Women's experiences of intrapartum care and recovery in relation to planned caesarean sections: An interview study

Morbidity of Repeat Cesarean Delivery after a Trial of Labor as Compared with Elective Repeat Cesarean Delivery

OBJECTIVE

 This study aimed to evaluate if a secondary repeat cesarean after a trial of labor (TOLAC) without uterine rupture is associated with increased morbidity as compared with a scheduled elective repeat cesarean delivery (ERCD).

STUDY DESIGN

 This was a retrospective cohort study of repeat cesarean delivery (CD) in a single obstetrical practice between 2005 and 2022. Patients were included if they had a singleton pregnancy at term with one prior CD and had a repeat CD this pregnancy resulting in live birth. Patients were excluded if they had a prior myomectomy, more than one prior CD, uterine rupture in a prior or current pregnancy, or placenta previa in this pregnancy. We compared baseline characteristics and outcomes between patients who had a repeat cesarean after TOLAC and ERCD. The primary outcome was a composite of maternal morbidity that included hysterectomy, blood transfusion, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, or maternal mortality.

RESULTS

 A total of 930 women met inclusion criteria. A total of 176 (18.9%) patients intended to labor and 754 (81.1%) planned an ERCD. There was no difference in the primary outcome between patients with a repeat cesarean after TOLAC compared with patients with ERCD (2.8 vs. 1.2%, p = 0.158). Patients with repeat cesarean after labor had significantly more 1-minute Apgar scores less than 7, but no difference in 5-minute Apgar scores. We were powered to detect a difference in the primary outcome from 1.2% in the ERCD group to 3.3% in the repeat cesarean after labor group. Results did not differ when we analyzed patients who intended to TOLAC versus patients who actually labored prior CD.

CONCLUSION

 For women with one prior CD the morbidity of repeat cesarean after labor is not more than the morbidity of planned repeat CD. Our study can be helpful in delivery planning counseling for patients with one prior CD.

KEY POINTS

· Uterine rupture is a known risk of TOLAC.. · This study aimed to understand morbidity associated with labor.. · No added morbidity of repeat cesarean after labor is inferred in this study..

The role of expectations, subjective experience, and pain in the recovery from an elective and emergency caesarean section: A structural equation model

BACKGROUND

Rapid return to mobilisation and daily function is essential for recovery after an elective and emergency caesarean section, prevention of short- and long-term complications, and mothers' well-being. High pain levels may delay recovery. Considering the biopsychosocial model, recovery is additionally complex and comprises social and psychological aspects.

OBJECTIVE

This study examined the relationships between preoperative expectations, perioperative subjective experience, postoperative pain levels, and postoperative interruption of functioning and recovery.

METHODS

Overall, 306 women completed a set of questionnaires on the fourth day after a caesarean section regarding their demographic information, levels of expectation matching the caesarean section and the perioperative subjective experience, and the pain levels and interruption to daily activities 24 hours postpartum.

RESULTS

Using a structural equation model, a gap between preoperative expectations and perioperative experience related to a poorer perioperative subjective experience was found. This was associated with higher postoperative pain levels that were directly and indirectly related to the interruption of various functions and activities during the initial 24 hours postpartum. The model explained 58% of the variance in postpartum functioning and had good goodness-of-fit (χ2 = 242.74, df = 112, χ2/df = 2.17, NFI = 0.93, CFI = 0.96, TLI = 0.94, RMSEA = 0.06). Additionally, pain levels were higher and daily activities were more severely impaired for women who had undergone emergency caesarean section compared to those who had undergone elective caesarean section.

CONCLUSION

The need for preoperative preparation and setting expectations, perioperative emotional support, continuous communication with the mother, and an efficient postoperative pain management was highlighted.

Using a scheduled caesarean birth plan: A cross-sectional exploration of women's perspectives

PROBLEM

There is minimal evidence regarding the role or impact of birth plans from the perspective of women experiencing scheduled caesarean birth.

BACKGROUND

Quality maternity care requires respect for women's preferences. Evidence suggests birth plans enable communication of women's preferences and may enhance agency when vaginal birth is intended, however there is limited evidence of how this translates in the perioperative environment where caesarean birth is the intended outcome.

AIM

Explore the experiences and perspectives of women who had utilised a scheduled caesarean birth plan at an Australian tertiary maternity hospital.

METHODS

A cross-sectional design was used; 294 participants completed the survey within two weeks post-birth. Descriptive statistics were used to analyse quantitative data, qualitative responses were analysed using content analysis.

FINDINGS

Over half of the women requested lowering of the surgical-screen at birth, most requested immediate skin-to-skin with their babies; around two-thirds of these preferences were met. Use of a birth plan for scheduled caesarean section supported women's ability to communicate their desires and choices, enhancing agency and reinforcing the significance of the caesarean birth experience. Qualitative data revealed two main categories: Perceptions and experiences; and Recommendations for improvement, with corresponding sub-categories.

DISCUSSION

Findings provide unique opportunities to consider the provision of woman-centred care within the highly technocratic perioperative environment.

CONCLUSION

All women, regardless of birth mode, have a right to respectful maternity care that prioritises their wishes and agency. This study provides evidence for the positive utility of birth plans in caesarean birth, local adaptation is encouraged.

Assessment of mental health issues in pregnant women with fetal complications: Relation to attachment and anxiety

PURPOSE

Pregnancy period is important for all women. The aim of this study was to evaluate mental status, antenatal depression, attachment, and anxiety in pregnant women with fetal complications.

DESIGN AND METHODS

Mothers who had been diagnosed with fetal complications during pregnancy were interviewed after the delivery of their babies.

FINDINGS

The results showed that anxiety and depression scores were significantly higher in the mothers who had received psychiatric support treatment. Maternal attachment scores were found low, depression scores were found high in mothers of children with congenital anomalies.

CONCLUSION

According to the results of the study, a maternal attachment was low and depression was high in mothers with congenital anomalies.

PRACTICE IMPLICATIONS

Possible psychological problems after birth can be prevented by psychotherapeutic nursing interventions during pregnancy to pregnant women who have babies with fetal anomalies.

Effectiveness of Acupuncture for Pain Control After Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

A pharmacological approach to pain control after cesarean delivery is often insufficient on its own. Acupuncture is a promising method for mitigating postoperative pain and reducing postoperative opioid requirements.

OBJECTIVE

To evaluate the efficacy and effectiveness of acupuncture as an adjunctive therapy for pain control after cesarean delivery, compared with a placebo intervention and standard care alone.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, placebo-controlled, patient- and assessor-blinded randomized clinical trial was conducted from January 13, 2015, to June 27, 2018, at a tertiary university hospital in Greifswald, Germany. Participants were women who were scheduled for elective cesarean delivery under spinal anesthesia and were randomized to either the acupuncture group (n = 60) or placebo group (n = 60). Another 60 consecutive patients who met the eligibility criteria and received the standard postoperative analgesia were selected to form a nonrandomized standard care group. The intention-to-treat analysis was performed from August 19, 2019, to September 13, 2019.

INTERVENTIONS

In addition to standard pain treatment, each patient in the acupuncture group received auricular and body acupuncture with indwelling intradermal needles, whereas patients in the placebo group were treated with nonpenetrating placebo needles.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain intensity on movement, which was measured using an 11-item verbal rating scale. Secondary outcomes were analgesia-related adverse effects, analgesics consumption, time to mobilization and Foley catheter removal, quality of patient blinding to randomization, and patient satisfaction with treatment of pain.

RESULTS

A total of 180 female patients (mean [SD] age, 31 [5] years) were included in the intention-to-treat analysis. The mean pain intensity on movement in the acupuncture group on the first postoperative day was lower than in the placebo group (4.7 [1.8] vs 6.0 [2.0] points; Cohen d, 0.73; 95% CI, 0.31-1.01; P = .001) and the standard care group (6.3 [1.3] points; Cohen d, 1.01; 95% CI, 0.63-1.40; P < .001). On the first postoperative day, 59 patients (98%) in the acupuncture group were fully mobilized vs 49 patients (83%) in the placebo group (relative risk [RR], 1.18; 95% CI, 1.06-1.33; P = .01) and 35 patients (58%) in the standard care group (RR, 1.69; 95% CI, 1.36-2.09; P < .001). The Foley catheter was removed in a total of 57 patients (93%) from the acupuncture group vs 43 patients (72%) from the placebo group (RR, 1.33; 95% CI, 1.12-1.57; P = .003) and 42 patients (70%) from the standard care group (RR, 1.37; 95% CI, 1.14-1.62; P = .002). Other parameters were comparable across the 3 study groups.

CONCLUSIONS AND RELEVANCE

Results of this trial showed that acupuncture was safe and effective in reducing pain and accelerating mobilization of patients after cesarean delivery. With consideration for personnel and time expenditures, acupuncture can be recommended as routine, supplemental therapy for pain control in patients after elective cesarean delivery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02364167.