Short-term morbidity associated with cesarean delivery

Concordance between Women's Self-Reported Reasons for Cesarean Delivery and Hospital Discharge Records

BACKGROUND

Women's self-reports of whether they had a cesarean delivery are nearly 100% accurate, but there is little extant research on how accurately women self-report reasons for cesarean delivery when asked to recall this information in the postpartum period.

OBJECTIVE

We compared women's self-reported reasons for cesarean with their hospital discharge records and examined correlates of variability in agreement between sources.

METHODS

Data are from the First Baby Study, a cohort of 3,006 women who gave birth to their first baby between 2009 and 2011. Survey data were linked to hospital discharge records. Among women who delivered by cesarean (n = 846), we assessed the probability that women's self-reported reasons for cesarean delivery were confirmed by hospital discharge records (positive predictive value [PPV]), and whether agreement differed by reason for cesarean or by women's characteristics.

RESULTS

Overall, 91% of women reported a reason for their cesarean that was present in the discharge data. PPV varied by reason for cesarean, with high PPV for dystocia, macrosomia, and cephalopelvic disproportion (91.1%), and lower PPV for malposition (81.7%). In multivariable models, women with more education and higher family income had higher odds of concordance.

CONCLUSIONS

Despite some variation in the probability that women's self-reported reason for cesarean is supported by the hospital discharge record, more than 90% of women reported a reason that was found in their discharge record. Accurate recall of reasons for prior cesarean may help women and clinicians to manage future pregnancies.

Gum chewing and gastrointestinal function following caesarean delivery: a systematic review and meta-analysis

AIMS AND OBJECTIVES

The aims of this systematic review and meta-analysis were to summarise current knowledge regarding gum chewing intervention for activation of the gastrointestinal (GI) system following caesarean delivery.

BACKGROUND

GI symptoms such as nausea, vomiting and defecatory difficulties are bothersome for women following a caesarean delivery. There is category A recommendation to not withhold oral intake postoperatively. However, current practice guidelines vary widely on time to initiate oral feeding post caesarean delivery, and additional research is needed. Gum chewing has been shown to stimulate the GI system in other postoperative patient populations.

DESIGN

A systematic review and meta-analysis.

METHODS

An electronic review was undertaken using the following resources: PubMed (Medline), CINAHL, EMBASE and ClinicalTrials.gov databases. Key words used in various combinations included cesarean section; cesarean delivery; postoperative chewing gum; bowel movement; bowel function and complications.

RESULTS

A total of 171 articles were found of which 166 were excluded: 157 were duplicates and the remainder did not meet the inclusion criteria. Five randomised control trials were included in the meta-analysis, focusing on gum chewing as an intervention as compared with a nongum chewing intervention, with a total of 846 participants. Compared with the nongum chewing group, gum chewing showed a beneficial impact on the major outcomes of digestive system activation, including bowel sound, gas passage and defecation.

CONCLUSIONS

This meta-analysis supports the effectiveness of gum chewing post caesarean delivery as a noninvasive/nonpharmacological intervention for reactivation of bowel movement.

RELEVANCE TO CLINICAL PRACTICE

Gum chewing in the immediate postoperative period following caesarean delivery may provide a socially acceptable, low-cost and safe intervention to reduce postcaesarean delivery GI complications and restore GI function.

A randomised controlled study of non-closure of peritoneum at caesarean section in a Nigerian population

A prospective randomised study of 54 patients undergoing caesarean section was carried out to determine if non-closure of peritoneum at lower segment caesarean section has advantages over suture peritonisation with regard to postoperative morbidity. A total of 27 women were randomised to closure and 27 to non-closure of peritoneum. Management decisions were made without reference to treatment groups. Statistical analysis compared the outcome between the two groups. The results revealed that anaesthesia and operating times were significantly shorter in patients that had the peritoneum left open. The incidence of febrile morbidity, wound infection, duration of postoperative and duration of hospital stay were not significantly different in both groups ( p < 0.05). The study concludes that non-closure of peritoneum is associated with significantly reduced operation and anaesthesia time with a non-significant difference in immediate postoperative outcome. Non-closure of peritoneum should be adopted at caesarean delivery.

Randomised controlled trial of community debriefing following operative delivery

OBJECTIVE

The aim of this study was to determine if two debriefing sessions following an operative delivery could reduce a woman's fear of future childbirth.

DESIGN

Prospective randomised controlled trial (RCT) with two arms comparing debriefing, aimed to reduce fear of future childbirth, with standard care after birth.

SETTING

District General Hospital with 2500 deliveries per year.

SAMPLE

Three hundred and nineteen mothers who delivered a first child by operative delivery (i.e. forceps, vacuum or emergency caesarean section). The study took place at Huddersfield Royal Infirmary, from January 2002 to July 2003.

METHODS

Debriefing by community midwives specifically trained in postpartum debriefing at 10 days and 10 weeks.

MAIN OUTCOME MEASURE

Fear of childbirth was assessed using the Wijma Delivery Expectancy Scale (WDEQ). WDEQ scores were measured 10 days, 10 weeks and 20 weeks following delivery.

RESULTS

Fear of childbirth as measured by the WDEQ was lower throughout the study for the debriefing group. However, it never reached statistical significance in the short term [10 days debriefing = 94.5, control = 97.5 (P= 0.295), 10 weeks debriefing = 92.0, control = 97.9 (P= 0.076), 20 weeks debriefing = 90.9, control = 97.4 (P= 0.057)].

CONCLUSION

This study shows in the short term there was no significant difference in the WDEQ fear of childbirth scores. The debriefing group were showing a tendency for lower scores. Long term follow up of these cases may be more relevant.

Psychosocial outcomes of vaginal and cesarean births in Taiwanese primiparas

The purpose of this study was to examine differences in psychosocial outcomes between primiparas experiencing vaginal deliveries and primiparas experiencing cesarean deliveries. One hundred and ninety-four vaginal delivery primiparas and 81 cesarean delivery primiparas from the Kaohsiung city area in Taiwan were recruited at 6 weeks postpartum to participate in this study. Using two-sample t tests, we found no significant differences in perceived stress, self-esteem, or depression between vaginal and cesarean delivery primiparas. However, the cesarean delivery primiparas showed a significantly higher level of perceived social support than vaginal delivery primiparas. Types of cesarean (planned vs. unplanned) and types of anesthesia (general vs. epidural) were not significant factors influencing psychosocial outcomes for cesarean delivery primiparas. The lack of substantial differences between the groups may be a result of the normalizing effect of the high cesarean birthrate and greater social support given to this method of childbirth. Cultural concerns of offspring gender and choosing an auspicious time for delivery may also have ameliorative effects on the occurrence of psychosocial difficulties with a cesarean delivery in Taiwan.

Prevalence and persistence of health problems after childbirth: associations with parity and method of birth

BACKGROUND

Awareness about the extent of maternal physical and emotional health problems after childbirth is increasing, but few longitudinal studies examining their duration have been published. The aim of this study was to describe changes in the prevalence of maternal health problems in the 6 months after birth and their association with parity and method of birth.

METHODS

A population-based, cohort study was conducted in the Australian Capital Territory (ACT), Australia. The study population, comprising women who gave birth to a live baby from March to October 1997, completed 4 questionnaires on the fourth postpartum day, and at 8, 16, and 24 weeks postpartum. Outcome measures were self-reported health problems during each of the three 8-week postpartum periods up to 24 weeks.

RESULTS

A total of 1295 women participated, and 1193 (92) completed the study. Health problems showing resolution between 8 and 24 weeks postpartum were exhaustion/extreme tiredness (60-49), backache (53-45), bowel problems (37-17), lack of sleep/baby crying (30-15), hemorrhoids (30-13), perineal pain (22-4), excessive/prolonged bleeding (20-2), urinary incontinence (19-11), mastitis (15-3), and other urinary problems (5-3). No significant changes occurred in the prevalence of frequent headaches or migraines, sexual problems, or depression over the 6 months. Adjusting for method of birth, primiparas were more likely than multiparas to report perineal pain and sexual problems. Compared with unassisted vaginal births, women who had cesarean sections reported more exhaustion, lack of sleep, and bowel problems; reported less perineal pain and urinary incontinence in the first 8 weeks; and were more likely to be readmitted to hospital within 8 weeks of the birth. Women with forceps or vacuum extraction reported more perineal pain and sexual problems than those with unassisted vaginal births after adjusting for parity, perineal trauma, and length of labor.

CONCLUSIONS

Health problems commonly occurred after childbirth with some resolution over the 6 months postpartum. Some important differences in prevalence of health problems were evident when parity and method of birth were considered.

Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth

OBJECTIVE

To assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction.

DESIGN

Randomised controlled trial.

SETTING

Large maternity teaching hospital in Melbourne, Australia.

PARTICIPANTS

1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64).

MAIN OUTCOME MEASURES

Maternal depression (score >/=13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF-36 subscales) measured by postal questionnaire at six months postpartum.

RESULTS

917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1. 37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= -2.31, 95% confidence interval -10.48 to -0.84).

CONCLUSIONS

Midwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded.

An investigation of women's involvement in the decision to deliver by caesarean section

OBJECTIVE

To assess the degree and nature of women's involvement in the decision to deliver by caesarean section, and women's satisfaction with this involvement.

DESIGN

Observational study.

SETTING

The maternity unit in a large teaching hospital.

SAMPLE

One hundred and sixty-six women undergoing caesarean section.

METHODS

Interviews with the women on the third or fourth day postpartum, questionnaires sent to the women at 6 weeks and at 12 weeks postpartum, and extraction of information from the women's medical records.

MAIN OUTCOME MEASURES

Women's knowledge, satisfaction, and involvement in making the decision concerning their caesarean section.

RESULTS

The majority of the women were satisfied with the information they received during pregnancy on caesarean section and with their involvement in making the decision, but the proportions were significantly higher for elective than emergency sections. For 7% of the women, maternal preference for caesarean section was a direct factor in making the decision. Just over half of the 166 women reported that they were not debriefed on the reasons for their caesarean section before their discharge from hospital. Almost a third of the women undergoing emergency caesarean section expressed negative feelings towards their delivery, compared with 13% of those undergoing elective caesarean sections.

CONCLUSION

Women are not a homogeneous group in terms of their requirements for information, nor their desire to be involved in the decision on mode of delivery. Health professionals need to be responsive to this variability and to agree on standards for communicating with women during pregnancy about the possibility of operative delivery and for debriefing women after caesarean section.

Maternal recall and medical records: an examination of events during pregnancy, childbirth, and early infancy

It is not currently known whether sufficiently precise data on a previous pregnancy, labor and delivery, and early infancy can be obtained retrospectively. We conducted a telephone survey in 1991 of women who delivered babies between 1984 and 1986 at two teaching hospitals in Nashville, Tennessee, to assess how well mothers recall information on factors predictive of an adverse birth outcome. The survey yielded 102 usable responses that were compared with hospital records for mothers and infants. Overall, 89 percent agreement was found between women's responses and their charts. Respondents were not reluctant to answer potentially sensitive questions, and their technical knowledge was typically better for their own health than about some prenatal diagnostic procedures and their infants' health. We found no difference in recall accuracy according to whether mothers experienced some adversity with the index pregnancy. Accurate perinatal information can generally be obtained with a recall period as high as four to six years.