This is a multicenter, 1:1 parallel-group, randomized controlled trial designed to compare the effect of the Enhanced Recovery After Cesarean (ERAS) protocol versus standard perioperative care on mother-infant and father-infant bonding in women undergoing cesarean delivery. The study will initially be conducted as a single-center trial at Istanbul Okan University Hospital. Once adequate site preparation is completed, additional centers will be added to expand the study to a multicenter setting.
Primary Outcome:
The primary outcome is the total score on the Postpartum Bonding Questionnaire (PBQ) assessed on postpartum day 7, reflecting mother-infant bonding.
Secondary Outcomes:
Secondary outcomes include:
Maternal/Parental Postnatal Attachment Scale (MIBS) score at 2 hours postpartum (mother)
PBQ score at 24 hours postpartum (mother)
PBQ score at day 4 postpartum (mother)
PBQ score at day 7 postpartum (father-infant bonding)
Edinburgh Postnatal Depression Scale (EPDS) scores for mothers at 2 hours and 7 days postpartum
Time to initiation of breastfeeding
Requirement for neonatal intensive care unit (NICU) admission
Sample Size:
The total multicenter target sample size is n=300, with 150 participants in the ERAS group and 150 in the standard care group. The initial single-center phase at Okan University Hospital will enroll a target of n=100 participants (50 per group).
Randomization:
Participants will be randomized using a block and stratified randomization approach based on parity (primiparous vs multiparous) and planned type of anesthesia.
Blinding (Masking):
Due to the nature of the intervention, care providers cannot be blinded to group assignment. However, outcome assessors and data analysts will remain blinded to treatment allocation to minimize bias.
Study Timeline and Visits:
Participants will be evaluated at multiple time points following cesarean delivery: 2 hours postpartum, 24 hours postpartum, day 4 postpartum, and day 7 postpartum. All primary and secondary outcomes will be collected at the specified time points.
Significance and Rationale:
The ERAS protocol for cesarean delivery is designed to optimize perioperative care, enhance recovery, and potentially improve early parent-infant bonding. While previous studies have focused on maternal recovery and clinical outcomes, evidence regarding the impact of ERAS on both mother-infant and father-infant bonding remains limited. This trial aims to provide high-quality evidence on whether ERAS implementation can improve early bonding experiences, maternal mental health, breastfeeding initiation, and neonatal outcomes compared with standard perioperative care. The findings may guide future clinical practice and contribute to optimizing family-centered care in cesarean deliveries.
Key Features:
Multicenter, randomized controlled design
Parallel 1:1 allocation
Stratified randomization by parity and anesthesia type
Blinded outcome assessment and data analysis
Multiple postpartum evaluation points
Focus on psychosocial and clinical outcomes
Expected Contributions:
This study will provide comprehensive data on the feasibility and effectiveness of ERAS protocols in cesarean deliveries and their potential benefits for both maternal and paternal bonding with the newborn. The inclusion of both mother-infant and father-infant outcomes, as well as maternal mental health and breastfeeding indicators, ensures a holistic assessment of early family-centered outcomes.
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Parallel
ERAS Protocol
BehavioralThe Enhanced Recovery After Cesarean (ERAS) protocol includes shortened preoperative fasting, preoperative carbohydrate loading, multimodal opioid-sparing analgesia, early oral intake, early ambulation, and early removal of urinary catheter. The protocol also incorporates immediate or early skin-to-skin contact, early initiation of breastfeeding, and structured parental involvement. ERAS aims to optimize maternal postoperative recovery, reduce analgesic requirements, enhance mobility, improve patient satisfaction, and support early maternal-infant and paternal-infant bonding. No surgical technique is altered; only perioperative care differs from usual practice.
Standard Perioperative Care
BehavioralStandard perioperative cesarean care includes routine preoperative fasting, no carbohydrate loading, conventional postoperative analgesia, delayed oral intake, delayed ambulation, and routine timing of urinary catheter removal. Immediate skin-to-skin contact and early breastfeeding are not systematically implemented. This arm reflects current institutional usual care and serves as the comparator to the ERAS protocol. No deviation from standard surgical or anesthetic techniques is introduced.
Mother-Infant Bonding Score at Postpartum Day 7 (PBQ Total Score)
The primary outcome is the maternal bonding score assessed on postpartum day 7 using the validated Postpartum Bonding Questionnaire (PBQ). The PBQ total score evaluates the quality of early emotional bonding between mother and infant across domains including affection, rejection, and anxiety. Higher scores indicate better bonding. The ERAS protocol is hypothesized to improve bonding through enhanced maternal recovery, reduced postoperative discomfort, earlier mobilization, improved emotional well-being, and structured support for early skin-to-skin contact and breastfeeding. PBQ is administered by trained staff blinded to group allocation.
Mother-Infant Bonding Score at 2 Hours Postpartum (MIBS Score)
Early maternal bonding is assessed using the validated Mother-to-Infant Bonding Scale (MIBS) at 2 hours postpartum. The scale evaluates emotional response, closeness, and early attachment behaviors. Higher scores indicate better bonding. Trained assessors blinded to group allocation administer the scale.
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