Low-Concentration Continuous Epidural Levobupivacaine 0.125% with Fentanyl as the Analgesic Backbone of an ERACS-Like Early Mobilisation Pathway after Repeat Caesarean Delivery in a Rural Type D Hospital in a Disadvantaged, Border and Island (DTPK) Region of Indonesia: A Case Report and Literature Review

Abstract

Introduction: Caesarean delivery is associated with moderate-to-severe postoperative pain, which is frequently accentuated after repeat caesarean delivery and may delay mobilisation, breastfeeding and discharge. Enhanced recovery after caesarean section (ERACS) pathways place opioid-sparing multimodal analgesia and early mobilisation at their core, yet published experience from rural, resource-limited hospitals in Indonesia’s disadvantaged, border and island (Daerah Tertinggal, Perbatasan dan Kepulauan, DTPK) regions is scarce. We describe an ERACS-like pathway anchored on low-concentration continuous epidural levobupivacaine combined with fentanyl in a Type D hospital.

Case report: A 22-year-old woman (G2P1001) at 37–38 weeks’ gestation with one previous caesarean delivery (2024) presented with latent-phase labour, clinically suspected cephalopelvic disproportion and prelabour rupture of membranes of <24 h. Admission haematology, bleeding and clotting times and infection serology were unremarkable (haemoglobin 13.3 g/dL; platelets 251 × 10³/µL). She was classified as ASA physical status II and underwent repeat caesarean delivery under neuraxial anaesthesia; an epidural catheter was retained for continuous postoperative analgesia with levobupivacaine 0.125% plus fentanyl 100 µg, supplemented by scheduled paracetamol and ketorolac. The visual analogue scale (VAS) pain score decreased from 5 at 4 h to 3 at 8 h, 2 at 17 h, 1 at 32 h and 0 at approximately 48 h, with a Bromage score of 0 at every assessment. She walked to the bathroom with assistance at 8 h, independently at 17 h, and was ready for discharge on postoperative day 2 without pruritus, postoperative nausea and vomiting or prolonged urinary retention.

Discussion: Levobupivacaine, the S(−)-enantiomer of bupivacaine, provides near-equivalent analgesic potency with a wider cardiovascular and central nervous system safety margin. At low concentration, its sensory-predominant block, potentiated by the predominantly spinal, supra-additive action of epidural fentanyl, allows effective analgesia without clinically detectable motor block. Continuous delivery yields steady-state analgesia that is particularly relevant after repeat caesarean delivery, a recognised risk factor for more severe acute pain. Safe implementation in a Type D hospital requires protocolised respiratory, haemodynamic and neurological surveillance, preparedness for local anaesthetic systemic toxicity, and alignment of the remaining ERACS elements, notably early urinary catheter removal, liberal clear-fluid intake, fluid and antimicrobial stewardship.

Conclusion: Low-concentration epidural levobupivacaine–fentanyl analgesia, embedded in multimodal care, was a feasible and well-tolerated analgesic backbone for early mobilisation after repeat caesarean delivery in a rural Type D hospital. Prospective protocolised evaluation using internationally agreed ERAC core outcomes is warranted before wider adoption.