Elective caesarean section: a case study.
Caesarean section as a means of delivering babies has been around
for centuries with numerous references to the procedure appearing in
ancient writings (Simm & Matthew 2008). It is now the most common
major surgical intervention carried out on women in the world, with
between 23% and 30% of deliveries in the UK performed by caesarean
section (Beech 2004). This rate is all the more surprising when one
considers that caesarean section accounted for just 5.3% of UK births in
1973 (Kitzinger 1998). This rising rate has many implications for both
clinical practice and the NHS. An Audit Commission report (1997)
suggested that each 1% rise in the caesarean section rate would cost the
NHS five million pounds per year. However, the increased rate also has
clinical implications, with some studies suggesting that maternal
mortality is three to seven times greater following abdominal rather
than vaginal birth and maternal morbidity is proportionately even
greater, even with elective procedures (McCourt et al 2004).
KEYWORDS Tokophobia / Caesarean section / Anxiety
|Article Type:||Clinical report|
Cesarean section (Case studies)
Surgery, Elective (Psychological aspects)
Surgery, Elective (Case studies)
Anxiety (Care and treatment)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Feb, 2011 Source Volume: 21 Source Issue: 2|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
AfPP et al (2009) identified that there are many variations in the
delivery of obstetric care in the theatre environment across the UK. The
following study aims to critically analyse the care and management of a
maternity patient undergoing an elective caesarean section. The study
reports on a midwifery led model, where the midwife has a role in all
aspects of the patient's obstetric journey including
pre-assessment. The patient's previous obstetric history, journey
and outcome will be discussed. Close attention will be given to the
maternal request for non-medically indicated surgery. The risks
associated with this, including the management, and the impact that
maternal anxiety has on decision making and perioperative midwifery
care, will also be discussed. No identifying details of the patient
concerned have been used in order to maintain confidentiality (NMC 2004)
and the individual concerned has given permission for their story to be
Mrs A was a 38 year old para 1 (i.e. she had had one previous birth). Her first pregnancy was uneventful and she had hoped to have a normal delivery. However, following a long and difficult labour, she had a forceps delivery in theatre due to a non-reassuring foetal heart rate and suspected foetal compromise. A healthy baby girl was born weighing 7lbs 5oz. Her postnatal course was uneventful but Mrs A found the whole labour and delivery experience deeply traumatic and it had resulted in her waiting ten years before trying for a second child.
Mrs A booked with the maternity unit in her second pregnancy at 12 weeks gestation and had routine antenatal care and a healthy and uneventful antenatal course. At 34 weeks gestation Mrs A saw her obstetric consultant and requested an elective caesarean section stating she had been left with a fear of childbirth due to her previous traumatic birth experience. After some discussion, her consultant agreed and Mrs A was booked to have an elective caesarean section at 39 weeks gestation.
The National Institute for Health and Clinical Excellence (NICE) recommends that elective caesarean section should only be performed in certain circumstances (NICE 2004). These include: breech presentation at term if external cephalic contraindicated or failed, twin pregnancy if first twin breech, HIV positive mothers, HIV and hepatitis C, primary genital herpes in the third trimester and grade 3 and 4 placenta praevia. The guidelines further recommend that maternal request on its own is not an indication for caesarean section and that women who present with a fear of childbirth should be offered counselling. Mrs A was not debriefed following her first birth nor was she offered counselling when she discussed her fear of childbirth with her consultant.
Rising caesarean section rates are causing worldwide concern (Lee & Kirkham 2008). The escalating rate has, in part, been attributed to maternal request (Young 2006). Despite women's perception that this mode of delivery is a safer option, studies have shown that caesarean section performed without medical indication has greater physical and emotional risks than vaginal birth (Armson 2007, McFarlin 2004). As Liu et al (2007) state 'although the absolute difference is small, the risks of severe maternal morbidity associated with planned caesarean delivery are higher than those associated with planned vaginal delivery'. These risks should be considered by women contemplating an elective caesarean delivery and by their physicians.
Informed consent and the role of the theatre midwife
Mrs A attended the pre-operative assessment clinic at 38 weeks gestation where the necessary blood tests were taken and consent form signed. In the maternity unit concerned, women are admitted directly to the obstetric theatre department on the morning of their surgery and the same midwife provides all preoperative, intraoperative and immediate postoperative care. Mrs A arrived at 8am as arranged with surgery planned for 9am.
A vital part of the theatre midwife's role is to check that all the necessary paperwork has been completed, including the consent form. Patients undergoing a caesarean section sign the standard universal consent form but are also asked to sign an extra form detailing the additional risks specific to caesarean. This arguably ensures that their consent is fully informed. However, although women are given information on the associated physical risks there is limited information given on the potential psychological implications of an operative delivery (McFarlin 2004). This has implications for the consent process as it could be argued that without being fully informed of the psychological risks an informed choice cannot be made.
An early study found that women delivering by both emergency and elective caesarean section were more likely to experience anxiety and postpartum depression than those delivering vaginally (Fisher et al 1997). These findings were echoed by Gamble & Creedy (2005) who found that 9 out of 35 women met the criteria for posttraumatic stress disorder at four to six weeks following an elective caesarean section. It is acknowledged that these figures were considerably higher in the emergency caesarean group.
One could argue that consent cannot be fully informed unless women are aware of all possible adverse outcomes. However, this must be balanced against women's choice and the giving of information swayed by a political and health care agenda which discourages elective caesarean section based on maternal request. Kingdom et al (2003) argued that there are complex ethical debates surrounding the overriding consideration in clinical decision-making, professional duty of care or women's choice.
With Mrs A being admitted to hospital only one hour prior to her elective surgery it could be argued that this is an inappropriate time to address issues or concerns around consent as any additional negative information may have only added to her already anxious mental state. The increasing demand for hospitals to work more efficiently means that it is now commonplace for patients to be admitted on the day of surgery. A consequence of this is that healthcare professionals have little time to talk to patients to ascertain their level of anxiety or to establish whether they require any additional information (Pritchard 2009a).
Extensive searching of the literature provides no evidence on the role of the obstetric theatre midwife, but the midwives' rules clearly state that if a midwife feels that the type of care a woman is requesting could cause significant risk, then her wishes should be discussed and detailed information provided which outlines the potential risks, so that a woman may make a fully informed decision (NMC 2004).
Mrs A had attended the preoperative assessment clinic prior to admission but a midwife had not been present at this clinic. Neither was a midwife present when Mrs A saw her consultant to request an elective caesarean section. There appears to be a role for obstetric theatre midwives at preoperative caesarean section clinics. This midwife would be available to discuss fully the issues around the procedure especially when women are requesting this option in the absence of medical indications. The information given by medical staff is based purely upon the risks and benefits of surgery. Due to time constraints the information given at this session does not include detail of the psychological implications and postnatal effects. Adequate time should be given to fully address the psychological influences that lead women to request elective caesarean in the absence of maternal or foetal indications.
Page (1999) suggests that midwives faced with women requesting an elective Caesarean section must adhere to basic midwifery practice principles and ensure that women have enough information to help them make a truly informed decision. One could argue that Mrs A's midwifery care failed to adhere to these basic principles by both failing to address her negative experiences following her first delivery and also failing to offer an opportunity to discuss her feelings and fully inform her about her present pregnancy. These failures had a huge impact on her emotional state and decision making.
Implications of tokophobia on care in the perioperative phase
While performing the usual preoperative theatre checks and preparation Mrs A became very visibly upset. She became weepy and agitated and expressed fear regarding her imminent surgery. Discussion with the anaesthetic consultant and obstetrician did little to calm or reassure her.
Tokophobia is described as anxiety and fear regarding labour and birth (Walsh 2002). It has been suggested that almost 20% of women are afraid of childbirth (Jolly et al 1999), and that this has caused an increase in the number of women requesting caesarean section (Waldenstrom et al 2006). This increase in the number of women requesting caesarean section for non-medical reasons presents huge challenges for midwives and obstetricians alike (Lotta et al 2010).
Mrs A had her baseline observations recorded during her preoperative checks. Blood pressure was raised at 148/96, she had a tachycardia of 106 beats per minute and her respiratory rate was 22. Her booking observations at 12 weeks gestation were blood pressure 118/70 with a heart rate of 72. It was evident that her distressed state was having a negative physiological impact. Mrs A stated that she had thought that an elective caesarean section would allay some of the fears she had as a result of her previous experience but that this was now not the case.
Early studies suggest that very strong fears of childbirth can have serious physiological implications resulting in high blood pressure and even toxaemia (Mansfield & Cohn 1986). These changes are due to sympathetic stimulation, which increases heart rate and blood pressure and causes peripheral shutdown and shunting of blood to the heart and central nervous system and also potentially reduces flow of blood to the foetus (Melender & Lauri 1999). These findings are echoed in later studies, which suggest that maternal anxiety commonly contributes to intrauterine growth restriction and birth asphyxia perhaps due to increased uterine artery resistance (Saisto et al 2001). Anxiety can cause a wide range of physiological responses. These include tachycardia, hypertension, increased temperature, sweating, nausea and an increased sensory perception, such as touch, smell and hearing (Pritchard 2009b). There is no doubt that these physiological manifestations of anxiety can have a huge impact on the management of the patient undergoing surgery.
As far back as 1958 studies were beginning to highlight the wider implications of anxiety in the surgical patient. Janis (1958) suggested that there was a direct correlation between anxiety levels and perception and management of pain, with high anxiety levels sensitising patients and making their pain more acute. This means that patients may require increased doses or alternate analgesics in order to maintain adequate pain relief, thereby putting them at risk of increased side effects and polypharmacy (Sjoling et al 2003). Anxiety can also affect an individual's response to anaesthetic meaning that they may require greater amounts of anaesthetic drugs (Hong & Koong 2003). This potentially had huge implications for Mrs A as the risks of higher levels of anaesthetic agents, if required, could have negative consequences for both her and her foetus.
Anxiety can also have an impact on patients' longer term recovery from surgery. Kiecolt-Glaser et al (1998) suggest that anxiety can lower a patient's immunity, delay healing and result in increased hospital stays. This has implications for the patient's well being and management, as well as having financial implications. More recent studies have had similar findings, with suggestions that pain, depression, nausea, fatigue and discomfort are all negatively influenced by anxiety amongst patients undergoing surgery (Montgomery & Bovbjerg 2004, Carr et al 2005).
Care of the anxious patient
The use of an individualised and patient centred approach in reducing anxiety is essential. In obstetrics a traumatic birthing experience can overwhelm a woman's normal ability to cope with stress (Gamble & Creedy 2005). During discussion with Mrs A she stated that she would like some additional time to talk through her concerns and anxieties. The midwife acting as the patient's advocate contacted the obstetric consultant and it was agreed she would be moved to a later position on the surgical list in order to facilitate this.
Support from health professionals has been identified as an important factor in helping women cope with childbirth (Gibbins & Thomson 2001). Mrs A spent an hour talking about her specific fears and anxieties and issues around her previous delivery in theatre that she had found particularly traumatic. It emerged that most of her fears came from her feelings of a loss of control and the large number of personnel and noise within the theatre during the procedure. Green & Coupland (1998) discussed that often it is not an obstetric emergency or the intervention which women find traumatic but the associated feelings of a lack of control. This sense of a loss of control can be terrifying and can cause feelings of panic in the mother (Henderson & MacDonald 2004).
Normally when women are having a spinal anaesthetic sited prior to caesarean section their birth partner is not present in theatre as there are risks associated with this procedure. The birth partner is not brought into theatre until sterile equipment is set up, drapes are in place and the procedure is ready to begin. However, Mrs A stated that having her partner present from the outset would be a support and allay some of her anxieties. Following discussion with the anaesthetist this was agreed. When Mrs A was taken into theatre her partner was present and only essential staff were allowed in theatre. Everyone concerned was informed of Mrs A's wishes and worked together as a team to make this a positive birth experience. Noise and conversation amongst staff were kept to a minimum and Mrs A had her choice of music playing in theatre. The caesarean section proceeded without complications and Mrs A's partner remained throughout. Following the procedure Mrs A was transferred to the postoperative recovery area within the labour ward. Skin to skin contact with her baby was initiated and interventions and noise were kept to a minimum. After two hours Mrs A was transferred to the postnatal ward. She stated that this had been a very positive birth experience and that the opportunity to discuss her previous negative experiences had been invaluable.
The rising caesarean section rate provides challenges for midwives working in the perioperative environment both in terms of the impact on the maternity services, but more importantly in terms of the diverse role of the midwife in caring for these women. Anxiety surrounding childbirth is well documented (Jolly 1999, Waldenstrom et al 2006). When this anxiety is manifested in patients undergoing caesarean section it can increase risk and present added potential for complications, both psychological and physiological (Mansfield & Cohn 1986, Melender & Lauri 1999, Saisto et al 2001, Pritchard, 2009b).
Midwives caring for women with severe fear and anxiety around childbirth must use an individualised and person centred approach in order to provide safe and optimum care (Gibbins & Thomson 2001). By using a multidisciplinary, holistic approach to perioperative care women can regain a sense of control which, when lost, can be a major factor in their anxiety (Green & Coupland 1998, Henderson & MacDonald 2004). Midwives must use this opportunity and the autonomy the profession offers in order to positively influence care of their surgical patients and to provide a holistic approach, which addresses both physical and psychological well being. This, as demonstrated in the case of Mrs A, has the potential to make a huge difference to the patient in tangible ways, and to reduce the unseen risks.
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Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication November 2010.
BSc (Hons), DipHE, RN, RM
Registered Midwife, Labour Ward and Obstetric Theatres, Ulster Hospital, Dundonald
RGN, MSc Nursing, PGCE, ENB 176
Teaching Fellow Short Course Perioperative Nursing Programme Coordinator, Queen's University Belfast
No competing interests declared
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