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.