A recording of this presentation is available HERE.
Thanks to Dr. Lily Morrison, R3 for a really thoughtful and important presentation on Caring for the Post-C-section Patient. Dr. Morrison shared her own learning after herself experiencing an emergency c-section last year. She did a wonderful job of marrying the evidence (qualitative and quantitative) and the patient experience (her own and that which is captured online and in the qualitative evidence) in her presentation. I highly recommend you watch it! If you just want the Cliff's notes, here they are:
>1,000,000 c-sections occur annually (about 1/3 of all US births)
C-section is the most common major surgery performed in this country
When Dr. Morrison had her c-section, she admits, she didn't really know what to expect, and as she dove into the literature, she was not alone:
Hospital discharge instructions given to Dr. Morrison did not answer her most basic questions-- e.g. when can I pick up my toddler and when is it safe to drive and return to other typical activity?
Dr. Morrison divided her presentation into first hours>> first days>> first 6 weeks>> first 3 months>> chronic as a way to think about post-op C-section care
The most updated evidence-based immediate C-section Guidelines come from Enhanced Recovery After C-section (ERAC) 2025 Update from the Society of Obstetric Anesthesia and Perinatology. This really outlines important actions while in the hospital after a c-section.
First 48 hours
Pain is obviously an important outcome after c-section and patient experience is highly variable
EARLY pain control is known to have positive impact long after the immediate post-op period
Standard care involves:
1) Neuraxial opioids in the first 12 hours after surgery (spinal/epidural during c-section by anesthesia)
2) For patients who have had a crash c-section under general anesthesia, consider ways to augment pain control including a transversus abdominus plane (TAP) block, which can be done by anesthesia
3) There is good evidence for 1gm of APAP pre-op
4) Scheduled ibuprofen/APAP after surgery (for weeks for some patients)
5) Opiates as a rescue (we generally use oxy in our hospital, oral is preferred to IV and try to limit to <30mg/first 24 hours)
6) Abdominal binders has mixed recommendations but does have evidence for improved early pain
Early function (i.e. encourage patient to walk) also has evidence. Walking ASAP after surgery leads to fewer complications (9716 steps during hospitalization showed significantly less complications), early showering (after 12 hours is fine, no need to wait 48 hours), early eating and drinking, early foley removal
Psychological healing: normalize the experience, help limit the guilt/shame of not having had a vaginal delivery, recognize for some women they have experienced a trauma, acknowledge their disappointment and grief. Some women really benefit from debriefing early (others needs/want it later)
Infant bonding: also important, pain control and encourage breastfeeding, skin to skin
First 6 weeks
Pain
median time to opioid cessation is 8 days
median time to analgesic cession 17 days
median time to pain resolution 21 days
There appears to be an inflection point for patients in pain at the 3 week mark-- 22 days +/- 9 (this is GOOD to share with patients). This means that pain is normal to still be experiencing at the 2 week visit, it is okay to continue APAP/Ibuprofen, keep using the binder
Function
There are really NO evidence based guidelines, really pain should be the guiding factor for everything from lifting to driving to having sex
there are increased rates of post partum depression and anxiety after LTCS, 20-40% of women with PPD in c-section patients, 4-20% with PTSD
Screen!
Treat with SSRI (sertraline has the best evidence), CBT
Address PPD and PTSD as a care team: stigma, disappointment, a sense of failure, poor communication, a lack of trust, loss of control, fear of the OR can all be normal>> consider addressing some of these expectations prenatally (since 1/3 pregnancies in the US will end in LTCS)
Post C-section debrief>> some patients do not want to revisit the event, but some DO!
Goal is rebuilding TRUST
Next 3 months
Pain
After 3 months, if patients still have pain, this should be considered "chronic"
~1/4 of patients after LTCS report chronic pain, likely 2/2 nerve entrapment, intrabdominal adhesions
Risk factor for chronic pain include: severe early post-op pain (this is why we want to treat pain EARLY), stress, smoking, pre-op depression or anxiety, and longer/more complex surgery
Treatment for chronic post-c-section pain:
1- rule out something medical (surgical referral for lysis of adhesions)
2-offer meds (SNRI, gabapentin)
3-physical therapy (scare and soft tissue mobilization)
4-topical medications (e.g. capsaicin, lidocaine)
5-acupuncture (there is an evidence based modality called "scar deactivation", protocolized)
6-lidocaine infiltration can be done 30-66 of 0.5% lidocaine significantly can improved pain (has been effective in early post-partum period as well)
Return to Exercise
Day 1: gentle walking pelvic flood exercises
2-6 weeks gentle abdominal engagement, increased walking, aim for 30 minutes 5x/week
6-8 weeks the abdominal fascia has 51-59% of its tensile strength
8-12 weeks high intensity, low impact
>12 weeks running/circuit training/full exercise
Reasons to slow down: severe pain, increased vaginal bleeding, excessive fatigue
Long term impact of birth method:
~5% of c-section patients still experience pain >1 year after surgery
Life long increased risk of miscarriage, previa, stillbirth and abruption
Of note, c-section patients have lower rates of urinary incontinence and prolapse
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