Problems Experienced by the Mothers in Post-Cesarean Period: A Narrative Review

Abstract

Cesarean delivery rates have been increasing which leads to a rise the problems experienced. After cesarean deliveries important problems for the mother and baby may be seen. The most common problems in the mothers after cesarean delivery are; bleeding, infection, fatigue, sleep disorders, breast problems, self-care issues, and sense of inadequacy in care of the newborn. The method used in this study was narrative review. A literature review was conducted by searching the materials published in databases including Web of Science, PubMed, Google Scholar search engine and, the WHO website. Pain, maternal death, breastfeeding problems, worsened sleep quality and comfort, anxiety, delayed recovery, prolonged hospitalization and infection rates in the cesarean deliveries are higher than in vaginal deliveries. Nurses can facilitate adaptation to the role of motherhood and prevent risky situations by evaluating mothers’ care needs and providing proper interventions and support. Nurses should not only focus on the physical care needs of the mother and baby; they should also ensure the physical and psychosocial adaptation of family members in the face of role changes.

Introduction

The act of labor is the expulsion of the fetus, which is a product of pregnancy, and its appendages from the uterus 40 wk after the last menstrual period. In cases when vaginal delivery cannot be performed, labor is done through Cesarean delivery (CD). The rates of CD are increasing rapidly all over the world (1,2). According to the Demographic and Health Survey of Turkey (2018) (52%) and Turkish Health Statistics (2019), more than half of the births (54.4%), are occurred by the SC (3, 4). According to the Organization for Economic Co-operation and Development (2022), the countries with the highest CD rates are Mexico (58.6%), Turkey (57.3%) whereas the country with the lowest rate is Israel (14.8%) (5).

Literature review shows that the reasons for the increase in CDs are the belief that CD is safer, the development of technology used to evaluate fetal health, the advancement of anesthesia, the ability to determine the timing and duration of delivery, and inadequate prenatal care (6, 7). In addition, the physician’s view of normal birth and follow-up as risky, the fear of being sued, and therefore the fact that cesarean section (CS) is more advantageous for the physician and the health institution are among the important reasons (6–8). Due to the medicalization of labor, women are not adequately informed and cannot participate in the decisions taken about their birth and delivery. Births are carried out away from the home environment and thus the cost of birth increases, attachment of the mother and infant is delayed. Today, excessive and unnecessary interventions, defined as “medicalised deliveries” are being questioned. The Ministry of Health has taken some measures to reduce the cesarean rates and support vaginal delivery in Turkey (9).

Post-partum period

The post-partum period (PPP) covers the 6 weeks after delivery when the anatomical and physiological changes that occur with pregnancy disappear and the body returns to its pre-pregnancy state. This process may take longer in some women (10). The first 24 h of PPP are defined as the “urgent puerperium”, the period up to the first 7–10 d as the “early puerperium”, and the next 6 weeks as the “late puerperium”. While late puerperium covers the first 6 weeks of post-partum in women who do not breastfeed, it can last for months in women who do (10,11).

PPP includes several physiological, psychological and social changes in women (10, 12). These changes bring along various problems that affect the daily life of the women (13,14). The most common problems seen in the PPP is given below (13, 15–18) (Table 1).

Table 1:

Problems seen in the PPP’s of cesarean section

Problems seen in the PPP	Problems seen in the breasts
Postpartum bleeding	Breast fullness
Sleep and rest problems	Sore and cracked nipples
Emotional problems	Pain in nipples
Constipation	Milk secretion
Gas out	Engorgement
Bathing
Nutrition
Taking care of other children
Painful sex
Urinary incontinence
Pain

References: (16, 17)

Reasons of mothers’ admission to the emergency service in the first 42 d of PPP were found; problems related to the incision site (17.5%), fever (17.1%), pain in the abdomen (15.9%), headache/dizziness (12.3%), breast problems (10.7%) and hypertension (10.3%) (19). In the late PPP period, mothers have psychiatric problems and the problem of not being able to start using contraception (20, 21). Although postpartum psychosis is seen at low rates, it should be detected as early as possible because it can lead to serious consequences (22). In addition, when studies conducted in 57 countries between 2005 and 2013 years were examined, 32 to 62% of the mothers in the PPP had problems related to contraception (21, 23).

Problems seen after cesarean section

Studies comparing cesarean and vaginal delivery report that mothers experience more problems after CS (24, 25). According to a meta-analysis on this subject, maternal death, bleeding and infection rates in cesarean deliveries are higher than in vaginal deliveries (24–26). Problems such as breastfeeding, nutrition, troubled family relations and pain are less common in the mothers who give birth vaginally (14). Mothers experience more pain, breastfeeding problems, worsened sleep quality and comfort, anxiety, delayed recovery, and prolonged hospitalization in the post-cesarean period (14, 27). Mothers mostly experience problems with breastfeeding and personal nutrition during the post CS period (24). Pain, breastfeeding problems, emotional changes, mobilization and lack of personal hygiene were reported as the most important problems in the mothers with CS (15, 28–30). In another study, the type of anesthesia as well as the mode of delivery affected the problems seen in PPP. In this study, difficulties in sitting in bed, standing up, maintaining personal hygiene and urination as well as bleeding problems were determined in the mothers. In addition, a statistically significant difference was found between the mothers’ problems in wind and discharge, difficulty in baby care, feeling pain in the operation area and throat, and headaches (P<0.05) (25). The frequency of nausea and vomiting increases in the mothers undergone CS. Nausea and vomiting also have negative effects on maternal and infant nutrition (31). Cesarean delivery causes mothers to neglect the baby by experiencing fluctuating feelings towards baby, to experience difficulties in adapting to the role of motherhood and worsened post-partum comfort levels, and to suffer from problems related to breastfeeding (25, 31, 32).

Nursing approach in the post-partum period

PPP is the period when the mother needs maximum nursing care. In this period, it is recommended to give qualified care to every mother (especially in the first 4–12 wk) (33). Although all the mothers need care and support in the PPP, especially primiparous mothers may need care and support even in solving very simple problems (32). The infection that develops in the mothers as a result of inadequate nursing care cannot be effectively prevented and treated (34). Mothers should be physically relieved starting from the first moments of PPP (35). Since the physiological changes seen in the PPP may cause stress in the mothers, personalized care should be provided to minimize or completely eliminate their stress level, the needs of the mother and family should be met, and problems should be prevented (36). Mothers should be supported to participate in the care of themselves and their babies during pregnancy and from the first days of PPP. Nurses can facilitate adaptation to the role of motherhood and prevent risky situations by evaluating mothers’ care needs and providing proper intervention and support (35, 37, 38). Nurses should not only focus on the physical care needs of the mother and baby; they should also ensure the physical and psycho-social adaptation of family members in the face of role changes. In addition, nurses should contribute to the development of affirmative health behaviors for the mothers to protect their health (37, 38).

The most important part of care should be health education that contributes to the development of the mother (32). Unfortunately, the health education given to the mothers in the PPP is rarely sufficient. Inadequate health education brings many problems in terms of maternal and infant health. The fact that health education is not planned effectively and is insufficient increases the problems experienced by the mothers and causes some emotional issues as well. When mothers cannot cope with the problems, they constitute a risky group in terms of post-partum depression (39). In a study analyzed twenty-nine guides dealing with the PPP and identified the most needed issues. During this period mothers had educational needs related to breastfeeding, nutrition, home visits, newborn care, sexual life and family planning (40). Issues related to bleeding, reproductive system infection, thromboembolism, headache, constipation, hemorrhoids, psychological conditions, breastfeeding, nipple pain, bleeding, parenting, emotional attachment and newborn care should be emphasized in the PPP (34). The nursing care given to the mothers who gave birth via CS in line with the comfort theory increased the comfort of the mother’s by meeting the comfort needs of the mothers (41). As the quality of postpartum care increases, the life quality of mothers will also improve (42).

Conclusion

The problems that may arise in the PPP according to the mode of delivery and type of anesthesia are discussed. In addition, the importance of nursing care and related education is emphasized in order to cope with and prevent these problems. It is of great importance to conduct a risk assessment for the problems that may arise in this process in order to protect and improve maternal and newborn health in PPP. Standard care protocols should be applied in the institutions so that the quality of care and education given can be improved. In addition, it is recommended to provide the care in line with nursing theories. Nursing care and education based on Kolcaba’s comfort theory will be beneficial and increase the postpartum comfort level which in turn, can improve poatpartum comfort. Nurses should be supported in the PPP to follow researches on care practices based on this theory and to participate in the studies related to the care practices. In addition, policies supporting vaginal delivery should be implemented in order to protect and improve maternal and newborn health and minimize problems seen in the PPP, and nurses should prepare pregnant women for vaginal delivery by educating them in the prenatal period.

Journalism ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.