Introduction
Cesarean delivery (CD) is an extended practice worldwide. The rate of CD
continues to increase mainly due to maternal factors such as advanced
maternal age and subsequent increased maternal comorbidities, maternal
preferences and having a previous CD(1). Therefore, numerous efforts
have been made to optimize perioperative care among these patients(2,3).
Enhanced Recovery After Surgery (ERAS) guidelines for CD have created a
pathway for postoperative care(2). Specific issues include early
feeding, nausea and vomiting prevention, accurate postoperative
analgesia, early mobilization and urinary drainage among others(2,4).
The best practice regarding postoperative care of women undergoing CD
remains a multidisciplinary challenge involving obstetricians,
anesthesiologists and midwives(2,4).
The insertion of a urinary catheter (UC) is a preoperative measure to
prevent iatrogenic damage of the urinary bladder. Traditionally retained
for up to 12-24 h after the procedure, it allows an objective and easy
assessment of urinary output volume and color and reduces postpartum
urinary retention. However, there is no strong evidence supporting the
prolonged use of UC(5). Moreover, the systematic use of UC has been
associated with a higher incidence of urinary tract infection, delayed
mobilization time and a longer hospital stay(6,7). ERAS protocols
recommend a removal of the UC within 6 h after the surgery but evidence
is still lacking (2). The advantages and disadvantages of the non-use of
UC and the early or delayed removal of it remains controversial, even
though the latest evidence suggest that early removal might be
beneficial(5).
Another trending focus of the ERAS protocol for CD is to optimize pain
management, since a good pain control has been demonstrated to
accelerate patient recovery. Neuraxial anesthesia is the recommended
modality for CD by the American Society of Anesthesiologists, with
spinal anesthesia being the most common technique for elective CD(3).
Neuraxial opioids provide an optimal analgesia in these patients(6,7).
Hydrophilic opioids such as morphine provide a longer length of action
than lipophilic opioids such as fentanyl, which is mainly used for
intraoperative anesthesia(7). The optimal dose of intrathecal morphine
is still uncertain, and ranges between 50 and 200 µg (7). Side effects
like nausea, vomiting and pruritus should not be overlooked, and may
increase with escalating doses(7).
The objective of this study was to assess whether the non-placement or
early removal of UC could improve the recovery of patients undergoing
CD. Moreover, we aimed to evaluate the impact of the perioperative use
of morphine and its adverse secondary effects in our study population.