European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 212–216

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Full length article

An enhanced recovery programme after caesarean delivery increases

maternal satisfaction and improves maternal-neonatal bonding: A case
control study
Anne Laronchea , Luiza Popescub , Dan Benhamouc,*
a
Maternity Unit, Centre Hospitalier Intercommunal de Créteil
b
Department of Anaesthesia and Intensive Care Medicine, Groupe Hospitalier et Faculté de Médecine Paris Sud, Le Kremlin-Bicêtre, France
c
Department of Anaesthesia and Intensive Care Medicine, Groupe Hospitalier et Faculté de Médecine Paris Sud, Le Kremlin-Bicêtre, France

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Enhanced recovery programmes (ERP) have been shown to improve postoperative outcomes.
Received 3 August 2016 The aim of our study was to investigate the impact of an ERP after caesarean delivery on maternal feelings
Received in revised form 22 December 2016 and satisfaction towards mother-child bonding initiation, in comparison with traditional postoperative
Accepted 28 December 2016
care.
Available online xxx
Study design: A comparative, prospective and multicentre study was conducted in three maternity units
of the Paris area: one applied traditional postoperative care while the two others applied an ERP, were
Keywords:
included patients after elective or emergency caesarean delivery who had given birth to full-term healthy
Enhanced recovery programme
Caesarean
singleton newborns. Data were collected from 8th October 2014 to 31st January 2015. Patients were asked
Mother-child bonding about their feelings toward the relationship with their infant using a questionnaire, to be completed one
Feelings (D1) and three (D3) days after caesarean delivery.
Satisfaction Results: Patients (n = 86) received post-operative care in agreement with what was expected in the group
in which they were included. Patients in the ERP group had more positive feelings toward the relationship
with their newborn on D1 and D3, had a greater maternal satisfaction level on D1 and were more
comfortable in caring for their newborn, especially for cradling and breastfeeding the child.
Conclusion: Our study suggests that application of ERP after caesarean delivery is associated with
improved maternal satisfaction and more positive feelings toward the relationship with the newborn.
© 2016 Elsevier Ireland Ltd. All rights reserved.

Introduction
During childbirth physical contact between mother and her
newborn is critical to allow the development of a bond. Bowlby
defines attachment as the “essential bond” reuniting mother and
child [1]. It requires significant physical contact that allows the
activation of sensorial stimuli to the mother and the newborn.
Various types of stimuli are used: the touch mainly by the
newborn, but also smell and mouth contact, while his (her) mother
essentially uses touch and sight. Stimulation of and interaction
between these senses for one or the other and also the presence of
primitive reflexes of the newborn enhance the mother-child bond
[1,2]. Hormonal mechanisms allow the strengthening of the
mother-child bond [2–5]. For the newborn a safety feeling is
created [2]. Psychologically, for the mother it allows the emergence
* Corresponding author.
E-mail address: dan.benhamou@aphp.fr (D. Benhamou).
of a mothering behaviour and also she realizes that the newborn “is
hers” and she is a mother [4–6].
Several situations in obstetrical care modify the usual
environment of birth and care, especially during caesarean
delivery and do not allow the attachment because of the distance
induced between the mother and her baby. Enhanced recovery
programmes (ERP) have been shown to improve postoperative
outcomes by reducing complications and hospital stay [7].
Although this benefit has not yet been proven for caesarean
delivery, ERP should be used [8] because their components can
improve maternal condition even when used separately [9–12].
After caesarean delivery, the postoperative period is particular
because it associates psychological and physical changes for the
mother on physical contact with the baby and nursing. Patient’s
wellbeing is enhanced due to same features of the programme [13]
and studies have shown greater maternal satisfaction when they
have greater control over childbirth [14,15]. Data suggest that ERP
may improve mother-child bond and experience. However there is
little scientific evidence on this behalf. The aim of this study is to

http://dx.doi.org/10.1016/j.ejogrb.2016.12.034
0301-2115/© 2016 Elsevier Ireland Ltd. All rights reserved.
 A. Laronche et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 212–216
compare the effects of an ERP with a conventional postoperative
management over the mother-child bond, perception and satis-
faction.
Materials and methods
The aim of this prospective, comparative, multicentre study was
to compare one maternity unit where an ERP was not used (CHU
Robert Debré, Paris) to two maternity units where it was used (Chu
KB, CHI Creteil). We defined an enhanced recovery programme as a
postoperative combination of the following practice patterns:
early mobilisation i.e. within 6–8 h after surgery (at least sitting in
a chair), early drinking and feeding (within 6–8 h after surgery and
generally including drinking during the PACU stay), maintenance
of intravenous infusion for less than 24 h, early urinary catheter
withdrawal (withdrawal within the first 12 h) and early use of oral
analgesics (first oral analgesic pills given within the first 24 h). The
first mobilisation takes place 12–24 h after surgery. Drinking is
encouraged during the stay in the PACU and the first light meal is
provided 6 h after surgery. Later on, normal meals are provided. A
maternity unit could be included if the ERP was in use for at least
several months. In the conventional recovery programme, the
urinary catheter is removed 24 h after caesarean delivery or later,
and the venous cannula even later, according to the time of return
of the first flatus.
Person protection committee agreement was not considered to
be necessary as no change of their practice was included in our
study. Patients were recruited during their hospital stay, after
childbirth, by the midwives, following several criteria. These
included patients after elective or emergency caesarean section
that had full term healthy singleton newborns and also French
speaking that could fill in questionnaires and give their consent.
Difficult caesarean delivery, pathological pregnancies, somatic and
psychiatric maternal conditions, or any foetal anomalies were
excluded. Caesarean deliveries under general anaesthesia were
also excluded. Eligible patients who joined the study had clear
explanation of on the study, its purpose, the number of
questionnaires to fill in, the respect of the confidentiality and
the possibility of quitting the study at any time. Ethical committee
was not deemed necessary due to the observational design of the
study.
On the basis of a literature review on mother – child bonding
after childbirth, two questionnaires were established using
questions which had been used in previous studies [16–18]. The
first contained eight questions that were focusing mainly on the
caesarean delivery (time, date, elective or emergency caesarean
delivery) as well as postoperative care (early mobilisation, oral
intake, urinary catheter removal and peripheral venous catheter
removal). To maintain confidentiality each questionnaire was
identified by an acronym corresponding to the maternity care unit,
the birth date using six digit numbers: MM/DD/YY. This was filled
in by the healthcare professional who had selected the patients.
The second questionnaire was anonymously filled in by the patient
herself, on day one (D1) after the caesarean delivery and three days
(D3) afterwards. The aim of this questionnaire was to assess the
way mothers lived this experience. Each patient was asked nine
questions, each assessing one dimension.
Pain was measured using a visual analogue scale rated from 0
(not at all) to 10 (worst pain ever). Patients were assessed at rest
and when mobilised at CD day one and three. Overall maternal
satisfaction was assessed using a visual analogue scale from 0
(completely unsatisfied) to 10 (totally satisfied). Feeling towards
her baby using propositions with the following wording: close,
difficult, unstable, distant. Feeling on the bonding process was
classified as “rather positive” when the following answers were
obtained: “I feel close” or “the bond is real”. On the other hand their
213
feelings were rated as “rather negative” when their answers were:
“I feel close but it seems unstable”, “I feel close but it seems difficult
to accomplish”, “The bond is unstable”, “The bond seems difficult
to accomplish”, “I feel distant and it’s a difficult situation”, “I feel
distant and the bond is unstable”. They were questioned about
their experience throughout for items using several possible
answers. Answers like: “happy”, “happy and reassured” were
placed in the “rather positive experience” category. Mother’ mood
was assessed using a list of four words: happy, sad, worried,
reassured. Answers such as: “sad”, “sad and reassured”, “sad and
worried” and “worried” were placed in the “rather negative
experience” category. Infant care (changing nappies, taking bath .
. . .) was also evaluated focusing on mother’s ability to nurse.
Answers were grouped in two categories:” very difficult” or
“sometimes difficult” and “sometimes easier” or ”easily”. Four
items were proposed to assess the frequency of holding the babies
such as: “not often”, “sometimes”, (the first category in the
analysis) “often”, “as often as possible” (second category). Finally,
mothers were assessed on their experience with feeding the
neonate. First they were questioned on their choice: breast milk,
formula or mixed. Then, their experience and ease with
breastfeeding were also assessed using several answers: comfort-
able, reassured, gradually more comfortable, troubled, concerned,
uncomfortable, discouraged. For analysis purposes, the first three
proposals corresponded to score “ +1”, and the others proposals
corresponded to score “ 1”. Adding answers led to three
categories: a score less than 0 interpreted as “rather negative
feeling”, a score than 0 as “neutral feeling”, and a score more than 0
as “rather positive feeling”.
Quantitative variables were presented as a mean and standard
deviation and were treated variables with parametric tests (such as
the Student T-test and analysis of variance) when continuous and
normally distributed. Quantitative variables presented as catego-
ries or as a percentage were processed by the Chi square test.
Results were analysed by comparing the “enhanced recovery”
group to the “conventional recovery” group on day 1 and 3. Results
were processed using Microsoft Excel. A significant difference
between the two groups was defined by a risk of alpha error less
than 5% (p < 0.05).
Results
The study was performed from October 8th, 2014 to January
31th, 2015. All three maternity units included were perinatal level
3 units. Of the 106 patients included in the study, twenty were
excluded secondarily due to various reasons. The study population
is represented as a flow diagram (Fig. 1). Patients’ general features
are included in Table 1. In all patients who had undergone
scheduled caesarean delivery, spinal anaesthesia was used and was
successful (i.e. none required any additive or sedative). In all
patients who had undergone n emergency caesarean delivery,
augmentation of epidural analgesia, previously placed for labour
analgesia was used.
The number of elective or emergency caesarean deliveries was
not significantly different in the two groups. The enhanced
recovery protocol was well applied in the ERP group (Table 1).
The patients of this group had indeed an earlier oral intake and
were mobilised earlier and had their urinary catheter removed
before discharge from the post anaesthesia unit (Table 1). Pain
rating on mobilisation was significantly lower in the ERP group at
CD day 3 (Table 2).
Maternal satisfaction rate toward their bond with the baby was
higher on the ERP group during the first 24 h postoperative
(Table 3). In the ERP group the number of mothers in a positive
mood was significantly greater at day 1 and 3 (Table 3), and women
described their relationship with their baby as better than those in
214 A. Laronche et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 212–216

Table 2
106 patients included Pain evaluation by a visual analogue scale from 0 to 10 at CD day 1 and 3, at rest and
during mobilisation.
59 patients in the 47 patients in the
ERP group CR group
ERP group CR group
D1 D3 D1 D3
At rest 3.2  2.4 2.1  2.2 3.9  2.3 2.1  1.4
Mobilisation 6.0  2.5 4  2.8* 6.8  2.1 4.5  2.2*

ERP: enhanced recovery after caesarean, CR: conventional recovery.

14 PATIENTS EXCLUDED 6 PATIENTS EXCLUDED *
p < 0.05 ERP versus CR.

2 (twin pregnancy) exclusion 5 lost questionnaires

criteria towards the relationship with their babies. Differences between
1 unfilled questionnaire the ERP and CR groups were mainly observed on the first 24 h after
2 the questionnaire at 24H surgery, with results in the CR group becoming close to those of the
and at D3 was filled after the ERP group on Day 3. Postoperative enhanced recovery seems to
delay
improve mainly the maternal childbirth experience on the first 24
8 lost questionnaires to 48 h postoperatively.
The ERP seems to make the carrying and nursing of the baby
2 unfilled questionnaires
more frequent and less difficult. This difference is probably due to
the fact that patients in the ERP group are rapidly mobilised, are
less constrained by their intravenous infusion and urinary catheter
ERP group CR group but they also benefited by a faster recovery and oral intake. On CD
day 3, in both groups were mothers able to nurse their newborn as
45 patients 41 patients women the “conventional recovery” group had also recovered their
essential physiological functions and had all their catheters
removed. Breastfeeding can be separated in two categories, on
one hand breast milk and on the other formula milk and mixed.
STUDY POPULATION Exclusive breastfeeding often requires a greater mother involve-
86 Patients ment, causing difficulties in implementation, especially in the first
day. So, exclusive breastfeeding may be influenced by the physical
Fig. 1. Flow diagram.
and mental state of the mother. The rate of exclusive breastfeeding
was 57% in our study and is close to the national French rate (59%)
the classical recovery group (Table 3). Exclusive breastfeeding was suggesting that our data are relevant [19]. This rate was higher on
observed more often in the ERP group (Table 3). Day 1 in the ERP group with a greater number of patients
expressing a positive feeling towards breastfeeding. On Day 3, the
Comment types of breastfeeding were not that different in the two groups
and the experience was rather positive in both groups. Practicing
This study shows that the ERP protocol applied in patients exclusive breastfeeding was less on CD day 3 in the ERP group,
undergoing caesarean delivery is associated with greater satisfac- which could be related to the greater number of primiparous
tion towards the mother and baby relationship. This result is women. Facing their first lactation period, they may have
confirmed by the perceived better maternal-neonatal relationship encountered some difficulties. These difficulties may have led
and improved maternal experience of childbirth. The ERP group them to choose to stop breastfeeding or choose formula milk
was more likely to report feeling close and/or to have a secure bottles. It is also important to know that the choice and the
contact with the newborn on Day 1 and 3. Also, in the ERP group, prolongation of exclusive breastfeeding in the first days after birth
patients more often expressed to be “happy” and/or “reassured” on is influenced by the local policies and support provided among
Day 1 and 3, compared to patients in the “conventional recovery” maternity units.
group. Positive or negative emotions expressed by the mothers in There seems that a correlation exists between the fact that
both groups are in relationship with the satisfaction that they feel mothers are able to nurse and carry their newborn and the

Table 1
Patient’s characteristics and postoperative care: comparison between the two groups.

ERP group CR group

Mean age (years) 33* 34*
Parity: primiparous/multiparous (%) 43/57 25/75
Obstetrical history 38/16/31/7 24/32/37/5
None/Vaginal delivery/Caesarean delivery/Vaginal and caesarean delivery (%)
Elective/emergency caesarean delivery (%) 38/62 32/68
First oral liquid intake (PACU/PACU-H6/>H6) (%) 27/64/9* 17/49/34*
First meal intake: <H6/>H6 (%) 64/36* 27/73*
First time mobilised: <H12/>H12 (%) 93/7* 0/100*
Urinary catheter removal PACU/PACU-H24/>H24 (%) 71/29/0* 0/58/39*
Peripheral venous cannula removal <H24/>H24 (%) 98/2* 37/63*

ERP: enhanced recovery CR: classical recovery.

 A. Laronche et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 212–216 215

Table 3
Maternal perception at CD day 1 and 3 on mother-baby bond: maternal state of mind, baby-carrying ability, nursing difficulties, feeding type and perception towards feeding
baby.

ERP group CR group

D1 D3 D1 D3
Feeling toward mother-child bonding: rather positive/rather negative (%patients) 95/5 100/0 48/52 76/24
Mean satisfaction number (0–10) 9.3  0.9* 9.5  0.73 8.2  1.5* 9  0.9
Mother’s mood: rather positive/rather negative (%) 89/11* 89/11* 66/34* 78/22*
Mothers carrying baby: often-sometimes/frequently-all the time 24/76* 16/84 73/27* 7/93
Nursing: a lot-difficult sometimes/not much-easy 60/40* 32/68 86/14* 32/68
Type of feeding: breast milk/formula or mixed (%) 64/36* 57/43 48/52* 48/52
Perception on breastfeeding: rather positive/rather negative or neutral (%) 69/31* 69/31 46/54* 68/32
Postoperative nausea and vomiting (PONV) number (%) 4 2 5 0

ERP: enhanced recovery after caesarean, CR: conventional recovery.

*
p < 0.05 ERP versus CR.

satisfaction they perceive. We have observed that in the ERP group
where mothers can easily nurse their babies and carry them more
frequently, they are at ease for breastfeeding and they report being
more satisfied with the relationship they have with their newborn
and describe a more positive experience. Several studies have
shown that mothers display a greater satisfaction when they
achieve control and active attitude during labour and childbirth
[16–18,20]. The analogy can be made regarding nursing, breast-
feeding and carrying the newborn.
This study also identifies areas of post-operative care which
remain only partially controlled nowadays. The ERP did not
provide any additional or specific answer on the pain relieving
issue. Pain scores were similar in both groups, except for those
recorded during mobilisation at CD Day 3, which were slightly
lower in the group ERP. Only at rest and three days after surgery,
pain scores expressed by patients were less than 3/10 in both
groups. Caesarean delivery is thus still causing moderate to severe
pain, and these results question the effectiveness of pain relief
protocols and/or their implementation. It is therefore necessary to
reassess postoperative analgesia protocols after caesarean deliv-
ery, perhaps using more widely the principle of patient-controlled
oral analgesia [21]. However, it appears that pain does not
influence the mother-child relationship and maternal satisfaction.
Building the mother-child bond through a caesarean delivery
appears to require more professional guidance, as well as greater
dedication of healthcare providers to improve the mother’s
involvement and physical closeness with their newborn. Thus,
the development of the use of early skin-to-skin contact [22,23] or
the concept of a “natural caesarean” could form the basis of
additional change of our practices [24].
Our study has many limitations, especially because it had a
nonrandomised design. In addition, the work was carried out in the
framework of the preparation of a final dissertation study of a
student midwife, limiting the capacity of inclusion number. Parity
was unevenly distributed and primiparous were more represented
in the ERP group whereas multiparous were mostly found in the CR
group. However, this difference seems rather in favour of the
hypothesis of our study, since patients who are mothers for the
first time may feel less comfortable in nursing and feeding and
therefore less satisfied. Our results seem to disprove this
hypothesis, suggesting that a specific management type is needed.
The “classical recovery” group included more patients who have
had a vaginal delivery before. This might be interpreted as an
additional cause of disappointment. Vaginal delivery is synony-
mous to achieving autonomy in the postpartum period and
comparing to today’s caesarean delivery may cause disappoint-
ment and trouble. This could have biased in the results. Most other
characteristics were however evenly distributed. Patient ages were
similar in the two groups. The distribution of caesarean deliveries
performed in emergency and elective ones was also similar in both
groups of patients. Although the timing and characteristics of
postoperative care had been conducted differently in the two
groups, this only proves that the maternity units were actually
practicing ERP as declared. Marital status would have been
interesting to record. Indeed, the relationship with the partner
and his support are important during arrival of a child and likely
impact the mother-child bond process. We could also have
assessed more precisely the indication of caesarean delivery and
the potential impact of different caesarean patterns.
Few studies allow us to assess the validity of our results because
little work is available on the mother-child relationship after
caesarean delivery especially in the context of ERP. However, our
results are similar to those which found improved maternal well-
being through increased maternal autonomy [14,15]. Our results
are in line with recent French Guidelines [25] which suggest that
the concept of enhanced recovery after caesarean delivery could be
of major interest, adding an important component represented by
the mother-child bond.
In conclusion, even if this study has undeniable limitations, it is
the first one which describes the effect of an enhanced recovery
programme (ERP) after caesarean delivery on patient’s experience.
Our preliminary data suggest that implementation of an ERP after
caesarean delivery improves maternal satisfaction and mother-
child bond. However, further information using randomised trials
is needed to confirm these results.
Conflict of interest
Pr Benhamou has received fees by Ferring for lecturing in
regional and national meetings as well as hospital staff meetings
on enhanced recovery programmes after caesarean delivery.
The two other authors do not declare any conflict of interest in
relation with the present study.
Acknowledgments
The authors would like to sincerely thank the midwives and
physicians of the three maternity units involved in the study.
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