In Norway, the incidence of emergency and elective caesarean sections is rising. In order to safeguard a high standard of follow-up for this patient group, it would therefore, in our view, be useful for the guidelines to include a good description of postnatal care for women who have given birth by caesarean section.
Long periods without receiving attention
The informants described how important it is that postnatal healthcare personnel make themselves accessible and provide good care. They had found that while they received close follow-up on the first day after surgery, the level of attention was then reduced, and they were left to their own devices for long periods. They felt uncomfortable about bothering busy maternity staff, and some felt that healthcare personnel had expected them to manage by themselves when their partner had gone home.
The women who had undergone an emergency caesarean section on a previous occasion were generally happier with the follow-up that they received. Two of the women had received counselling and had drawn up a plan for their postnatal hospital care. Hjälmhult and Økland (14) found that postpartum women received little help or practical support from staff, and that the women felt they were not treated as individuals. Similar findings are described in other studies (24–28).
Our informants explained that they had endured hours without receiving attention from postnatal personnel immediately after transfer from the recovery unit. One informant was even told that the ward was busy, and that the staff had forgotten about her.
According to Thorstensson et al. (25), women were left to their own devices for hours without receiving attention, whether delivery had been vaginal or by caesarean section. This is disconcerting considering the fact that women who have undergone a caesarean section have an elevated risk of complications. At the same time, the rate of birthing women with risk factors is rising (29, 30), which means that there is a general need for better postnatal care.
One of our informants felt increasingly unwell during her postnatal stay in hospital, but neither her blood pressure nor her temperature was measured. She returned home in poor health and was re-admitted after two days due to complications associated with the caesarean section. Complications associated with caesarean sections and surgical deliveries are undesirable incidents that may jeopardise patient safety, particularly when the complications are not identified before discharge from hospital and the follow-up responsibility is left to the woman herself and a potential partner.
The clinical guidelines issued by the National Institute for Health and Care Excellence (NICE) specify that fit and healthy women should be discharged from hospital no earlier than 24 hours after a caesarean section, but that prior to discharge they must be monitored in hospital with a view to complications (7). Postnatal personnel must be available and trained to undertake the required observations.
Good help and support provided by the partner
Studies show that women’s satisfaction with their postnatal stay in hospital increases if their partner can stay with them (26). Our study highlights the partner’s presence as being highly valuable for women who have given birth by caesarean section. Some informants were unable to imagine how they would have coped on the postnatal ward without the assistance of their partner, while others chose to go home to make sure they would receive adequate assistance and respite.
The informants’ descriptions of how important it is to receive help, support and care from their partner gives the impression that the partner’s presence is of great value. Patient safety should be part of the ward culture rather than dependent on the presence of relatives. However, the practical assistance that a relative is able to provide for a new mother who is recovering from surgery is a weighty argument for prioritising family rooms for these couples.
Strengths and weaknesses of the study
All of the authors are midwives with either a masters or doctoral degree on top of many years’ experience of work in delivery and maternity wards, including professional development. One author is still working as a midwife in clinical practice, while two are training midwifery students. Our work experience has impacted on our understanding of the data.
We used semi-structured interviews to gain insight into the women’s experiences (16), combined with thematic cross-case data analysis. This method was useful and pragmatic given our relatively large body of data (16), and the informants talked willingly about their postnatal experiences. This enabled us to collect a rich material that contributed to shedding light on the study’s research question.
Three women had experience of more than one caesarean section. They found it unproblematic to distinguish between the caesarean sections but talked about their experiences in relation to both operations.
The women we recruited contacted us after seeing a social media post shared by midwifery colleagues and others among their personal Facebook networks. The use of social media and snowball sampling (16), i.e. that the informants communicated the information to other potential recruits, meant that the sample was somewhat homogeneous, since all informants were resourceful women with a higher education.
On the other hand, it is a strength of the study that both primiparous and secundiparous women took part. The inclusion of more women with an immigrant background would have strengthened the study’s external validity, as there is a higher risk of emergency caesarean section among immigrant women (30).
The study shows that women who had given birth by emergency caesarean section experienced inadequate care for their physical health after surgery. Although the postnatal women felt no pressure to go home early, several experienced that midwifery help and support was not always available to the extent that they needed it. Some endured long periods without receiving attention, little assistance was forthcoming once their partner had gone home, medicines were forgotten about and complications were overlooked.
There is a need for further research to be carried out on the quality of postnatal care provided in Norwegian hospitals. There is also a need to investigate the consequences of inadequate follow-up after delivery by caesarean section for the mother, the child and the wider family.
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