http://doi.org/10.33698/NRF0180 –  Harmanjyot kaur, Sukhjit kaur, Pooja sikka

Abstract: A mother who has been delivered by caesarean section has a dual role in both post-operative care as well as maternal care. Mothers undergoing Caesarean need more care and attention than mothers undergoing normal vaginal delivery. The current study was undertaken with the objective to assess the effect of early ambulation on post-operative recovery among post caesarean mothers. The Study design was quasi-experimental. Total 80 subjects were enrolled by total enumerative sampling technique, 40 in each experiment and control group. Subjects in experiment group were early ambulated at 6 hours of caesarean section covering a distance of 40 meters whereas control group was ambulated as per routine care i.e. after 13-14 hours of caesarean section. Post- operative recovery was assessed in both the groups by structured nursing assessment sheet including intensity of pain perceived by post caesarean mother before and after ambulation, use of analgesics after ambulation, duration of catheterization, self-void after removal of catheter, passage of first flatus, initiation of oral intake and breast-feeding and holding baby independently. Pain score was assessed with numerical pain rating scale. Results showed that there was significant difference between the mean post-operative pain score after ambulation among experimental and control group as shown by Independent t-test (p<0.05).Other aspects of Post-operative recovery were compared between experiment and control group by independent t-test. This difference was statistically significant in all the variables except duration of catheterization as per the independent t-test (p<0.05). So, it was concluded that early ambulation was effective in postoperative recovery among post caesarean mothers.

Keywords: Early ambulation, Post caesarean mother, Postoperative recovery.

Correspondence at: Sukhjit Kaur Clinical Instructor,National Institute of Nursing Education (NINE), PGIMER, Chandigarh

Introduction:The well being of societies linked to the health and survival of mothers and children. When mothers survive and thrive, their children survive and thrive as well and the societies in which they live prosper. The survival and well-being of mothers and children are not only important in their own self, but are also central to solving much broader economic, social and developmental challenges. Health of a women is not a merely a state of physical well being but also an expression of many roles they play as wives, mothers and health care providers in the family. 1Childbirth is viewed as an important life event. It is a natural, normal physiological phenomenon which introduces new experiences in a women’s reproductive life. The child birth events have a great physiological, emotional and social impact on a women and her family.2 She experiences stress, physiological pain and fear of dangers related to bleeding, operative procedures like caesarean section and possibility of loss of life. Mc Donald also pointed out that emotional factors might influence reproductive events, including obstetric complications such as eclampsia, prolonged labour and puerperal depression etc. The care giver should be tactful, sensitive, and respectful to her.3 Vaginal delivery of a full term normal pregnancy is a natural physiological process. In caesarean section the specific needs of the mother are much more than in the normal child birth. Caesarean section can be in the form of planned elective or an emergency procedure. Physical, physiological, psychological and socio cultural factors are the various kinds of stressors experienced by each woman who undergoes caesarean section.4 Caesarean section is an operation with many risks, less than a century ago. Today, it is one of the most frequently performed surgeries in the world. Caesarean births are more common than most surgeries due to many factors. One factor, of course, is that nearly 50% of the world population is women, and pregnancy is still a very common condition. 5 A Caesarean section is a surgical procedure in which incision is made through mother’s abdomen (laparotomy) and uterus (hysterectomy) to deliver one or more babies or, rarely, to remove a dead fetus. It is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk. 6 The Origin of the name is unclear, but believed to be named for Julius Caesar, because this surgical procedure was used at the time of his birth. It may have been so named because of law, enacted under Julius Caesar’s rule, which required this form of birth, when a mother was sick or dying.The incidence of caesarean section is steadily rising. However, rates between five percent to ten percent are best but during the last decade there has been two to three fold increase in these incidences from the initial rate of about 10%. The World Health Organization (WHO) recommends that caesarean sections rates should not go above 15% in any country.7 Absolute indications for caesarean section are post caesarean pregnancy, failure to progress in labour, malpresentations , ante partum hemorrhage , fetal distress, cephalopelvic disproportion, PIH and other high risk pregnancies and foetus.8.The post-operative course of a patient undergone Caesarean section may be described in terms of varying from uneventful to extreme distress. Some mothers experience Deep venous thrombosis, Pulmonary embolism, Urinary tract infection, Urinary retention, Chest infection, constipation and psychological problems in post-operative period. Symptoms such as fatigue, headache, lack of sleep, anaemia, urinary infection and other conditions needing treatment in the first 8 weeks after delivery are higher in women who delivered by caesarean section than those who underwent vaginal delivery.9 So by preventive and promotive post- operative care the women can be helped to avoid the post-operative problems and complications, which can help in early recovery. One of the important aspects of comprehensive post-operative care can be planned early ambulation. Planned early ambulation means that patients can be out of bed as early as possible based on type of surgery. Early ambulation after surgery as a newer concept raises medical interest and enthusiasm.10 The goal of this concept is to optimize the post-operative management of the patient in order to reduce morbidity, to enhance recovery of the patient after a surgical procedure, to reduce hospital stay and to reduce the costs. Thus studies have showed that ambulation plays a great role in early post-operative recovery among post- caesarean mothers

Objectives:To assess the effects of early ambulation on post-operative recovery among post caesarean mothers

Materials and Methods:A quasi experimental design was employed to study the effect of early ambulation on post-operative recovery among post caesarean mothers. Null hypothesis (H0) formulated was that: There was no effect of early ambulation on post- operative recovery among post caesarean mothers at 0.05 level of significance.The study was conducted in Labour room, Maternity and Gynae ward of Nehru Hospital, PGIMER, Chandigarh .Study subjects were selected from the mothers undergoing caesarean section in Labour Room. The study population was post caesarean mothers (18-40 years) with 32 weeks to 41weeks of gestational age and undergoing caesarean section with spinal anaesthesia during the month of July and August, 2013. The subjects were recruited by total enumerative sampling technique. Women were consecutively allotted into experiment (group I) and control (group II) groups by Block randomization i.e. women undergoing during caesarean section were allotted in experimental group and similarly women undergoing during caesarean section in control group. Each group had 40 patients after excluding high risk factors like caesarean section under general anaesthesia, mothers on magnesium sulphate therapy, mothers with cardiovascular problems. Data was collected after getting permission from head of the department of Obstetrics and Gynaecology and ethical Clearance from Institute ethical committee. The study was carried out in three steps: Development of procedure and tools, Intervention (early ambulation), and Assessment of postoperative recovery. Firstly, protocol was developed for providing early ambulation i.e. walking a distance of 40 meters at 6 hours of caesarean section. The tools for data collection were: Interview schedule which included identification date, Numerical pain rating scale, Structured nursing assessment sheet for assessing post-operative recovery in terms of use of analgesia after ambulation, duration of catheterization, self-void after removal of catheter, passage of first flatus, initiation of oral intake and breast-feeding and holding the baby independently .The tools and protocol were developed through review of relevant literature and validated by experts from field of nursing and department of Obstetrics and Gynaecology. After validation of tool pilot study was conducted in labour room of PGIMER, Chandigarh for assessing feasibility of the study. Results of the pilot study indicated that study was feasible.Study subjects were selected and after taking the written informed consent. They were explained about the purpose of the study and were told that data so collected will be kept confidential & will be used only for research purpose. They were given full autonomy to participate in the study. After recruiting the subjects for the study, socio- demographic details were collected.In experiment group after explaining, the subjects were ambulation early i.e. after 6 hours of caesarean section. Post-operative Pain score was assessed before and immediately after ambulating the mothers. Whereas Subjects of control group were assessed without intervention with normal routine care i.e. ambulation at 13-14 hours after caesarean section as usually practical in labour room. The subjects (experimental & control group) were kept under observation throughout the procedure and monitored for any discomfort. Interview schedule was used to collect the information related to caesarean section details and baby details. Subjects were assessed after the ambulation of caesarean section with the help of structured assessment sheet for intensity of post-operative pain, use of analgesics after ambulation, duration of catheterization, self- void after removal of catheter, passage of first flatus, initiation of oral intake and breast- feeding and holding baby independently soon after ambulation.The data was analyzed using descriptive and inferential statistics. Analysis was carried out with the help of statistical package for social sciences (SPSS-16) program. The findings were interpreted and presented with the help of tables and graphs.

Results:n the control group. In experimental group 45% subjects were matriculate and in control group 37.5%were graduate and above. Most of the subjects in both groups were not working i.e. 65% in experimental and 80% in control group. In experimental group 70% of subjects belonged to Hindu religion 52.5% in control group. Most of the subjects in both the groups had joint family i.e. 77.5% in experimental group and 70 % in control group. Both the groups were found to be homogenous in nature in terms of age, education, occupation, religion and type of family of the subjects as per chi-square test (p> 0.05).

Table 1: Distribution of subjects as per Socio Demographic variables

N=80

Variables Experiment group (n1=40)

f (%)

Control group (n2=40)

f (%)

X2

df

p value

Age category (in years)*
18-23 7(17.5) 9(22.5) 0.333
24-29

≥30

25(62.5)

8(20.0)

23(57.5)

8(20.0)

2

0.846

Education
Primary 5(12.5) 4(10.0) 6.74
Matric 18(45.0) 12(30.0) 3
10+2 12(30.0) 9(22.5) .081
Graduate and above 5(12.5) 15(37.5)
Occupation 2.257
Working 14(35.0) 8(20.0) 1
Not working 26(65.0) 32(80.0) 0.133
Type of family .581
Joint 31(77.5) 28(70.0) 1
Nuclear 9(22.5) 12(30.0) 0.446
Religion 4.38
Hindu 30(75.0) 21(52.5) 1
Sikh and others 10(25) 19(47.5) 0.136

 *Mean ± SD (Range) in experimental group = 26.7 ± 3.65 (20-35) years

*Mean ± SD (Range) in control group = 26.4 ± 3.90 (19 – 37) years

Period of gestation (POG), Parity of the subjects:Table 2 depicts that more than half of the subjects (60%) in experiment and half of control group were primiparous. In relation to period of gestation 45% in experiment were having gestation of 36+1 to 38 weeks and in control groups 37.5% were between 34+1 to 36 and 36+1 to 38 weeks. Both the groups were found to be homogenous in terms of parity and period of gestation as per chi square test (p > 0.05).

Table 2 : Period of gestation (POG) and parity of subjects   N=80

Variables Experiment group (n1=40)

f (%)

Control group (n2=40)

f (%)

X2

df

p value

Parity .80
Primiparous 24 ( 60.0) 20 ( 50.0) 1
Multiparous 16 ( 40.0 ) 20 ( 50.0) 0.36
Period of gestation (weeks)
32 – 34 3 (7.5) 7 (17.5) 2.0
34+1 – 36 15 (37.5) 15 (37.5) 2
>36+1 22 (55.0) 18 (45) 0.368

Mean ambulation time of subjects after caesarean section:Figure 1 reveals that mean ambulation time after caesarean section in experimental group was 6.00 ± 0.00 hours where as in control group it was 13.35 ± 2.38hours.

Figure 1: Mean ambulation time of subjects after caesarean section

Pain score before and after early ambulation after Caesarean Section among post-caesarean mothers in both groups.

Table 3 shows that in both the groups the post operative pain significantly reduced after ambulation. This was indicated as per Pair t test that in experimental group it was reduced from 6.5 ± 1.82 to 5.30 ± 1.34 where as in control group it was reduced from 7.25 ± 1.94 to 6.00 ± 1.31. But the reduction was more evident in experiment group which was further indicated by independent t test which shows that difference in pain score in both groups was not significant before ambulation but significant difference was observed after ambulation. Experimental group has significant less pain as compare to control group.

Table 3: Mean post-operativePain score before and after ambulation among post- caesarean mothers in both groups

N=80

Pain Scores (Numerical Pain Rating Scale) Experiment group (n1=40)

Mean ± SD (Range)

Control group (n2=40)

Mean ± SD (Range)

Independent t-test t-value df, p value
 

Before Ambulation

 

6.5 ± 1.825

(5-9)

 

7.25 ± 1.944

(6-9)

-1.778

78

0.07

 

After Ambulating

 

5.30 ± 1.34

(4-6)

 

6.00 ± 1.31

(5-7)

-2.106

78

0.038

Paired t test t-value,

df

p value

3.47

39

0.001

4.01

39

<0.001

Baseline data of the mothers in first 6 hours after Caesarean Section: Table 4 demonstrates the baseline data of the post caesarean mothers in first 6 hours after caesarean section. All the subjects in experiment group and control group had normal vitals sign. Nearly half of the subjects (47.5%) in experimental and 67.5% in control group had urine output >450 ml in first 6 hours. None of the subjects from experiment and control group moved out of the bed and none of than passed flatus. 32.5% subjects in experimental and 10% in control group initiated of breast feed after caesarean section.

Table 4: Baseline data of the mothers in first 6 hours after Caesarean Section

Variable Experimental N1=40

f (%)

Control n2=40

f(%)

Vital

Normal

 

40 (100)

 

40 (100)

Total Urine Output

150-300 ml

301-450 ml

> 450 ml

 

7 (17.5)

14 (35.0)

19 (47.5)

 

7 (17.5)

6 (15.0)

27 (67.5)

Moved out of bed Nil Nil
Passed flatus Nil Nil
Initiation of breastfeeding after caesarean section 13 (32.5) 4 (10)

Post-operative recovery after ambulation among post-caesarean mothers in both groups:The data in Table 5 reveals that the higher percentage of subjects in control group (70%) required more number of analgesics i.e. 2-3 injection than experiment group (27.5%). Duration of catheterization was same in both experiment group (45%) and control group (37.5%) in 19-24 hours. Nearly half of subjects (45%) in experiment group self-voided within 1 hour after removal of catheter while only 20% in control group. In experiment group 57.5%subjects initiated breast feeding at 6 hours whereas in control group it was only 15%. 80% subjects in experimental group had given breastfeeding and hold the baby independently at 6 hourly and started oral intake after one hour of ambulation and 62.5% passed first flatus within one hour of ambulation as compare to control group it was 10% only. These differences were statistically significant as per Chi-square test (p<0.05).

Table 5 : Post-operative recovery among post-caesarean mothers in both groups

Variables Experiment group (n1=40)

f (%)

Control group (n2=40)

f (%)

X2

df

p value

Number of analgesic required after ambulation

nil-1 injection 2-3 injection

 

29 ( 72.5)

11 ( 27.5)

 

12 (30)

28 (70)

14.45

1

<0.001

Duration of catheterization after caesarean section  

4 (10.0)

15 (37.5)

18 (45.0)

3 (7.5)

 

6 (15)

16 (40)

15 (37.5)

3 (7.5)

6-12 hours

13-18 hours

19-24 hours

25 – 30 hours

3.17

3

0.36

Self-void after removal of catheter  

18 (45)

18 (45)

4 (10)

 

8 (20)

17 (42.5)

15 (37.5)

 

10.24

2

0.006

<1 hour

1-2 hour

>2 hour

Initiation of breast-feedafter caesarean section

At 6 hour

>6 hour

*N1= 27

23(57.5)

4 (10)

*N2 = 36

6(15)

30 (75)

3.53

1

<0.001

Breast feeding and Holding baby independently after caesarean section  

18.33

At  6 hour 32 (80) 13 (32.5) 1
>6 hour 8 (20) 27 (67.5) <0.001
Start of oral intake after ambulation

Within  1 hour

After 1 hour

 

32 (80)

8 (20)

 

7 (17.5)

33 (82.5)

31.27

1

<0.001

First flatus passed after ambulation

Within  1 hour

After 1 hour

 

25 (62.5)

15 (37.5)

 

4(10)

36(90)

23.85

1

<0.001

*Subjects excluded who breast feed in first 6 hours of caesarean section

Impact of early ambulation on post- operative recovery among post-caesarean mothers shows the comparison of variables assessing the post-operative recovery among post-caesarean mothers between experimental and control group. The difference in duration of post-operative recovery variables among experiment and control groups was statistically significant as per Independent t-test(p <0.05).Table 6: Impact of early ambulation on post-operative recovery among post-caesarean mothers

Variables Experimental group (N1= 40)

Mean Duration in hours ± SD

Control group (N2= 40)

Mean Duration in hours ± SD

t-value df

p value

Duration of catheterization after caesarean section  

19.37 ± 4.60

 

19.85 ± 5.47

1.34

78

0.18

Self-voided after catheter removal  

1.65 ± 0.66

 

2.25 ± 0.86

-3.47

78

<0.001

Start of oral intake after caesarean section  

6.20 ± 0.83

 

8.92 ± 2.65

-6.13

78

<0.001

Breastfeed and Holding the baby independently  

6.42 ± 1.69

 

13.27 ± 2.39

-14.76

78

<0.001

First Flatus passed after caesarean section  

6.77 ± 1.09

 

12.02 ± 4.46

-7.72

78

<0.001

 

 

Discussion

Caesarean section is a method of delivering baby through an incision made in the mother’s lower abdomen wall and uterus instead of delivering through vagina. Post caesarean mothers require special care and it is quiet challenging to make this special care available to them. A little care given to post- operative phase will confirm the post- operative period to be healthy and safe. Early ambulation is a key factor in

helping the patient to re-establish the normal physiology and preventing or minimizing post-operative complications after the caesarean section. Ambulation hastens muscle redevelopment and wound healing.Post caesarean mother should be encouraged to get up and try to go to the bathroom after the effect of regional anaesthesia gone off.11

Studies have shown that ambulation at 4-6 hours after caesarean section is recommended in some hospitals. In present study the subjects in experiment group were ambulated at 6 hours of caesarean section by means of walking a distance of 40 meters where as subjects in control group ambulated at 13-14 hours after caesarean section which was normal practiced in the labour room. A number of studies on caesareans have reported increased risk of maternal morbidities such as; hysterectomy, haemorrhage, infection, thrombosis and postpartum depression. UK obstetric anaesthesia guidelines suggest that the post- operative care of a caesarean patient should be in accordance with the care of any post- operative patient as laid out in guidelines for suture pain score of caesarean section mothers in control group was higher than experimental group which indicated that early ambulation has a positive effect on reduction of post-operative pain.13In relation to comparison of post- operative recovery after ambulation among post-caesarean mothers between both groups depicts that higher percentage subjects in experiment group self- voided within 1 hour after removal of catheter as compare to control group. This result was in accordance with a prospective randomized study which revealed that early removal of urinary catheter after a caesarean section offers more advantages to the patient in terms of first-void discomfort, time of first post anaesthetic recovery.12 Early catheter spontaneous void and time of ambulation.removal, early onset of peristalsis movement, early feeding after caesarean section and other supportive treatment such as ambulation and privacy can enhance the likelihood of post-operative recovery.Hence in present study the post operative recovery was considered in terms of the intensity of post-operative pain perceived by post caesarean mother, use of analgesics after ambulation, duration of catheterization, self void after removal of catheter, passage of first flatus, initiation of oral intake and breast-feeding and holding baby independently.The findings of the present study revealed that mean post-operative pain score after ambulation was reduced significantly in experiment group as compared to mean pain score in control group. These findings were accordance to the study conducted by Chaudhary S which concluded that the mean Ambulation time in 4-hour catheterized group was 13.15 hours and 25.46 in the 24- hour catheterized group which was statistically significant14  Present study also showed that maximum subjects in experimental group started oral intake at much earlier time as compare to control group. The finding was supported by randomized controlled trail by Adupa D et al in which he compared the early feeding group v/s routine feeding group in post caesarean mothers. The findings significantly indicated that women in the early feeding group got out of mobilization earlier, had more rapid return of their bowel function (p = 0.001) than the control group15.The finding of the present study depict that maximum subjects in experiment group initiated breast feeding at 6 hours as compare to control group. This finding was similar to that of study done by Harper J on Keeping mothers and newborns together after caesarean section and early ambulating has got several benefits, including the promotion of maternal-infant bonding and breastfeeding, which are essential components of care. Results have shown that women who delivered by caesarean recovered with their infants at faster rate if they are early ambulated.16 The finding of the present study also showed that there was significant difference between the post-operative recovery among experimental and control group. The finding of the present study were in accordance to the study of Dube J V et.al on effect of planned early ambulation on Selected Postnatal Activities of Post caesarean Patients concluded that there was significant difference in the activities carried out by the study subjects of experimental and control group, as evidenced by better activities of experimental group. This indicated the beneficial effect of planned early ambulation on resumption of activities of post caesarean patients.17 Result of another study on effectiveness of early ambulation on post- operative recovery and activities of daily living (ADL) on patients undergone abdominal surger y showed that, experimental group experienced a significant decrease in morbidity as well as significant improvement in ADL as compared to control group. 18 Another study on effect of Planned Early Recommended Ambulation Technique on Selected Post caesarean Bio physiological Health Parameters concluded that planned early ambulation after lower segment caesarean section plays an important and beneficial role in improving the post caesarean bio physiological health parameters of postnatal mothers. Thus it is effective strategy which can help in early post caesarean recovery of the postnatal mothers. It can also be practiced safely in hospital setting for the benefit of patients and health care team members.11Hence the null hypothesis (H0) was rejected and it showed that there was significant impact of early ambulation on post-operative recovery among post- caesarean mothers. Based on the present study findings it was concluded that early ambulation was effective in post-operative recovery after caesarean section. Early ambulation i.e. 6 hours can be initiated after caesarean section for speedy post-operative recovery and to prevent post-operative complications. Hence it s recommended that early ambulation can be incorporated into nursing practice in labour room as it can enhance the post- operative recovery and reduce the post- operative complications. Study could generate protocol for early ambulation after caesarean section which can help the staff nurses to enhance their competences in managing the post-caesarean mothers.

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