Surgery is an indispensable component of modern health care. Estimates suggest that more than 230 million major surgical procedures are performed worldwide every year [1,2], yet the burden of preventable postoperative morbidity remains high, and a large proportion of the world’s population still lacks access to safe, affordable surgical care. In low- and middle-income countries, including India, postoperative complications prolong hospital stay, consume scarce bed capacity and inflate out-of-pocket expenditure for families. Among abdominal operations, caesarean section is now the most commonly performed major surgery in women. The global caesarean rate was estimated at 18.6% of all births in 2014 [3]. In India, the National Family Health Survey (NFHS-5, 2019–21) reported a caesarean rate of 21.5%, up from 17.2% in NFHS-4 (2015–16), with a considerably higher rate in the private sector [4,5]. India also continues to carry a substantial maternal health burden, with a maternal mortality ratio of 113 per 100,000 live births reported for 2016–18 [6]. Alongside caesarean delivery, general surgical procedures such as laparotomy, cholecystectomy, appendicectomy and hernia repair account for a major share of the workload of tertiary care teaching hospitals. Postoperative care in both groups therefore has a direct bearing on hospital efficiency and patient outcomes. Traditionally, patients were advised prolonged bed rest after surgery to “conserve energy” and protect the wound. This belief was challenged as early as 1947, when Asher described the dangers of going to bed and highlighted the harmful effects of recumbency [7]. Prolonged immobility reduces muscle mass and strength, impairs pulmonary ventilation, promotes venous stasis, slows gastrointestinal motility, increases insulin resistance and predisposes to pressure injury and deconditioning [8]. Surgical stress itself amplifies these effects through neuroendocrine and inflammatory responses [9,10]. Early mobilisation, defined as getting the patient out of bed, sitting, standing and walking as soon as haemodynamically and neurologically permissible after surgery, counteracts many of these changes. Kehlet’s concept of multimodal rehabilitation placed early mobilisation alongside effective analgesia, minimal drains and catheters, and early enteral nutrition as pillars of accelerated recovery [9–11]. Observational data show that delayed mobilisation after major abdominal surgery is associated with a higher rate of postoperative pulmonary complications [12]. A systematic review of early mobilisation protocols after abdominal and thoracic surgery suggested potential benefit but also highlighted heterogeneity in definitions, protocols and study quality [13]. Integrated reviews in medical–surgical inpatients similarly report shorter stay and fewer complications with structured mobilisation, while emphasising the need for good-quality comparative data [14,15]. Enhanced Recovery After Surgery (ERAS) programmes have formalised early mobilisation within evidence-based care bundles [16]. The ERAS Society guidelines for caesarean delivery recommend early oral intake, early removal of the urinary catheter and early mobilisation after surgery [17,18], and the colorectal guidelines likewise recommend that patients be mobilised from the day of surgery [19]. Nevertheless, in many Indian teaching hospitals, postoperative mobilisation is still left to individual preference, is often delayed until the second or third postoperative day, and is rarely documented as a protocol. Infection prevention and control guidance issued by the national agencies stresses the importance of reducing hospital-acquired infections, which are among the complications most influenced by recovery practices [20,21]. Most published trials have examined a single surgical specialty, and there are few comparative data from India evaluating the same mobilisation approach in both obstetric and general surgical patients within one institution. Such data are valuable because these two groups differ in physiology, anaesthetic technique, wound type and baseline risk. This study was therefore designed to compare early mobilisation with conventional mobilisation with respect to postoperative complications and length of hospital stay in obstetric and general surgical patients in a tertiary care teaching hospital. 1. Aim and objectives Aim: To evaluate the effect of early mobilisation on postoperative outcomes in obstetric and general surgical patients. • Primary objective: to compare the incidence and severity of postoperative complications between early and conventional mobilisation groups. • Secondary objectives: to compare length of hospital stay, return of bowel function, time to oral intake, catheter duration, postoperative pain scores and 30-day readmission; and to perform subgroup comparison between obstetric and general surgical patients

Study design, setting and duration This was a hospital-based, prospective, comparative study conducted in the Departments of Obstetrics & Gynaecology and General Surgery of a tertiary care teaching hospital in India over a period of 6 months (January to June 2025). Patients admitted to the participating surgical units were enrolled consecutively. Ethical clearance was obtained from the Institutional Ethics Committee and written informed consent was obtained from every participant in the language they understood. 2.2 Study population Inclusion criteria: (a) adults aged 18–60 years; (b) women undergoing elective or emergency lower segment caesarean section (LSCS) under spinal anaesthesia; (c) patients undergoing elective or emergency open abdominal surgery under general or regional anaesthesia (open cholecystectomy, midline laparotomy, appendicectomy and ventral/incisional hernia repair); (d) American Society of Anesthesiologists (ASA) physical status I–III; and (e) willingness to participate and comply with the protocol. Exclusion criteria: (a) haemodynamic instability or need for postoperative intensive care or ventilation; (b) severe pre-eclampsia, eclampsia, postpartum haemorrhage requiring massive transfusion or hysterectomy; (c) pre-existing neuromuscular, spinal or orthopaedic conditions limiting ambulation; (d) bedridden status before surgery; (e) re-exploration within 24 hours; and (f) refusal of consent. 2.3 Sample size Based on an anticipated postoperative complication rate of about 40% with conventional care and 20% with early mobilisation, at 5% level of significance (two-sided) and 80% power, the minimum required sample was 79 patients per group. Allowing for about 20% dropout and protocol deviation, 100 patients per group were enrolled (total n = 200), comprising 50 obstetric and 50 general surgical patients in each group. 2.4 Group allocation and intervention Patients were allocated to one of two groups according to the postoperative care pathway of the admitting unit during the study period: Group A (early mobilisation, n = 100) and Group B (conventional mobilisation, n = 100). Surgical technique, antibiotic prophylaxis, analgesia regimen, thromboprophylaxis policy and discharge criteria were kept the same in both groups so that the timing of mobilisation was the principal variable. Group A – Early mobilisation protocol • Obstetric patients: after recovery from spinal block (return of motor power in both lower limbs), the patient was helped to sit up and dangle her legs at the bedside within 6 hours, to stand within 8–12 hours and to walk with assistance at least three times on the day of surgery or by the following morning. • General surgical patients: supported sitting in bed or chair within 6–12 hours, standing at the bedside within 12–24 hours and walking at least three to four times a day from postoperative day (POD) 1, increasing distance as tolerated. • Ambulation was supervised by a trained nurse or physiotherapist using a structured checklist; adequate analgesia, abdominal binder support when required, and early (within 6–8 hours) sips and oral feeds were encouraged as per surgical advice. • Mobilisation was stopped and documented if the patient developed hypotension (systolic BP < 90 mmHg), tachycardia (> 120/min), desaturation (SpO₂ < 92%), dizziness, severe pain or wound-related concern. Group B – Conventional mobilisation Patients remained in bed until the morning of POD 2 or later, or until the treating team permitted ambulation, as per the prevailing routine. Standard bedside care, including turning in bed, deep-breathing exercises and limb movements, was permitted in both groups. 2.5 Data collection A pre-tested proforma was used to record demographic details, body mass index (BMI), comorbidities, ASA grade, indication and type of surgery (elective or emergency), duration of surgery and anaesthetic technique. Postoperatively, the following were recorded by a trained resident not involved in direct patient care: time to first sitting and first ambulation (hours from the end of surgery), time to first flatus, time to first oral intake, duration of urinary catheterisation, pain intensity on a 10-point visual analogue scale (VAS) at 24 and 48 hours, complications, day of discharge and any readmission within 30 days. Patients were examined daily during the hospital stay and followed up by outpatient visit or telephone on POD 7 and POD 30. 2.6 Outcome measures and operational definitions • Postoperative complications: any deviation from the expected postoperative course within 30 days, graded using the Clavien–Dindo classification [22]. • Paralytic ileus: absence of flatus or bowel sounds with abdominal distension beyond 72 hours (general surgery) or 48 hours (caesarean section), without mechanical obstruction. • Pulmonary complications: atelectasis or chest infection diagnosed by fever, cough, crepitations or reduced air entry with radiological confirmation where required [23]. • Surgical site infection (SSI): purulent discharge, erythema with induration, or culture-positive discharge at the incision within 30 days, defined according to standard CDC/national infection control criteria [20]. • Urinary tract infection (UTI): symptoms with a positive urine culture (≥ 10⁵ CFU/mL) after catheter removal. • Deep vein thrombosis (DVT): calf pain/swelling confirmed on compression Doppler ultrasonography; thromboprophylaxis followed accepted guidelines [24]. • Length of hospital stay (LOS): days from the date of surgery to the date of discharge, with discharge criteria (afebrile, tolerating diet, normal bowel function, wound satisfactory, pain controlled on oral analgesia) identical in both groups. 2.7 Statistical analysis Data were entered in Microsoft Excel and analysed with SPSS software (version 26.0). Continuous variables are expressed as mean ± standard deviation (SD) and compared using the independent-samples (Welch) t-test; categorical variables are expressed as numbers and percentages and compared with the Chi-square test or Fisher’s exact test when expected cell counts were less than 5. Relative risk (RR) is presented for complications. Pearson’s correlation coefficient was used to assess the relationship between time to first ambulation and LOS. A p-value < 0.05 was considered statistically significant

A total of 214 patients were assessed; 8 declined consent and 6 did not meet the inclusion criteria. Two hundred patients completed the study and 30-day follow-up and were analysed: 100 in Group A and 100 in Group B, each comprising 50 obstetric and 50 general surgical patients. There were no losses to follow-up and no protocol violations requiring exclusion. 3.1 Baseline characteristics The two groups were comparable with respect to age, BMI, ASA status, comorbidities, urgency of surgery and duration of operation (Table 1). The distribution of surgical procedures was also similar (Table 2). Table 1: Baseline characteristics of the study groups (n = 200) Characteristic Group A (n = 100) Group B (n = 100) p-value Age (years), mean ± SD 30.9 ± 9.8 31.6 ± 10.2 0.62 BMI (kg/m²), mean ± SD 24.1 ± 3.6 24.6 ± 3.9 0.35 ASA I / II / III, n 52 / 41 / 7 49 / 43 / 8 0.90 Diabetes mellitus, n (%) 14 (14%) 17 (17%) 0.70 Anaemia (Hb < 11 g/dL), n (%) 22 (22%) 25 (25%) 0.74 Elective surgery, n (%) 58 (58%) 55 (55%) 0.67 Emergency surgery, n (%) 42 (42%) 45 (45%) 0.67 Duration of surgery (min), mean ± SD 68.4 ± 22.5 70.1 ± 24.3 0.61 Independent t-test for continuous and Chi-square test for categorical variables; p > 0.05 indicates comparable groups. Table 2: Distribution of surgical procedures Type of surgery Group A (n = 100) Group B (n = 100) Total Obstetric: lower segment caesarean section 50 50 100 General: open cholecystectomy 14 13 27 General: midline laparotomy (perforation repair / resection) 16 17 33 General: appendicectomy (open) 9 10 19 General: ventral / incisional hernia repair 11 10 21 Total 100 100 200 Chi-square test for distribution of general surgical procedures, p = 0.96. 3.2 Recovery parameters By design, patients in Group A were mobilised significantly earlier. Mean time to first ambulation was 14.6 ± 4.2 hours in Group A compared with 38.5 ± 9.8 hours in Group B (p < 0.001). Group A also showed earlier return of bowel function, earlier oral intake and earlier catheter removal (Table 3). Pain scores at 24 and 48 hours were lower in the early mobilisation group (Table 4). No patient in Group A had to discontinue the protocol because of a mobilisation-related adverse event such as syncope, fall, wound dehiscence or haemodynamic instability. Table 3: Postoperative recovery parameters (hours, mean ± SD) Parameter Group A (n = 100) Group B (n = 100) p-value Time to first ambulation 14.6 ± 4.2 38.5 ± 9.8 < 0.001 Time to first flatus 22.4 ± 6.1 34.8 ± 8.7 < 0.001 Time to first oral intake 10.2 ± 3.5 17.6 ± 5.4 < 0.001 Duration of urinary catheterisation 14.8 ± 4.0 26.2 ± 6.3 < 0.001 Independent (Welch) t-test. Table 4: Postoperative pain scores (VAS 0–10, mean ± SD) Time point Group A (n = 100) Group B (n = 100) p-value 24 hours after surgery 5.1 ± 1.3 5.9 ± 1.4 < 0.001 48 hours after surgery 3.2 ± 1.1 4.3 ± 1.3 < 0.001 Independent (Welch) t-test. 3.3 Postoperative complications At least one postoperative complication was observed in 18 patients (18%) in Group A and 38 patients (38%) in Group B, a relative risk of 0.47 (p = 0.002). Individually, paralytic ileus and pulmonary complications were significantly less frequent in Group A (Table 5, Figure 1). Surgical site infection, urinary tract infection and DVT were numerically lower in the early mobilisation group but the differences did not reach statistical significance, which is likely to reflect the limited number of events. Table 5: Postoperative complications in the two groups (n = 100 each) Complication Group A n (%) Group B n (%) RR p-value Test Paralytic ileus 6 (6%) 15 (15%) 0.40 0.038 Chi-square Pulmonary complications 4 (4%) 12 (12%) 0.33 0.037 Chi-square Surgical site infection 7 (7%) 13 (13%) 0.54 0.157 Chi-square Urinary tract infection 3 (3%) 9 (9%) 0.33 0.074 Chi-square Deep vein thrombosis 1 (1%) 5 (5%) 0.20 0.211 Fisher Patients with ≥ 1 complication 18 (18%) 38 (38%) 0.47 0.002 Chi-square Some patients had more than one complication; total events were 21 (Group A) and 54 (Group B). RR = relative risk (Group A vs Group B). 3.4 Subgroup analysis: obstetric versus general surgical patients The benefit of early mobilisation was seen in both surgical populations. In obstetric patients, 7 of 50 (14%) in Group A and 17 of 50 (34%) in Group B developed at least one complication (p = 0.019). In general surgical patients the corresponding figures were 11 of 50 (22%) and 21 of 50 (42%) (p = 0.032). The distribution of individual complications is shown in Table 6. General surgical patients had a higher absolute complication rate than obstetric patients in both groups, reflecting greater physiological stress, more extensive bowel handling and longer operating time. Table 6: Complications by type of surgery (number of events) Complication Ob. A (n=50) Ob. B (n=50) GS A (n=50) GS B (n=50) Total events Paralytic ileus 1 4 5 11 21 Pulmonary complications 1 3 3 9 16 Surgical site infection 4 7 3 6 20 Urinary tract infection 2 5 1 4 12 Deep vein thrombosis 0 1 1 4 6 Patients with ≥ 1 complication 7 (14%) 17 (34%) 11 (22%) 21 (42%) 56 p-value (A vs B within specialty) 0.019 0.032 Ob. = obstetric (caesarean section); GS = general surgery; A = early mobilisation; B = conventional mobilisation. 3.5 Severity of complications (Clavien–Dindo grade) Complications in the early mobilisation group were also less severe (Table 7). Among patients with complications, no patient in Group A required re-operation (grade IIIb), whereas two patients in Group B required re-exploration, one for wound dehiscence with burst abdomen and one for adhesive intestinal obstruction. There were no grade IV or V events (organ failure or death) in either group. Table 7: Highest Clavien–Dindo grade per patient with a complication Grade Group A (n = 18) Group B (n = 38) Management Grade I 9 15 Bedside / no drug change Grade II 7 17 Pharmacological (antibiotics etc.) Grade IIIa 2 4 Intervention without GA Grade IIIb 0 2 Intervention under GA Grade IV–V 0 0 — Grades I–II (minor): 16 (88.9%) vs 32 (84.2%); grades III and above: 2 (11.1%) vs 6 (15.8%). 3.6 Length of hospital stay and readmission Early mobilisation was associated with a significantly shorter hospital stay overall (5.0 ± 1.9 vs 6.8 ± 2.5 days; p < 0.001), a mean reduction of 1.8 days (about 26%). The reduction was seen in obstetric patients (3.8 ± 0.9 vs 5.1 ± 1.2 days) and in general surgical patients (6.2 ± 1.8 vs 8.4 ± 2.3 days), as shown in Table 8 and Figure 2. Time to first ambulation showed a moderate positive correlation with LOS (r = 0.58, p < 0.001), meaning that the later a patient was mobilised, the longer the stay. Thirty-day readmission occurred in 3 patients (3%) in Group A and 7 patients (7%) in Group B (p = 0.33). Table 8: Length of hospital stay (days, mean ± SD) Population Group A Group B Diff. p-value Obstetric (n = 50 per group) 3.8 ± 0.9 5.1 ± 1.2 1.3 < 0.001 General surgery (n = 50 per group) 6.2 ± 1.8 8.4 ± 2.3 2.2 < 0.001 Overall (n = 100 per group) 5.0 ± 1.9 6.8 ± 2.5 1.8 < 0.001 30-day readmission, n (%) 3 (3%) 7 (7%) — 0.33 Independent (Welch) t-test; readmission compared by Fisher’s exact test

In this comparative study of 200 obstetric and general surgical patients, early mobilisation was associated with a significantly lower overall complication rate (18% vs 38%), a lower severity of complications and a shorter hospital stay by almost two days. The benefit was consistent across both surgical populations and was achieved without any mobilisation-related adverse event, supporting the view that early mobilisation is safe and practical when supervised and adequately supported by analgesia. Patients mobilised early passed flatus, accepted oral feeds and had their urinary catheters removed sooner than those in the conventional group. This finding is physiologically plausible. Upright posture and walking improve diaphragmatic excursion, stimulate gut motility, enhance venous return and reduce insulin resistance, whereas recumbency has the opposite effect. Early mobilisation is a recognised component of the multimodal strategy to attenuate surgical stress and accelerate rehabilitation and its inclusion in ERAS pathways is based on this rationale. Our recovery results are in line with the ERAS recommendations for caesarean delivery and colorectal surgery, which advise early feeding, early catheter removal and mobilisation within hours of surgery. Lower pain scores in Group A at 24 and 48 hours were also observed. Although this may seem counter-intuitive, similar observations have been attributed to reduced ileus-related distension, better respiratory function and a greater sense of control and well-being in actively participating patients; the finding could also partly reflect observer expectation, since pain is a subjective measure. Pulmonary complications occurred in 4% of early-mobilised and 12% of conventionally managed patients. Postoperative atelectasis and pneumonia result from shallow breathing, reduced functional residual capacity, impaired mucociliary clearance and retained secretions, all of which are aggravated by prolonged supine positioning and pain [23]. Haines and colleagues observed that delayed mobilisation after major abdominal surgery was independently associated with postoperative pulmonary complications and the systematic review by Castelino et al. similarly pointed to a respiratory benefit of mobilisation protocols, while cautioning that trial quality was variable. Our results contribute prospective comparative data from an Indian tertiary hospital in support of this association. The significantly lower incidence of paralytic ileus in Group A (6% vs 15%) corresponds with earlier return of flatus. Gastrointestinal motility after laparotomy is determined by inflammatory, neurogenic and pharmacological factors, and walking, early enteral feeding and opioid-sparing analgesia are the most practical measures to shorten the duration of ileus. The ERAS Society guidelines specifically recommend mobilisation from the day of surgery for this reason. The effect was most evident among general surgical patients, in whom bowel handling is greater (5 vs 11 events), whereas the numbers in obstetric patients were small (1 vs 4 events). Deep vein thrombosis occurred in 1% of Group A and 5% of Group B patients; the difference was not statistically significant, probably because the study was not powered for this low-frequency event. Pregnancy and the puerperium are hypercoagulable states, and abdominal surgery adds further risk through venous stasis and endothelial injury. Early ambulation is generally considered an adjunct to, and not a replacement for, pharmacological and mechanical thromboprophylaxis [24]. All our patients received prophylaxis according to risk, and the trend towards fewer events in the early mobilisation group is consistent with the pathophysiological expectation but needs confirmation in larger studies. Surgical site infection (7% vs 13%) and UTI (3% vs 9%) were lower in Group A without reaching statistical significance. The lower UTI rate may be partly explained by earlier removal of the urinary catheter, a key modifiable risk factor for catheter-associated infection that is emphasised in national infection prevention and control guidance. Early mobilisation may influence SSI indirectly by improving tissue perfusion and oxygenation, supporting glycaemic control and enabling earlier discharge from an environment with a high burden of hospital-acquired and often multidrug-resistant organisms. In India, where antimicrobial resistance in hospitals is a major concern, any strategy that reduces infection and thereby antibiotic exposure assumes special importance, and national guidelines on the rational use of antimicrobials underline this [21]. Because SSI is influenced chiefly by perioperative antibiotic timing, wound class, surgical technique and asepsis, our finding should be interpreted cautiously. The relative reduction in complications was of similar magnitude in the two populations (RR 0.41 in obstetric and 0.52 in general surgical patients), but the absolute baseline risk and the absolute reduction in length of stay were greater in general surgery (2.2 days) than in caesarean section (1.3 days). This is expected because caesarean section is usually performed in young, otherwise healthy women under neuraxial anaesthesia, with minimal bowel handling, and has a shorter natural recovery trajectory, whereas general surgical patients are older, have more comorbidity and often undergo emergency surgery for peritoneal sepsis or obstruction. Early mobilisation after caesarean delivery also has additional benefits that were not measured in this study, such as earlier and more successful initiation of breastfeeding, improved mother–infant bonding and greater maternal satisfaction, which are cited as justification for the ERAS recommendations in obstetrics. In the Indian context, where the caesarean rate continues to rise even a modest reduction in the postpartum stay represents a substantial saving in bed days. The mean reduction in hospital stay of 1.8 days (26%) is clinically and economically meaningful. Previous reviews of inpatient mobilisation reported shorter stay and fewer complications with structured mobilisation programmes and our figures are broadly comparable with those reported for ERAS pathways. In public-sector teaching hospitals in India, bed occupancy is frequently above 100%, and a shorter stay would free beds for waiting patients, reduce nosocomial exposure and decrease catastrophic out-of-pocket expenditure for patients and their families. The positive correlation between time to first ambulation and length of stay (r = 0.58) further supports a dose–response relationship, in which each additional hour of bed rest is associated with a longer stay. Because early mobilisation requires no equipment and only modest staff training, it is particularly attractive for resource-limited settings. Notably, it can be implemented even where full ERAS pathways, which require multidisciplinary coordination, are not yet in place. Strengths and limitations The main strengths of this study are its prospective design, inclusion of two distinct surgical populations in the same institution, standardised definitions of outcomes, use of the Clavien–Dindo classification, uniform discharge criteria, and complete 30-day follow-up. The limitations should also be acknowledged. First, allocation was not randomised and was based on the postoperative care pathway of the unit, so that selection bias and unmeasured confounding cannot be excluded, although baseline characteristics were comparable. Second, blinding of the clinicians and patients was not possible, which may have influenced subjective outcomes such as pain scores and the timing of discharge. Third, the study was conducted in a single centre and was not powered to detect differences in individual low-frequency complications such as DVT, SSI and UTI. Fourth, other elements of enhanced recovery (early feeding and early catheter removal) were encouraged in Group A and may have contributed to the observed benefit, so the effect cannot be attributed to ambulation alone. Finally, the study did not evaluate patient-reported outcomes, cost, or the level of physical activity achieved after discharge.

Early mobilisation after obstetric and general abdominal surgery was safe, feasible and associated with faster return of bowel function, lower pain scores, fewer and less severe postoperative complications (particularly paralytic ileus and pulmonary complications) and a significantly shorter hospital stay. The benefit was demonstrated in both caesarean section and general surgical patients. Early mobilisation is a simple, inexpensive and effective measure that should be incorporated into routine postoperative care in tertiary care teaching hospitals. Larger randomised multicentre studies are warranted to confirm these findings.

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