Caesarean section is now one of the most common obstetric surgeries worldwide. In India, its rate has risen from 17.2% in NFHS-4 to 21.5% in NFHS-5, with many being emergencies requiring urgent intervention (1). Such cases often involve physical stress, anaesthetic challenges, and slower recovery compared with planned deliveries (2). Conventional postoperative care still relies on delayed feeding, prolonged bed rest, and opioid-based pain control. These measures, once considered safe, may actually delay mobilization and discharge. The Enhanced Recovery After Surgery (ERAS) approach, introduced for colorectal operations, offers an alternative built on early oral intake, multimodal analgesia, and patient participation (3,4).ERAS has shown encouraging results in elective caesarean sections, improving pain control and reducing hospital stay without raising complication rates (5,6). Applying the same principles to emergency cases, however, remains underexplored, especially in India, where surgical workloads are high and resources are limited (7). This randomized controlled trial, conducted at Vels Medical College and Hospital, Tiruvallur, aimed to evaluate whether ERAS-based perioperative care could improve maternal recovery after emergency caesarean delivery. The focus was not only on measurable outcomes such as ambulation time or pain score, but also on whether structured recovery could make recovery smoother and more dignified for mothers in high-stress surgical situations.

Study Design and Setting This was a prospective randomized controlled trial conducted in the Department of Obstetrics and Gynaecology, Vels Medical College and Hospital, Bandikavanoor, Manjankaranai, Tiruvallur, Tamil Nadu, India, over a period of six months (January 2024–October 2025). Ethical approval was obtained from the Institutional Ethics Committee. Sample Size and Participants A total of 100 parturients who underwent emergency lower segment caesarean delivery (LSCS) during the study period were enrolled after obtaining informed consent. The sample size was calculated using the standard formula for estimating proportions: n = (Z² × p × q) / d² where Z = 1.96 for a 95% confidence level, p = expected improvement in early ambulation (50%), q = 1 − p, and d = allowable error (10%). The required sample size was estimated at 92, and this was rounded to 100 to account for possible attrition. Randomization and Group Allocation Participants were randomly assigned to two groups of 50 each using a computer-generated random sequence. Allocation concealment was ensured through sealed opaque envelopes opened only at the time of enrolment. • Group A (ERAS group, n=50): Received perioperative care following the Enhanced Recovery After Surgery (ERAS) protocol. • Group B (Control group, n=50): Received conventional postoperative care according to standard institutional protocols. Inclusion Criteria 1. Women aged 18–40 years undergoing emergency LSCS under spinal or general anaesthesia. 2. Haemodynamically stable at the end of surgery. 3. Willing to provide written informed consent. Exclusion Criteria 1. Severe preeclampsia, eclampsia, or cardiac disease. 2. Intraoperative complications such as major haemorrhage or visceral injury. 3. Known gastrointestinal disease, diabetes mellitus, or neurological deficit affecting mobility. 4. Postoperative intensive care requirement or need for re-exploration. ERAS Protocol Details Women in the ERAS arm received a structured multimodal pathway that included: • Early oral intake (clear fluids after 2 hours, soft diet within 6 hours). • Early ambulation within 6 to 8 hours after surgery. • Multimodal analgesia with paracetamol and NSAIDs, minimizing opioid use. • Catheter removal within 8 hours of surgery. • Encouragement of early breastfeeding and avoidance of routine abdominal drains. The control group followed traditional postoperative routines, including nil per oral for 12–24 hours, delayed mobilization, and opioid-based analgesia. Outcome Measures Primary outcomes: 1. Time to first ambulation (hours). 2. Postoperative pain score measured using the Visual Analogue Scale (VAS) at 6 and 24 hours. 3. Length of hospital stay (days). Secondary outcomes: 1. Time to oral intake (hours). 2. Maternal satisfaction was assessed with a 5-point Likert scale at discharge. 3. Postoperative complications include wound infection, fever, urinary retention, or readmission. Data Collection and Statistical Analysis Demographic, intraoperative, and postoperative details were recorded using a predesigned proforma. Data were analyzed using IBM SPSS Statistics Version 28.0 (Armonk, NY, USA). Quantitative variables were expressed as mean ± standard deviation (SD), while categorical data were presented as frequency and percentage. The independent t-test was used for continuous variables, and the chi-square test or Fisher’s exact test was applied to categorical variables. A p-value of less than 0.05 was considered statistically significant.

Study Population A total of 100 participants were included in the study, with 50 in the ERAS group and 50 in the control group. All participants completed the study, and there were no protocol violations. The CONSORT flow diagram (Figure 1) illustrates the recruitment, randomization, and analysis process. Baseline Characteristics The baseline demographic and clinical parameters of both groups were comparable, with no statistically significant differences in age, BMI, parity, gestational age, or indication for caesarean delivery (Table 1). Most surgeries were performed under spinal anaesthesia, and fetal distress was the most common indication across both groups. Table 1. Baseline Demographic and Clinical Characteristics of Participants Variable ERAS Group (n=50) Control Group (n=50) p-value Mean Age (years) 27.6 ± 3.9 28.1 ± 4.1 0.48 Primigravida (%) 58 54 0.67 Mean BMI (kg/m²) 25.4 ± 2.8 25.8 ± 3.0 0.53 Gestational Age (weeks) 38.2 ± 1.5 38.1 ± 1.6 0.74 Indication for LSCS (Fetal distress %) 46 48 0.82 Anaesthesia (Spinal %) 94 92 0.71 (Data expressed as mean ± SD or percentage as applicable) Demographic and obstetric parameters were comparable between the ERAS and control groups. No statistically significant differences were observed in maternal age, BMI, parity, gestational age, indication for caesarean, or type of anaesthesia (p > 0.05 for all variables). Data are presented as mean ± SD or percentage as appropriate Primary Outcomes Early recovery parameters showed significant improvement in the ERAS group (Table 2). The mean time to ambulation was 7.8 ± 2.4 hours in the ERAS group compared to 16.2 ± 3.1 hours in the control group (p < 0.001). Similarly, oral intake was resumed earlier (4.6 ± 1.7 vs. 10.5 ± 2.6 hours, p < 0.001).The average length of hospital stay was 2.3 ± 0.8 days in the ERAS group versus 3.4 ± 0.9 days among controls (p = 0.002). Postoperative pain scores were significantly lower in the ERAS group at both 6 and 24 hours (VAS 3.2 ± 1.1 vs. 5.6 ± 1.4 and 2.4 ± 1.0 vs. 4.8 ± 1.3, p < 0.001). Table 2. Comparison of Primary Maternal Outcomes Between Groups Parameter ERAS Group (n=50) Control Group (n=50) p-value Time to Ambulation (hours) 7.8 ± 2.4 16.2 ± 3.1 <0.001 Time to Oral Intake (hours) 4.6 ± 1.7 10.5 ± 2.6 <0.001 Postoperative Pain (6 h, VAS) 3.2 ± 1.1 5.6 ± 1.4 <0.001 Postoperative Pain (24 h, VAS) 2.4 ± 1.0 4.8 ± 1.3 <0.001 Length of Hospital Stay (days) 2.3 ± 0.8 3.4 ± 0.9 0.002 Women in the ERAS group demonstrated significantly earlier ambulation and oral intake, lower pain scores at 6 h and 24 h, and shorter hospital stay compared with the control group. Statistical significance was tested using the independent t-test (p < 0.05 considered significant). Values expressed as mean ± SD Secondary Outcomes Secondary outcomes are summarized in Table 3. Maternal satisfaction scores were significantly higher in the ERAS group (92% reporting “high satisfaction”) compared to the control group (74%, p = 0.01). No statistically significant differences were found in postoperative wound infection, urinary retention, or readmission rates between groups. Table 3. Comparison of Secondary Maternal Outcomes Parameter ERAS Group (n=50) Control Group (n=50) p-value Maternal Satisfaction (High %) 92 74 0.01 Wound Infection (%) 6 8 0.74 Fever (%) 10 12 0.72 Urinary Retention (%) 4 6 0.65 Readmission (%) 0 2 0.32 Maternal satisfaction was markedly higher among ERAS participants, while rates of wound infection, fever, urinary retention, and readmission showed no significant differences between groups. Chi-square or Fisher’s exact test applied where appropriate; p < 0.05 considered statistically significant Summary of Findings In this randomized controlled trial, women receiving ERAS-based perioperative care demonstrated earlier mobilization, reduced postoperative pain, shorter hospital stay, and greater satisfaction compared to those managed conventionally. Importantly, these benefits were achieved without increasing postoperative morbidity or readmissions.

The present research explored how an Enhanced Recovery After Surgery (ERAS) pathway could influence the immediate recovery of mothers undergoing emergency caesarean section in a tertiary hospital in Tamil Nadu. The overall outcomes were consistent and encouraging. Women managed under ERAS protocols stood out for their faster physical recovery, lower pain intensity, and earlier discharge when compared with those who received routine care.Historically, postoperative care in obstetrics has focused on rest and delayed feeding. ERAS challenged that paradigm by encouraging mobility and physiological restoration soon after surgery. Its introduction in abdominal surgery more than two decades ago marked a quiet revolution in perioperative medicine (9). What began as a theoretical framework has since matured into a practical checklist guiding every stage of recovery, from pre-anaesthetic counselling to discharge planning.In elective caesarean deliveries, several studies have already demonstrated that applying ERAS principles can shorten hospital stay and improve maternal comfort (10,11). Yet emergencies are a different clinical reality. Patients arrive without preparation, often exhausted or anxious, and teams must balance safety with efficiency. The current trial demonstrates that even in such high-pressure settings, a structured recovery pathway can still work.The significant improvement in ambulation and oral intake timings in our cohort echoes findings from Indian and international studies (12). Earlier mobilization aids bowel function, reduces thromboembolic risk, and restores a sense of autonomy for mothers recovering from unexpected surgery. Likewise, early feeding supports metabolic recovery and shortens the catabolic phase after delivery. Pain control remains the heart of any ERAS strategy. By using a combination of paracetamol and non-steroidal anti-inflammatory agents while limiting opioids, our study achieved lower VAS scores at both 6 and 24 hours. Similar analgesic advantages were reported by Bollag and colleagues, who observed better maternal alertness and breastfeeding success when multimodal non-opioid regimens were used (14,15).A reduction of roughly one hospital day in the ERAS group compared with conventional care mirrors data from several other tertiary units. In an Indian public hospital, this improvement is not merely statistical, it represents faster bed turnover and reduced healthcare expenditure. Maternal satisfaction was also noticeably higher, driven by earlier independence and a smoother transition to newborn care.Although our findings strengthen the case for ERAS integration in emergency obstetrics, successful implementation requires interdepartmental coordination. An anaesthesia team that prioritizes early pain control, nurses who encourage mobility, and obstetricians willing to revise postoperative traditions are all vital to sustaining the protocol. Limitations This single-centre trial had a modest sample size, and blinding was not feasible due to the intervention’s nature. Subjective factors such as satisfaction may vary with education, family support, and sociocultural expectations. A multicentric design with larger and more diverse participants would offer stronger external validity.

The Enhanced Recovery After Surgery (ERAS) protocol significantly improved postoperative recovery among women undergoing emergency caesarean delivery. Mothers managed with ERAS ambulated earlier, experienced less pain, and were discharged sooner without an increase in complications. Adoption of ERAS principles in obstetric surgery can promote faster recovery, enhance satisfaction, and optimize hospital resource use in Indian tertiary settings.

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