillers prescribed when you need them. The majority of women going home will be advised to take regular Paracetamol (1g four times a day) and a non-steroidal anti-inflammatory like Ibuprofen (400mg three times a day), unless otherwise advised. This may be needed for at least 5 days after your operation. Keeping the pain well controlled will allow you to look after your baby. For example, we suggest taking the Paracetamol at approximately 6 am, 12 mid-day, 6 pm and 10-12pm and the Ibuprofen at 6am, 2pm and 10pm.

It is very important to walk around at home to help prevent a clot developing. Some women may need blood thinning injections for ten days or longer to prevent a blood clot. The midwife will show you how to give yourself the injection before you are discharged and will give you a special box for disposing of the needle and syringe.

Contraception advice
Fertility can return as early as three weeks after birth, so ensure you have appropriate contraception when you resume sexual activity. You will be given contraception advice prior to discharge.

If you drive, it is best to check with your insurance company if there any restrictions to driving following a caesarean section. Some companies require your GP to certify you fit to drive. Many women wait until after the six-week check.

Your body will have undergone significant changes during the pregnancy and birth and will need time to heal and recover. You should get as much rest as possible, take gentle exercise and have a well-balanced diet. You should follow the postnatal exercise handout and information you receive while in hospital. These exercises focus on the pelvic floor and core abdominal muscles. These are very important to prepare your body for more strenuous exercise later on. Start gentle walking as pain/discomfort allows, gradually increasing your distance then your speed up to 30 minutes of a walk each day. You can start swimming at 6 weeks following your caesarean section. For the first 6 weeks avoid lifting anything heavier than your baby, including housework or other strenuous activity. Heavy or more strenuous exercise should wait until 3 months after birth to allow the pelvic floor to recover.