Early discharge from hospital after caesarean section at Chris Hani Baragwanath Hospital.
|Article Type:||Letter to the editor|
Postpartum depression (Patient outcomes)
Hospitals (Admission and discharge)
|Publication:||Name: South African Journal of Obstetrics and Gynaecology Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 0038-2329|
|Issue:||Date: March, 2011 Source Volume: 17 Source Issue: 1|
|Geographic:||Geographic Scope: South Africa Geographic Code: 6SOUT South Africa|
To the Editor: It has become common practice to discharge women
from hospital early after caesarean section, to satisfy their wishes or
to reduce workload. This practice has not been evaluated in South
Africa. We undertook this study to find out if discharge from hospital
on the 2nd postoperative day after uncomplicated caesarean section was
acceptable to women, and to what extent it was followed by adverse
clinical outcomes. Only one such study has been performed in Africa, in
which Nigerian women were discharged on the 3rd instead of the usual 7th
postoperative day, with good results. (1) No studies from Africa have
investigated discharge from hospital on the 2nd postoperative day,
although there have been reports of good outcomes from high-income
countries. (2,3) The objectives of this study were to determine
women's satisfaction, and rates of wound infection, maternal
readmission, infant readmission and early postnatal depression.
We performed a cohort study of women discharged on the 2nd postoperative day after caesarean section at Chris Hani Baragwanath Hospital, with the permission of the University of the Witwatersrand's Human Research and Ethics Committee. The 2nd postoperative day was defined as 'day 2' on the postnatal morning round, from the date of delivery. This corresponds to a surgery-to-discharge interval of 33--57 hours. Women were discharged with no arrangement for home visits from nurses, and with routine follow-up only for removal of sutures. The following categories of women were excluded from the study: (i) age < 18 or > 45 years; (ii) hypertension, cardiac disease, diabetes mellitus, or antenatal anaemia (haemoglobin < 10 g/dl); (iii) high risk of postoperative infection (rupture of membranes [greater than or equal to] 24 hours, cephalopelvic disproportion, labour duration [greater than or equal to] 20 hours, pyrexia in labour; (iv) surgical difficulties such as vertical or upper-segment uterine incision or suspected bladder injury, or excessive intra-operative or peripartum bleeding requiring packing, draining or blood transfusion; (v) stillbirth; (vi) evidence of infection after 24 hours postoperatively (heart rate [greater than or equal to]110 beats/min, temperature [greater than or equal to]37.5[degrees]C); (vii) poor clinical condition on the 2nd postoperative day, such as not getting up, not eating, vomiting, evidence of ileus, purulent wound discharge or dehiscence; (viii) infant not yet discharged from the hospital; (ix) unwillingness to be discharged; and (x) no telephone contact number for follow-up.
We used a consecutive sampling method. The researcher (NP) collected data from the case notes and conducted a short interview, and then arranged a follow-up telephonic interview 14 days after discharge. At follow-up, the researcher asked the woman her experience of early discharge, and about evidence of wound dehiscence or purulent discharge, bleeding from the wound, pain associated with the wound, and readmission of the woman or her infant. Postnatal depression was assessed using a simple early postnatal depression tool described by Whooley et al. (4) Two questions were used as markers of postnatal depression. These were: 'Since the birth, how often have you been down, depressed, or hopeless?', and 'Since the birth, how often did you have little interest or pleasure in doing things?' If the responses to either question were 'often' or 'always', the woman was classified as having self-reported postnatal depression. Data analysis was done using Epi-Info software. Statements of descriptive statistics included frequencies with percentages, means and ranges. Differences in proportions were assessed using the chi-square test or Fisher's exact test with a p-value <0.05 suggesting statistical significance.
Of 107 women recruited, 9 (8.4%) were lost to follow-up, with no reply at their telephone numbers despite repeated efforts to contact them. Among the 98 who were followed up, the mean age was 26.5 years, with a range of 18--43 years. Most women (N=69, 70.4%) had emergency caesarean sections. Seventy-eight (79.6%) had transverse abdominal incisions and the remainder had vertical midline incisions. The mean birth weight was 3 164 g. The most frequent primary indications for caesarean section were fetal distress (N=48, 49.0%) and elective operation for previous caesarean section (N=20, 20.4%). At the 2-week follow-up telephone call, 88 women (89.8%) said they would choose early discharge again. Wound complications were described in a minority of women. Most women (N=57, 58.2%) reported no problems (Table I). Comparison of HIV-infected (N=26) and uninfected women (N=72) showed no statistically significant differences in terms of wound dehiscence, bleeding, pain, postnatal depression or readmission.
Three women were readmitted. One suffered a sprained ankle on the 7th postoperative day. A second was HIV infected and was admitted on the 12th day for endometritis, which was successfully treated with intravenous antibiotics. A third woman was admitted to a private hospital with eclamptic convulsions on the 4th day. There had been no evidence of a hypertensive disorder during her confinement at Chris Hani Baragwanath Hospital. Following treatment for eclampsia, she had a good clinical outcome.
Discharge from hospital on the 2nd postoperative day after caesarean section was found to be acceptable to the majority of women. The 3 maternal readmissions were all for complications that occurred after our standard 3rd-day discharge protocol, suggesting that the standard 3rd-day discharge would probably not have prevented their readmissions. The self-reported wound problems were not serious enough to require professional help, and were managed or tolerated by the women at their homes. A question mark remains over the 9 women who could not be contacted. None of them could be traced in other hospital wards in other institutions in the district, or in maternal death records. Their characteristics on recruitment into the study were not significantly different from those who were successfully followed up. The results of this study cannot be extended to women who had caesarean section for prolonged or obstructed labour, a common indication at this hospital. These women were excluded because of the high associated risk of subsequent infection. (5,6) In conclusion, discharge from hospital on the 2nd postoperative day after uncomplicated caesarean section without home visits in this setting appears to be acceptable and safe.
(1.) Fasubaa OB, Ogunniyi SO, Dare FO, Isawumi AI, Ezechi OC, Orji EO. Uncomplicated caesarean section: is prolonged hospital stay necessary? East Afr Med J 2000;77:448-451.
(2.) Brooten D, Roncoli M, Finkler S, Arnold L, Cohen A, Mennuti M. A randomized trial of early hospital discharge and home follow-up of women having cesarean birth. Obstet Gynecol 1994;84:832-838.
(3.) Strong TH Jr, Brown WL Jr, Brown WL, Curry CM. Experience with early postcesarean hospital dismissal. Am J Obstet Gynecol 1993;169:116-119.
(4.) Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997;12:439^45.
(5.) Hawrylyshyn PA, Bernstein P, Papsin FR. Risk factors associated with infection following cesarean section. Am J Obstet Gynecol 1981;139:294-298.
(6.) Koigi-Kamau R, Kabare LW, Wanyoike-Gichuhi J. Incidence of wound infection after caesarean delivery in a district hospital in central Kenya. East Afr Med J 2005;82:357-361.
Table I. Women's answers at the 2-week follow-up telephone call (N (%), N=98) Would choose early discharge again 88 (89.8) Wound open 9 (9.2) Wound draining pus 8 (8.2) Wound bleeding 4 (4.1) Pain associated with the wound 13 (13.2) Early postnatal depression 7 (7.1) Maternal readmission 3 (3.1) Infant readmission 0 (0.0) No problems reported 57 (58.2)
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