Enhanced Recovery After Surgery (ERAS) protocol encompasses preoperative, intraoperative and postoperative measures to reduce the catabolic stress of surgery and anaesthesia. ERAS protocols are multipronged evidence-based practices designed to optimise standardised perioperative care [1,2]. Surgical procedures disrupt the physiologic balance of the body and trigger a general stress response, altering hormonal, metabolic, immunologic, and neurological functions. A surgical procedure is associated with a 20–40 % decrease in patient's functional capacity, even without perioperative complications [3]. ERAS improves patient outcomes and provides faster recovery [4].

ERAS principles were initially evaluated in colorectal cancer surgeries [5]. Later, these were extended to other surgical fields, including gynaecology. ERAS is a relatively new concept in the context of caesarean section and was developed by Steenhagen [6]. The ERAS Society recently published guidelines for preoperative, intraoperative, and postoperative ERAS components for both scheduled and unscheduled caesarean deliveries [[7], [8], [9], [10]]. In recent publications, the term ERAC (Enhanced Recovery After Caesarean) has been used to describe the implementation of the ERAS protocol in caesarean births [11].

Adherence to ERAS protocol in surgical practice is difficult as it requires the participation and commitment of the entire surgical team, including surgeons and anaesthetists, paediatricians, nurses, and physical therapists. In addition, ERAS programs include several elements that must be met to achieve optimum surgical outcomes. Although surgeons already practice most elements, only a few adopt the entire ERAS concept to obtain the maximum benefit for the patient [12]. Patient motivation also contributes to the successful implementation, justifying counselling as one of the preoperative components of ERAS.

Most reported studies on ERAS after caesarean are primarily from developed countries. Traditional practices for immediate care of women after childbirth vary among cultures and influence the start of physical activity and nutrition after birth, with a more reserved attitude after caesarean delivery. In addition to personal functional recovery, post-caesarean patients have to care for their newborns. Emotional changes after childbirth and background risk of postpartum psychiatric illness may also affect ERAS acceptability. Hence, reluctance to follow ERAS protocol is expected after caesarean, and the patient's motivation is of paramount importance, which in turn largely depends on postoperative pain relief.

The most essential component of the ERAS protocol is adequate post-operative pain management. Suboptimal analgesia is associated with failure of other components of ERAS, including early mobilisation, early functional recovery, breastfeeding and bonding with newborns and is also associated with postpartum depression and persistent pain [5,11,12]. Therefore, adequate analgesia affects the success of ERAS protocol, though, as suggested by Sultan et al., combined strategies rather than an individual strategy improve patient's overall recovery experience [11]. There are few prospective studies on the utility of ERAS in caesarean in terms of efficacy and feasibility [13].

The present comparative study was planned to evaluate the efficacy and feasibility of the ERAS protocol incorporating multimodal analgesia for women undergoing elective caesarean delivery in a tertiary care centre.