INTRODUCTION:

Childbirth is a joyful experience; however, giving birth through cesarean section is one of the most common surgical procedures. C-section is a major abdominal surgery and may cause more discomfort, prolonged recovery and difficulty returning to normal activity than vaginal delivery (Ana, 2016)¹. Worldwide, it comprises 60% of total childbirths (Sussan et al., 2016)².

It is extreme above the acceptable rate of 10 to 15 percent recommended by World Health Organization (MOHP (2014): Naeem etal 2015 and Yassin etal 2012^3-5.

It is important to understand that the woman who had a cesarean section may face particular condition after the operation when compared to the clients who have gone through other surgical procedures, because they need surgical care and maternal care (Berghella, 2017)⁶.

Post cesarean section woman requires both postpartum and postoperative surgical care to prevent post-operative complications and optimize the health. Routine post –operative nursing care following cesarean birth includes monitoring bleeding and vital signs (blood pressure, pulse and respirations). Body temperatures should be assessed regularly. Patients shouldn't be fed orally before bowel movements had started. This practice is based on the belief that intra-abdominal surgical procedures are followed by paralytic ileus (National Institute for Health and Clinical Excellence, 2011)⁷. Post-operative pain control in the first 24 h and non-steroid anti-inflammatory medicine must be initiated intravenously by nurses. Finally the mother has to be encouraged for early ambulation after delivery (Moore et al., 2014)⁸.

Pain from the wound after a caesarean section may interfere with functional daily activities and quality of life, gentle exercise and early movement may help in reducing post-surgical pain and adhesions. Also, prevent faulty posture, improve pelvic floor function and strengthen abdominal muscles (Jeffrey and Quinlan, 2015). Postpartum care includes assessment for perineum and fundus beside the amount and character of lochia (Moore et al., 2014)⁸.

Uterotonic drug should be regulated and uterine massage is indicated if uterus is not firmly contracted. Nurses should teach post-cesarean section women how to start deep breathing and huffing/coughing exercises as soon as possible to keep the chest clear (Rooks etal, 2016)⁹.

On the other hand simple leg exercises should be performed to increase the blood circulation in legs and reduce the risk of clotting. Bend and stretch the ankle and legs 10 times every hour leads to comfortably get in/out of bed and walk around (Ronald and Miller 2010)¹⁰.

SIGNIFICANCE OF THE STUDY:

Worldwide, the rise in caesarean section rate during the last three decades is alarming which needs an in-depth study (Martens et al., 2013)¹¹. Nearly one-third of all deliveries in the United States are cesarean deliveries compared with spontaneous vaginal delivery. In a recent research carried out at Mansoura University Hospital; in Egypt, the rate of cesarean section was significantly increased from 42.7% in 2006 to 55.3% in 2010 (Helal, 2013)¹². Also, Egypt Demographic and Health Survey (EDHS) obtained information on Caesarean sections the frequency of in Egypt. It showed that more than one-half of the deliveries in the five-year period before the survey were by Caesarean section (El-Zanaty, Fatma and Ann, 2014)¹³. The consensus of cases of CS in the university hospital at Menoufia Governorate during 2012 increased from 1200 to 1300, and in 2013 from 1300 to 1400 cases, whilst in 2014 it ranged between 1400 to 1500 cases, and in 2015 ranged between 1700 to 1900 cases (Statistic Menoufia University Hospital, 2015).

There is only one study, which presents the results of respiratory exercise on pulmonary functions of women following CS under general anesthesia (Thorp and Laughon 2014)¹⁴. Comprehensive online searches was finished using the search engines Cinahl, Ovid, Medline and PubMed. Searches were limited to 2006 to 2016, with exclusion of a historical search from 1946. Key words used included early mobilization, early ambulation, postoperative, barriers, nursing care, missed care, complications of immobility, bedrest and bowel activity.

Difficulty during functional activities showed lack of information about the use and effectiveness of nursing interventions in the early post-cesarean period. So, this study was planned to assess the effectiveness of a nursing intervention on post-cesarean ambulation time and resume of normal life style.

AIM OF THE STUDY:

This study aimed at assessing the effectiveness of post-operative nursing intervention on functional activities in early post-cesarean period.

Research hypothesis:

Women who will receive post-cesarean nursing intervention (study group) will exhibit: 1- Reduction in difficulties of functional activities in the early period of post-cesarean than women who will receive routine hospital nursing care (control group) 2- Earlier postoperative ambulation and return of bowel activity than the control group.

METHODOLOGY:

Research design:

Quasi experimental research design was used to achieve the aim of the study.

Research setting:

The study was carried out in university hospital at Shebin El kom, Menoufia governorate, Egypt.

Sample:

A purposive sample of 150 post-operative cesarean section women due to obstetric indications or elective cesarean were recruited in the study based on the sample size calculation with 95% confidence interval. The subjects were divided randomly into two groups (75 women in the study group and 75 in the control group).

Exclusion criteria was women who had multiple births or operative complications,

The study group [1]: Comprised of 75 women who received routine medical and nursing post-operative cesarean care in addition to post-operative nursing intervention as exercise for improving respiratory functions, blood circulation, intestinal activity, and other strategies for improving posture and prevent possible postnatal musculoskeletal pain problems.

Control group [II]: Comprised of 75 women who received only routine medical and nursing post-operative cesarean care.

Tools of the study:

Two tools were used in the study, based on the review of the related literature:

Tool (I):

structured Interview questionnaire that was developed by the researcher after reviewing of the related literature. It was divided into four parts:

Part 1: Socio-demographic data: it included data about age of women, education level and husband education level, occupation, income and residence.

Part 2: Medical history: it contained health problems pre and during pregnancy as hypertension, thyroid dysfunction, diabetes mellitus, back pain, headache, disc, urinary incontinence and constipation.

Part 3: Obstetric history: It included questions about number of pregnancy abortion and delivery, numbers of cesarean and gestational age.

Part 4: It contained questions to estimate the effects of post-operative nursing intervention on the following: first time of breaking gas and defecation after cesarean, first ambulation after cesarean, the presence of pre-syncopal symptoms during the first ambulation.

Tool (II):

A visual analogue scale developed by Noble et al., (2005)¹⁵ to assess the physical activity to estimate the difficulty during functional activities as: turning in bed, coming into sitting/standing positions, and walking. The visual analogue scales (VASs) asked the subject to rate her activities for three days on the scale using numbers from zero to ten where 0 = no difficulty, 10 = unable to perform the activity. The total score was recorded (0–30 points).

Data collection was extended from January 2017 to April 2017 at the following phases:

1-Preparatory phase:

In this phase the researchers started to review recent, current, national and international related literature. Also, journals, magazines, text books, internet, and theoretical knowledge, of the various aspects concerning the study topics were prepared. The researcher prepared the tools for data collection and translated them into Arabic then back to English to validate the translation.

Also, the researchers attended two weeks training sessions by a physiotherapist in the physiotherapy department at university hospital, to learn how to apply connective tissue manipulation (CTM) on the post-operative women

2- Assessment phase (for both groups):

Interviews were conducted on the first day of the CS, to collect baseline data. The form was filled- in while conducting the interviews. It required approximately 15 minutes for completing the interview. Then the researchers recorded the participants' telephone number and address to follow them up. The questionnaires were filled twice (immediate after subjects were transferred to obstetric ward, and post intervention).

3-Implementation phase (for both the control and study Groups):

Routine hospital nursing care after cesarean delivery: Subjects were transferred to obstetric ward. Vital signs and body temperatures were assessed regularly. Patients were not allowed to be fed orally before bowel movements had started.

For post-operative pain control in the first 24 h, Ketolac (50mg, 4×1) and non-steroid anti-inflammatory medicine (4×1) were administered intravenously. If the patient required additional analgesics or anti-inflammatory medications, they were also administered by the nurses. Patients were encouraged for early breast feeding and ambulation after delivery if they were not hypotensive and uterine bleeding was under control.

Initially, the researcher asked women to ambulate for 10–15 minute in their rooms. Patients were usually discharged within 24h in uncomplicated cases.

The postoperative nursing intervention:

It was applied for the study group beside the routine nursing care. It included intervention for improving functions of respiratory system which are not among the standards of care for post-cesarean patients: Thoracic expansion exercises effects on expansion of the lungs and lead to complete exchange of gases, removal of waste products, increase in abdominal muscle tonus, blood circulation, secretions, and relaxation Thompson et al. (2012).¹⁶ Thoracic expansion and active lower limb exercises were implemented every hour when the subjects were awake, with five repetitions in the operation day. Afterwards, exercises were performed with ten repetitions, three times a day. The huffing technique which is an easier, less painful and more efficient method than coughing, was taught to the subjects Noble (2013). ¹⁷

For blood circulation:

Women were taught to do bending, stretching and circumflexion of feet at the ankles, leg bracing, knee bending and straightening exercises to improve circulation, reduce edema, prevent possible post-operational circulatory problems as deep vein thrombosis, hasten recovery from the anesthetics and prepare the subject for the effort required in first getting out of the bed Noble (2013) ¹⁷

For intestinal activity:

The researchers attended a two weeks training sessions to learn how to apply connective tissue manipulation (CTM) from physiotherapist in physiotherapy unit at university hospital, then applied it on the post -operative women. Connective tissue manipulation was applied daily to the lumbar and sacral area. This was conducted after the subjects could come into sitting position, and carried on about 5 min in each session. In CTM, localized special strokes are applied by the third fingertip to make traction between skin and tissues underneath Goats and Keir (2012):¹⁸ special strokes utilized in this research comprised: strokes to the sacrum, iliac crests, sacroiliac joints, lumbar paravertebral region and subcostal region, as explained by Tappan Erdogan etal., (2014)¹⁹ This was involved in the intervention because of its influences on pain and visceral dysfunction as decreased in intestinal motility Goats and Keir (2012).¹⁸

Posterior pelvic tilt exercises were also used in the intervention to contract muscles of abdomen, increase intestinal activity and control or prevent gas pain Noble (2013)¹⁷.

These exercises were applied three times/ day, with ten repetitions, according to the thresholds of pain. Women were told about the anatomy, functions and importance of the pelvic floor. They were also asked to contract their pelvic floor during activities to increase intra-abdominal pressure (such as laughing, sneezing and coughing) Johnson (2010)²⁰

Subjects of the study group were educated about proper use of body mechanics during baby caring and daily activities so as to acquire postural awareness, improve posture and prevent possible postnatal pain problems related to musculoskeletal system. Also exercises were applied to improve posture, and repeated 5–10 minutes for three times a day, especially after breastfeeding Wilder E (2015).²¹

Content validity and reliability:

Tools were submitted to a panel of five experts in the field of Maternity Nursing, Obstetric Medicine to test the content validity.

Modifications were carried out according to the panel judgment on clarity of the sentences and appropriateness of the content.

Reliability:

Cronbach Alpha computer test was used, (r=0.89)

Pilot Study:

It was conducted on 10% of the study sample who were selected randomly and excluded from the main study sample. Its aim was to evaluate the simplicity and clarity of the tools. It also helped in the estimation of the time needed to fill- in the forms. As the result of the pilot study have revealed, simple modifications were done as rephrasing questions or cancelling some questions.

Ethical consideration:

An official permission was granted from the director of the University hospital. The researchers introduced themselves to the women who passed the inclusion criteria and informed them about the study’s purpose so as to get their acceptance to participate in the study. The subjects were ensured that, the study will pose no risk for their health and that their participation in the study is primarily voluntary. Post cesarean women who met the inclusion criteria were approached by the researchers and asked for verbal consent to confirm their acceptance, and that all procedures that will occur during data collection will be considered confidential. Before being discharged, the control group received a copy of the intervention instruction to apply it at home.

Statistical analysis:

Data were coded, prepared for computer entry, followed by tabulation and data analysis. The Statistical Package for Social Sciences (SPSS) version 20 was used for that purpose. Descriptive statistics were applied (e.g., frequency, percentages, mean, range and standard deviation, ). A test of significance as chi-square, Paired t-test was also used. A significant level value was considered when p > 0.05, and a highly significant level value was considered when p > 0.001

RESULTS:

Table (1) showed socio-demographic characteristics of the studied mothers. The mean age of the studied mothers was 27.9± 5.9 for study group and 27.3 ± 4.9 years for control with a range of 18–42 years.

There was no statistical significant difference between study and control groups when compared for age, maternal education, & occupation, husband education & occupation, and family income (p > 0.05 for each).

Table (2) revealed that obstetric history parameters are higher significantly in control group in each of gravida, parity, and number of caesarean sections (p < 0.01). While number of abortions were higher significantly among the study group (P=0.000).

Table (3) illustrated that the number of subjects with health problems before and during pregnancy is similar in both groups (p > 0.05). Headaches and back pain are the highest percentages among both groups.

Table (4) showed presence of pre-syncopal symptoms during first ambulation, return of intestinal function, and difficulties in daily activities among the studied mothers after the implementation of the nursing intervention. In relation to time from transfer to obstetric department room to ambulation after cesarean (hours, minutes), it was lower (3.28) in the study group compared to the control group (4.57).

In addition, the occurrence of pre-syncopal symptoms during first ambulation was lower among the studied group (36%) compared to the control group (56%), the difference was statistically significant P<0.01). Moreover, the returning of intestinal function was earlier in the studied women who received the nursing intervention in comparison to the control group. The time of breaking gas as well as starting defecation was lower in the studied group than the control group.

Furthermore, regarding the difficulties in daily activities, the mean total score in delivery day, first day after delivery, and second day after delivery highlighted a lower mean scores among the intervention group than control group. The difference was highly significant statistically (P=0.000).

Table 1: Socio-demographic characteristics of studied mothers

Socio-demographic characters	Study group N0. %	Control group N0. %	X2	P
Age (years) X± SD	27.9±5.9	27.3±4.9	t=0.69	0.48 NS
Education:				0.08 NS
Illiterate & 1ry edu.	18 24	11 14.7	6.6
2ry education	40 53.3	52 69.3
University	17 22.7	12 16
Husband education				0.06 NS
Illiterate & 1ry edu.	15 20	14 18.6	7.5
2ry education	44 58.7	56 74.7
University	16 21.3	5 6.7
Occupation:				0.32 NS
Housewives	53 70.7	50 66.7	3.5
Workers	4 5.3	9 12
Administrative	18 24	16 21.3
Husband education				0.12 NS
Farmers	16 21.3	21 28	5.8
Workers	29 38.7	27 36
Administrative	25 33.3	27 36
Others	5 6.7	0 0
Family income				0.57 NS
Enough	17 22.7	20 26.7	0.32
Not enough	58 77.3	55 73.3	0.32
Total	75 100	75 100

NS: means not significant

Table 2: Obstetric history of the studied mothers

Socio-demographic characters	Study group X± SD	Control group X± SD	T	P
Gravida (n)	2.6 ± 0.6	2.7± 0.5	-1.4	0.12 NS.
Parity (n)	2.5 ± 0.6	2.6 ± 0.5	-1.3	0.10 NS
Abortion(n)	0.73 ± 0.9	0.71 ± 0.6	-1.7	0.09 NS
C Section (n)	2.5 ± 0.3	2.4 ± 0.4	1.3	0.10 NS

NS: means not significant

Table 3: Health problems of the studied mothers before and during pregnancy

Health problems	Study group N0. %	Control group N0. %	X2	P
Before pregnancy				0.12 NS
Yes	52 69.3	43 57.3	2.3
No	23 30.7	32 42.7	2.3
If yes which diseases*?				0.83 NS
Hypertension	8 10.7	4 5.3	2.8
Headache	18 24	17 22.7
Back pain	11 14.7	15 20
Constipation	4 5.3	2 2.7
DM	4 5.3	4 5.3
Other or no diseases	30 40	33 44
During pregnancy			2.3	0.12 NS
Yes	52 69.3	43 57.3
No	23 30.7	32 42.7
If yes which diseases*?
Hypertension	8 10.7	4 5.3	0.28	0.83 NS
Headache	18 24	17 22.7
Back pain	11 14.7	15 20
Constipation	4 5.3	2 2.7
DM	4 5.3	4 5.3
Other or no diseases	30 40	33 44
Total	75 100	75 100

*NB: Percentage may add to more than 100% because a mother may complain from more than one symptoms and disease.

Table 4: Pre-syncopal symptoms during first ambulation, return of intestinal function, and difficulties in daily activities among the studied mothers.

Items	Study group X± SD	Control group X± SD	T	P
Time from transfer to obstetric department room up to ambulation after cesarean (h:min)	3.28 ± 0.4	4.57± 0.54	-15.7	0.000HS
Presence of pre-syncopal symptoms during first ambulation (Yes) (n(%)	27 (36%)	42 (56%)	6.01	0.01 Sig.
Return of intestinal function
Breaking gas (h:min)	1.21 ± 0.41	2.3 ± 0.77	-10.8	0.000 HS
Defecation (h:min)	194 ± 0.54	2.54 ±0.50	-7.03	0.000 HS
Difficulties in daily activities
Total score of daily activities in delivery day	16.56±1.3	21.7±3.6	-11.56	0.000 HS
Total score of daily activities in 1^st day after delivery.	9.16±0.93	16.6±1.39	-39.03	0.000HS
Total score of daily activities in 2^nd day after delivery.	5.61±1.19	12.93±1.65	-31.05	0.000HS

HS: means highly statistically significant

Sig: means statistically significant

DISCUSSION:

Although C-section is less painful experience to the mother and child, than vaginal delivery, it carries some postoperative risk of complications. The current research illustrated no statistical significant differences in socio- demographic characteristics. This minimized the group differences that could affect the outcome measures. This was in agreement with (lkim et al., 2011) ²² who stated that when the different groups had not significant differences related to socio- demographic characteristics and past medical history, the comparison between these groups could be related to the intervention. In addition to, the current findings indicated that was not statistically significant differences in relation to obstetric history parameters among the control group in items of gravida, parity, and previous C-sections.

The results supported the study hypothesis, and indicated statistical improvement among the studied group after the intervention than the control group in relation to the total score of daily activities which indicated the success of the nursing intervention. Also, the ambulation and resuming the bowel movements earlier was statistically significant among the study group than the control group. Moreover, the nursing intervention related to respiratory and lower extremity exercises was successful among the studied women, and lead to early movement and improved lung function than the control group who received the usual nursing care. The literature search encourages early moving after C- section for women as evidence based practice, though most nurses missed this point. The MISSCARE Survey of 1, 098 nurses in four U.S. hospitals illustrated that ambulation was noted by 86.6% of nurses as being missed (Mazzoni etal, 2011).²³ Moreover, this finding is supported by Wall, et al (2014).²⁴ In his study about "effect of the exercises on early ambulation after cesarean section" and stated that this could be related to the effect of the exercises in thoracic expansion and improvement of blood circulation, which was helpful in avoiding the side effects of anesthetics, and helped the studied group to get out of bed early than the control group.

Concerning to the effect of the nursing intervention on the study group related to the syncopal symptoms at the first movement out of bed, the findings showed that it was significantly lower among the study group. In agreement with the present finding, (lkim et al., 2011)²² who reported in their study about "Effects of physiotherapy on pain and functional activities after cesarean delivery" that the pre- syncopal symptoms was approximately three times higher among the control group compared to the study group who received “respiratory and lower extremity exercises" however, the difference wasn't significant statistically.

Regarding to the effect of the “Connective tissue manipulation” of the sacral part and the lumber region, the intervention showed that both time of breaking gas and starting defecation, was earlier among the study group than the control group. This finding illustrated that the intervention was successful. In the same line Erdogan K. (2014)¹⁹ found in his study about "Effect of abdominal massage combined with abdominal breathing exercise on recovery of gastrointestinal function in women after cesarean section" that the times to bloating relief, intestinal movement, breaking gas and first defecation were significantly shorter in women received abdominal massage post C- section than women received conventional nursing intervention. This finding could be because massaging of sacral part and CTM improve the circulation and stimulate bowel movement.

The current study findings indicated that the nursing intervention was successful and showed high statistical significant lower in total score of difficulties in daily activities in the delivery day, first day after delivery, and second day after delivery among the study group than the control group. This finding was consistent with the results of Bahadori etal (2013)²⁵ who found in their study about "The trend of caesarean delivery in the Islamic Republic of Iran" that the women who received respiratory and lower extremity exercises could ambulate earlier than the control group. Respiratory and lower extremity exercises were shown to help avoiding the effects of anesthetics, preparing the subjects for the effort for ambulation and improving blood circulation. Also, this finding was supported by Jeffrey D. Quinlan, M (2015):²⁶ who stated that it is very important to women after C-section to start 3-4 deep breathing and a huffing (forced breath out) while supporting the surgical incision with hand or a pillow to improve the lung function clear the chest, and improve blood circulation.

Likewise, the nursing intervention related to leg exercise (bending and stretching the ankle and legs10 times every hour) was successful in helping the study group to feel comfortable to ambulate early and get out/in of bed, which may lead to reduce the risk of developing deep vein thrombosis and walk around.

CONCLUSION:

Based on the study finding, the researchers concluded that the nursing intervention was effective and achieved the hypothesis and aim of the study as:

The syncopal symptoms at the first movement out of bed, was significantly lower among the study group than the control group. Also, statistical improvement among the studied group after the intervention than the control group in relation to the total score of daily living activities. In addition, the ambulation and resuming the bowel movements earlier was statistically significant among the study group than the control group. Moreover, the nursing intervention related to lower extremities and respiratory exercises was successful among the study group, and lead to early movement and improved lung function than the control group who received the usual nursing care. The “Connective tissue manipulation” of the sacral part and the lumber region, showed that both time of breaking gas and starting defecation, was earlier among the study group than the control group. The nursing intervention was successful and showed high statistical significant lower in total score of difficulties in daily activities among the study group than the control group and it was successful in helping the study group to feel comfortable to ambulate early and get out/in of bed

RECOMMENDATIONS:

Since the findings of the study supported the hypothesis and proved to be highly significant in improving post C-section complaints it is recommended to:

- Replicate the study on different settings and more sample size to validate the findings and create an evidence based practice.

- Train obstetric nurses to include the current intervention in their routine post C- section care.

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Received on 27.07.2018 Modified on 30.07.2018

Int. J. Nur. Edu. and Research. 2019; 7(1): 63-70.

DOI: 10.5958/2454-2660.2019.00013.9