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Table of Contents
RESEARCH IN BRIEF
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 144-148

Effect of structured exercise sessions on post-operative problems related to immobility in post-caesarean patients


Gokhale Education Society's, Institute of Nursing Education and Training, Nasik, Maharashtra, India

Date of Submission26-Dec-2018
Date of Acceptance14-Oct-2019
Date of Web Publication01-Jun-2020

Correspondence Address:
Dr. Jyoti Thakur
MSG Center for Excellence, Principal TA Kulkarani Vidhyanagar, Near Jogging Track, Krushi Nagar, College Road, Nashik - 422 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCN.IJCN_16_20

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  Abstract 

As the well-being of maternal and child health occupies a paramount place in the healthcare delivery system, caesarean section (CS) has become the most common intervention in obstetrics care, in many countries. Although the indicated and timely CS has tremendous advantages for the mother and the baby, there are several consequences of caesarean delivery in comparison to normal delivery. Being one of the major abdominal surgeries, it also carries the risk associated with general surgeries. Non-probability sampling design was used to recruit 500 participants, who were allotted to experimental and control groups. With the routine post-caesarean care as per hospital routine, the planned structured exercise session was initiated for the experimental group on the day of lower segment caesarean section and was followed twice a day for the first 5 post-caesarean days. The study participants of the control group were given the routine care only. At the end of each day, the selected data for the presence of post-operative complications were collected by structured observation and self-report techniques. It was evident that the selected post-operative problems related to immobility were less in the experimental group as compared to that of the control group. The study concluded that structured post-operative exercise sessions are effective in reducing the potential post-operative problems associated with immobility in post-caesarean period. It can be implemented effectively to enhance the recovery of women after CS.

Keywords: Structured post-operative exercise, post-operative problems, caesarean section


How to cite this article:
Thakur J. Effect of structured exercise sessions on post-operative problems related to immobility in post-caesarean patients. Indian J Cont Nsg Edn 2019;20:144-8

How to cite this URL:
Thakur J. Effect of structured exercise sessions on post-operative problems related to immobility in post-caesarean patients. Indian J Cont Nsg Edn [serial online] 2019 [cited 2020 Aug 10];20:144-8. Available from: http://www.ijcne.org/text.asp?2019/20/2/144/285584


  Introduction Top


Caesarean section (CS) has been an essential intervention in obstetric care since ancient times. It is the oldest worldwide surgery performed in obstetrics, and also the second most common surgery performed on women in India.[1] CS is not performed as a last resort, but as a safe alternative to risky vaginal delivery. Timely CS with the right indications is of tremendous benefit to the mother and the baby.[2]

Globally, there were wide geographical variations in CS rates, but almost all show a quadrupled rise in less than two decades. In the past three decades, the world has witnessed a dramatic rise in CS rates.[3] CS now is frequently performed for no obstetrical abnormality or indication at all.[4]

The steady rise in CS rates has become an emerging issue in maternal and child care globally and even in India.[5] Over the past 25 years, many factors such as medical, psychological, social, financial and legal seem to have contributed to a rise in CS rates. The increase in the rates of CS is a global phenomenon that has got the profession, the public and those who care for women's health worried. Although it is a comparatively risk-free procedure, it is not without problems for anaesthetists, obstetricians, midwives and most important of all for the woman herself. In India, the increase in the number of CS has been associated with the women's request and the physician's preference for CS over normal delivery because it is convenient and is considered to be a quick method of delivering a baby.[6]

The consequences of CS are inadequately discussed in the literatures. As a major abdominal surgery, CS carries the risks of complications due to anaesthesia, surgical intervention and blood loss. In addition, the baby has to be delivered safely. Unlike other major abdominal surgeries, the potential complications after CS, which is also a major abdominal surgery, are often not given consideration as the focus shifts to baby care and the related issues than the post-operative surgical concerns. There are increased incidences of post-operative problems following CS including haemorrhage, thromboembolic events, infection and risks from anaesthesia.[7] It is also associated with longer duration of hospital stay, post-operative pain, increased period required to return to normal meals, breast engorgement, urination problems, problems in relation to bowel movements, lactation failure and less maternal newborn bonding.[2] Problems related to immobility such as hypostatic pneumonia, deep-vein thrombosis and gastrointestinal complications are rarely addressed. Increase in CS in low-risk women is associated with more maternal morbidity and mortality.[3]

There is an increased risk of possible post-operative complications following CS; therefore, prophylaxis is essential.[8] By preventive and promotive post-operative care, the women can be helped to avoid post-operative complications, which can help in early recovery and better mother and infant outcomes. One of the important aspects of comprehensive post-operative care is post-operative exercises.[9]

Therefore, this study was undertaken to assess the effect of structured post-operative exercise sessions on post-operative problems likely to be faced by post-caesarean patients.

Objectives

The objective was to assess and compare the post-operative problems in post-caesarean patients who had structured exercise sessions and those who had the standard post-operative care in a tertiary care hospital.


  Methodology Top


A quantitative quasi-experimental post-test only design was adopted for the study. The investigator carried out the study in selected tertiary care hospital of Jalgaon, North India.

The study participants for the study consisted of 500 post-caesarean patients with 250 in experimental and 250 in control groups. The sampling technique used was non-probability purposive sampling. The participants who underwent primary or repeat CS, emergency or planned CS under spinal anaesthesia, with minimum discomfort in post-operative period, who were available within first 4–5 h after surgery and were willing to participate in the study were included in the study. Post-caesarean patients with general anaesthesia; who had developed major complications in post-caesarean period; who were not willing to participate in the study; who are suffering with major pregnancy complications such as severe anaemia, diabetes mellitus, heart diseases, post-partum haemorrhage, severe pregnancy-induced hypertension with eclampsia and post-partum psychosis and whose newborns were stillborn or admitted in neonatal intensive care unit were excluded from the study.

Data collection procedure

After obtaining ethical clearance from the review committee and after securing the permission from the concerned authority of hospital, the study participants were recruited from the population of maternity patients who had undergone CS. The patients who met the study criteria were requested to participate in the study, and written informed consent was obtained. The participants were allotted to either of the group, i.e. experimental or control group. Before the allocation, the study participants were assessed for any pre-existing respiratory, vascular or gastrointestinal problems, which may influence the post-CS assessment. Patients who had any such problems were further excluded from the study.

The structured post-operative exercise session was introduced at predetermined multiple times for the study participants of the experimental group. Based on the predetermined plan of action, the investigator carried out the intervention of planned post-operative exercises and observations for each study participant. It included exercises such as deep breathing exercises, coughing exercises, leg exercises and ambulation, as per the post-operative day. It was followed for two times a day with a time interval of 4–5 h. The study participants were not disturbed during their sleep. Later on, the study participants were instructed and motivated to follow the techniques for two times in a day with an interval of 4–5 h, for the first 5 post-caesarean days. This intervention was continued daily until the 5th post-caesarean day in addition to the routine post-operative care. The study participants of the control group received routine post-operative care.

Exercises were taught by explanation and demonstration to the study participants, and they were supervised. The study participants were carefully monitored for follow-up of exercises for 5 consecutive days even as new women were recruited in the study. Preference was given for participants' willingness, convenience and comfort. Each study participant was given an identification number.

The tool used for data collection was a checklist of potential post-operative problems likely to be faced in the post-operative period after a major abdominal surgery. The different problems observed and recorded were in relation to the respiratory system, circulatory system, urinary system and gastrointestinal system. The content validity of the selected tool was carried out by 11 subject experts for its adequacy, relevance, objectivity and usability. The technique followed for data collection was structured observation and self-report techniques. The study participants were assessed for the occurrence for clinical signs of selected post-operative problems associated with immobility at a predetermined schedule at the end of each post-caesarean day for the first 5 post-caesarean days. The first occurrence of clinical signs or symptoms of the selected post-operative problem was noted in the record and used for further reference.


  Results Top


The participants were observed for the occurrence of selected post-operative problems related to immobility or prolonged bed rest. Demographic and obstetrical data of the study participants were analysed with frequency, percentage and Chi-square test. The comparison of potential post-operative problems likely to be faced due to immobility between the experimental and control groups was done by using 'z' test. The data in relation to selected demographic and obstetrical parameters presented in [Table 1] show that out of the total 500 study participants, majority of the study participants that is, 244 (48.8%), were in the age group of 21–25 years.
Table 1: Distribution of study participants based on selected demographic and obstetrical characteristics (n=500)

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Majority of the study participants, collectively of both the groups, that is, 267 (53.4%) were multigravida at the time of CS. More than half of (260, 52%) the study participants were primipara and the remaining 240 (48%) were multipara. For majority of participants that is, for 395 (79%), emergency CS was done. Majority (313, 62.6%) had primary CS at the time of study and also for majority of participants (309, 61.8%), surgery was done due to maternal indication. In the post-caesarean period, the maximum number of participants (173, 34.6%) were discharged on the 8th post-operative day, in which 82 (32.8%) were from experimental group and 91 (36.4%) were from control group.

The analysis of data by test statistics (Chi-square) showed that there was no significant difference in the distribution of the study participants based on the selected demographic variables of age, gravida, parity, type of CS and indication for CS. Hence, it was concluded that the samples of both the groups were homogenous and were representative of the population. The day of discharge was observed in the post-CS period as a secondary outcome variable.

The data presented in [Table 2] and [Figure 1] in relation to post-operative problems faced show that the participants of both the groups suffered with some problems in the first 5 post-caesarean days. Overall, it was observed that from the experimental group, 40 (16%) participants suffered with any one of the selected problems in comparison to 156 (62.4%) participants of the control group.
Table 2: Distribution and comparison of post.operative problems related to immobility by the participants of experimental and control groups (n=500)

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Figure 1: Post Operative problems due to immobility

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Based on the data in relation to the percentage of participants suffered from selected post-operative problems, it was evident that the few potential post-operative problems such as urinary tract infection, constipation and tympanites were noticed more in the control group (3.2%, 20.4% and 34%, respectively) as compared to that of the experimental group (2.0%, 5.6% and 6.4%, respectively). A statistically significant difference was observed between both the study groups, at P < 0.05 level of significance, for constipation (Z = 5.04) and tympanites (Z = 8.18), which was more than table Z = 1.64. No significant difference was noticed in the problems related to other systems. However, there was a statistically significant difference (P < 0.05) in the overall proportion of participants with post-operative complications between the experimental and control groups. These findings may be the result of the intervention of early planned ambulation which was practiced for the study participants for the experimental group and was refrained from the control group. None of the participants from either of the group suffered with respiratory problems in the post-operative period. As far as the days of discharge, the experimental and control groups differed statistically significantly at P < 0.05.


  Discussion Top


Although the participants of both groups, experimental and control groups, suffered with some of the post-operative problems, a few were noticed more in the control group as compared to that of the experimental group. Overall, the experimental group had significantly less number of women with post-operative complications than in the control group, showing that a planned structured exercise session is more useful than just routine care. Similar results on postnatal well-being after CS with exercises have been shown in another study.[10] The findings of this study also reveal that in both experimental and control groups, women experienced gastrointestinal-related complication more than other complications. Abdominal distension, constipation and blotting are common complications that are found after CS. Constipation was a problem in a significantly more number of women in the control group compared to the experimental group in this study. This finding supports other study findings that in addition to routine care, planned structured exercises, which include ambulation, relieve bowel distension and improve bowel movements.[11] Urinary tract infection, another complication in CS, was also another concern in this study. Significant bacteriuria was found in > 11% of women who underwent CS in another study.[12] Urinary catheterisation is a procedure done for all women undergoing CS, and urinary infections and urinary retention are related to this procedure. The data on catheterisation were not captured in this study. The non-occurrence of pulmonary complications in this study is positive and may be associated with the improved movement, even in bed, that is generated essentially to feed and care for the baby from the 1st post-operative day.

The difference in the day of discharge between the experimental and control groups is noteworthy. The length of stay was 8 days or more for more number of participants in the control group compared to the experimental group. Although a definite causal relationship cannot be established by this study, this result is suggestive of the effect of the structured post-operative exercise sessions administered to the experimental group.


  Conclusion Top


The present study showed that the structured post-operative exercise schedule is an effective strategy which helps in the early recovery of post-caesarean patients by reducing the number of post-operative problems associated with immobility. The planned post-operative exercises/sessions are useful in the prevention of the morbidity associated with surgical procedure. Thus, as a preventive and promotive aspect of care, exercises that include early ambulation are an effective strategy to facilitate early recovery in post-operative period, which is applicable to post-caesarean patients also. Therefore, it can be implemented for quicker recovery of caesarean patients and for the prevention of morbidity associated with potential post-operative problems related to immobility.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Akolekar R, Pandit S, Rao SB. Indications for cesarean delivery. Textbook of the Cesarean Birth. Mumbai: A FOGSI Publication; 2010. p. 53-5.  Back to cited text no. 1
    
2.
Lemay C. Day Surgery: Principles and Nursing Practice. Can J of Surg 1998;41:73.  Back to cited text no. 2
    
3.
Chhabra S, Shende A, Zope M, Bangal V. Caesarean sections in developing and developed countries. J Trop Med Hyg 1992;95:343-5.  Back to cited text no. 3
    
4.
Choudhury C. Caesarean Births: The Indian Scenario. Population Association of America; 2008. p. 1-8.  Back to cited text no. 4
    
5.
Oumachigui A. Rising rates of caesarean section: The way ahead. Indian J Med Res 2006;124:119-22.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Pai M. Unnecessary Medical Interventions: Caesarean Sections as a Case Study. Economic and Political Weekly; 2000. p. 2755-61.  Back to cited text no. 6
    
7.
James DK, Steer PJ, Weiner CP, Gonik B, Robson SC, editors. High Risk Pregnancy: Management Options. United Kingdom: Cambridge University Press; 2017.  Back to cited text no. 7
    
8.
Mantle J, Haslam J, Barton S. Physiotherapy in Obstetrics and Gynaecology. London: Elsevier Health Sciences; 2004.  Back to cited text no. 8
    
9.
Gillane O, Pollard M. Early ambulation of patients post-angiography with femoral puncture. Br J Cardiol 2009;16:137-40.  Back to cited text no. 9
    
10.
Çıtak Karakaya İ, Yüksel İ, Akbayrak T, Demirtürk F, Karakaya MG, Ozyüncü Ö, et al. Effects of physiotherapy on pain and functional activities after cesarean delivery. Arch Gynecol Obstet 2012;285:621-7.  Back to cited text no. 10
    
11.
Kaur H, Kaur S, Sikka P. A quasi-experimental study to assess the effectiveness of early ambulation in post-operative recovery among post-caesarean mothers admitted in selected areas of Nehru Hospital, PGIMER, Chandigarh. Nurs Midwife Res 2015;11:33.  Back to cited text no. 11
    
12.
Buchholz NP, Daly-Grandeau E, Huber-Buchholz MM. Urological complications associated with caesarean section. Eur J Obstet Gynecol Reprod Biol 1994;56:161-3.  Back to cited text no. 12
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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