Adaptation, postpartum concerns, and learning needs in the first two weeks after caesarean birth

Authors

  • Marianne Weiss,

    1. Authors:Marianne Weiss, DNSc, RN, Associate Professor and Wheaton Franciscan Healthcare – St. Joseph/Sister Rosalie Klein Professor of Women’s Health, Marquette University College of Nursing, Milwaukee, WI, USA; Jacqueline Fawcett, FAAN, PhD, Professor, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA; Cynthia Aber, EdD, RN, Associate Professor (Retired), College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
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  • Jacqueline Fawcett,

    1. Authors:Marianne Weiss, DNSc, RN, Associate Professor and Wheaton Franciscan Healthcare – St. Joseph/Sister Rosalie Klein Professor of Women’s Health, Marquette University College of Nursing, Milwaukee, WI, USA; Jacqueline Fawcett, FAAN, PhD, Professor, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA; Cynthia Aber, EdD, RN, Associate Professor (Retired), College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
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  • Cynthia Aber

    1. Authors:Marianne Weiss, DNSc, RN, Associate Professor and Wheaton Franciscan Healthcare – St. Joseph/Sister Rosalie Klein Professor of Women’s Health, Marquette University College of Nursing, Milwaukee, WI, USA; Jacqueline Fawcett, FAAN, PhD, Professor, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA; Cynthia Aber, EdD, RN, Associate Professor (Retired), College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
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Dr Marianne Weiss, Marquette University College of Nursing, PO Box 1881, Milwaukee WI 53201-1881, USA. Telephone: 414 288 3855.
E-mail: marianne.weiss@marquette.edu

Abstract

Aims.  The purpose of this Roy Adaptation Model-based study was to describe women’s physical, emotional, functional and social adaptation; postpartum concerns; and learning needs during the first two weeks following caesarean birth and identify relevant nursing interventions.

Background.  Studies of caesarean-delivered women indicated a trend toward normalisation of the caesarean birth experience. Escalating caesarean birth rates mandate continued study of contemporary caesarean-delivered women.

Design.  Mixed methods (qualitative and quantitative) descriptive research design.

Methods.  Nursing students collected data from 233 culturally diverse caesarean-delivered women in urban areas of the Midwestern and Northeastern USA between 2002–2004. The focal stimulus was the planned or unplanned caesarean birth; contextual stimuli were cultural identity and parity. Adaptation was measured by open-ended interview questions, fixed choice questionnaires about postpartum concerns and learning needs and nurse assessment of post-discharge problems. Potential interventions were identified using the Omaha System Intervention Scheme.

Results.  More positive than negative responses were reported for functional and social adaptation than for physical and emotional adaptation. Women with unplanned caesarean births and primiparous women reported less favourable adaptation than planned caesarean mothers and multiparas. Black women reported lower social adaptation, Hispanic women had more role function concerns and Black and Hispanic women had more learning needs than White women. Post-discharge nursing assessments revealed that actual problems accounted for 40% of identified actual or potential problems or needs. Health teaching was the most commonly recommended postpartum intervention strategy followed by case management, treatment and surveillance interventions.

Conclusions.  Caesarean-delivered women continue to experience some problems with adapting to childbirth. Recommended intervention strategies reflect the importance of health teaching following hospital discharge.

Relevance to clinical practice.  Women who experience caesarean birth require comprehensive assessment during the early postpartum period. Nurses should devise strategies to continue care services for these women following hospital discharge.

Introduction

Popular and professional conceptions have shaped the caesarean birth experience over the past four decades. Most of the research on women’s psychosocial reactions to caesarean birth was conducted in the 1970s and 1980s, perhaps in response to the escalating caesarean birth rate, which reached a peak of 24·7% of all births in the USA in 1988 (Clark & Taffel 1995). Reports of caesarean mothers’ negative reactions compared to positive experiences described by vaginal birth mothers catalysed a successful movement to reduce the caesarean birth rate (Cohen & Estner 1983) to a low of 20·8% in 1996 (Martin et al. 2003), when the trend reversed. By 2006, the caesarean rate rose beyond 30% (Hamilton et al. 2007). Globally, caesarean rates have also increased (Betran et al. 2007, Callister 2008).

The paucity of research reports on women’s experiences with caesarean birthing in the current decade and the availability of elective caesarean by maternal choice reflect popular notions of relative ease and lack of complications associated with caesarean birth. Normalisation of caesarean birth (Shearer 1989), is now fully integrated within contemporary American culture and healthcare practice. Yet, understanding of contemporary women’s experiences of the caesarean birth experience is rooted in research conducted in a different time and generational context.

Therefore, the purpose of this Roy Adaptation Model-based study was to describe contemporary caesarean-delivered women’s physical, emotional, functional and social adaptation; postpartum concerns; and learning needs during the first two weeks postpartum and to identify relevant nursing interventions. The study is an extension of a series of studies about women’s responses to caesarean birth that began in the late 1970s (Fawcett 1981, Fawcett & Burritt 1985, Fawcett et al. 1992, Fawcett & Weiss 1993, Reichert et al. 1993) and evolved into a research programme using an approach to integration of faculty scholarship and undergraduate student learning developed and operationalised by the research team (Fawcett et al. 2003).

Background

Conceptual framework

The Roy Adaptation Model (RAM; Roy & Andrews 1999), widely used by nurses in the United States and many other countries, depicts individuals as adaptive systems who interact with constantly changing environmental focal and contextual stimuli. Figure 1 illustrates the study conceptual-theoretical-empirical structure (Fawcett 1999). The focal stimulus is the one most immediately confronting the person, represented in this study by type of caesarean delivery--planned or unplanned. The contextual stimuli are all other stimuli contributing directly to adaptation, represented by self-reported cultural identity (race/ethnicity) and parity. Responses to stimuli are manifested in four modes of adaptation. The physiological mode, emphasising maintenance of physiological integrity, was represented by physical adaptation and selected postpartum concerns. The self-concept mode, focusing on psychic integrity manifested through perceptions of the physical and personal self, was represented by emotional adaptation and selected postpartum concerns. The role function mode, dealing with social integrity associated with performance of activities in various roles enacted throughout life, was represented by functional adaptation, selected postpartum concerns and postpartum learning needs. The interdependence mode, dealing with social integrity encompassing development and maintenance of satisfying affectionate and supportive relationships with significant others and provision and receipt of social support, was represented by social adaptation and selected postpartum concerns. The RAM nursing process includes assessment of stimuli and intervention targeted to stimuli management. Assessment was represented by assessment of post-caesarean adaptation problems; intervention was represented by recommendations for intervention strategies following hospital discharge. Actual implementation of interventions was not included in the study design.

Figure 1.

 Conceptual-theoretical-empirical structure for study of women’s postpartum adaptation, concerns and learning needs.

Review of literature

Adaptation to caesarean birth

Early studies of caesarean-delivered women focused on immediate reactions to caesarean birth. Women reported negative perceptions, describing the birth as different from ‘normal’ (i.e., vaginal) birth and accompanied by fears about surgery, death and injury to the child (Affonso & Stichler 1978, Marut & Mercer 1979). Women who had unplanned emergency caesarean deliveries, especially those requiring general anaesthesia, reported more negative experiences than women who had planned caesarean births or regional anaesthesia (Marut & Mercer 1979, Fawcett 1981, Tilden & Lipson 1981, Cranley et al. 1983).

Reichert et al.'s (1993) three sample comparison of caesarean-delivered women’s responses (1973–1980, 1981–1982 and 1989–1990) revealed that responses became less negative over time. They attributed the decrease in negative responses to caesarean-delivered women’s feeling of normality as a result of increasingly higher caesarean birth rates in the United States during the 1980s (Shearer 1989).

The impact of caesarean birth on women during the early postpartum has received little attention in recent years. Search of electronic databases, including CINAHL, Medline and PsychInfo from 1995–2007, yielded few studies concerning caesarean-delivered women’s post-birth experiences. Those studies, conducted by researchers around the globe, continue to document both normalisation and some continuing negative psychological responses to caesarean delivery among women and their partners (Fisher et al. 1997, Durik et al. 2000, Greenhalgh et al. 2000, Chen & Wang 2002, Thompson et al. 2002, Porter et al. 2007). Women who have unplanned caesarean deliveries continue to report more negative emotional responses and dissatisfaction with childbearing than women who have planned caesarean births (DeLuca 1999, Stadlmayr et al. 2004). Recently, emotional reactions to unplanned caesarean birth have been described as post-traumatic stress (Gamble & Creedy 2005, Tham et al. 2007) associated with negative perceptions of birth, self and infant; poor parenting behaviours; and risk for postpartum mood disorders (Lobel & DeLuca 2007).

Postpartum concerns and learning needs of caesarean-delivered women

Childbearing women’s concerns change during the postpartum period. Affonso and Stichler (1978) reported numerous concerns in the first 2–4 days following caesarean birth, including incisional pain, activity restriction, role changes and family relationships. Fawcett et al. (1993) found that post-caesarean women reported moderately positive birth experiences despite moderate levels of pain intensity and relatively little distress related to childbearing in the first two days postpartum. At six weeks postpartum, women continued to report positive adaptation responses, including relatively high self-esteem, nearly full functional status, positive feelings about the baby, and positive changes in marital relationship quality. Miovech et al. (1994) identified physiologic concerns at two weeks postpartum, including pain, incision problems, activity intolerance, fatigue, gastrointestinal disturbances and breast and nipple problems, which decreased by eight weeks postpartum. The women also reported psychological concerns about changes in activity, mood, family interactions, body image, child care arrangements, healing, fatigue, finances and work or school, which diminished slightly between 2–8 weeks postpartum.

Bowman’s (2005) review of 18 studies of postpartum learning needs revealed an emphasis on differentiating learning needs during the early postpartum period, with a focus on information needed and desired during the postpartum hospital stay. Women and nurses identify immediate self and infant physical care needs as the priority for postpartum teaching (Beger & Cook 1998, Ruchala 2000). Primiparas rated more topics as important to their learning needs than multiparas (Beger & Cook). No studies addressed specific postpartum informational needs of caesarean-delivered women. Childbirth and postpartum education does not adequately address the full continuum of learning needs of childbearing women (Moran et al. 1997), as new learning needs continue to develop after hospital discharge (Sword & Watt 2005).

Cultural identity and caesarean birth

Culture can be regarded as a way of living and interpreting the world. Cultural identity, subsuming ethnicity and race (Outlaw 1997), is a ‘learned, patterned behavioural response acquired over time and includes explicit and implicit beliefs, attitudes, values, customs, norms, taboos, arts, habits and life ways accepted by a community of individuals’ (Giger et al. 2007, p. 212). Limited information exists about the extent to which culture influences caesarean birth adaptation. Mercer and Stainton (1984) found no differences in the responses of caesarean-delivered women from Calgary, Alberta, Canada and those from San Francisco, California. Fawcett and Weiss (1993) reported no substantial differences in adaptation to caesarean birth across three cultural groups – White Caucasian, Hispanic and Asian. McClain (1990) found that ethnic minority women, including English-speaking Blacks, Latinas, Asians and Palestinians who had lived in the United States at least five years, had a more positive view of their past caesarean birth experiences than did White counterparts and more ethnic minority women chose elective repeat caesarean deliveries over a trial of labour than did White women. These findings are consistent with findings of more positive reactions to caesarean birth among Black women (Sandelowski & Bustamante 1986) and women of Mexican origin (Cummins et al. 1988) than among White women. The studies focused on responses to the caesarean birth experience during the immediate hospital postpartum period and did not include post-discharge concerns or learning needs data.

Parity and adaptation to caesarean birth

The relationship of parity to adaptation to caesarean birth has not been well articulated primarily because of confounding of type of caesarean birth (planned/unplanned) with parity. Most researchers differentiate responses to planned and unplanned caesarean (Visco et al. 2006) but the comparison groups may include primiparas and multiparas. In the era of elective primary caesarean birth (Minkoff & Chervenak 2003), the contribution of type of birth and parity to adaptation requires systematic examination.

Interventions for caesarean-delivered women

The focus of nursing interventions in the postpartum period should be maintenance and promotion of care continuity, access to teaching and counselling and monitoring for early detection and treatment for problems (Brooten 1995). Research-based recommendations for nursing interventions to improve responses to caesarean birth include comprehensive antenatal preparation (Fawcett & Burritt 1985), changes in hospital policies to support partner participation and sustained contact with the neonate (Reichert et al. 1993) and discharge planning, education and extended home follow-up through the first 2–3 months postpartum (Miovech et al. 1994). Burns-Vandenburg and Jones (1999) retrospectively examined nursing interventions identified by student nurses during postpartum home visits, using the Omaha System Intervention Scheme. The most common nursing interventions were health guidance, teaching and counselling, surveillance, and case management.

Summary of literature review

Literature about adaptation to caesarean birthing is rooted in the experiences of women in the last three decades of the 20th century and may not inform care of contemporary caesarean-delivered women. Research findings document both normalisation and negative psychological outcomes. Although most research has focussed on unplanned caesarean birth, elective planned caesarean is increasing in popularity. Postpartum care studies are limited to needs during hospitalisation. This study addresses gaps in knowledge about adaptation to planned and unplanned caesarean birth, post-discharge needs and relevant interventions.

Methods

Design

A mixed method descriptive research design using qualitative and quantitative data addressed three research questions:

  • 1 What adaptation responses, postpartum concerns and learning needs do caesarean-delivered women report in the first two postpartum weeks?
  • 2 What are the associations of type of caesarean birth, cultural identity and parity to adaptation responses, postpartum concerns and learning needs?
  • 3 What caesarean-delivered women’s postpartum problems and nursing interventions are identified by student nurses?

Sample

The convenience sample consisted of 233 English-speaking women at least 18 years old who gave birth by caesarean at urban hospitals in Midwestern and Northeastern regions of the United States. The sample was limited to women who had an uncomplicated hospital course and were discharged by the fourth postpartum day with their infants.

Data collection procedures

Institutional Review Board approval was obtained from two universities and participating hospitals. Nursing students completed human subjects’ protection training and were instructed by an investigator or investigator-trained clinical instructor in procedures for describing the study, assuring voluntary participation, obtaining informed consent, interviewing techniques and collecting data. Women asked to participate had received care during hospitalisation from a pre-licensure baccalaureate or master’s degree nursing student during the student’s maternal-neonatal nursing practicum experience. Nursing students collected data during a post-discharge home visit or telephone call conducted for joint clinical and research learning purposes (Fawcett et al. 2003). Each student collected data from one woman. Participant selection and data collection were supervised by clinical instructors. The decision regarding home visit or telephone contact was based on course requirements and women’s preferences. Students collected data within one month postpartum, with a target of two weeks. The median interval from birth to data collection was 16 days (mean = 16·3 days, SD 5·3 days).

Instruments

Instruments were administered during the post-discharge interview by telephone or home visit. Students were instructed to record all responses verbatim.

Background data sheet (BDS)

The investigator-developed BDS was used to record women’s reports of focal and contextual stimuli and other demographic and perinatal characteristics. Type of birth was classified as unplanned if the woman indicated that the decision to perform a caesarean birth was made after labour onset or attempted labour initiation and as planned if the decision occurred during pregnancy prior to labour onset or attempted labour initiation. Cultural identity was women’s self-reported primary race/ethnicity. Four race/ethnicity groups were generated from the data – White/non-Hispanic, Black/non-Hispanic, Hispanic, Asian. Parity was classified as primiparity or multiparity. Family socioeconomic status was calculated using the Hollingshead Four Factor Index of Social Status, which incorporates education, occupation and marital status (Hollingshead 1975).

Post-caesarean adaptation interview schedule (PCAIS)

The investigator-developed PCAIS measured women’s physical, emotional, functional and social adaptation to caesarean birth. This interview guide consists of four open-ended questions, each of which reflects one of four RAM modes of adaptation (Table 1). Students asked the questions, probed for clarification if necessary and recorded responses verbatim. Responses were coded using content analysis (Weber 1990). The unit of analysis was the word, phrase, or sentence that expressed a response. Responses were categorised as adaptive (positive) or ineffective (negative). Adaptive responses indicate that the woman’s goals for caesarean birth were achieved; ineffective responses indicate that goals were not yet attained and signal a need for nursing intervention. Each question was coded independently by one of the researchers and a trained graduate research assistant and disagreements were resolved by discussion.

Table 1.  Roy adaptation model (RAM)-based post-caesarean adaptation interview schedule (PCAIS) and examples of adaptive and ineffective responses
RAM: adaptation mode/post-caesarean adaptation PCAIS question
Examples of adaptive and ineffective responses
Physiological mode
Physical adaptation
How have you been feeling physically since you went home from the hospital?
Adaptive responses: Feel very well, Feel good
Ineffective responses: Tired, Headache, Fever, Pain
Self-Concept mode
Emotional adaptation
How have you been feeling emotionally since you went home from the hospital?
Adaptive responses: More good days than bad days, Excited, Happy
Ineffective responses: Stressed, Feel drained
Role Function mode
Functional adaptation
How are you adjusting to being a new mother? (primiparas)
How are you adjusting having a new baby at home? (multiparas)
Adaptive responses: Adjusting OK, I love it!, Very rewarding
Ineffective responses: No time for own activities, Not enough time for all children
Interdependence mode
Social adaptation
How is your husband /partner adjusting to having a new family member?
Adaptive responses: Overjoyed, Loves being a Daddy, Extremely helpful with baby
Ineffective responses: Not enough sleep, Does not help with changing baby diapers

Responses for each component of adaptation (physical, emotional, functional, social) were tallied using frequency statistics. Adaptation scores in each mode and for all modes combined were then calculated for each woman by dividing the number of adaptive responses by the total number of responses (adaptive + ineffective) and then multiplying by 100 (Fawcett 2006). The adaptation scores of 0–100 indicate the proportion of adaptive responses.

Maternal concerns questionnaire (MCQ)

The MCQ is a 50-item scale designed to measure the intensity of mothers’ postpartum concerns (Bull 1979, 1981, Moxon 1989). Postpartum concerns, defined as any question, worry, or problem, are rated on a four-point scale from 1 = ‘no concern’ to 4 = ‘much concern’. The original scale comprised four subscales: self, baby, community, partner. Item scores are summed to generate total and subscale scores. Total scale score range is 50–200, with a midpoint of 125. Higher scores represent a greater level of concerns. The MCQ has been used primarily with urban and rural White middle-class women and vaginally-delivered primiparas and multiparas to measure early (1–2 weeks) and later (6–8 weeks) postpartum concerns. Internal consistency reliability estimates ranged from 0·90–0·96 (Bull 1979, Muehl 1983, Peterson-Palmberg 1987, Moxon 1989, Sheil et al. 1995).

Evaluation by the research team revealed that items could be assigned to subscales representing the four RAM modes of adaptation: physiologic (11 items); self-concept (seven items); role function (17 items); interdependence (15 items). Minor wording changes made items more appropriate for caesarean birth (e.g., incision instead of episiotomy). Total scale Cronbach’s alpha reliability coefficient for the study sample was 0·96; subscale coefficients ranged from 0·79 to 0·94.

Postpartum self and infant care knowledge and behaviours inventory (PKBI)

The investigator-developed PKBI measured postpartum learning needs. Items are based on content derived from postpartum teaching literature and clinical teaching documentation forms. The 16 PKBI questions measure retention of information from hospital discharge teaching and behaviours consistent with knowledge acquisition. Items reflect knowledge and behaviours needed for positive postpartum role function adaptation. Responses to this criterion-based instrument are scored ‘0 = incorrect’ and ‘1 = correct’; the number of correct responses is summed with a possible score range of 0–16. Higher scores indicate greater knowledge acquisition and application and, therefore, fewer learning deficits.

RAM-based assessment of post-discharge problems

Student nurses were asked to identify three priority areas of problems or needs related to adaptation based on their assessments during hospitalisation and the interview conducted following hospital discharge. Students were given detailed definitions and instructions for categorising each problem or need in one of the four modes of adaptation and indicated whether the problem or need was actual, potential or a health promotion concern. Frequency statistics were used to tally problems/needs in each adaptation mode. A maximum of 699 problems/needs were expected for the total sample.

Omaha system intervention scheme (OSIS)

The OSIS was used to classify recommendations for nursing interventions as health teaching, treatments or procedures, case management or surveillance (Martin & Scheet 1992). Students were provided with detailed definitions from OSIS for the four nursing intervention types. They were instructed to recommend an intervention strategy for each of the three priority problems or needs identified during the assessment. Frequency statistics were used to tally types of interventions.

Results

Sample demographic and perinatal characteristics are presented in Table 2. The women’s mean age was 31 years. Most women had post-secondary education, which was reflected in an above average socioeconomic status score (46 of a possible 66). Private health insurance was the predominant payor source. The women lived primarily in urban or suburban settings. More than 80% were married and 65% were White. Midwestern women were younger, t (119·31) = −4·84, <0·001; of lower socioeconomic status, t(227) = −3·40, = 0·001; and more likely to reside in an urban setting, χ2 (2, n = 231) = 25·60, < 0·001 and be unmarried, χ2(1, n = 233) = 22·62, < 0·001) than Northeastern women. More than 40% of women experienced unplanned caesarean birth. Slightly more than one-half (54%) were primiparas, 65% of whom experienced unplanned caesarean birth compared to 17% of multiparas.

Table 2.  Demographic and perinatal characteristics of the sample
  1. *p < 0·05, **p < 0·01, ***p < 0·001.

  2. †Hollingshead Four Factor Index of Social Status (1975). Possible range of scores is 0–66.

  3. Note: In some categories, N is less than the total sample size due to missing data.

 Midwest n = 75Northeast n = 158Total N = 233
Demographic characteristics
 Age [M(SD)]***28·6 (6·2) 32·5 (4·9) 31·2 (5·6)
 Socioeconomic Status [M(SD)]**41·6 (13·8) 47·7 (12·2) 45·8 (13·0)
 Payor (n, %)***
  Public17 (22·7)5 (3·2)22 (9·4)
  Private54 (72·0)150 (95·0)204 (50·6)
  Other (none/self/unknown)4 (5·3)3 (1·9)7 (3·0)
 Place of Residence (n, %)***
  Urban51 (68·0)52 (33·3)103 (44·6)
  Suburban23 (30·7)91 (58·3)114 (49·4)
  Rural1 (1·3) 13 (8·3) 14 (6·1)
 Marital Status (n, %)***
  Married48 (64·0)142 (91·0)190 (82·3)
  Single living with father of baby13 (17·3)8 (5·1)21 (9·1)
  Single not living with father of baby14 (18·7) 6 (3·8) 20 (8·7)
 Cultural identity (n, %)**
  White, non-Hispanic42 (56·0)111 (71·2)153 (66·2)
  Black, non-Hispanic21 (28·0)17 (10·9)38 (16·5)
  Hispanic10 (13·3)16 (10·3)26 (11·3)
  Asian2 (2·7) 12 (7·7) 14 (6·1)
Perinatal Characteristics
 Type of caesarean birth*
  Planned caesarean birth34 (45·3)99 (62·7)133 (57·1)
  Unplanned caesarean birth41 (54·7) 59 (37·3) 100 (42·9)
 Parity
  Primipara40 (53·3)86 (54·4)126 (54·3)
  Multipara35 (46·7) 71 (44·9) 106 (45·7)

Adaptation, postpartum concerns and learning needs

On average, the women reported a moderate level of overall physical, emotional, functional and social adaptation (mean = 57·0, SD 21·6). Examination of mean scores for each adaptation component revealed relatively low physical adaptation (mean = 39·5, SD 36·1), moderate emotional adaptation (mean = 56·2, SD 41·0) and functional adaptation (mean = 69·5, SD 36·3) and high social adaptation (mean = 80·7, SD 31·9). Examples of women’s verbatim responses coded as adaptive or ineffective are given in Table 1.

Scores for postpartum concerns ranged from 1·6 to 2·0, reflecting ‘little concern’ across subscales. The mean number of correct responses on the PKBI was 10·7 (SD 1·9), indicating that knowledge and related postpartum self and infant care behaviours were achieved in some areas whereas needs were evident in others. The three items with the lowest correct responses were related to maternal self-care practices--appropriate foods and fluids the mother should eat and drink (26·8%); amount of milk consumed during prior day (11·8%); and knowledge of maternal temperature that should trigger a call to the provider (31·2%). The only infant care item falling below a 50% correct response rate was related to misconception that babies require a daily full bath in the first two weeks.

Influence of type of childbirth on adaptation, postpartum concerns and learning needs

Women experiencing unplanned caesarean births had lower PCAIS adaptation scores (mean = 52·5, SD 22·5) than women experiencing planned caesarean births (mean = 60·2, SD 20·4), t(231) = −2·79, = 0·006). Additional analyses revealed that women experiencing unplanned caesareans had lower scores than their planned caesarean counterparts for emotional [t(228) = −2·18, = 0·04] and social adaptation [t(171·4) = −3·51, = 0·001]; no differences were found for physical or functional adaptation. No differences were found between the two groups for postpartum concerns (MCQ) or learning needs (PKBI) scores.

Influence of cultural identity on adaptation, postpartum concerns and learning needs

Differences in PCAIS social adaptation scores were evident across cultural identity groups, F(3,223) = 4·20, = 0·006. Pair-wise comparisons revealed a statistically significant difference in social adaptation only between Black non-Hispanic (mean = 64·0, SD = 44·3) and White non-Hispanic women (mean = 84·1, SD 28·5, = 0·006). No differences across cultural identify groups were found for other adaptation components.

Differences across cultural identity groups in role function postpartum concerns also were found, F(3, 227) = 4·11, = .007. Pair-wise comparisons indicated a statistically significant difference in MCQ scores between White non-Hispanic (mean = 32·3, SD 11·3) and Hispanic women (mean = 39·6, SD = 13·3, = 0·02). No differences between cultural groups were evident for postpartum concerns related to the other three adaptation modes.

The level of learning needs also differed across cultural identity groups, F(3,196) = 4·83, = 0·003. Pairwise comparisons revealed that Black non-Hispanic (mean = 10·0, SD 2·1, p = 0·04) and Hispanic (mean = 9·7, SD 1·9, p = 0·01) women had lower PKBI scores than White non-Hispanic women (mean = 11·0, SD 1·9), indicating greater learning needs.

Influence of parity on adaptation, postpartum concerns and learning needs

Primiparas had lower overall adaptation scores [t(230) = 2·75, = 0·007] and lower emotional [t(227) = 2·97, = 0·003] and social [t(226) = 2·12, = 0·04] adaptation scores than multiparas. There were no differences in physical or functional adaptation. Primiparas reported greater postpartum concerns than multiparas in all adaptation modes, t(229) = 2·70, = 0·007. There was no difference in learning needs.

Interaction effects

Factorial analyses of variance revealed no evidence of interaction effects among type of caesarean birth, cultural identity and parity for adaptation, postpartum concerns, or learning needs.

Nursing assessment and intervention

A total of 676 problems/needs were identified and classified as actual (40%), potential (44%) or health promotion (16%). Problems and needs reflecting physiological mode adaptation (38%) were most frequently identified, followed by problems reflecting role function (25%), interdependence (20%) and self-concept (17%) mode adaptation.

As seen in Table 3, 71% of recommended interventions were health teaching strategies. Treatments and procedures were more frequently recommended for problems reflecting the physiological adaptation mode, whereas active case management was most commonly recommended for problems reflecting role function and interdependence modes. Surveillance, or ongoing monitoring strategies, was the least commonly recommended type intervention.

Table 3.  Total number of adaptation problems or needs and recommended nursing interventions at two weeks postpartum (N = 699)*
RAM ModesProblems or needsRecommended interventions
ActualPotentialHealth promotionHealth teachingTreatment/ procedureCase managementSurveillance Total (n%)
  1. *N = 699 represents the 233 participants multiplied by a maximum of three problems and related interventions per participant.

Physiologic (n)142 803218149 816254 (37·6%)
Self Concept (n) 30 6225 97 7 5 8117 (17·3%)
Role Function (n) 50 8635121 33611171 (25·3%)
Interdependence (n) 48 6818 80 441 9134 (19·8%)
Total (n%)270 (39·9%)296 (43·8%)110 (16·3%)479 (70·9%)63 (9·3%)90 (13·3%)44 (6·5%)676 (100%)

Strengths and limitations

The Roy Adaptation Model was particularly useful for this study. The four modes of adaptation provided a comprehensive frame of reference for postpartum assessment and the environmental stimuli pointed to factors that might influence responses in each mode (see Fig. 1). Inasmuch as the women’s responses reflected each mode of adaptation, the results support legitimacy of the RAM as a guide for research and practice.

The research instruments can be used as practice tools to record and then quantify narrative responses (PCAIS), categorise concerns by adaptation mode (MCQ) and tally postpartum learning needs (PKBI). Further use and testing of these instruments should strengthen their applicability for postpartum assessment and extend utility to evaluation of nursing interventions.

The sample was limited to women experiencing uncomplicated caesarean birth who were selected for the nursing students’ clinical assignments and may not represent the diversity of caesarean-delivered women or their adaptation experiences. Students’ inexperience with interviewing may have limited the scope or depth of responses to interview questions. Adaptation to a complicated caesarean birth or mothering a newborn with complications was not explored. Postpartum adaptation problems and recommended interventions represent the students’ judgments, guided and reviewed by clinical instructors. Assessments were based on two contacts with the woman, once while the student cared for the woman during hospitalisation and again during a home visit or telephone call. Assessments by expert nurses many have yielded different results.

Power analyses indicated that the available sample had a power of 0·80 to detect significant differences in comparisons by type of caesarean and by parity and 0·71 in comparisons by cultural group. The study required 33 independent statistical tests to examine associations of focal and contextual stimuli with modes of adaptation. Bonferroni adjustment to reduce Type 1 error risk for several analyses conducted concurrently on the same data set yielded a p-value of 0·0015 (0·05 divided by 33). Inasmuch as the intent of this RAM-based study was to explore possible associations of stimuli with each of the four adaptation modes, the p-values were reported without adjustment. Hence, the results of any statistical tests with p-values greater the 0·002 should be interpreted with caution and as tentative, pending further research.

Discussion

Women’s adaptation scores convey their perceptions of partial recovery and developing but not yet complete establishment or re-establishment of patterns of functioning within the new family constellation. As expected during the early postpartum period, physical adaptation was lower than emotional, functional, or social adaptation. The finding that functional and social adaptation scores were higher than emotional or physical adaptation scores may be a reflection of women’s investment in and prioritisation of family needs rather than own needs and their need for rapid re-establishing of family functioning in preparation for the normative pattern within USA society of women’s return to work following childbirth (Tulman & Fawcett 2003). The low number of postpartum concerns reported by the women supports the conclusion that overall, these women were beginning to adapt positively to caesarean birth.

Stimuli associated with caesarean birth may influence maternal adaptation. Lower emotional and social adaptation scores were evident among primiparas and women experiencing unplanned caesarean births. The psychic and social impact of caesarean birth that is negotiated with the birth of the first child or a first caesarean may not be experienced to the same extent with subsequent caesarean births. Lack of congruence with expectations for childbirth may affect a woman’s sense of self and increase her need for emotional and social support. The simultaneous experience of unplanned caesarean birth and primiparity places women at risk for negative reactions to the birth experience and transition to motherhood.

The lack of differences in physical and functional adaptation scores between parity and type of caesarean birth groups suggests some aspects of recovery are a trajectory navigated by all women experiencing caesarean birth. Although primiparas expressed a greater number of postpartum concerns in all modes of adaptation than multiparas, on average the women reported little concern. Postpartum learning needs scores did not differ between primiparas and multiparas or by type of caesarean, however the results suggest that women’s needs for information about self and infant care extend into the post-hospitalisation period.

Women’s cultural identity also influences adaptation to caesarean birth. Black women’s lower social adaptation scores, Hispanic women’s role function concerns and both Black and Hispanic women’s learning needs may reflect inadequate social support networks. Inasmuch as lack of supportive networks is associated with poor infant outcomes (Hoffman & Hatch 1996, Norbeck et al. 1996), the findings serve as a warning of risks for later adverse outcomes.

Student nurse assessments revealed more frequent identification of physiological mode problems than other modes, consistent with the women’s reported lower physical adaptation scores. Problems in self-concept mode adaptation were infrequently identified by students although were evident in the women’s emotional adaptation scores. This inconsistency may be related to students’ under-developed skills or to prioritisation of physiologic and role function mode problems. Consistent with student emphasis on physiological and role function problems, health teaching was identified as the primary nursing intervention strategy. However, the women’s responses indicate that case management and surveillance to monitor emotional adaptation could be beneficial.

Conclusions

Four methods of assessing caesarean birth adaptation (PCAIS, MCQ, PKBI, Postpartum Problem Assessment) yielded complementary findings. Each approach is a window to the caesarean birth experience and provides useful information for nursing practice. Women in this study reported moderate functional adaptation and high social adaptation, findings that are consistent with women’s need for immediate reorganisation of family roles and relationships. Physical and emotional adaptation, in contrast, may require a more extended period of time. That the women expressed few postpartum concerns supports the thesis that caesarean birth has become a normative event in the USA. Yet, the high number of actual postpartum problems identified by student nurses indicates that the women could benefit from early postpartum health teaching. The role of nurses in postpartum follow-up care is clear and continues to require attention by those who are developing home care services.

Relevance to clinical practice

The childbearing cycle does not end at hospital discharge. Shortened length of stay following vaginal and caesarean births has elicited repeated calls for postpartum follow-up services to support adaptation (Brooten et al. 1994, Evans 1995). Recommended maternal and newborn medical follow-up visits at 7–14 days for caesarean-delivered women (American Academy of Pediatrics/American College of Obstetricians and Gynaecologists 2007) and within one month and again at two months for newborns (American Academy of Pediatrics 2007) are unlikely to thoroughly address the totality of adaptation-related needs.

Comprehensive assessment of caesarean birth responses should continue after women are discharged from the hospital. The instruments used in this study are appropriate for use during telephone, home visit, or online contacts with postpartum women. The data from this study can be used as evidence for development of targeted interventions to foster positive postpartum adaptation. Virtually all women need some health teaching during the early postpartum period and many also need additional treatment, case management or surveillance. Nurses need to develop cost-effective and feasible clinical practice guidelines for all caesarean-delivered women that include follow-up after hospital discharge. Reports of models of care from counties around the world are needed to inform the development of optimal caesarean birth care services.

Acknowledgments

The authors wish to thank the clinical instructors who incorporated conduct of this study as a learning activity in undergraduate maternal-neonatal clinical practica at the University of Massachusetts-Boston--Amy L. Berkovitz, RN, MS; Mary Ellen Jagelski, RN, MS; Helen D’Alelio, RN, MS; and Mary Beth Murphy, RN, MS – and at Marquette University, Milwaukee, WI – Amy Borkowski, RN, MSN; Renee Gosselin, RN, MSN; Kate Harrington, RN, MSN, CNM; Judith Kowatsch, RN, MSN;, RN; Lynne Senkerik, RN, MSN; Paula Winter, RN, MSN, CNM.

Contributions

Study design: MW, JF, CA; data collection and analysis: MW, JF, CA; manuscript preparation: MW, JF, CA.

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