Abstract
This study, conducted as a randomized clinical trial, focuses on acute care visits and rehospitalizations of mothers whose infants were delivered by cesarean section (n = 122) and infants (n = 123) for 8 weeks after hospital discharge. There were three maternal rehospitalizations. Maternal acute care visits were for wound infections or complications (27 of 34); 21 occurred in the first 4 weeks. Seventy-five percent of infant rehospitalizations were for infection or possible infection; 22 of 31 infant acute care visits occurred in first 4 weeks for bilirubin checks and infant care problems, and 21 of 25 visits in weeks 5 to 8 were for infections. Discharge teaching and home care in first 4 weeks after discharge and issues related to infant infections in the second 4-week period may reduce the need for rehospitalizations and acute care visits in both mothers who had cesarean section and their infants.
Currently about one in four women who give birth do’so by cesarean delivery, making it the most common hospital surgical procedure.1–3 Although cesarean deliveries are performed to protect the health of both mother and infant, the procedure is associated with increased medical risk for both; maternal psychologic sequelae; longer hospital stay for both mother and infant; and higher medical costs including treatment for complications both during hospitalization and after discharge.4–7
Both maternal and neonatal morbidity are higher with cesarean delivery. Maternal postoperative infection rates range from 5% to 15% but are reported to be as high as 20% to 85% among indigent populations.5,6 Maternal infections include endometritis (most prevalent), urinary tract infection, wound infection, and lower respiratory tract infection.5,8 Although antibiotic prophylactic regimens at delivery are used to prevent endometritis and wound infection, 15% of women undergoing unplanned cesarean birth still have postparturm infection.9
Noninfectious postoperative complications include excessive blood loss, paralytic ileus, pulmonary embolus, deep vein thrombosis, operative lower urinary tract injury, and, when general anesthesia is used, the development of atelectasis in as many as 5% of women.5,6,10 Factors associated with increased risk of complications include age (teenagers and women older than 30 years of age), low socioeconomic status, primary and unplanned cesarean birth, obesity, and anemia. 4,7,9,10 Neonatal morbidity is higher in cesarean birth, resulting from higher rates of respiratory distress syndrome, transient tachypnea, and lower Apgar scores attributed to use of general anesthesia.5
Although data are available on complications for mothers and infants during hospitalization, very little information is available on the postdischarge complications of both after cesarean delivery. This information assumes greater importance in this period of earlier hospital discharge of mothers and infants. The purpose of this study was to examine the reasons for rehospitalizations and acute care visits for both mothers and infants followed for 8 weeks after hospital discharge after cesarean birth.
METHODS
This study was conducted as part of a larger study on arly hospital discharge and nurse specialist home follow-up of women having cesarean delivery. The larger study was a randomized clinical trial in which one group of women undergoing cesarean birth received routine care. A second group received teaching, counseling, and early hospital discharge, as well as telephone contact and home visits for 8 weeks after hospital discharge.
Data on all maternal and infant rehospitalizations were collected from hospital chart review and validated by attending physicians. Data on acute care visits (non-routine visits to emergency departments, walk-in clinics, and physician offices) were collected from chart review and monthly telephone calls to mothers. All routinely scheduled postpartum and well-baby check-ups were excluded from analysis. All data for rehospitalizations and acute care visits for the 122 mothers and 123 infants during the 8-week follow-up period were analyzed, categorized, and totaled.
The sample consisted of 122 mothers and 123 well, term infants (one set of twins; Table 1).
Table 1.
CHARACTERISTICS OF STUDY SUBJECTS, 122 MOTHERS AND 123 INFANTS*
| X̄ maternal age | 29 y |
| Range | 18–41 y |
| X̄ gestational age | 39 wk |
| Range | 35–42 wk |
| X̄ birth weight | 3364 gm |
| Range | 2250–4680 gm |
| Marital status | |
| Married | 61% |
| Unmarried | 39% |
| Maternal educational level | |
| < High school | 18% |
| High school | 26% |
| > High school | 55% |
| Unknown | 1% |
| Race | |
| White | 52% |
| Black | 43% |
| Other | 5% |
| Insurance | |
| Private | 58% |
| Medicaid | 34% |
| Self-pay or unknown | 8% |
| Income ranges | |
| < $10,000 | 30% |
| $10,000–$24,999 | 25% |
| $25,000–549,999 | 31% |
| > $50,000 | 14% |
One set of twins.
RESULTS
Maternal Rehospitalizations
Only 3 of the 122 women followed after cesarean delivery required rehospitalization (Table 2). Two women were rehospitalized for wound infection, one at 4 days after discharge, the other at 3 weeks after discharge. The third mother had pneumonia 3 days after hospital discharge and was admitted to the intensive care unit for pneumonia complicated by congestive heart failure. The total length of stay for all three women was 22 days, more than half (13 days) for the woman with pneumonia. Of the women who were rehospitalized, two had Medicaid and one had private insurance.
Table 2.
MATERNAL REHOSPITALIZATIONS TO 8 WEEKS AFTER DISCHARGE (N = 122)
| Diagnosis | No. of Women | No. of Rehospitalization*
|
|||
|---|---|---|---|---|---|
| Discharge-1 Wk | 2–4 Wk | 5–8 Wk | Total | ||
| Wound | |||||
| Infection | 2 | 1 | 1 | – | 2 |
| Pneumonia | 1 | 1 | – | – | 1 |
| Total | 3 | 2 | 1 | 3 | |
Maternal Acute Care Visits
Of the 122 women followed, 19 women had acute care visits. The total number of acute care visits was 34, with a range of 1 to 7 visits. Reasons for the visits are categorized in Table 3. Fifteen women required only one visit. One women required six visits for wound complications, and one woman had a total of seven visits for pain caused by an entrapped nerve in her incision. Two women required three visits each, both for wound complications. Thus, four women accounted for 19 visits, 56% of the total number of visits, and wound infections and wound complications were the chief reasons for the maternal acute care visits. In these women 38% had Medicaid and 62% had private insurance.
Table 3.
MATERNAL ACUTE CARE VISITS TO 8 WEEKS AFTER DISCHARGE (N = 122)
| Diagnosis | No. of Women | No. of Visits
|
||
|---|---|---|---|---|
| Discharge-4Wk | 5–8 Wk | Total | ||
| Wound dehiscence | 3 | 9 | 1 | 10 |
| Reaction to sutures | 1 | 1 | – | 1 |
| Staples removed | 1 | 1 | – | 1 |
| Reddened incision | 1 | 1 | – | 1 |
| Abdominal pain | 1 | 1 | – | 1 |
| Incisional pain | 2 | 4 | 4 | 8 |
| Wound infection | 4 | 4 | 2 | 6 |
| Endometritis | 2 | 1 | 1 | 2 |
| Bronchitis | 1 | 1 | – | 1 |
| Hemorrhoids | 1 | – | 1 | 1 |
| Gastritis | 1 | – | 1 | 1 |
| Pelvic inflammatory disease | 1 | 1 | – | 1 |
| Total | 19 | 24 | 10 | 34 |
No acute care visits were required during the first 24 hours after hospital discharge. The majority of visits (24) occurred during the first 4 weeks after discharge.
Infant Rehospitalizations
Eight of the 123 infants followed required rehospitalization (Table 4). Unlike the maternal rehospitalizations, all of which occurred within the first 4 weeks after discharge, the infant rehospitalizations occurred somewhat later after discharge. There were no rehospitalizations within the first week after discharge, but there were five between 2 and 4 weeks and three between 5 to 8 weeks.
Table 4.
INFANT REHOSPITALIZATIONS TO 8 WEEKS AFTER DISCHARGE (N = 123)
| Diagnosis | No. of Infants | No. of Rehospitalizations
|
||
|---|---|---|---|---|
| Discharge- 4Wk | 5–8 Wk | Total | ||
| Surgery | 1 | 1 | – | 1 |
| Viral syndrome | 1 | – | 1 | 1 |
| Ruling out sepsis | 3 | 3 | – | 3 |
| Pneumonia | 1 | – | 1 | 1 |
| Respiratory syncytial virus | 1 | – | 1 | 1 |
| Transfusion (ABO incompatibility) | 1 | 1 | – | 1 |
| Total | 8 | 5 | 3 | 8 |
The eight infants rehospitalized had a total of 23 hospital days. Two of the three infants rehospitalized to “rule out sepsis” had a length of stay of 3 days each. The third infant was hospitalized for 5 days. None of the three infants was found to have sepsis and thus did not require antibiotic therapy after discharge. One infant was rehospitalized for surgery to repair a uterocoele and remained in the hospital just 1 day. Another infant developed pneumonia at slightly less than 8 weeks after discharge. This infant’s mother was also rehospitalized with pneumonia in preceding weeks (as previously reported). Another infant was followed on an outpatient basis for hyperbilirubinemia caused by ABO incompatibility and was rehospitalized at 3 weeks of age for anemia requiring a transfusion. This rehospitalization was for only 1 day. The two remaining infants were admitted for viral syndrome and respiratory syncytial virus at 6 and 4 weeks after discharge, respectively. Therefore, six of the eight rehospitalizations (75%) were for infections or possible infections and the remaining were for a congenital anomaly and a blood group incompatibility. Of the eight infants who were rehospitalized, 50% were covered by Medicaid and the other 50% had private insurance.
Infant Acute Care Visits
Of the 123 infants followed during the 8-week postdischarge period, 38 infants (31%) had a total of 56 acute care visits (Table 5). The number of visits was similar in the discharge to 4-week period and the 5- to 8-week period. The median number of visits was one, with a range of one to three.
Table 5.
INFANT ACUTE CARE VISITS TO 8 WEEKS AFTER DISCHARGE (N = 123)
| Diagnosis* | No. of Infants | No. of Visits
|
||
|---|---|---|---|---|
| Discharge- 4 Wk | 5–8 Wk | Total | ||
| Bilirubin | 5 | 12 | – | 12 |
| Diaper rash | 3 | 3 | – | 3 |
| Cord complication | 4 | 3 | 2 | 5 |
| Crying | 2 | 2 | 1 | 3 |
| Colic | 2 | 2 | – | 2 |
| Diarrhea | 1 | – | 1 | 1 |
| Ruling out sepsis | 1 | 1 | – | 1 |
| Upper respiratory tract infection | 13 | 2 | 11 | 13 |
| Conjunctivitis | 4 | 2 | 2 | 4 |
| Viral syndrome | 2 | – | 4 | 4 |
| Gastroenteritis | 2 | – | 2 | 2 |
| Thrush | 3 | 2 | 1 | 3 |
| Weight check | 1 | 2 | – | 2 |
| Face rash | 1 | 1 | 1 | |
| Treatment for congenital syphilis | 1 | 1 | – | 1 |
| Total† | 45 | 32 | 25 | 56 |
Six infants had more than one diagnosis per acute care visit, and one infant had three different diagnoses per acute care visit.
Only 38 infants had a total of 56 acute care visits, but these 38 infants had a total of 45 diagnoses.
The most commonly occurring problem was upper respiratory tract infection, which involved 13 infants. Other infections included gastroenteritis (2), diarrhea (1), thrush (3), viral syndrome (2), eye infection (4), and ruling out sepsis (1). These infections or potential infections accounted for a total of 29 visits involving 22 infants (some infants had more than one diagnosis). Therefore, 52% of the acute care visits (29 of 56) were for infections. In the first 4-week period, eye infection, gastroenteritis, and thrush were the most common infection, and in the second 4-week period, upper respiratory tract infection and viral syndrome were prevalent. One infant had three acute care visits with four diagnoses: colic, thrush, diaper rash, and viral syndrome. Two other infants had a total of three visits collectively for colic and infant crying. Five infants had a total of 12 post-hospital discharge bilirubin checks. Significant ABO incompatibility was diagnosed in one infant. All of the acute care visits for bilirubin monitoring were in the first 4-week period. Four infants were seen for cord complications, but no treatment was given other than cleansing. Among the infants who had acute care visits, 33% had Medicaid, 64% had private insurance, and 3% had self-pay.
DISCUSSION
Our study findings are consistent with other reports of complications, rehospitalizations, and postdischarge acute care visits in mothers and newborn infants after cesarean delivery. A major complication after cesarean delivery is maternal infection, with rates ranging from 5% to 85%. These reported maternal infection rates, however, represent postpartum infection rates while women were hospitalized. In this study, the rate for infection while women were hospitalized was 28%. After hospital discharge, the infection rate for women in whom infection was undiagnosed at the time of discharge but diagnosed within the 8 weeks of postdischarge follow-up was 8%.
The peak time of postdischarge maternal complications after cesarean birth is also important. The rehospitalization of three women and 71% of the maternal acute care visits occurred within the first 4 weeks after discharge. Study results indicated that complications of infants after cesarean birth tend to be less concentrated in the first 4 weeks after discharge. This is reflected in both rehospitalizations and acute care visits.
The majority of infant rehospitalizations (75%) were to treat infection or to rule out infection. In the first 4 weeks after discharge, the majority of acute care visits for infants (71%) were for non-infection-related problems, most involving hyperbilirubinemia and routine infant are issues. In contrast, during the second 4 weeks after discharge, 92% of the acute care visits were for infections, most commonly respiratory tract infections. This finding is consistent with those of other reported studies.11–14
The results of this study demonstrate a distinct timeframe for specific groups of problems. In the first 4-week period after discharge, maternal wound complications and routine infant care problems predominated. In the second 4-week period, infant infections were the major concern. This raises pertinent points for both the content and the sequencing of discharge teaching for this group.
Although there are currently standards regarding discharge teaching of women who have cesarean births, the results of this study demonstrate a need for concentrating more emphasis on wound care and signs and symptoms of wound problems on the basis of research findings that wound complications occur more frequently in the first 4 weeks after discharge. Such teaching should include signs and symptoms of maternal infection including fever; foul-smelling lochia; swollen, reddened, or weeping incision; increased pain; or a general feeling of illness; as well as routine information on personal hygiene, normal lochia flow, and activity levels to avoid fatigue.
Teaching regarding infant care should include routine infant care topics followed by normal infant behavior and how this behavior may differ from signs and symptoms of an illness. Information needed includes cord care, hygiene to prevent diaper rash, infant feeding and formula preparation including refrigeration, and the importance of keeping bottles, nipples, pacifiers, and toys clean. Temperature taking, how to use a bulb syringe, and infant safety should also be taught. Measures to prevent infection should be emphasized including good hand washing before handling the infant and his or her articles, avoiding infant contact with infected individuals or with large crowds such as those found in shopping malls, and avoiding infant contact with large groups of children.13 Teaching recognition of infant illness is important including increased congestion, irritability, fever, how difficulty in breathing may be different from normal neonatal breathing patterns, how vomiting differs from spitting up, and how diarrhea differs from frequent stools with breast-feeding.13
Extensive teaching is difficult the first few days after cesarean birth because of the mother’s discomfort and her need to rest and recover, particularly if complications are present. The amount of information that must be taken in and processed by the mother and the other family members can rarely be conveyed effectively before discharge. This is especially true with current short lengths of hospital stay for these women and infants.
Follow-up teaching after discharge by using telephone calls and or home visits has become important in identifying and preventing complications. Follow-up teaching can reinforce previously taught information and provide reassurance, particularly in the first 4 weeks after discharge. Routine postdischarge follow-up can also potentially reduce the number of acute care visits. In this study, several infant acute care visits such as those for infant crying and cord problems could have been eliminated through postdischarge telephone or home visit follow-up. In addition, bilirubin levels can be obtained safely and accurately in the home, thus obviating other acute care visits.16
In summary, the first few months after cesarean birth is an important period for the mother, infant, and family because maternal and infant complications can be significant in the postdischarge period. Teaching and counseling regarding prevention or early detection can be accomplished during the period of hospitalization and through follow-up by using telephone calls and or home visits. Such an approach can also potentially reduce health care costs and increase consumer satisfaction with health care services.
Acknowledgments
Supported by grant 1-P01-NR01859 from the National Center for Nursing Research, National Institutes of Health. Bethesda, Md.
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