CHAPTER NO# 1

INTRODUCTION

1.1 Definition of cesarean section:

Cesarean delivery is defined as the delivery of a fetus through surgical incisions made through
the abdominal wall (laparotomy) and the uterine wall (hysterectomy) ( Joy,2016)
1.2 Purpose:

The purpose of the cesarean delivery is where vaginal delivery would be eigther impossible or
dangerous to to the life or health of the mother or baby.
Cesarean section are performed whenever abnormal conditions complicate labor and vaginal
delivery, threatening the life or health of mother or baby.
1.3 Types of cesarean section:

Several types of cesarean deliveries exist with the main difference of incisions made ( Mandal,
2014)
 Traditional C-section:

It involves long vertical incision made in the midline of abdomen. it is associated with post-
surgical complications so it is not commonly carries today
 Lower segment C-section:

In this type a horizontal incision is made just above the pubic hairline .this is the most common c
section method. It is the most commonly performed cesarean section.

1
 Cesarean hysterectomy:

It involves removing the uterus during the same procedure of C-section delivery due to severe
blood loss after delivery.

2
1.4 Problems faced commonly after cesarean:

The most common problems faced by the patient after cesarean section are:
1) Post cesarean pain
2) Limitations in functional activities
3) Other complications that can occur are:

4) Urinary retention and kidney dysfunction for the urinary system;

5) And dizziness, vomiting, decreased peristalsis and postoperative ileus for the gastrointestinal
system (Taskın,2009)

1.5 Prevalence of problems after cesarean:

3
 In Australia in 2002 the prevalence of pain after cesarean delivery was 53-45%
In India the prevalence of pain after first post cesarean day is 40.9% and after one week it
is35.2% (Abbasi etall,2014)
1.6 Role of physiotherapy after cesarean delivery

There is a vast role of physiotherapy after cesarean section .physiotherapist ease the patient
problems by some exercises and modalities
 Physiotherapist act in the best interest of patient
 They make the patient independent as soon as possible to carry out the daily activities with the new born
 They improve the maternal and new born bonding
 Physiotherapy prevent the complications of prolong bed rest after cesarean
e.g (ankle swelling , back pain ,neck pain ,flatulence problem etc)
(Dube and Kshirsagar,2014)
1.7 Operational definition:

Cesarean section:
A surgical procedure involving incision of the walls of the abdomen and uterus for delivery of
offspring
TENS:
Transcutaneous electrical nerve stimulation is a modality that in experimental settings has been
able to reduce pain
1.8 Rationale:

Only few hospitals provide physiotherapy services after cesarean section. That causes late
recovery of mother. This study will enlighten the effectiveness of physiotherapy plan of care for
immediate post cesarean women.
1.9 Objective: To find out the effectiveness of physiotherapy intervention and modalities after
immediate post cesarean pain, and functional activities.

4
Chapter No. 2

LITERATURE REVIEW
Cevik and baser(2016) conducted a Randomized control experimental design at surgery service
of obstetrics and gynecology in Gaziantep to investigate the effect of bed exercises on flatulence
and early discharge from the hospital after cesarean delivery.120 women were included and
results were compared in two groups (exercise group an control group).it was examined that
bowel movements started at the same time in these groups .concluded that spinal anesthesia has a
positive effect on discharge time after cesarean section delivery.
Morisawa etall(2015) worked in department of physical therapy , school of rehabilitation in
Japan using a randomized control trial. The purpose of the study was to compare the effects of

5
passive exercise of the lower limb and trunk and combination therapy with those of
thermotherapy on bowel sounds in healthy adult subjects. Passive exercise of limb resulted in
significant increase of bowel sounds after treatment (9.45&3.93Mv.sec) compared with before
treatment (7.87&1.31mV.sec), suggesting that it is beneficial for those patients who are unable to
rise up from the bed or after cesarean section.
Kayman-kose etall.(2014) conducted a research in department of obstetrics and gynecology in
Turkey to determine the effectiveness of TENS in pain management which is related to uterine
contractions plus incision. He took 100 post cesarean patients and grouped them in placebo and
TENS groups. The results were the analgesic requirement at the eighth hour of cesarean section
was significantly lower in the patients who were treated with TENS (p = 0.006).concluding that
TENS is easy and reliable modality for the treatment of post partum pain.
Dube etall (2013) conducted a research at Dr ulhas patil medical college and hospital of jalgon in
India by using quantitative quasi experimental approach to determine the effect of planned early
ambulation after cesarean section. He gave the plan of walk to the experimental group starting
from the day of surgery to the next 5 days .the results showed that there was marked difference
between the activities carried out by experimental group VS control group. it showed the effect
of early planned ambulation after cesarean delivery
Karakaya etall(2011) worked at university hospital of Ankara and conducted a
randomized trial to detect the effect of exercise plan on incisional pain and functional activities
in the early post cesarean time. He evaluated 50 women after cesarean delivery and evaluated
time of ambulation, intensity of incisional pain, difficulty in functional activities. The results of
the study are; time to first walk after delivery in study and control group were 6:18 (h:m) and 8:1
(h:m), respectively showing the conclusion that post cesarean exercise plan is very effective
Bjordal etall. (2003) worked at university of Bergen in Europe to find out if TENS can reduce
analgesic consumption after surgery .he used randomized placebo control trials. They reported a
mean weighted reduction in analgesic consumption of 35.5% (range 14-51%) better than
placebo. In nine trials without explicit confirmation of sufficient current intensity and adequate
frequency, the mean weighted analgesic consumption was 4.1% (range -10 to +29%) in favor of
active treatment. it was concluded that the TENS used in wound area significantly decrease the
analgesic consumption in patients

6
Rakel and frantz(2003) performed a prospective randomized research at Midwestern tertiary
health care center in America and took a sample of 24 subjects to test the effectiveness of
episodic TENS on pain with movement after abdominal surgery . He investigated on two groups
(TENS treated and placebo TENS treated). The results were the mean pain score at rest was 4.2
for TENS group and 5.4 for placebo TENS which concluded that TENS was more effective in
reducing the cutaneous pain and movement related pain than placebo TENS.

7
CHAPTER# 3
MATERRIALS AND METHODS

3.1 Study design:

Interventional study.

3.2 Setting:

Jinnah hospital Lahore.

3.3 Duration of study:

Three months from the time of approval of synopsis.

3.4 Sample size:

n=45.

As it is an interventional study and most of the relevant studies considered small sample size.

3.5 Data collection procedure:

All the females in the post-operative ward of Jinnah hospital Lahore fulfilling the inclusion
criteria were included in this study during a span of three months. Two groups were formed (a study
group receiving physiotherapy intervention and a control group not receiving physiotherapy intervention
after post cesarean period).Study group received physiotherapy intervention as soon as possible for
following 3 post cesarean days .and control group didn’t receive this intervention. The pain intensity ,
and functional activities were compared in these groups daily until the last session. Self made
questionnaire will be used .Questionnaire consisted of four parts; physical characteristics, obstetrical
history, health problems before and during pregnancies, pain and functional activity assessment. Pain and
functional activity limitations were assessed via VAS (visual analogue scale).And its validity and
reliabilits scores from 0.76-0.84%(Boonstra etal, 2008)

3.6 Inclusion criteria:

1) Age 25_35 years

2) Females receiving same hospital environment and nursing care.
3) Females undergone lower segment cesarean section operation.

8
3.7 Exclusion criteria:

1) Having multiple births

2) Deliveries with operative complications
3) Cesarean section with epidural anesthesia
4) Other health problems that may cause low back pain
3.8 Data collection tool:
Questionnaire.
3.9 Sampling technique:
Convenient sampling
3.10 Funds for research:
This research project was not funded by the institute.
3.11 Ethical issues:
Approval of instituitional ethical committee was obtained as synopsis level of
project(annex III)
3.12 Data analysis:
All the data collected through questionnaire was entered & analyzed by SPSS 20.0
version. data was described in terms of frequencies and percentages for categorical variables.
Continoues variables were described in terms of mean and standard deviation (mean± SD).Chi
square and ANOVA were applied for testing significant association between variables. a 5%
levekl of significance was used. Data is described in terms of frequency and percentage for
qualitative variables and in the form of mean and standard deviation for quantitative variable. A
p-value less than 0.05 will be considered significant . SPSS 20th edition will be used to manage
and analyze data.

9
 CHAPTER #4
Results:

Table 4.1 reveals that the mean age of subjects of study groups is 31(SD=3.81) and the mean
age of control group is 29.28(SD=3.007).There was no difference between groups when
compared for age (p=0.04) height (p=0.146) weight (p=0.57) and body mass index (p=0.99) as
these values are (p>0.05).
Table 4.2 revealed that 0bstetric history variables of groups were similar as no. of pregnancy
(p=1.08), d and c (p=0.55), previous cesarean (p=1), duration of gestation (p=0.28).As these
values are (p>0.05)
Table4.3 revealed that physical status before pregnancy (musculoskeletal, urinary incontinence,
constipation) were similar when compared between groups as musculoskeletal (p=0.55) urinary
incontinence (p=0.54) constipation (0.48) as all values are (p>0.05)
Table 4.4 revealed that physical status during pregnancy (musculoskeletal, urinary incontinence,
constipation) were similar when compared between groups as musculoskeletal (p=0.508)
urinary incontinence (p=0.75) constipation (p=1) as all values are (p>0.05).
Table 4.5 revealed that intensity of pain between groups at operation day was similar as
(p=0.17) which is greater than 0.05. But intensity of pain in first and second post op day were
different when compared between groups as intensity of pain at first post op day (p=0.007),
intensity of pain at second post op day (0.001) which are less than 0.05
It also showed that intensity of pain values decreased significantly from the operation to second
post cesarean day in study group (F315=,P=0.00) and in control group(F=261,p=0.00) as p
values are less than 0.05.

Table 4.6 revealed that functional activities limitations between groups at operation day was
similar as (p=0.630) which is greater than 0.05. But functional activities limitation in first and
second post op day were different when compared between groups as functional activities
limitation at first post operative day (p=0.008) , functional limitation at second post op day
(p=0.00) both are less than 0.05.

10
It also showed that functional activity limitations values decreased significantly from the
operation to second post cesarean day in study group (F=281=,P=0.00) and in control
group(F=629,p=0.00) as p values are less than 0.05.

11
 Table4.1:Descriptive statistics of age

Physical study group Control group T P

characteristics
Mean SD Mean SD

Age 31 3.81 29.28 3.007 -2.059 .045

Height 4.97 0.46 4.76 0.51 -1.47 0.146

Weight 58.48 5.65 59.60 8.20 0.56 0.57

BMI 24.82 13.85 24.79 2.79 -0.13 0.99

12
Table4.2Comparative analysis of obstetric history between study group & control group

Obstetrical Study group Control group T P

history
mean SD Mean SD

No of 1.48 0.50 1.24 0.43 1.08 -1.78

pregnancy

D&C 0.20 0.40 0.28 0.54 0.55 0.590

Previous 0.16 0.37 0.16 0.37 1 0.00

cesarean

Duration of 36.52 1.41 36.92 1.48 0.289 1.07

gestation

13
Table4.3:Comparitive aanalysis of physical status between study group & treatment group

Physical status Study Control

group group
Before pregnancy T P

musculoskeletal yes 7 5 0.439 0.508

no 18 20

Urinary Yes 0 3
incontinence
no 25 22 0.319 0.074

yes 2 2 0.00 1

constipation no 23 23

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Table4.4:Comparison of physical status during pregnancy between study group & control
group

Physical status Study Control

group group
During pregnancy T P

musculoskeletal yes 10 8 0.347 0.556

no 15 17

Urinary Yes 9 7
incontinence
no 16 18 0.36 0.544

yes 4 6 0.50 0.48

constipation no 21 19

Table4.5:Comparative analysis of severity of pain between study group & control group

Study group Control group T P

15
 Intensity of pain mean SD mean SD

Operation day 8.08 1.73 7.20 2.64 -1.39 0.17

1st post operative day 5.96 1.92 5.96 2.76 2.837 0.007

2nd post operative 3.88 2.14 4.60 2.87 3.508 0.001

day

F value 315.36 261.14

P value 0.00 0.00

Table4.6:Comparative analysis of functional activity limitation between study group &

control group

16
Functional activities Study group Control group T P
limitation
Mean SD Mean SD

Operation day 19.20 4.94 19.36 5.59 0.485 0.630

1st post op day 14.20 5.24 15.88 6.24 2.770 0.008

2nd post op day 8.64 5.33 11.80 6.23 -3.936 0.000

F value 281.73 629.9

P value 0.00 0.00

CHAPTER #5

17
 DISCUSSION
An interventional study was conducted to evaluate the effect of physical therapy
intervention in post cesarean period. Total 45 females participated in the study
from Jinnah hospital.
Females face problems in functional activities and pain in early post cesarean
period. Many studies are conducted to evaluate physiotherapy interventions.
Dube etall(2013) conducted a research to determine the effect of planned early
ambulation after cesarean section. The result was marked difference between
activities carried out by experimental group VS control group (p<0.05)
In agreement with above study, regarding functional activities our study reported
that at operation day functional activity limitation in study and control group is
similar as (p=0.630) which is greater than 0.05. But functional activities limitation
in first post op day (p=0.008) and in second post operative day (p=0.00) were
different in study and control group as p values are less than 0.05.

Karakaya etall(2011) conducted a study to detect the effect of exercise plan on

incisional pain and functional activities limitation in early post cesarean period.
The result of the study was: time to first walk after delivery in study and control
group were 6:18(h:m) and 8:1(h:m) respectively showing the effectiveness of
exercise plan.

Our study disagree this study as in our study the functional activity limitation were
similar in control and study group at operation day as (p=0.63) which is greater
than 0.05.
Biordal etall.(2003) worked to find out if TENS can reduce analgesic consumption
after surgery. The result showed mean weighed reduction in analgesic consumption
of 35.5% (range 14-51%) better than placebo.
18
In agreement with this study our study showed that pain intensity at operation day
was same in study group and control group (p=0.17). But pain intensity at first post
operation day(p=0.007) and second post operation day(p=0.001) were different as
these p values are less than 0.05.

5.1 Conclusion:
Pain and functional activity limitations are major complains of post
cesarean women. In study groups physical therapy interventions were given, early
ambulation, ankle pumping exercises, leg rolling and TENS was applied for pain
management and the results were compared to control group which were not given
such interventions. The results showed physical therapy interventions very
effective as study group recovered earlier than control group
5.2 Limitations:
Time duration was short
Sample size was short due to interventional studies
Loss to follow up of some patients due to early discharge
5.3 Suggestions:
Physical therapy interventions must be included in every clinical setup
after 4-5 hours of cesarean section until the discharge of the women to minimize
the complications, pain and functional activity limitations.

References

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Çevik, S. A., &Başer, M. (2016). Effect of bed exercises and gum chewing on abdominal
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Morisawa, T., Takahashi, T., & Nishi, S. (2015). The effect of a physiotherapy intervention on
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commonly done cesarean section. Journal of gynecology 2(10) 15-35

Abbasi, S., Hamid, M., Ahmed, Z., & Nawaz, F. H. (2014). Prevalence of low back pain
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(1993).Transcutaneus electrical nerve stimulation can reduce postoperative
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APPENDIX # 1
QUESTIONNAIRE

1. Physical Characteristics:

22
 Name: __________________ Age: __________________

Height: __________________ Weight: ________________

BMI: ____________________

2. Obstetrical History:

 No. of Pregnancies: ____________ D & C: _____________________

 Caesarean Section: _______ Duration of gestation:

__________

3. Health Problems during & before pregnancy

 Systematic

a. Hypertension b. Diabetes Mellitus

 Musculoskeletal

a. Back Pain

 Neurologic

a. Headache b. Disc hernia

c. Urinary incontinence

 Previous Survey

a. Caesarean b. Other

if other, which___________________

4. Complications during pregnancy

23
 a. Pre-eclampsia b. Pelvic girdle pain

Pain Assessment

1st Post OP day

2ndPost OP day

3rdPost OP day

Functional Activity

1st Post OP day

Turning in bed

Coming into Sitting/standing

Walking

24
2nd Post OP day

Turning in bed

Coming into Sitting/standing

Walking

3rd Post OP day

Turning in bed

Coming into Sitting/standing

Walking

25
26
 APPENDIX II
CONSENT FORM
Department of physiotherapy,
The Children's Hospital and the Institute of Child Health, Lahore
Title of Research Project: Effect of aerobic and /or resistive training on
body mass in overweight adults.

I______________________________________ hereby fully agrees to contribute to

above mentioned study. I understand that study is designed to add to the
medical knowledge. I have been informed about the nature of procedure and
possible risks/ discomforts involved. I had the opportunity to ask any
question about the study and I agree to give my data as requested by Miss
Humaile Iqbal, the researcher. I have no objection in case the data obtained
from me is published in research profile maintaining confidentiality.

Signature/ Thumb impression__________________

Date____________________________
Contact number___________________

27