The ERAS protocol is widely regarded as the preferred standard of care after cesarean section. It includes a variety of different elements and the optimal synergistic benefit of them is only achieved, when all the elements are carefully considered. In this study, we solely wanted to focus on the associations of catheter therapy and mobilization after cesarean. In clinical practice, this association is easily underestimated and yet, it plays a significant role in enhanced postoperative recovery.
The use and length of catheter therapy should be carefully considered and based on justified clinical need. Inappropriate use of catheter increases the risk of urinary infections [17, 18] and causes inconvenience and discomfort to the patient [19–21]. According to ERAS guidelines [7] an immediate removal of the catheter after surgery is recommended. However, concerns have been raised, particularly regarding the impaired bladder function and delayed return of spontaneous micturition [22] after neuraxial anesthesia and long-acting opioids, such as intrathecal morphine. In the absence of detailed data that could be widely generalized, the recent meta-analysis by Hou et al. [23] considered the optimal time for removal to be 6 hours after surgery.
Why is early mobilization so important? As thromboembolic events still remain one of the main causes of maternal deaths [24], early mobilization has a critical prophylactic role in reducing the risk [25]. Compared to non-pregnant women, the risk of thromboembolic events during the post-partum period is described to be up to 60 times higher [26–28] and the risk after cesarean is fourfold compared to the risk after vaginal delivery [29]. Even though the absolute risk (3/1000) can be considered low [29], the role of mobilization cannot be underestimated. In this study, only ten (19.2%) and four parturients (7.7%) in the study and control groups had their urinary catheters removed before mobilization (p = 0.075). In other words, most patients had no need to mobilize themselves.
A significant proportion of patients experience high-intensity post-operative pain and require opioids within the first 24 hours following cesarean section [30]. Several studies [31] have demonstrated that early mobilization significantly reduced pain levels after cesarean. In our study, women in the control group needed more additional pain medication and, thus, assumingly had more severe pain. However, this did not reach statistical significance. It can be speculated, that the causality of these factors was the opposite and delayed mobilization was caused by pain. This is however unlikely since no differences were detected in maternal demographics, the indications for the operations, and the assumed difficulty of operations. It has also been reported that adherence to the ERAS -protocol is associated with reduced incidences of wound complications [31, 32]. The independent value of mobilization itself may be challenging to distinguish, but it is widely acknowledged that mobilization enhances tissue oxygenation, thereby improves the wound healing process.
The study by Ulfa [33] reported that limitations in mobility and wound pain are factors that interfere with the ability to breastfeed after cesarean. A French study by Laronche et al. [34] studied post-operative maternal satisfaction and maternal neonatal bonding in three hospitals, two of them using an ERAS-protocol (i.e., catheter removal ≤ 12 hours, mobilization, at least sitting, in 6–8 hours) and one applying a more conventional protocol (i.e., urinary catheter removal at 24 hours). They reported that mothers undergoing recovery by ERAS-protocol felt more close and secure in contact with the newborn and were more satisfied with the mother and baby relationship. They concluded that the ERAS-protocol made carrying and nursing the baby less difficult and was associated with more rapid mobilization of the mother. Our study did not reveal any differences in the overall maternal satisfaction, but details regarding breastfeeding or maternal neonatal bonding were not studied. Except for the catheter therapy, the post-partum treatment protocol in groups was similar.
Together with chewing gum and early oral intake after surgery, early post-operative mobilization enhances the recovery of bowel function [35]. According to the study by Adeli et al., mobilization is important to avoid post-operative paralytic ileus and pain associated with intestinal distension caused by gas [36].
Both the early catheter removal [11] and early mobilization [37] have been associated with a shorter hospital stay. In this study we did not find any association with the time of catheter treatment, earlier mobilization, and the length of hospital stay. Since 76% (79/104) of our study population was discharged at, or before, the second post-operative day, the length of stay is already quite short. Furthermore, the length of the maternal hospital stay is strongly associated with the length of necessary treatments and follow-ups of the newborn. It is therefore not possible to independently analyze the impact of early mobilization on the length of maternal hospital stay.
Since both, the early removal of urinary catheter and early post-operative mobilization appear to have clear benefits, what are the barriers in their implementation and optimal patient care? The lack of knowledge, education and resources are described to be among the most important barriers to achieve optimal catheter use and early mobilization. The studies by Jain et al. [38] and Niedeshauser et al. [39] described that the knowledge and perceptions of doctors and nurses regarding the appropriate use of urinary catheter can be variable and inefficient. As far as it concerns the use of catheter in cesarean section, this is understandable, as the available information is contradictory. Earlier studies have reported that the lack of education and awareness can hinder patient’s early mobilization [40], as well as a working culture that does not prioritize physical activity after surgery [37].
The lack of personnel and limitations in resources can also be obstacles in the way of optimal recovery. When the staff is limited, the prolonged use of catheter and decreased need for patient’s toileting may be more convenient to the personnel [41, 42]. This reality also applies to the assistance in the mobilization of the patient [43, 44]. Somewhat alarmingly the parturients in our study group should have had their catheters removed at a mean time of 10 hours but this was delayed by a mean (95% CI) 188 (70–307) minutes (p = 0.002). To some extent, the reasons may lie in the aforementioned factors. The patient perspective on mobilization was studied by Hu et al. [45], and they concluded that the most common barrier to mobilization was the urinary catheter.
The study setting can be considered a strength of this study. All patients were treated in the same hospital and by the same personnel using a standardized treatment protocol. It is thus unlikely that the results could be attributed to different treatment protocols. Also, the midwives’ documentations regarding patient mobilization were made precisely and gave us reliable information on the actual mobilization of the patient.
Even though some studies have hinted, that smoking potentially enhances mobilization [46], we did not analyze the effect of smoking. This may be a minor limitation of the study but given the low prevalence of maternal smoking during pregnancy (reported at 7.5% in 2022 by by the national birth statistics) [47], the impact is assumed to be minimal. We did not study the patient's activity after the initial upright mobilization because we regarded it as the most critical moment of mobilization. Consequently, some differences in and between the groups may have gone unnoticed.
We conclude that even though the issue concerning the need and length of catheter therapy still remains controversial, it is crucial to recognize its impact on mobilization, another critical aspect of recovery. As shown in this study, the duration of post cesarean catheter therapy strongly associates with the time of post-operative mobilization and thus, the unwarranted prolongation of catheter time should be avoided. As the role of the personnel is to provide care that enables and supports the enhanced recovery and well-being of the mother, it is important to understand the interactive, rather than independent, role of these components.