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J Obstet Gynecol Neonatal Nurs. Author manuscript; available in PMC 2013 June 27.
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J Obstet Gynecol Neonatal Nurs. 1994 January ; 23(1): 53–59.

Major Concerns of Women After Cesarean Delivery

Susan M. Miovech, RNC, BSN, Helen Knapp, CRNP, MSN, Lynne Borucki, RNC, MSN,
Marianne Roncoli, RN, PhD, Lauren Arnold, RN, PhD, and Dorothy Brooten, RN, PhD, FAAN

Abstract
Objective—To identify women’s major physiologic, psychologic, and life-style concerns at 2
and 8 weeks after cesarean delivery.
Design—Descriptive study with open-ended interviews.
Setting—Large urban hospital affiliated with a major university.
Participants—One hundred six women who had unplanned cesarean deliveries and delivered
live, full-term neonates.
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The mean maternal age was 28.7 years.

Main Outcome Measures—The major physiologic, psychologic, and life-style concerns.
Results—Seven women reported no concerns at both data points. The number of physiologic
concerns that the women expressed decreased markedly from 2 to 8 weeks postdelivery, but the
number of psychologic and life-style concerns did not.
Conclusions—These findings reinforce the need for prenatal teaching and postnatal follow-up
regarding these concerns.

One in four women who gives birth in the United States does so by cesarean delivery,
making cesarean section the most common hospital surgical procedure (Stafford, 1990).
Health professionals have attributed this high rate of cesarean delivery to an increased use of
electronic fetal monitoring, a reluctance to deliver vaginally in cases of breech presentation
or prolonged labor, a decreased use of forceps, a fear of malpractice suits, and increasing
numbers of previous cesarean deliveries (Zdeb & Logrillo, 1989).

In 1987, health-care providers performed 934,000 cesarean deliveries, one-third of them

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repeat procedures. This trend continues even in the face of a National Institutes of Health
recommendation “that a proper selection of cases should permit a safe trial of labor and
vaginal delivery for women who have had a previous low segment transverse cesarean birth”
(Marieskind, 1989, p. 196). The American College of Obstetricians and Gynecologists in
1982, 1985, and 1988 repeated and further defined this recommendation (Marieskind, 1989).
Past and current trends indicate that the incidence of cesarean delivery is likely to remain
significant (Holland, Dupre, Blake, Martin, & Martin, 1992), making care of women who
have cesarean deliveries a major focus of perinatal nursing.

Cesarean delivery is not benign. Normally, birth involves stress associated with the
physiologic, emotional, and life-style changes of pregnancy and the puerperium, including
fatigue, mood swings, body image changes, and assumption of the parental role (Berry,
1983; Brouse, 1988; Mercer & Stainton, 1984; Tilden & Lipson, 1981). Cesarean birth adds
additional stress, including the stress of surgery. Women who experience cesarean delivery

Address for correspondence: Susan M. Miovech, RNC, BSN, 1910 Arrowood Dr., Bensalem, PA 19020.
 Miovech et al. Page 2

have reported feelings of depression, anxiety, guilt, less satisfaction with the birth
experience, loss of control, and loss of self-esteem (Cox & Smith, 1982; Crowe & Von
Baeyer, 1989; Hedahl, 1980; Tilden & Lipson, 1981; Trowell, 1982). Reportedly, unplanned
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or emergency cesarean birth is especially problematic (Affonso, 1977; Lipson & Tilden,
1980; Marut & Mercer, 1979).

Physiologic Stresses
Cesarean birth imposes the physiologic stresses of anesthesia, a major surgical procedure,
physical recovery, and postoperative complications (Mercer & Stainton, 1984). Women who
experience an unplanned cesarean birth are at greater risk for infection, including
endometritis, bacteremia, and urinary tract and wound infection (Nielsen & Hokegard, 1983;
Yudkin & Redman, 1986). Lengthened hospitalization caused by such infections can make
the mother more vulnerable to both physiologic and psychosocial concerns, including
nosocomial infection, depression, and anxiety.

Psychologic and Life-Style Stresses

Researchers have reported a variety of maternal psychologic responses to cesarean birth.
Trowell (1982) reported increased anxiety in women who experience cesarean deliveries.
Affonso and Stichler (1978) reported that 88% of their sample of women who experienced
cesarean birth expressed a fear of surgery, pain, possible death, injury to their child, or a
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changed relationship with their spouse or children. Marut and Mercer (1979) found that
women who have cesarean deliveries are less satisfied with the birth experience and
themselves, perceiving the cesarean delivery as significantly different from “normal” birth.
Walker (1989) reported similar findings. Concerns with body image after cesarean birth also
have been reported (Cox & Smith, 1982; Mercer & Stainton, 1984).

An unplanned, emergency cesarean delivery can be especially stressful. As Cranley noted,

the unplanned experience, with its unfamiliar and intrusive procedures occurring in rapid
succession, strain the ability of the woman to assimilate the experience (Cranley, Hedahl, &
Peggs, 1983). Additionally, several researchers reported that women who have emergency
cesarean deliveries express more negative perceptions of the birth experience than those
who have planned cesarean deliveries (Cranley, Hedahl, & Peggs, 1983; Fawcett, 1981;
Hart, 1980; Lipson & Tilden, 1980; Marut & Mercer, 1979; Trowell, 1982).

In sum, the current rate of cesarean delivery in the United States remains high. Numerous
investigators have reported physiologic and psychologic stresses accompanying cesarean
birth; however, the researchers conducted most of this work in the late 1970s and early
1980s. Given changes in protocols, technology, and consumer awareness over the last 20
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years, the literature does not clearly indicate whether or not the concerns women associated
with cesarean delivery previously reflect the concerns of women experiencing cesarean
delivery today (Erb, Hill, & Houston, 1983; Shearer, 1989). The purpose of the current study
was to determine the major physiologic, psychosocial, and life-style concerns women report
today at two points in time: 2 weeks and 8 weeks after an unplanned cesarean delivery.

Design and Method

This descriptive study used an open-ended interview to obtain women’s major physiologic
and psychologic and life-style concerns at 2 and 8 weeks postdelivery. The researchers
chose the 2-week data point because that is a time of known stress and letdown as family
supports diminish and mothers assume a greater role in caring for the newborn, themselves,
and the house-hold. The researchers chose the 8-week data point because normal postpartum
physiologic recovery is expected by that time. The interview, conducted by telephone,

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consisted of three open-ended questions. The questions were: What are your major physical
concerns at this time following your cesarean delivery? What are your major psychologic
concerns at this time following your cesarean delivery? What are your major life-style
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concerns at this time following your cesarean delivery? The researchers pretested these
questions for clarity on the first 10 women in the larger study of which this interview was a
part, but they did not include these women’s responses in the analysis.
The likelihood that the incidence of cesarean delivery will remain significant
makes care of women who deliver by cesarean section a major focus of perinatal
nursing.
Two perinatal master’s degree students who were trained for the interviews by members of
the research team conducted the interviews. The interviews lasted a mean of 15 minutes,
with a range of 10–20 minutes. The researchers collected data between July 1988 and
January 1991. The study was part of a larger study on early hospital discharge and the role
of the clinical nurse specialist in the home follow-up of women who experience unplanned
cesarean delivery (Brooten, Gennaro, Knapp, Brown, & York, 1989).

Sample
The larger study, of which the current study was a part, was a randomized clinical trial of
early hospital discharge for 122 women who experienced unplanned cesarean delivery. The
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university’s institutional human subjects review committee and the hospital’s research
review committee approved the study. Women participated in the study after receiving a
thorough explanation of it and signing an informed consent form. The sample for this
portion of the larger study (n = 106) consisted of 110 subjects who were asked to respond to
the interview after a phased-in start of the larger study. Four subjects chose not to respond to
this portion of the larger study. All the women delivered full-term, live neonates at a large
urban hospital affiliated with a major university. The mean age of the mothers was 28.7
years (range, 16–42 years; SD, 6.4 years). The educational level of the respondents was as
follows: less than high school education (24%), a high school education (25%), and greater
than a high school education (58%). The average annual income was between $17,500 and
$19,999 (range, < $5,000 to > $50,000). Hospital insurance coverage included private
insurance (58%), public insurance (33%), and no insurance (9%). Race distribution was as
follows: white 46%, black 48%, Asian-American and other 6%. Sixty-four percent of the
women in the sample were married, and 64% were primiparas.
Total reported physiologic concerns decreased markedly by the 8-week data
point; total reported psychologic/life-style concerns did not.
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Results
Of the 106 subjects, 7 reported no concerns at both the 2-week and 8-week data points. Of
the remaining 99 women, 8 reported no concerns at 2 weeks but did report concerns at 8
weeks; and 34 reported no concerns at 8 weeks, but reported concerns at 2 weeks. Tables 1
and 2 list the results of the physiologic, psychologic, and life-style concerns reported at the
2- and 8-week data points. Because considerable overlap occurred in the responses to the
psychologic and life-style concerns questions, the researchers combined the responses to
these two questions in reporting the data. Because most women reported more than one
concern, the researchers discuss the results as a percentage of total reported concerns.

Physiologic Concerns
Of the 99 women who reported concerns after cesarean delivery, 14% reported no
physiologic concerns at 2 weeks, and 24% reported no physiologic concerns at 8 weeks. The

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women reported the most physiologic concerns at the 2-week postdelivery data point and
markedly fewer by the 8-week data point (see Table 1).
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At 2 weeks postdelivery, the concerns reported most frequently were pain, incisional
problems, activity intolerance, fatigue, and gastrointestinal disturbances. Regarding the 30
reports of pain at 2 weeks postdelivery, 21 subjects reported abdominal pain (70%), 6
reported incisional pain (20%), and 2 reported back pain (7%). The researchers included
concerns regarding pain in this category only if the women mentioned pain and discomfort
as opposed to tenderness or similar sensations.

In the reports of incisional problems, concern focused on incisional itching, wound pulling,
incisional “dent,” wound infection, staples, “hard incision,” and incisional numbness. At 2
weeks postdelivery, 20 subjects reported concerns with activity intolerance, including
getting out of bed and walking, bending, lifting, handling the newborn, not being able to
take a bath, and not being able to do everything the subjects wanted to do. Fifteen subjects
reported concerns with fatigue, including lack of sleep. Gastrointestinal disturbances
included complaints of gas, vomiting, and intolerance to certain foods. Two subjects
complained of breast engorgement, and two complained of nipple soreness. Other concerns
included difficulties with an ovarian cyst, bronchitis, leg edema, elevated blood pressure,
Bell’s palsy, and chest discomfort.
The major physiologic concerns at 2 weeks were pain, incisional problems, and
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activity intolerance; at 8 weeks, incisional problems, pain, and fatigue.

At 8 weeks, the major concerns focused on incisional problems (42%). Women complained
of numbness of the incision, pulling and itching, and tenderness around the incision. Seven
subjects complained of pain at 8 weeks postdelivery, and six still reported concerns with
fatigue.

Psychologic and Life-Style Concerns

Of the 99 women who reported psychologic and life-style concerns postdelivery, 21%
reported no concerns at 2 weeks postdelivery, and 19% reported no concerns in this category
at 8 weeks postdelivery. Compared to the total reported physiologic concerns, which
decreased markedly at 8 weeks, the total reported psychologic and life-style concerns
differed less at the 2- and 8-week data points. As with the physiologic concerns, however,
the types of concerns changed between the 2-week and 8-week data points.

The major psychologic and life-style concern at the 2-week data point was change in activity
(40%). This category included complaints of being limited in activity, not feeling like
entertaining visitors, not being able to get out, taking too long to feel better, having trouble
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getting organized, and being tied to the house. The next most reported concern was
depression (16%). This was described as feeling blue, feeling low, just not feeling like
themselves, feeling alone and bored, and feeling emotionally overwhelmed. The reported
concerns in family interaction (13%) related to changed family patterns, including having
less time with older children, sharing the house all day with a partner or significant other,
not being interested in sex, and husbands having to make major changes in activities at
home. Concerns regarding body image (11%) included feelings of being out of shape or
being “damaged.” Eight subjects reported child-care concerns. These concerns related to
getting upset when the newborn cried, having problems feeding the newborn, and feeling
that life was all mothering.
The major psychologic and life-style concerns at 2 weeks were changes in
activity, depression, and concerns related to family interactions; at 8 weeks,
changes in activity, body image, and family interactions.

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At the 8-week data point, the most frequently reported concern was still changes in activity
(27%). These concerns included reports of having less time for socializing, being
housebound, being much busier, taking longer to do things, being bored when the infant
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slept, and having less time for oneself. The second major area of concern at the 8-week data
point focused on body image changes (23%). The concerns here focused on weight gain and
abdominal stretching. Eleven of the subjects (12%) reported concerns with family
interactions. This category included concerns over family members who were relocating, the
husband’s job loss, a perceived lack of support by partners, and separations. The next major
concerns (11%) related to school and work. This category included planning future
educational goals, worrying about becoming pregnant again too soon, reexamining returning
to work, and not liking to leave the infant to go back to work. Nine (10%) of the respondents
still reported child-care concerns, including feeding, spending all available time caring for
the infant, not being able to go out without help, and feeling nervous going shopping or
doing errands with the. infant. The researchers received only 5 reports of depression at 8
weeks postdelivery, compared with 17 at the 2-week data point.

Discussion
The study results support, in part, findings of previous work. The total reported physiologic
concerns (160) were slightly fewer than the total reported psychologic and life-style
concerns (197). The reported data also made clear that overall physical concerns decreased
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markedly from the 2nd week postdelivery, whereas psychologic and life-style concerns did
not.

Concerns with pain, which were the most frequently reported concerns at 2 weeks after
cesarean delivery in this study, were an area of concern identified previously by Affonso and
Stichler (1978) in a similar sample. In later work (1980), the same investigators reported that
women’s concerns over incisional healing after cesarean delivery were similar to those
identified in this study. In the current study, incisional concerns ranked as the number two
and number one physiologic concerns at the 2- and 8-week data points, respectively.

Activity intolerance, the third most frequently expressed concern at the 2-week data point,
was much less problematic at 8 weeks postdelivery. Affonso and Stichler (1978) reported
that 100% of the women in their sample reported this concern at 2–4 days postdelivery.
Fatigue also was an important concern at 2 weeks postdelivery but was less problematic at
the 8-week data point. This finding supports the work of Tulman and Fawcett (1991), and
Tulman, Fawcett, Groblewski, and Silverman (1990), who reported that while women who
have cesarean deliveries experience lessening fatigue as time progresses, these women still
are not fully recovered at 6 months postdelivery.
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Previous studies have identified such psychologic and life-style concerns as depression,
changed activity patterns, fatigue, and work-related concerns in association with cesarean
delivery. In the current study, concerns about changed activity patterns were the major
psychologic concerns at both the 2- and 8-week data points. These findings support the work
of Tulman and Fawcett mentioned previously. Depression, the second-ranking concern at 2
weeks postdelivery in this study, also was reported as problematic by Tilden and Lipson
(1981) in their study of women that extended 2 years postdelivery. Those findings indicated
that a cesarean birth for many women was a negative experience causing emotions ranging
from disappointment to serious postpartum depression. Cohen (1977), who interviewed
women in postcesarean delivery support groups, found unexpected cesarean deliveries to be
associated with increased reports of depression.

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Concerns with changes in family relationships, which ranked as the third concern at 2 and 8
weeks in this study, also were reported to be concerns by Affonso and Stichler (1978) in
their sample taken at 2–4 days postdelivery. Concerns in Affonso and Stichler’s study
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focused on the roles of mother and wife, changing family relationships, and topics similar to
those identified in the current study. In a later study, Affonso, Mayberry, and Sheptak
(1988) found similar concerns at 6 weeks postpartum.

Concerns about body image changes ranked fourth at the 2-week data point and second at 8
weeks. Numerous investigators have reported similar concerns between 2 days and 5 weeks
postpartum (Affonso & Stichler, 1978; Berry, 1983; Cohen, 1977; Mercer & Stainton, 1984;
Smith, 1989; Tilden & Lipson, 1981). Child-care concerns ranked fifth at 2 and 8 weeks.
Other investigators have reported similar concerns in caring for children, including physical
care of the infant and interpreting newborn behaviors and abilities (Brouse, 1988; Smith,
1989; Trowell, 1982; Tulman, Fawcett, Groblewski, & Silverman, 1990). These studies
reported data from 3 days postdelivery to 1 year postdelivery.

Work and school-related concerns were more problematic at the 8-week data point than at
the 2-week data point. Returning to work or starting a new job was related to perceived
stress in Walker’s (1989) study of women between 2 and 12 weeks postdelivery. Gardner
and Campbell (1991) also discussed the economic pressure to return to work as a stress
factor in a group of postpartum women followed between 2 days and 6 weeks postpartum.
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Killien (1990) reported working during pregnancy and returning to work after delivery as
both a psychologic stressor and an asset.
Decreased lengths of stay necessitate providing anticipatory guidance related
to these concerns during both the antepartum and postpartum periods.

Implications for Nursing Care

These study findings have clear implications for child-birth classes and for discharge
teaching for women and couples. Today women are being discharged from the hospital
earlier than ever before. Early discharge potentially compromises the ability of the
postpartum nurse to provide comprehensive care by seriously limiting the time available for
transmitting information and supporting role changes and physiologic adaptation (Gillerman
& Beckham, 1991). Each interaction with the postpartum woman should have specific
teaching and learning goals because often the woman will be discharged according to
externally applied criteria (e.g., diagnostic-related groupings) rather than personal readiness.
Therefore, the nurse must assure that the woman and family are prepared for discharge. Both
the prenatal and postdelivery periods are needed to prepare the woman and family
adequately for recovery and parenting. Methods to accomplish this teaching can include
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pamphlets, videos in the postpartum unit, audiocassettes, and postpartum follow-up calls.
Fawcett (1990) developed a pamphlet that focused on cesarean delivery and was
incorporated into the teaching materials of prenatal classes. Discussions of the pamphlet
near the end of the classes, combined with postdelivery phone calls, helped the women and
families integrate the cesarean experience.

On the basis of the study findings, specific information about the incision, pain and
discomfort, body image changes, and changes in family interactions should be included in
prenatal classes. Explanations about the process of returning to the nonpregnant state should
be provided at this time, along with information on all the changes the woman will
experience as her pregnancy advances. Women need to learn that the discomfort associated
with the healing incision (pain, tingling, numbness, tenderness, and abdominal muscle
flabbiness) may take months to be resolved. The ability to move quickly and easily will
return gradually. Fatigue, and often feelings of inadequacy related to caring for the new

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infant and other members of the family, also will take time to resolve. Encouraging
exercises, such as walking, during pregnancy will increase muscle tone and potentially
improve post-partum healing so that incisional concerns maybe less problematic. Realistic
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expectations of the healing process should be emphasized.

Discharge planning should include helping parents make arrangements for obtaining help
from relatives and friends and spacing activities throughout the day to reduce fatigue.
Frequent rest periods are important, along with good nutrition and adequate fluid intake.
Careful assessment of the effects and symptoms of depression should be made so that true
depression can be differentiated from the normal changes associated with pregnancy
(Affonso, Lovett, Paul, & Sheptak, 1990). The management of one is not effective for the
other; therefore, a correct evaluation is necessary so that the woman receives the appropriate
interventions. Furthermore, the findings suggest that postpartum visits might be scheduled
over the first 2 or 3 months rather than immediately after discharge. Nurses need to assume a
larger role in providing postpartum care, which has traditionally been offered, if at all, only
during the 6-week postpartum visit to the obstetrician.

Limitations and Recommendations for Further Research

Study limitations include the limitations inherent in using open-ended questionnaires and
problems generalizing study results beyond urban middle class populations.
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Recommendations for further work include refinement of the open-ended questions to

include specific probes or cues. These more specific questions might be developed from the
major concerns reported in each category in the current study. Further research should be
targeted to other populations, including lower socioeconomic, rural, and suburban
populations and different racial and ethnic groups.

Conclusion
After cesarean delivery, women report both physiologic, psychologic, and life-style
concerns associated with it. Although physiologic concerns decrease markedly from the 2nd
to the 8th week postdelivery, psychologic and life-style concerns do not. In this time of early
hospital discharge, anticipatory guidance and teaching regarding these concerns should be
initiated during the antepartum period, reinforced during the hospital stay, and followed up
during the postpartum period.

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Biographies
Susan M. Miovech is a graduate student and research assistant at the University of
Pennsylvania School of Nursing and a staff nurse at the Lower Bucks Hospital in Bristol,
PA. She is a member of AWHONN.

Helen Knapp is a clinical lecturer and project manager in the University of Pennsylvania
School of Nursing and a staff nurse at the Hospital of the University of Pennsylvania. She is
a member of AWHONN.

Lynne Borucki is a clinical lecturer at the University of Pennsylvania School of Nursing.

She is a member of AWHONN.

Marianne Roncoli is an assistant professor at the University of Pennsylvania School of

Nursing.
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Lauren Arnold is the clinical director of obstetric-neonatal nursing at the Hospital of the
University of Pennsylvania and an assistant professor at the University of Pennsylvania
School of Nursing. She is a member of AWHONN.

Dorothy Brooten is a professor within and chair of the Health Care of Women and
Childbearing Division of the University of Pennsylvania School of Nursing. She also is the
director of that school’s center for Low Birthweight Research: Prevention and Care and a
member of AWHONN.
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 Miovech et al. Page 10

Table 1
Physiological Concerns of Women Postcesarean Delivery, N = 99 Women
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Category of concerns 2 Weeks 8 Weeks

reported # (%) # (%)
Pain 30 (26) 7 (16)
Incisional problems 29 (25) 18 (42)
Activity intolerance 20 (17) 4 (9)
Fatigue 15 (13) 6 (14)
Gastrointestinal disturbances 11 (9) 3 (7)
Breast/nipple problems 4 (3) 1 (2)
Other 8 (7) 4 (9)
Totals 117 (100) 43 (100)
NIH-PA Author Manuscript
NIH-PA Author Manuscript

J Obstet Gynecol Neonatal Nurs. Author manuscript; available in PMC 2013 June 27.
 Miovech et al. Page 11

Table 2
Psychological and Life-style Concerns of Women Postcesarean Delivery, N = 99 Women
NIH-PA Author Manuscript

Category of concerns 2 Weeks 8 Weeks

reported # (%) # (%)
Changes in activity 44 (40) 24 (27)
Depression 17 (16) 5 (6)
Family interactions 14 (13) 11 (12)
Body image changes 12 (11) 20 (23)
Child care 8 (7) 9 (10)
Healing 5 (4) 1 (1)
Fatigue 4 (4) 4 (5)
Financial concerns 4 (4) 4 (5)
Work/school related 1 (1) 10 (11)
Totals 109 (100) 88 (100)
NIH-PA Author Manuscript
NIH-PA Author Manuscript

J Obstet Gynecol Neonatal Nurs. Author manuscript; available in PMC 2013 June 27.