Caring for the Post C-section Patient (Morrison, 9/2/2026)

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

Psychological healing

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

Spine Surgery for the PCP (Athanassious, 7/15/26)

A recording of this presentation is available HERE.

Many thanks to Dr. Christian Athanassious, orthopedic spine surgeon, who gave a really great Grand Rounds Treatment of the Spine for the PCP. The recording is worth watching! For those who prefer the written word. . .

Key learning points:

-The cervical and lumbar spine contains mobile segments>> most likely to develop problems (in contrast to thoracic spine)

-Cervical DJD can often radiate to the scapula

-Be sure to give high enough doses of gabapentin (e.g. 300mg QHS) for acute back pain, helping pts sleep improves pain

-Myelopathy with acute change in function (e.g. ability to hold a cup, balance) needs urgent eval

-If patient has >6 months pain with stenosis on MRI, they are unlikely to get better and should be referred to spine surgeon

-Spinal precautions: no twisting, bending or lifting > 10 pounds (fusion x  6 weeks, then can increase weight to 25 pounds x 3 months, laminectomy x 6 weeks)

Neck Pain

-Radiculopathy: compression of cervical nerve roots: deep aching, electrical feeling, stabbing, numbness/tingling (must be differentiated from carpal tunnel syndrome)

-DJD means "less hydration in the disk level" (doesn't mean there is compression nerve or pain generator)-- most adults will have 1-2 levels of DJD on imaging, must always correlate with history and physical exam findings

-Most common cervical problem is C5/C6:  neuroforaminal narrowing will affect the C6 nerve root (weak biceps, wrist extension, deltoid weak)

-Second most common: C6/C7: numbness and tingling over forearm, 2nd and 3rd digit (radial), wrist flexion weakness, triceps weakness

-if a cervical problem > 6 months, should refer to spine surgery

-Myelopathy: can present as a step-like decline (from one day to next), more urgent than radiculopathy. Pain doesn't follow dermatomal distribution because whole spinal cord is being compressed

-while nerve roots can recover (even after 1-2 years of injury), spinal cord injury does not recover as well

-surgical emergency if acute change in function

-"I was walking with a cane independently, and now I feel like I am drunk, I cannot control my feet, I do not know where my arms/legs are in space">> needs cervical and thoracic MRI and spine surgery consultation, may need ED visit

-sudden change in handwriting, in ability to hold a cup

-bowel and bladder dysfunction are rare (need major compression)

Lumbar Pain

Less urgent low back pain: sciatica/back pain

More urgent: cauda equina

L1-L5/Sacrum (6 vertebrae)

Discs: annulus fibrosis (outer fibrous layer), nucleus pulposus (gelatinous)>> pain from annulus being torn, another part is nerve roots being compressed or the pulp putting pressure on the nerves  caustic to nerve root, can cause pain). Acute annular tear, release of NT and tear can cause acute pain>> PT, back precautions, NSAIDSs vs. oral steroids

Non-operative management of acute lumbar disc herniation

-NSAID
-Physical therapy

-gabapentin/lyrica: make sure to dose gabapentin high enough

-oral steroid

-referral to pain mgt for epidural steroid injection

-brace (for fracture, first line for fracture tx unless severe compression of nerve root, patient with a body habitus that doesn't allow, or emphysema dx cannot tolerate) >>vertebroplasty/kyphoplasty: spine surgeon, IR, pain mgt surgeon (okay to call spine surgery if we have questions about what to do)

Ddx lumbar Pain: arthritis, stenosis, DJD (if bad enough), facet disease

Back symptoms:

-axial back pain: doesn't radiate (stenosis, arthritis in facet, severe DJD leading to bone on bone)

-radicular: irritates the nerve root, radiates down legs or out to arms, or to scapula (if thoracic, can radiate mid back toward ribs)

-loss of balance (spinal cord compression)

-loss of dexterity (spinal cord compression)

-weakness (can happen with nerve root or spinal cord compression)

***

Neck surgery:

-Most common: Anterior cervical discectomy and fusion (ACDF), less common disc arthroplasty (if disease limited to 1-2 levels)

-Disc removed, spinal cord and facet decompressed>> spacer placed. If fusion, plate placed over the top (if just arthroplasty, no plate placed)

-Disc arthroplasty: not indicated for >2 disc levels, facet disease often a problem. Usually indicated only in young patient with little facet disease, short hx of axial neck pain, acute issue 2/2 fall or accident (disc replacement). Many will eventually need a fusion

Normal ACDF recovery: 

    -some degree of difficulty swallowing (no need for swallow study), have to chew longer, cut smaller. Pay attention when swallowing. Can last weeks to 1-2 months, almost always resolves

    -pain in front of neck

    -mild swelling in front of neck>> make sure breathing okay, can speak, eat and drink. Can consider TXA post-op to prevent seeping

    -mid-scapula pain: spacers cause stretch on facets and capsule and can cause posterior neck that radiates to scapula

    -strength doesn't come back right away, can continue to see recovery up too 2 years post-op

    -neck braces after fusion (1 level 4 weeks, 2 levels 8 weeks, 3 level 12 weeks in brace)

Abnormal ACDF recovery:

    -C5 radiculopathy (difficulty lifting shoulder) common after severe spinal stenosis due to posterior drift, not permanent, give brace so arm not hanging, will resolve over time

    -redness/infection of surgical site (if no fever, can rx cephalexin; if fever, may need admission for IV abx, MRI to ensure infection is superficial)

    -any NEW dense weakness>> get MRI

    -Horner syndrome: symptomatic treatment, lubricating drops for eyes

surgical decompression (microdiscectomy)

Low Back Surgery

    -microdiscectomy most common

    -laminectomy (full removal) vs. laminotomy

    -#1 indication for spinal fusion is mobile spondylolisthesis (pt flexes and extends and has >3mm motion between flexion/extension). If spinal stenosis and symptoms correlate, not improving 3-6 months, intolerable of pain

    -Why fuse?

        -DJD with stenosis

    -Adjacent level disease

        -degenerative scoliosis

Access lumbar spine from the 1) front (anterior retroperitoneal approach): incision in midline of stomach, go around peritoneum, fuse in retroperitoneal. 2) lateral anterior retroperitoneal approach, 3)  posterior fusion

ALIF: anterior lumbar interbody fusion. Very stable, access via vascular surgery (higher risk of bleeding), powerful way to treat patients IF treating L5/S1 (cannot be accessed frmo the side). Downsides: post-op bleeding, post-op infection (superficial vs. deep (abnormal labs, fever/vital sign instability), DVT/PE (increased due to vessel manipulation), sympathetic chain compromise 

PLIF: posterior lumbar interbody fusion. Less effective, more problematic. Have to take down a lot of paraspinal musculature, removal of bone and ligament from posterior canal. Cannot correct deformity as well as ALIF. 

EXLIF: minimally invasive procedure, eXtreme lateral interbody fusion. Much smaller incision (compared to PLIF). Can use large cage. large graft to increase stability. L5-S1 cannot be accessed due to the anatomy (pelvis in the way). Can get anterior thigh numbness/hip flexion weakness (psoas mm)

What requires urgent spine surgery attention?

-Myelopathy: quick change in function, send to ED, call spine surgeon

-Severe radiculopathy with weakness

-If symptoms > 6 months, doesn't need ED eval but should refer to spine surgery (especially if MRI finds stenosis)

-Cauda equina: severe excruciating back pain, weakness on exam, numbness ins addle, bowel/bladder incontinence. Usually caused by acute event (should be treated within 48 hours, bowel and bladder function may not return)