A quasi-experimental study to assess the effectiveness of

early ambulation in post-operative recovery among post-caesarean

mothers admitted in selected areas of Nehru Hospital, PGIMER, Chandigarh
Harmanjyot Kaur, Sukhjit Kaur, Pooja Sikka
Abstract: A mother who has been delivered by caesarean section has a dual role in both
post-operative care as well as maternal care. Mothers undergoing Caesarean need more care and
attention than mothers undergoing normal vaginal delivery. The current study was undertaken with the
objective to assess the effect of early ambulation on post-operative recovery among post caesarean
mothers. The Study design was quasi-experimental. Total 80 subjects were enrolled by total
enumerative sampling technique, 40 in each experiment and control group. Subjects in experiment
group were early ambulated at 6 hours of caesarean section covering a distance of 40 meters whereas
control group was ambulated as per routine care i.e. after 13-14 hours of caesarean section. Post-
operative recovery was assessed in both the groups by structured nursing assessment sheet including
intensity of pain perceived by post caesarean mother before and after ambulation, use of analgesics
after ambulation, duration of catheterization, self-void after removal of catheter, passage of first flatus,
initiation of oral intake and breast-feeding and holding baby independently. Pain score was assessed
with numerical pain rating scale. Results showed that there was significant difference between the
mean post-operative pain score after ambulation among experimental and control group as shown by
Independent t-test (p<0.05).Other aspects of Post-operative recovery were compared between
experiment and control group by independent t-test. This difference was statistically significant in all
the variables except duration of catheterization as per the independent t-test (p<0.05). So, it was
concluded that early ambulation was effective in postoperative recovery among post caesarean
mothers.
Keywords Introduction
Early ambulation, Post caesarean mother, The well being of societies linked to the
Postoperative recovery. health and survival of mothers and children.
When mothers survive and thrive, their
children survive and thrive as well and the
Correspondence at societies in which they live prosper. The
survival and well-being of mothers and
Sukhjit Kaur children are not only important in their own
Clinical Instructor,
National Institute of Nursing Education (NINE),
self, but are also central to solving much
PGIMER, Chandigarh broader economic, social and developmental

Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015 33

challenges. Health of a women is not a
merely a state of physical well being but also
an expression of many roles they play as
wives, mothers and health care providers in
1
the family.
Childbirth is viewed as an important life
event. It is a natural, normal physiological
phenomenon which introduces new
experiences in a women's reproductive life.
The child birth events have a great
physiological, emotional and social impact
2
on a women and her family. She experiences
stress, physiological pain and fear of dangers
related to bleeding, operative procedures like
caesarean section and possibility of loss of
life. Mc Donald also pointed out that
emotional factors might influence
reproductive events, including obstetric
complications such as eclampsia, prolonged
labour and puerperal depression etc. The
care giver should be tactful, sensitive, and
3
respectful to her.
Vaginal delivery of a full term normal
pregnancy is a natural physiological process.
In caesarean section the specific needs of the
mother are much more than in the normal
child birth. Caesarean section can be in the
form of planned elective or an emergency
procedure. Physical, physiological,
psychological and socio cultural factors are
the various kinds of stressors experienced by
each woman who undergoes caesarean
section.4
Caesarean section is an operation with
many risks, less than a century ago. Today, it
is one of the most frequently performed
surgeries in the world. Caesarean births are
more common than most surgeries due to
many factors. One factor, of course, is that
nearly 50% of the world population is
women, and pregnancy is still a very
common condition.
5 weeks after delivery are higher in women
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
A Caesarean section is a surgical
procedure in which incision is made through
mother's abdomen (laparotomy) and uterus
(hysterectomy) to deliver one or more babies
, or, rarely, to remove a dead fetus. It is
usually performed when a vaginal delivery
would put the baby's or mother's life or
health at risk. 6 The Origin of the name is
unclear, but believed to be named for Julius
Caesar, because this surgical procedure was
used at the time of his birth. It may have been
so named because of law, enacted under
Julius Caesar's rule, which required this form
of birth, when a mother was sick or dying.
The incidence of caesarean section is
steadily rising. However, rates between five
percent to ten percent are best but during the
last decade there has been two to three fold
increase in these incidences from the initial
rate of about 10%. The World Health
Organization (WHO) recommends that
caesarean sections rates should not go
7
above 15% in any country. Absolute
indications for caesarean section are post
caesarean pregnancy, failure to progress in
labour, malpresentations , ante partum
hemorrhage , fetal distress, cephalopelvic
disproportion, PIH and other high risk
8
pregnancies and foetus.
The post-operative course of a patient
undergone Caesarean section may be
described in terms of varying from
uneventful to extreme distress. Some
mothers experience Deep venous
thrombosis, Pulmonary embolism, Urinary
tract infection, Urinary retention, Chest
infection, constipation and psychological
problems in post-operative period.
Symptoms such as fatigue, headache, lack of
sleep, anaemia, urinary infection and other
conditions needing treatment in the first 8
34
who delivered by caesarean section than
9
those who underwent vaginal delivery.
So by preventive and promotive post-
operative care the women can be helped to
avoid the post-operative problems and
complications, which can help in early
recovery. One of the important aspects of
comprehensive post-operative care can be
planned early ambulation. Planned early
ambulation means that patients can be out of
bed as early as possible based on type of
surgery. Early ambulation after surgery as a
newer concept raises medical interest and
enthusiasm.10 The goal of this concept is to
optimize the post-operative management of
the patient in order to reduce morbidity, to
enhance recovery of the patient after a
surgical procedure, to reduce hospital stay
and to reduce the costs. Thus studies have
showed that ambulation plays a great role in
early post-operative recovery among post-
caesarean mothers
Objectives
To assess the effects of early
ambulation on post-operative recovery
among post caesarean mothers
Materials and Methods
A quasi experimental design was
employed to study the effect of early
ambulation on post-operative recovery
among post caesarean mothers. Null
hypothesis (H0) formulated was that: There
was no effect of early ambulation on post-
operative recovery among post caesarean
mothers at 0.05 level of significance.
The study was conducted in Labour
room, Maternity and Gynae ward of Nehru
Hospital, PGIMER, Chandigarh .Study
subjects were selected from the mothers
undergoing caesarean section in Labour
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
Room. The study population was post
caesarean mothers (18-40 years) with 32
weeks to 41weeks of gestational age and
undergoing caesarean section with spinal
anaesthesia during the month of July and
August, 2013. The subjects were recruited by
total enumerative sampling technique.
Women were consecutively allotted into
experiment (group I) and control (group II)
groups by Block randomization i.e. women
undergoing during caesarean section were
allotted in experimental group and similarly
women undergoing during caesarean
section in control group. Each group had 40
patients after excluding high risk factors like
caesarean section under general
anaesthesia, mothers on magnesium
s u l p h a t e t h e r a p y, m o t h e r s w i t h
cardiovascular problems. Data was collected
after getting permission from head of the
department of Obstetrics and Gynaecology
and ethical Clearance from Institute ethical
committee. The study was carried out in
three steps: Development of procedure and
tools, Intervention (early ambulation), and
Assessment of postoperative recovery.
Firstly, protocol was developed for providing
early ambulation i.e. walking a distance of 40
meters at 6 hours of caesarean section. The
tools for data collection were: Interview
schedule which included identification date,
Numerical pain rating scale, Structured
nursing assessment sheet for assessing
post-operative recovery in terms of use of
analgesia after ambulation, duration of
catheterization, self-void after removal of
catheter, passage of first flatus, initiation of
oral intake and breast-feeding and holding
the baby independently .The tools and
protocol were developed through review of
35
relevant literature and validated by experts
from field of nursing and department of
Obstetrics and Gynaecology. After validation
of tool pilot study was conducted in labour
room of PGIMER, Chandigarh for assessing
feasibility of the study. Results of the pilot
study indicated that study was feasible.
Study subjects were selected and after
taking the written informed consent. They
were explained about the purpose of the
study and were told that data so collected will
be kept confidential & will be used only for
research purpose. They were given full
autonomy to participate in the study. After
recruiting the subjects for the study, socio-
demographic details were collected.
In experiment group after explaining,
the subjects were ambulation early i.e. after 6
hours of caesarean section. Post-operative
Pain score was assessed before and
immediately after ambulating the mothers.
Whereas Subjects of control group were
assessed without intervention with normal
routine care i.e. ambulation at 13-14 hours
after caesarean section as usually practical
in labour room. The subjects (experimental &
control group) were kept under observation
throughout the procedure and monitored for
any discomfort. Interview schedule was used
to collect the information related to
caesarean section details and baby details.
Subjects were assessed after the ambulation
of caesarean section with the help of
structured assessment sheet for intensity of
post-operative pain, use of analgesics after
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
ambulation, duration of catheterization, self-
void after removal of catheter, passage of
first flatus, initiation of oral intake and breast-
feeding and holding baby independently
soon after ambulation.
The data was analyzed using
descriptive and inferential statistics. Analysis
was carried out with the help of statistical
package for social sciences (SPSS-16)
program. The findings were interpreted and
presented with the help of tables and graphs.
Results
As per socio demographic data
summarized in the Table 1, majority of the
subjects in both the groups were in the age
group of 24-29 year i.e. 62.5% in
experimental group and 57.5% in control
group with the mean age of 26.7 ± 3.65 years
in experimental group and 26.4 ± 3.90 years
in the control group. In experimental group
45% subjects were matriculate and in control
group 37.5%were graduate and above. Most
of the subjects in both groups were not
working i.e. 65% in experimental and 80% in
control group. In experimental group 70% of
subjects belonged to Hindu religion 52.5% in
control group. Most of the subjects in both
the groups had joint family i.e. 77.5% in
experimental group and 70 % in control
group. Both the groups were found to be
homogenous in nature in terms of age,
education, occupation, religion and type of
family of the subjects as per chi-square test
(p> 0.05).
36
 Table 1: Distribution of subjects as per Socio Demographic variables
N=80
2
Variables Experiment group Control group X
(n1=40) (n2=40) df
f (%) f (%) p value
Age category (in years)*
18-23 7(17.5) 9(22.5) 0.333
24-29 25(62.5) 23(57.5) 2
≥30 8(20.0) 8(20.0) 0.846
Education
Primary 5(12.5) 4(10.0) 6.74
Matric 18(45.0) 12(30.0) 3
10+2 12(30.0) 9(22.5) .081
Graduate and above 5(12.5) 15(37.5)
Occupation 2.257
Working 14(35.0) 8(20.0) 1
Not working 26(65.0) 32(80.0) 0.133
Type of family .581
Joint 31(77.5) 28(70.0) 1
Nuclear 9(22.5) 12(30.0) 0.446
Religion 4.38
Hindu 30(75.0) 21(52.5) 1
Sikh and others 10(25) 19(47.5) 0.136

*Mean ± SD (Range) in experimental group = 26.7 ± 3.65 (20-35) years

*Mean ± SD (Range) in control group = 26.4 ± 3.90 (19 – 37) years

Period of gestation (POG), Parity of the
subjects
Table 2 depicts that more than half of
the subjects (60%) in experiment and half of
control group were primiparous. In relation
to period of gestation 45% in experiment
were having gestation of 36+1 to 38 weeks
and in control groups 37.5% were between
34+1 to 36 and 36+1 to 38 weeks. Both the
groups were found to be homogenous in
terms of parity and period of gestation as per
chi square test (p > 0.05).

Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015 37

 Table 2 : Period of gestation (POG) and parity of subjects
N=80
2
Variables Experiment group Control group X
(n1=40) (n2=40) df
f (%) f (%) p value
Parity .80
Primiparous 24 ( 60.0) 20 ( 50.0) 1
Multiparous 16 ( 40.0 ) 20 ( 50.0) 0.36
Period of gestation (weeks)
32 – 34 3 (7.5) 7 (17.5) 2.0
+1
34 – 36 15 (37.5) 15 (37.5) 2
>36+1 22 (55.0) 18 (45) 0.368

Mean ambulation time of subjects after caesarean section

Figure 1 reveals that mean ambulation time after caesarean section in experimental group
was 6.00 ± 0.00 hours where as in control group it was 13.35 ± 2.38hours.

15 13.35 hours
Mean Ambulation
Time (hours)

10 6 hours

0
Experiment Group Control Group

Figure 1: Mean ambulation time of subjects after caesarean section

Pain score before and after early
ambulation after Caesarean Section
among post-caesarean mothers in both
groups.
Table 3 shows that in both the groups
the post operative pain significantly reduced
after ambulation. This was indicated as per
Pair t test that in experimental group it was
reduced from 6.5 ± 1.82 to 5.30 ± 1.34 where
as in control group it was reduced from 7.25
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
± 1.94 to 6.00 ± 1.31. But the reduction was
more evident in experiment group which was
further indicated by independent t test which
shows that difference in pain score in both
groups was not significant before
ambulation but significant difference was
observed after ambulation. Experimental
group has significant less pain as compare to
control group.
38
 Table 3: Mean post-operativePain score before and after ambulation among post-
caesarean mothers in both groups
N=80
Pain Scores Experiment group Control group Independent
(Numerical Pain (n1=40) (n2=40) t-test t-value
Rating Scale) Mean ± SD (Range) Mean ± SD (Range) df, p value
-1.778
Before Ambulation 6.5 ± 1.825 7.25 ± 1.944 78
(5-9) (6-9) 0.07
-2.106
After Ambulating 5.30 ± 1.34 6.00 ± 1.31 78
(4-6) (5-7) 0.038
Paired t test 3.47 4.01
t-value, 39 39
df 0.001 <0.001
p value
Baseline data of the mothers in first 6 hours control group had urine output >450 ml in
after Caesarean Section first 6 hours. None of the subjects from
Table 4 demonstrates the baseline data experiment and control group moved out of
of the post caesarean mothers in first 6 hours the bed and none of than passed flatus.
after caesarean section. All the subjects in 32.5% subjects in experimental and 10% in
experiment group and control group had control group initiated of breast feed after
normal vitals sign. Nearly half of the subjects caesarean section.
(47.5%) in experimental and 67.5% in
Table 4: Baseline data of the mothers in first 6 hours after Caesarean Section
Variable Experimental Control
N1=40 n2=40
f (%) f(%)
Vital
Normal 40 (100) 40 (100)
Total Urine Output
150-300 ml 7 (17.5) 7 (17.5)
301-450 ml 14 (35.0) 6 (15.0)
> 450 ml 19 (47.5) 27 (67.5)
Moved out of bed Nil Nil
Passed flatus Nil Nil
Initiation of breastfeeding 13 (32.5) 4 (10)
after caesarean section
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015 39
Post-operative recovery after ambulation
among post-caesarean mothers in both
groups
The data in Table 5 reveals that the
higher percentage of subjects in control
group (70%) required more number of
analgesics i.e. 2-3 injection than experiment
group (27.5%). Duration of catheterization
was same in both experiment group (45%)
and control group (37.5%) in 19-24 hours.
Nearly half of subjects (45%) in experiment
group self-voided within 1 hour after removal
of catheter while only 20% in control group.
In experiment group 57.5%subjects initiated
breast feeding at 6 hours whereas in control
group it was only 15%. 80% subjects in
experimental group had given breastfeeding
and hold the baby independently at 6 hourly
and started oral intake after one hour of
ambulation and 62.5% passed first flatus
within one hour of ambulation as compare to
control group it was 10% only. These
differences were statistically significant as
per Chi-square test (p<0.05).

Table 5 : Post-operative recovery among post-caesarean mothers in both groups

Variables Experiment group Control group X2
(n1=40) (n2=40) df
f (%) f (%) p value
Number of analgesic required after ambulation 14.45
nil-1 injection 29 ( 72.5) 12 (30) 1
2-3 injection 11 ( 27.5) 28 (70) <0.001
Duration of catheterization after caesarean section
6-12 hours 4 (10.0) 6 (15) 3.17
13-18 hours 15 (37.5) 16 (40) 3
19-24 hours 18 (45.0) 15 (37.5) 0.36
25 – 30 hours 3 (7.5) 3 (7.5)
Self-void after removal of catheter
<1 hour 18 (45) 8 (20) 10.24
1-2 hour 18 (45) 17 (42.5) 2
>2 hour 4 (10) 15 (37.5) 0.006
Initiation of breast-feedafter caesarean section *N1= 27 *N2 = 36 3.53
At 6 hour 23(57.5) 6(15) 1
>6 hour 4 (10) 30 (75) <0.001
Breast feeding and Holding baby
independently after caesarean section 18.33
At 6 hour 32 (80) 13 (32.5) 1
>6 hour 8 (20) 27 (67.5) <0.001
Start of oral intake after ambulation 31.27
Within 1 hour 32 (80) 7 (17.5) 1
After 1 hour 8 (20) 33 (82.5) <0.001
First flatus passed after ambulation 23.85
Within 1 hour 25 (62.5) 4(10) 1
After 1 hour 15 (37.5) 36(90) <0.001
*Subjects excluded who breast feed in first 6 hours of caesarean section
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015 40
Impact of early ambulation on post- experimental and control group. The
operative recovery among post-caesarean difference in duration of post-operative
mothers shows the comparison of variables recovery variables among experiment and
assessing the post-operative recovery control groups was statistically significant as
among post-caesarean mothers between per Independent t-test(p <0.05).
Table 6: Impact of early ambulation on post-operative recovery
among post-caesarean mothers
Variables Experimental group Control group t-value
(N1= 40) (N2= 40) df
Mean Duration in Mean Duration in p value
hours ± SD hours ± SD
Duration of catheterization 1.34
after caesarean section 19.37 ± 4.60 19.85 ± 5.47 78
0.18
Self-voided after -3.47
catheter removal 1.65 ± 0.66 2.25 ± 0.86 78
<0.001
Start of oral intake after -6.13
caesarean section 6.20 ± 0.83 8.92 ± 2.65 78
<0.001
Breastfeed and Holding -14.76
the baby independently 6.42 ± 1.69 13.27 ± 2.39 78
<0.001
First Flatus passed after -7.72
caesarean section 6.77 ± 1.09 12.02 ± 4.46 78
<0.001
Discussion helping the patient to re-establish the normal
Caesarean section is a method of physiology and preventing or minimizing
delivering baby through an incision made in post-operative complications after the
the mother's lower abdomen wall and uterus caesarean section. Ambulation hastens
instead of delivering through vagina. Post muscle redevelopment and wound
caesarean mothers require special care and it healing.Post caesarean mother should be
is quiet challenging to make this special care encouraged to get up and try to go to the
available to them. A little care given to post- bathroom after the effect of regional
11
operative phase will confirm the post- anaesthesia gone off.
operative period to be healthy and safe. Studies have shown that ambulation at
Early ambulation is a key factor in 4-6 hours after caesarean section is

Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015 41

recommended in some hospitals. In present
study the subjects in experiment group were
ambulated at 6 hours of caesarean section by
means of walking a distance of 40 meters
where as subjects in control group
ambulated at 13-14 hours after caesarean
section which was normal practiced in the
labour room.
A number of studies on caesareans
have reported increased risk of maternal
morbidities such as; hysterectomy,
haemorrhage, infection, thrombosis and
postpartum depression. UK obstetric
anaesthesia guidelines suggest that the post-
operative care of a caesarean patient should
be in accordance with the care of any post-
operative patient as laid out in guidelines for
12
post anaesthetic recovery. Early catheter
removal, early onset of peristalsis
movement, early feeding after caesarean
section and other supportive treatment such
as ambulation and privacy can enhance the
likelihood of post-operative recovery.
Hence in present study the post
operative recovery was considered in terms
of the intensity of post-operative pain
perceived by post caesarean mother, use of
analgesics after ambulation, duration of
catheterization, self void after removal of
catheter, passage of first flatus, initiation of
oral intake and breast-feeding and holding
baby independently.
The findings of the present study
revealed that mean post-operative pain score
after ambulation was reduced significantly in
experiment group as compared to mean pain
score in control group. These findings were
accordance to the study conducted by
Chaudhary S which concluded that the mean
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
suture pain score of caesarean section
mothers in control group was higher than
experimental group which indicated that
early ambulation has a positive effect on
13
reduction of post-operative pain.
In relation to comparison of post-
operative recovery after ambulation among
post-caesarean mothers between both
groups depicts that higher percentage
subjects in experiment group self-voided
within 1 hour after removal of catheter as
compare to control group. This result was in
accordance with a prospective randomized
study which revealed that early removal of
urinary catheter after a caesarean section
offers more advantages to the patient in
terms of first-void discomfort, time of first
spontaneous void and time of ambulation.
Ambulation time in 4-hour catheterized
group was 13.15 hours and 25.46 in the 24-
hour catheterized group which was
14
statistically significant
Present study also showed that
maximum subjects in experimental group
started oral intake at much earlier time as
compare to control group. The finding was
supported by randomized controlled trail by
Adupa D et al in which he compared the early
feeding group v/s routine feeding group in
post caesarean mothers. The findings
significantly indicated that women in the
early feeding group got out of mobilization
earlier, had more rapid return of their bowel
function (p = 0.001) than the control group15.
The finding of the present study depict
that maximum subjects in experiment
group initiated breast feeding at 6 hours as
compare to control group. This finding was
similar to that of study done by Harper J on
42
Keeping mothers and newborns together
after caesarean section and early ambulating
has got several benefits, including the
promotion of maternal-infant bonding and
breastfeeding, which are essential
components of care. Results have shown
that women who delivered by caesarean
recovered with their infants at faster rate if
16
they are early ambulated.
The finding of the present study also
showed that there was significant difference
between the post-operative recovery among
experimental and control group. The finding
of the present study were in accordance to
the study of Dube J V et.al on effect of
planned early ambulation on Selected
Postnatal Activities of Post caesarean
Patients concluded that there was significant
difference in the activities carried out by the
study subjects of experimental and control
group, as evidenced by better activities of
experimental group. This indicated the
beneficial effect of planned early ambulation
on resumption of activities of post caesarean
patients.17
Result of another study on
effectiveness of early ambulation on post-
operative recovery and activities of daily
living (ADL) on patients undergone
abdominal surgery showed that,
experimental group experienced a significant
decrease in morbidity as well as significant
improvement in ADL as compared to control
group. 18
Another study on effect of Planned Early
Recommended Ambulation Technique on
Selected Post caesarean Bio physiological
Health Parameters concluded that planned
early ambulation after lower segment
Nursing and Midwifery Research Journal, Vol-11, No. 1, January 2015
caesarean section plays an important and
beneficial role in improving the post
caesarean bio physiological health
parameters of postnatal mothers. Thus it is
effective strategy which can help in early post
caesarean recovery of the postnatal mothers.
It can also be practiced safely in hospital
setting for the benefit of patients and health
11
care team members.
Hence the null hypothesis (H0) was
rejected and it showed that there was
significant impact of early ambulation on
post-operative recovery among post-
caesarean mothers.
Based on the present study findings it
was concluded that early ambulation was
effective in post-operative recovery after
caesarean section. Early ambulation i.e. 6
hours can be initiated after caesarean section
for speedy post-operative recovery and to
prevent post-operative complications. Hence
it s recommended that early ambulation can
be incorporated into nursing practice in
labour room as it can enhance the post-
operative recovery and reduce the post-
operative complications. Study could
generate protocol for early ambulation after
caesarean section which can help the staff
nurses to enhance their competences in
managing the post-caesarean mothers.
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