Cesarean Delivery Section Surgery - Essay Example

Cesarean Section Delivery: The Role of the Nurse in Stemming the Epidemic of Elective C- Section Surgery in the United s. William L. Mixson INTRODUCTION: Cesarean section delivery has recently become almost a routine in many maternity hospitals. This is mainly due to the reason that cooperation from the pregnant women and the nonprofessionals (like birth attendants), essentials in effecting a normal vaginal delivery, have become a rare phenomenon. The foremost reason for opting for cesarean deliveries is pelvic floor dysfunction. Moreover, the legal implications involved in the failure of deliveries have also paved the way for Cesarean Deliveries at Maternal Request (CDMR). Although studies made so far pronounce that the number of women requesting cesarean sections in the absence of clinical indications is almost zero, however obstetricians consider maternal request a major factor in driving the cesarean rate upward. (Jane J. Weaver et al., 2007). Chris McCourt et al., (2007) also accede to the above findings, adding further that a range of personal and societal reasons, including fear of labor/delivery and perceived inadequacy of care, are the underlying cause behind many pregnant women’s request for cesarean section surgery. (Chris McCourt et al., 2007) Since quite a long time, the responsibility of obtaining a mother’s “request” for cesarean surgery has been placed on the nursing community. Because of the position of the nursing community with respect to interaction with both patients and the doctors, and the trust that their interaction elicits in the patients, nurses were and are able to draw out such “requests” from pregnant women with less difficulty. Now scores of pregnant women have started insisting on cesarean surgery not only as a matter of choice but also as a matter of right. The positive and negative factors of both vaginal and cesarean section delivery are yet to be understood in full almost by both the mothers and medical community. But the “epidemic” of elective C-section surgery has spread greatly. Although the dictum, ‘cesarean follows cesarean’ has begun to fade slowly over the last three decades, the effectiveness of vaginal delivery is yet to be understood in its entirety. W. Benson Harer’s view, which he propounded in 1997, that there is a very slow decrease in the rate of cesarean section delivery is still prevailing. The increase in percentage of VBAC from 3% in 1981 to 27.4% in 1997 was not surpassed, as the total increase of cesarean in US was 20.8%. (Benson Harer Jr., 2002). The Mortality Morbidity Weekly Report1 (MMWR) issued from the Centers for Disease Control and Prevention also agree with these findings for the period 1992-2002. The report while analyzing the reasons for increased cesarean rate in Puerto Rico ascribed such increase to maternal characteristics, attitude towards cesarean delivery, obstetric practices or health insurance coverage. The current rate of concern over cesarean section surgery among women is worrying. Maureen Porter et al. (2007) conducted a large-scale postal survey in which they were able to elicit that around 36% of women expressed distress over cesarean section delivery, which was based on psychological grounds and poor communication. (Maureen Porter et al., 2007) Nurses are to devise strategies to stem this so-called epidemic. Fear over normal vaginal delivery must be removed and complications arising during delivery must be addressed in an appropriate and efficient manner. Feasibility of vaginal delivery over cesarean section surgery should be emphasized, and the need for opting cesarean has to be analyzed with a multi directional approach; including ethical and socio-economic perspectives apart from clinical obligations and/or constraints. The pregnant women must be made to opt either for vaginal or cesarean delivery after making them understand the prospects of both forms of delivery as completely as possible. Initially the nurses have to alleviate the fear of labor in pregnant women. This is not an easy job for them and they have to walk a very tight rope as their own forerunners sowed the fear of labor. This previous line may seem exaggerated, but seeing how even primiparous women wish to undergo cesarean section delivery it can be affirmed that they are instilled with fear of vaginal delivery. I. Fears: In the words of Jane Pincus2, fears and phobias of pregnant women are renamed ‘requests’ and ‘rights’ and, consequently, the phobias are not addressed and are reinforced. The intrusive management styles in hospitals normally invade the personal boundaries of women. In the process of removing the fear of labor among mothers, nurses should place all relevant facts regarding vaginal and cesarean section delivery in a balanced manner. To attain this goal a smooth atmosphere for discussion between medical communities themselves, especially nurses and pregnant women, is needed. But in truth reluctance to disclose sensitive issues by pregnant women and reluctance to ask such questions by medical practitioners still prevails. Kelsey Hegarty et al. (2007) have shown that with the help of a new educational intervention program a trend of better communication between health professionals and pregnant women can be seen. They trained 21 midwives and five doctors and found that pregnant women were more likely to respond when midwives asked questions that helped them talk about psychosocial problems including concerns relating to sex. The team also concluded that the intervention program needed to be evaluated using rigorous methods in other settings (Kelsey Hegarty et al., 2007). Fear of urinary incontinence, a disorder that can be blamed on vaginal delivery, has made several primiparous mothers opt for cesarean surgery. Mary E. Hennah et al. (2002) conducted a RCT between 1997 and 2000 on 1940 women from 110 centers worldwide to arrive at the result that the basic information was similar for both cesarean and vaginal delivery groups. However, the team also concluded that women in the planned cesarean delivery group were less likely to report urinary incontinence than those in the planned vaginal delivery group. (Mary E. Hannah et al., 2002) Joshua Z Press et al. (2007) have done an excellent research on this issue and have found that urinary incontinence did not differ due to the mode of birth. On calculating odds ratio (OR), absolute risk deduction (ARD) and number needed to prevent, the team was able to conclude that although short-term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent in both modes of birth. (Joshua Z Press et al., 2007) II. Complications Related to Cesarean: Incidence of Respiratory distress syndrome in neonates is still prevalent in cases of cesarean. The predictions made by D. N. Danforth (1985) do not seem to have changed over a period of two decades. Maternal mortality from cesarean section too is almost three to five times higher than from vaginal delivery. (D.N. Danforth, 1985). Cesarean delivery was associated with significantly increased risks of uterine infection, obstetrical surgical wound complications and cardio pulmonary and thrombo-embolic conditions. Mona Lyndon Rochelle et al (2000) arrived at the conclusion that women with cesarean deliveries were at increased risk for rehospitalization particularly with infectious maladies. (Mona Lyndon-Rochelle et al., 2000). Other complications feared, that follow cesarean section, include Transient trachypnea, Placenta previa, Placenta accrete and Peripartum hysterectomy. The fear of peripheral neuropathy is one of the aspects that cause fear in pregnant women. This complication is mostly due to prolonged squatting during normal vaginal delivery. Soma Sahai Srivatsava & Liyana Amezcua (2007) confirmed through neurological examination and electro diagnostic studies that bilateral common peroneal mono neuropathy were most likely secondary to prolonged and excessive knee pressure given by attendants during birth. This team also concludes that patient education and awareness among the labor and delivery team can prevent this avoidable complication. (Soma Sahai-Srivastava & Lilyana Amezcua, 2007). While determining the risk factors of maternal death, Gustavo R.G et al. (2007) found that 49% of such deaths were among those undergoing a cesarean section. Citing Van Roosmalen (1995) of Netherlands, the team emphasized that the practice of cesarean section should be reduced in countries where the maternal mortality ratio after the operation exceeds 100/100,000 live births. (van Roosmalen & van der Does, 1995) (Romero-Gutierrez et al, 2007) II. a. Complications Related to Vaginal Delivery: Stillbirth: Stillbirth generally occurs due to placental dysfunction in the first 10 weeks after conception. (Smith, et al., 2004). Stillbirth in labor after a previous cesarean delivery is commonly due to increased risk of uterine rupture. (Smith, et al., 2002) The fact that such risk is minimized considerably in a planned repetition of cesarean delivery does not highlight any decisive factor against vaginal delivery. Stillbirth is not always associated with vaginal delivery. Hence this cannot be construed as a complication of vaginal delivery. Incontinence: Urinary incontinence was often found to follow vaginal deliveries in many cases. Susan L. Hendrix et al. (2005) have landed at a plausible solution for the treatment of urinary incontinence (UI). They have evaluated the effects of estrogen with Progestin and without Progestin. They selected around 27000 post-menopausal women in the age group of 50 – 79 with hysterectomy status. The study divided these women in two groups one with estrogen alone and the other with estrogen and progestin. The team was able to found that conjugate equine estrogen alone and CEE+MPA increased the risk of Urinary Incontinence among continent women. This type of menopausal hormone therapy MHT and related research findings could be taken in to account for women subjected to vaginal delivery. (Hendrix et al., 2005) III. Feasibility of Vaginal Delivery: Feasibility of vaginal delivery can be enhanced by way of perineal massage during the last four or five weeks of pregnancy. This process of massages has been proven to reduce the number of episiotomies in vaginal delivery attempts. (Kuehn, 2006) IV. Reason of Need for Cesarean Option: So far indicators analyzed for cesarean birth rates vary in every study. One such study was conducted by Anita J. Gagnon et al. (2007) to identify and describe indicators of continuity of nursing care responsibility during labor and to explore any association between these indicators and risk of cesarean birth that could be identified empirically. The team decided to conduct their study to explore the link of continuity of nursing care with cesarean birth rates on the ground that small studies hitherto conducted in US examined simply the maternal perception of nursing care. In their study obstetricians were mostly the birth attendants with a few general practitioners and a very few doulas; no midwives were allowed. Only two nurses were assigned, one during early labor and the other at late labor. The team arrived at the conclusion that an association was found between the number of nurses caring for a laboring woman and risk of cesarean delivery. However the team could not precisely draw any conclusion to the effect of patterns of nursing care responsibility on cesarean birth rates. (Gagnon, et al., 2007) This might be due to the allocation of a limited number of nurses during labor. The chief psychological effect being that pregnant women, especially primiparous women, tend to expect a nurse, who gave them medical and psychological support before labor, to be present during labor. V. How to Curtail this Trend: The alarming increase in the rate of cesarean section is of concern to the entire medical community. All over the world studies and researches are being conducted to identify ways to reduce the rate of cesarean sections. Nils Chaillet and Alexandre Dumont (2007) have rendered a fine research on this subject. They conducted a meta-analysis to assess the effectiveness of interventions for reducing the cesarean section rate and to assess the impact of such reduction on maternal and perinatal mortality and morbidity. In their study, they found no significant differences for perinatal and neonatal mortality and morbidity with respect to the mode of delivery. But they derived the conclusion that an identification of barriers to change was more effective than any other intervention for reducing cesarean section rate, describing it as a major key to success. (Chaillet & Dumont, 2007). A study performed in Brazil indicates that even before admission to the hospital, cesarean delivery is decided upon. Joseph E. Potter et al. (2001) while making a research on this issue with Brazilian pregnant women were able to conclude that preferences in the mode of delivery were not the factors in the difference between cesarean and vaginal delivery modes. They discovered that Brazilian middle and upper class women did not want to deliver by cesarean section. This aspect was attributed to the non-reflection of demand for surgical delivery despite the high rates of cesarean delivery. (Potter, et al., 2001) VI. Services of Midwives and Birth Attendants: Presently many obstetricians consider services of midwives and birth attendants incompatible with their clinical approach. While the need for stemming the cesarean section rate is the current issue under concern, the primordial services of traditional birth attendants and midwives, who have direct contact with pregnant women, cannot be rejected altogether on the ground that they lack sophisticated medical and clinical technological knowledge. The insufficient judgment of midwife services by the medical professionals is pointed out by Judith Rooks3. While talking about the use of nitrous oxide as the pain reliever during labor, Rooks brings out the factual plight of American midwives who had few experiences with nitrous oxide as they considered it a medicine although the same is treated as a natural adjunct of midwifery model of care by medical teams. VII. Apprising Pregnant Women: To remove the fear of labor, pregnant women have to be made to step in to the trial of labor with the intent to experience a new realm perhaps with pain. Here also the role of nurses is crucial in making their pain tentatively diminish – apart from resorting to medical aid for the purpose – at least during the time of labor, by way of boosting her image as a Great Mother. Post-natal care then automatically brings down all the pain and fear in mothers. Pain and fear become components of their trial of experience in giving birth to their second offspring and in their third delivery the fear almost vanishes and the pain is felt like a bit of a heavy tweak. Detailed discussions between pregnant women and doctors are appreciated. The discussions should maximize the mothers’ understanding of the issues and should be specific to their personal needs, such as future reproductive plans, medical risk factors, psychological needs, social and family situation and other factors. CONCLUSION: The increasing rate of elective C-section surgery all over the world especially in US is ascribed mainly to the medical community’s approach towards vaginal delivery that has been given priority and importance since long. The conveniences of obstetricians in performing cesarean section have been imbibed in the minds of pregnant women as their own conveniences. Over-emphasis of pain of vaginal delivery above normal has been infused in the minds of primiparous women. Not only the medical community but also the society everywhere as a whole contributes to the spread of fear of pain. Elimination of fear is the foremost part of the job of a nurse. The current advancements in medicine and technology force nurses to appraise the patients in a well-balanced manner, for which they ought to place relevant information to the pregnant women. Although the concern over the increase in the rate of cesarean delivery is on the rise, researches to stem the practice are underway and the efficacy of vaginal birth is being given much publicity. The mixed responses from many pregnant women indicate that the output of one mode of birth over the other cannot accurately be weighed or judged. The complications in both the modes of delivery are to be viewed in individualized environment. Any decision to perform a CDMR must therefore be meticulously calculated in consistence with ethical principles. * * * * * * References: Bridget M. Kuehn, B.M. (2006). “Massage during Last Weeks of Pregnancy Reduces Episiotomies During Delivery”. JAMA, Vol. 295, No. 12, 1361-1362. Chaillet, N., & Dumont, A. (2007). “Evidence-Based Strategies for Reducing Cesarean Section Rates: A Meta-Analysis”. Birth, 34:1, 53- 64 (12). Danforth, D. N. (1985). “Cesarean Section”. JAMA, Vol. 253. No. 66, 811-818. Gagnon, Anita J., Meier, Katharine M. & Waghorn, Kathy. (2007). “Continuity of Nursing Care and its Link to Cesarean Birth Rate”. Birth, 34:1, 26-31. Hannah, M. E., Hannah, W. J., Hodnett, E. D., Chalmers, B., Kung, R., Willan, A., et al. (2002) “Outcomes at 3 month after Planned Cesarean Vs Planned Vaginal delivery for Breech Presentation at term”, JAMA, Vol. 287, No. 14, 1822-1831. Harer Jr., B. (2002). “Vaginal Birth After Cesarean Delivery”. JAMA, 287, 2627-2630. Hegarty, K., Brown, S., Gunn, J., Forster, D., Nagle, C., Grant, B., et al. (2007). “Women’s Views and Outcomes of an Educational Intervention Designed to Enhance Psychosocial Support for Women During Pregnancy”. Birth, 34 (2), 155–163. Hendrix, S. L., Cochrane, B. B., Nygaard, I. E., Handa, V. L., Barnabei, V. M., Iglesia, C., et al. (2005) “Effects of Estrogen With and Without Progestin on Urinary Incontinence”. JAMA, Vol. 293, No. 8, 935-948. Lyndon-Rochelle, M., Holt, V. L., Martin, D. P. & Easterling, T. R. (2000). “Association between Method of Delivery and Maternal Rehospitalization”. JAMA, Vol. 283, No.18, 2411-2416. McCourt, C., Weaver, J., Stathman, H., Beake, S., Gamble, J. & Creedy, D. K. (2007). “Elective Cesarean section and Decision Making: A Critical Review of the Literature”. Birth, 34:1, 65 -79. Porter, M., van Teijlingen, E., Chi Ying Yip, L., Bhattacharya, S. (2007). “Satisfaction with Cesarean Section: Qualitative Analysis of Open-Ended Questions in a Large Postal Survey”. Birth, 34 (2), 148–154 (7). Potter, J. E., Berquó, E., Perpétuo, I. H. O., Leal, O. F., Hopkins, K., Souza, M. R. & de Carvalho Formiga, M. C. (2001). “Unwanted cesarean sections among public and private patients in Brazil: prospective study”. BMJ, Vol.323 (7322), 1155-1158. Press, J. Z., Klein, M. C., Kaczorowski, J., Liston, R. M. & von Dadelszen, P. (2007) “Does Cesarean Section Reduce Postpartum Urinary Incontinence? A Systematic Review”. Birth, 34 (3), 228–237. Romero-Gutierrez, G., Espitia-Vera, A., Ponce-Ponce de Leon, A. L., & Huerta-Vargas, L. F. (2007) “Risk Factors of Maternal Death in Mexico”. Birth, 34:1, 21-25. Sahai-Srivastava, S. & Amezcua, L. (2007) “Compressive Neuropathies Complicating Normal Childbirth: Case Report and Literature Review”. Birth, 34 (2), 173–175. Smith, G. C. S., Crossley, J. A., Aitken, D. A., Pell, J. P., Cameron, A. D., Connor, J. M. & Dobbie, R. (2004). “First Trimester-Placentation and the Risk of Antepartum Stillbirth”. JAMA, Vol. 292, No.18, 2249-2254. Smith, G. C. S., Pell, J. P., Cameron, A. D. & Dobbie, R. (2002). “Risk of Perinatal death Associated With Labor After Previous Cesarean Delivery in Uncomplicated Term Pregnancies”. JAMA, Vol. 287, No. 287, 2684-2690. van Roosmalen, J. & van der Does, C. D. 1995, “Caesarean birth rates worldwide. A search for determinants”, Trop Geogr Med, 47 (1), 19-22. Weaver, J. J., Statham, H. & Richards, M. (2007). “Are there ‘Unnecessary’ Cesarean Sections? Perceptions of Women and Obstetricians about Cesarean Sections for Non-clinical Indications”. Birth, 34:1, 32-41. Read More