A study was conducted to describe midwives’ adherence to preoperative care during emergency caesarian section at Bwaila Maternity Wing in 2012 in Malawi. The study utilized a descriptive prospective and retrospective design. A structured questionnaire was administered to all 28 midwives who were directly involved in the preparation of clients for emergency caesarean section. Clients charts were also reviewed using a standard checklist to determine adherence to preoperative care. Data were analyzed using SPSS version 16.0 and descriptive statistics in the form of frequencies and percentages were computed for the dataset. A midwife was supposed to score at least 80% on each component of preoperative care guidelines to be compliant to the stipulated pre-operation standards. The midwives scored above 80% on only four of the 14 preoperative care guidelines which were; bladder catheterization (100%, n = 14), obtaining informed consent (92.9%, n = 12), administration of IV (96.4%, n = 13) and administration of preoperative antibiotics (82.1%, n = 11). Midwives however scored less than 80% on preoperative procedures that dealt with vital signs (28.6%, n = 4): BP check (28.6%, n = 4); Pulse rate check (25%, n = 3.5); respiration check (25%, n = 3.5) and temperature check (25%, n = 3.5). The midwives scored further below standard on blood specimen collection (78.6%, n = 11). Psychological support to clients was also below standard at 60.7%, n = 8. Other components of psychological support such as surgery information (57.1%, n = 8), allowing clients ask questions (28.6%, n = 4) and answering clients’ questions (25%, n = 3.5) were also scored below standard. Overall the standard of preoperative care was below standard at the facility. Most of the midwives were new graduates, who had never received any in-service training on preoperative care. Therefore in service training it is recommended for the midwives to provide good quality of care.
Clients undergoing emergency caesarean section (EmC/s) require good quality of care which prevents complications that are associated with EmC/s. Worldwide, 35.7% of women suffer from major complications due to post caesarian section such as pelvic infection, sepsis, deep vein thrombosis, and other minor complications [
In Africa, cesarean deliveries account for about 8.8% of all births and are associated with maternal mortality ratios of 305 per 100,000 live births and still birth ratios of 36.6 per 1000 live births [
According to literature [
In Malawi, the guidelines on preoperative care for emergency caesarean section give reference to obstructed labor, which is one of the indications of EmC/s [
Generally it has been observed that the care provided to clients undergoing EmC/s varies according to who has prepared the client before operation. Most of these clients are from rural areas, where care is of poor quality before arriving at the referral hospital. Clients therefore suffer from severe dehydration, anemia, and/or sepsis thus putting them at increased risk of morbidity and mortality. Nurses and midwives have a major role to play in the preoperative care of clients to reduce morbidity and mortality in the postoperative period [
The study design was descriptive prospective and retrospective and employed quantitative data collection and analysis method.
The study was conducted at Bwaila Maternity Unit in Lilongwe District of Central Malawi from September to October, 2012. Bwaila maternity unit serves a population of 2,203,911. Out of this 506,900 were women of child bearing age [
The study targeted all available and consenting midwives at the facility during the time of study. All the 28 midwives that were available at the maternity and antenatal wards consented and participated in the study.
The study included all consenting midwives that were working at the antenatal and labor wards of Bwaila Maternity Unit, regardless of cadre but rendered preoperative care for EmC/s. The study did not recruit midwives that were working at Bwaila on part time basis or those working in other wards other than antenatal, labor and delivery.
A structured questionnaire was used to collect data from the midwives. The instrument consisted of three sections; the first section collected demographic data of the midwives. The second part collected data regarding participants’ awareness on the components of preoperative care for EmC/s as stipulated in the RH guidelines [
Data were analyzed using SPSS Version 16.0. Descriptive statistics were computed for the dataset and the results are presented as percentages across each component of preoperative guidelines. The midwives’ mean percentage scores for each component of care were compared to the stipulated reproductive health guidelines. According to the reproductive health guidelines [
The research protocol was approved by the College of Medicine Research and Ethics Committee (COMREC) the internal ethical review board for Kamuzu College of Nursing. Permission was obtained from the District Health Officer for Lilongwe to conduct research at Bwaila Maternity Unit. Informed consent was obtained from each participant before they participated in the study. Other ethical issues such as maintaining confidentiality and anonymity were strictly observed and participants were given the freedom to withdraw from the study anytime if they wished to do so.
The midwives’ ages ranged from 25 to over 50 years, with a mean of 37.5 years but the majority (39.3%) was aged less 30 years. Regarding their education, most of the participants (89.3%, n = 25) had Malawi School Certificate of Education (MSCE). The participants comprised different cadres with most of them being the Nurse Midwife Technicians (39.3%, n = 11). Enrolled Nurse Midwives comprised (35.7%, n = 10). There were few registered nurse midwives (21.4%, n = 6), and registered midwives (3.6%, n = 1).
Furthermore, most of the midwives (53.6%, n = 15) had graduated from college less than five years ago. The number of years in practice as a midwife was less than five for 64.3%, n = 18 of them. The majority (92.9%, n = 26) had only been practicing in their present department or ward for less than five years.
The midwives awareness regarding components of preoperative care is shown in
Component | Adherence (%) | Component | Adherence (%) |
---|---|---|---|
Obtain informed consent | 92.9 | Pulse rate check | 25.0 |
Offer surgery information | 57.1 | Respirations check | 25.0 |
Allow client to ask questions | 28.6 | Temperature check | 25.0 |
Offer psychological support | 60.7 | Administer preoperative antibiotics | 82.1 |
Administer IV fluids | 96.4 | Collect blood specimens | 78.6 |
Check vital signs | 28.6 | Perform bladder catheterization | 100.0 |
Bp check | 28.6 |
knowledge among the midwives on only four of the 14 preoperative components (
The midwives scored below 80% on preoperative teaching that was offered to clients. Only 11.1% (n = 4) knew about teaching their clients on deep breathing and coughing exercises. Teaching on leg exercises was known by only 10.7% (n = 3) of the midwives and only 14.3% (n = 4) of the midwives mentioned frequent turning of clients in bed and early ambulation. Few midwives (19.2%, n = 5) indicated that they instructed their clients on when to take food or water after surgery.
All midwives interviewed (100%, n = 28) mentioned that they had not attended any form of in-service training in perioperative care. The source of knowledge for preoperative preparation of clients for 89.3% (n = 25) of the midwives was from pre-service training. The majority (82.1%, n = 23) did not have preoperative care guidelines in their wards.
The review of clients records showed variation between the results of midwives knowledge from the interviews and actual practice. The midwives failed to document all the component of preoperative care. The highest documented component was informed consent (77%, n = 22), followed by IV fluids (51.7%, n = 14), bladder catheterisation (50.6%, n = 14), and administration of preoperative antibiotics (37.9%, n = 11). Documentation was less than 20% (n = 6) for the rest of the components and there was completely no documentation for preoperative teaching on position change, leg exercises, early ambulation, incision area care and when to eat or drink.
The results of the duration of practice for the midwives in the maternity and antenatal wards show that most of the health workers were less experienced with their work in the maternity wards. The results that most of the care was provided by Nurse Midwife Technicians and Enrolled Nurse midwives have implications on adherence to preoperative standards of care. The Nurse Midwife Technicians and Enrolled Midwives are normally trained to conduct low risk care and deliveries for mothers that did not have any complications when giving birth. On the other hand the Registered Midwives are the ones that are trained to assist laboring mothers with pregnancy related complications. Registered midwives have extended and expanded roles and are trained to utilize critical cognitive skills and evidence based knowledge to plan, implement and evaluate maternal and new born care. In addition they are also trained to supervise the enrolled midwife [
The high awareness in some of the components of preoperative care for emergency caesarean section amongst the midwives is commendable. However the inability of most of the midwives to mention that they would allow the client to ask questions and also for them to answer the clients’ questions implies that the psychological care of these clients was a neglected part of their preoperative care. These results agree with those reported by Lungu, et al. [
The results that the midwives performed below standard on the psychological preparation of the clients before EmC/s have implications on the clients’ perception regarding the quality of care at the facility. There is evidence that many women have tokophobia (anxiety regarding labor and child birth) and that more women undergoing emergency caesarean section express negative feelings towards their delivery as compared to those undergoing elective caesarean section [
When this anxiety is manifested in patients undergoing emergency caesarean section it can increase their risks and present added potential for complications both psychological and physiological [
The results that most midwives did not check vital signs on the clients before EmC/s imply that clients at risk for EmC/s were missed out. Generally vital signs provide baseline data which is important for detecting signs of impending deterioration especially in such cases as emergency caesarean section. Knowing the clients’ vital signs is important before operation for the detection of overt or covert complications such as hypovolemia, high blood pressure and tachypnoea [
Another neglected area on the preoperative guidelines of care was preoperative teaching rendered to the client before EmC/s. Results indicated that this was the most neglected area of care. Furthermore the results show that the type of preoperative teaching that was rendered to clients varied from one midwife to another. These results imply that majority of the clients were not properly taught hence they missed out on important information. These results are consistent with those reported by Fitzpatrick and Hyde [
The midwives mostly relied on knowledge from pre-service training during their practice because in-service training sessions on perinatal care were rare. Additionally the results show that the majority of the midwives were not aware of the availability of preoperative care guidelines in their wards. These results agree with those reported by Kaye [
The study results showed a wide gap between midwives’ awareness of the components of preoperative care and what was actually documented in the clients’ charts. A wider gap was noted in components of bladder catheterization where all midwives had shown awareness yet documentation was seen in only half of the charts. Similarly administration of preoperative antibiotics awareness was more than 80% but documentation was less than 50%. A similar trend was observed in all the other components. It is a well known fact in nursing that what is not documented is considered to have not been done. Results show that though midwives were aware of the components of preoperative care they were not able to put them into practice. These results have adverse consequences on clients’ outcomes because despite the debate regarding routine bladder catheterization prior to caesarean section, it has still been proved to be beneficial for the prevention of a full bladder during and immediately after operation [
Prophylactic antibiotics administration is important in prevention of post caesarean surgical wound infection, and post caesarean maternal infections such as endometritis, urinary infections, and pneumonia [
Standard of preoperative care for emergency caesarean section is compromised at Bwaila maternity due to health care provider problems and policy issues. There is need to deploy more Registered Midwives to this hospital to render evidence based preoperative care and supervise the junior cadres who are in large numbers. There is also need to upgrade all the junior midwives who are eligible to Registered Nurse level to ensure delivery of quality evidence based care. The existing preoperative care guidelines need to be revised to include the missing components of preoperative care. There is need for all midwives to be oriented to the guidelines for preoperative care and the supervision of midwives to ensure that their knowledge on preoperative care is put into practice.
The study was conducted at one facility only and the results may not be applicable to all facilities in Malawi although the trend is similar.
This study was conducted as part of the senior author's Master of Science degree in Midwifery at the University of Malawi, Kamuzu College of Nursing with sponsorship from USAID grant No. REQ-612-12-000036. The preparation of the manuscript for publication was funded by the Norwegian Arctic University at Tromso, Norway and the Agency for Norwegian Development Cooperation under the Maternal and Neonatal Intervention Project in Chiradzulu District.
The authors have no conflict of interest to disclose.