Short hospitalization after caesarean delivery: effects on maternal pain and stress at discharge

Association of Caesarean delivery and breastfeeding difficulties during the delivery hospitalization: a community-based cohort of women and full-term infants in Alberta, Canada

OBJECTIVE

Breastfeeding difficulties are the most common reason for breastfeeding cessation, particularly in the early postpartum. Caesarean delivery is associated with earlier breastfeeding cessation than is the case with vaginal delivery, but differences in breastfeeding difficulties by mode of delivery have not been thoroughly examined. Our objective was to explore the association between Caesarean delivery and types of breastfeeding difficulties.

METHODS

We conducted a secondary analysis of data from a prospective cohort study of mothers who delivered full-term, singleton infants in Calgary, Alberta, Canada (N = 418). Women completed self-report questionnaires during the delivery hospitalization. Mode of delivery was defined as vaginal or Caesarean, and further classified as planned or unplanned Caesarean. Breastfeeding difficulties were measured using the Breastfeeding Experiences Scale and operationalized with binary variables for presence of various types of maternal (i.e. physical, supply, social) and infant (i.e. latch, behaviour/health) difficulties that were reported as moderate to unbearable. Multivariable logistic regression was used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs).

RESULTS

Overall, 37.1% of women had a Caesarean delivery and 80.9% experienced a breastfeeding difficulty during the delivery hospitalization. Of the difficulties studied, Caesarean delivery was significantly associated with low milk supply (AOR = 1.62, 95% CI = 1.16-2.28) and infant behaviour/health difficulties (AOR = 1.33, 95% CI = 1.01-1.75). The association with low milk supply persisted when examining both planned (AOR = 2.42, 95% CI = 1.19-4.92) and unplanned (AOR = 2.21, 95% CI = 1.16-4.22) Caesarean deliveries.

CONCLUSION

Mothers who deliver by Caesarean have higher odds of reporting low milk supply and infant behaviour/health difficulties than women who deliver vaginally.

A systematic review of patient-reported outcome measures to assess postpartum pain using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines

BACKGROUND

We performed a systematic review using Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines to identify the best available patient-reported outcome measure (PROM) of postpartum pain.

METHODS

This review follows COSMIN guidelines. We searched four databases with no date limiters, for previously identified validated PROMs used to assess postpartum pain. PROMs evaluating more than one author-defined domain of postpartum pain were assessed. We sought studies evaluating psychometric properties. An overall rating was then assigned based upon COSMIN analysis, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the level of evidence for psychometric properties of included PROMs. These assessments were used to make recommendations and identify the best PROM to assess postpartum pain.

RESULTS

We identified 19 studies using seven PROMs (involving 3511 women), which evaluated postpartum pain. All included studies evaluated ≥1 psychometric property of the included PROMs. An adequate number of pain domains was assessed by the Brief Pain Inventory (BPI), Short Form-BPI (SF-BPI), and McGill Pain Questionnaire (MPQ). The SF-BPI was the only PROM to demonstrate adequate content validity and at least a low-level of evidence for sufficient internal consistency, resulting in a Class A recommendation (the best performing instrument, recommended for use).

CONCLUSION

SF-BPI is the best currently available PROM to assess postpartum pain. However, it fails to assess several important domains and only just met the criteria for a Class A recommendation. Future studies are warranted to develop, evaluate, and implement a new PROM designed to specifically assess postpartum pain.

Reduced length of hospital stay after caesarean section: A systematic review examining women's experiences and psychosocial outcomes

BACKGROUND

Globally, reducing hospital stays after caesarean section is becoming more prevalent. Whilst this reduction in length of stay after caesarean section has not been found to be associated with adverse maternal health outcomes, the psychosocial impact and women's experiences have not been systematically reviewed. This review aims to evaluate the literature on women's experiences and psychosocial outcomes (including infant feeding) associated with a reduced hospital stay after caesarean section.

METHODS

A mixed methods systematic review examining records between 1980 and 2019 was undertaken. The review included research which defines a reduced length of stay in comparison with standard care or a comparator with a longer discharge time. It considered data related to the antenatal period, time of discharge and postnatal period. The following databases were searched: PsycINFO, CINAHL, PubMed, Embase and ProQuest Dissertations and Theses. 13,760 records were identified, after duplicates were removed, 10,902 articles were reviewed for suitability by title and abstract. 78 full text articles were assessed, and the final review included 8 articles.

RESULTS

A total of 8 articles were included, and four areas were examined: satisfaction with care, mental wellbeing, infant feeding and pain. Articles were of mixed quality when assessed using the Mixed Methods Appraisal Tool.

CONCLUSIONS

This review indicated no evidence of a systematic negative impact on women's psychosocial outcomes and experiences. The review also identifies a number of characteristics of care associated with more positive experiences and psychosocial outcomes. These include the provision of support systems, access to pain management before and after discharge and continued care with home midwifery. The limited number of studies point to the need for more research, and especially those using qualitative methods.

Pain and stress after vaginal delivery: characteristics at hospital discharge and associations with parity

The objective of this study was to characterise pre-discharge maternal pain and stress severity after vaginal delivery and associations with parity. This is a descriptive analysis with 148 women in the early post-partum period (84 primiparae and 64 secondiparae) after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Psychological Stress Measure (PSM). Vaginal delivery in primiparae women was associated with MGPQ, significantly higher pain scores. Sensorial, affective and mixed pain descriptive categories were also significantly higher. Pain location involved lower abdomen, vagina and perianal area. In addition, their PSM showed a significantly higher 'Sense of effort and confusion' subscale scores. In conclusion, this study provides important information on the quality of care implications of hospital-to-home discharge practices in puerperae after vaginal delivery, a critical time characterised by qualitatively and quantitatively high pain and stress in primiparae.Impact statementWhat is already known on this subject? Pain and fatigue are the most common problems reported by women in the early postpartum period.What the results of this study add? Primiparae who delivered vaginally presented at the time of hospital-to-home discharge significantly higher pain and stress, as compared to secondiparae. Pain involved lower abdomen, vagina and perianal area, whereas the stress was quantitatively higher in the 'sense of effort and confusion'.What the implications are of these findings for clinical practice and/or further research? Awareness of problematic pain and stress associations with parity may offer the opportunity to better support puerperae to develop maternal orientation and adjust to motherhood.

Parents' experiences of early discharge after a planned caesarean section: A qualitative interpretive study

OBJECTIVE

The birth rate in Denmark is increasing, and the rate of births by caesarean section has increased to more than 20%. Thus, the obstetric departments have been put under pressure to identify new solutions to optimize the maternity care system, in which early discharge might be considered. The aim of this study was to explore parents' experiences of the postnatal care after planned caesarean section with focus on factors that support or hinder early discharge.

DESIGN

An interpretive, hermeneutic approach was chosen, using qualitative interviews with multiparous women and their partners. Data analysis was performed using thematic analysis.

PARTICIPANTS AND SETTING

Twelve women and partners were recruited from two hospital-based maternity units in Denmark. The inclusion criteria were low-risk Danish-speaking multiparous women having a planned caesarean section with a singleton pregnancy (gestational age between 37+0 and 41+6 weeks). Seven sets of parents were discharged before 28 h and five were discharged after 48 h.

FINDINGS

Three main themes were identified as important for timing of discharge: (1) Setting for recovery (2) Views on length of stay, and (3) Preparation and individual planning. All parents valued the safe and supportive environment at the hospital, but several preferred early discharge as they felt more comfortable in their home environment and wanted to be together as a family with all siblings. When considering appropriate time of discharge, the main issues were that pain was manageable, that breastfeeding was initiated successfully and that professional support was available after discharge. Finally, early discharge required preparation and planning and the parents stressed the importance of knowing that they would not be discharged unless they felt ready.

CONCLUSION AND IMPLICATION FOR PRACTICE

A clear link was observed between the care package the parents received and their views on the optimal time of discharge. Based on our findings it seems likely that a significant proportion of parents will accept and feel confident about early discharge if individual circumstances are taken into account in the antenatal planning of a caesarean section.