PhysiotheraPy management strategies for women Post-caesarean section delivery in Public hosPitals in KwaZulu-natal , south africa

Correspondence Author: Preshani Reddy College of Health Sciences Westville Campus University of KwaZulu Natal, Faculty of Health Science South Africa Email: reddypr@ukzn.ac.za AbstrACt: South Africa has seen a steady increase in the rate of caesarean section deliveries, and while physiotherapists are often requested to treat these patients, there are no guidelines on their physiotherapeutic management. Current treatment is therefore based on clinical presentations of the patient. This paper reports on the physiotherapy management strategies for women post-caesarean section delivery used at four public hospitals in KwaZulu-Natal during 2011-2012. The study used a quantitative, cross-sectional, descriptive design. The sample consisted of 31 physiotherapists who completed an anonymous self-administered questionnaire, of whom eight had not treated post-caesarean section delivery women at all in the one year period. The results showed mobilization (100%), breathing exercises (94%) and education (94%) were common choices, with 68% selecting pelvic floor exercises as part of their management strategy. The study concluded that the current physiotherapy management strategy for women post-caesarean section delivery is based mainly on the doctors’ referral. Due to their limited knowledge about physiotherapy treatment, doctors overlook other complication(s) and potential complication(s) that could benefit from treatment post-delivery. The study showed that there is a need to improve the role and influence of physiotherapists in the multidisciplinary team.

Today, physiotherapists play an essen tial role in the multidisciplinary treat ment team, and treat a wide variety of obstetric and gynaecological issues. In this capacity, they are required to keep abreast with the latest medical tech niques and associated complications.
Caesarean section delivery (CSD) has become one of the most common sur gical procedures performed by obstetri cians (Penna and Arulkumaran, 2003). In 1989, the World Health Organization (WHO) stated that caesarean section rates should account for between 1015% of births. Betrán et al (2007) reported that the global CSD rate was 15%, with higher rates found in developed coun tries (21.1%) compared to developing countries (2%). In Africa, South Africa has the highest CSD rates (Betrán et al, 2007), with an average of 16.1 % in iNtRODUctiON Physiotherapy has been involved in women's health since the early 19 th cen tury (Mantle et al, 2006). While they were initially mainly involved with obstetric work, this gradually changed, and in the 1970s, physiotherapists also began to treat patients with gynae cological problems. (Mantle et al, 2006). /09 (Health Systems Trust, 2009). Provincially, KwaZuluNatal has the highest CSD rates amongst district hos pitals in the country at 22.1% (Health Systems Trust, 2009). An audit done by Naidoo and Moodley (2009) on a spe cialist private practice within KwaZulu Natal found that maternal requests, breech delivery, HIV and previous CSD contributed to the high CSD rates in that particular practice. Literature has further cited that fear of vaginal deli very, the need for control in the birthing process (Lavender et al, 2012;Dhai et al, 2011), convenience, and the preserva tion of the pelvic floor (Dhai et al, 2011) are some of the reasons why women opt for a CSD. Although CSD are consi dered relatively safe (Dhai et al, 2011), there are still a number of complications associated with this procedure.
The rate of complications following CSDs has been reported at 36%, regard less of the type of CSD (van Ham et al, 1997). Complications include: sepsis, thromboembolic problems, anaesthetic complications (Koroukian, 2004), an increased rate of maternal morbidity (Kuklina et al, 2009) and pneumonia (Belfort et al, 2010). Conflicting evi dence is presented in the literature as to whether a CSD can prevent pelvic floor trauma when compared to a normal vagi nal delivery. Literature has suggested that the incidence of urinary stress incontinence following a CSD may be reduced if the procedure is performed prior to the onset of labor (Chin et al, 2005). However, it is still evident that a significant number of women expe rience urinary stress incontinence following a CSD (Chin et al., 2005). Pregnancy is more significant than vaginal delivery as a factor for permanent urinary inconti nence (Faundes et al, 2001) and is largely attributed to the increased mechanical compression placed on the pelvic floor area during pregnancy (Faunders et al, 2001;Mant et al, 2009).
A problem that is often unreported and untreated in pregnant women is lower back pain (Wang et al, 2004;Morgren and Pohjanen, 2005). While the patho physiology and etiology of lower back pain in pregnancy is poorly understood (Morgren and Pohjanen, 2005), contri buting factors highlighted in the lite rature are an increase in weight (To and Wong, 2003), and an increase in joint mobility due to hormonal changes (Marnach et al, 2003). In terms of lower back pain and the use of epidural anesthesia, the literature indicates that immediate postoperative back pain was prevalent in patients, but that this was significantly reduced over time, with no difference found after a year between patients who had received epi dural anal gesia and patients who had not (Macarthur et al, 1997). What is noteworthy is a review by MacEvilly and Buggy (1996), which stated that the type of anaesesthia injected into the epi dural space is also relevant in causing lower back pain.
Physiotherapists are well equipped to address these complications and pre vent the onset of new ones with the CSD treated and reasons for not treat ing patients, Section C: physiotherapy management postCSD and Section D: referral to members of the multidiscipli nary team and discharge advice. Section C identified the management of patients' postCSD or the strategies that would have been used by those participants who had treated a postCSD patient in 20112012.
A pilot study was conducted to deter mine the validity and reliability for the questionnaire, with experts (N=5) in the area of women's health being asked to review the questionnaire for content validity, after which minor changes were made. A focus group discussion was then done with physiotherapists not included in the study sample, for face validity and no problems were noted. Finally, the reliability of the study using the testretest method was conducted among another group of physiothera pists (N=15) who were not included in the study. Repeatability analysis was undertaken using McNemar test between the same questions at pre and posttest stage. No statistical difference (p = 1.00) was noted between the responses pre and posttest.
As part of a PhD study, ethical approval (project number: 11/8/11) was obtained from the University of Western Cape Ethics Committee and the neces sary documentation was sent to the respective hospitals within KwaZulu Natal. Permission to conduct the study was obtained from all the relevant faci lity managers, the eThekwini District office and the Provincial Department of Health. Once permission was obtained, final arrangements were made with the Physiotherapy Departments at the hos pitals to conduct the study. All partici pants signed an informed consent form prior to participating in the study, and the consent form was detachable from the questionnaire to retain anonymity. The participants were allowed to with draw at any stage. Completed question naires were captured on Microsoft Excel and exported to SPSS version 15 where the data was analyzed. Descriptive data analysis was then carried out for each section of the survey. Fisher's exact test was used to test for significance between categorical data; CI = 95%. use of manual therapy, exercise and/or electrotherapeutic modalities. However, there is currently no literature available on the physiotherapeutic management of women postCSD, with the treat ment techniques used being primarily based on patient presentation and cli nical reasoning. This lack of research means that complication(s) or potential complication(s) postCSD can there fore potentially not be addressed using bestpractice methods. As there are no standardized physiotherapy manage ment strategies for postCSD complica tions used in South African hospitals, this study aimed to identify the manage ment strategies used by physiotherapists to treat women postCSD in four pu blic hospitals in KwaZuluNatal during 2011 2012. The objectives of the study were: (1) to identify the demographic profile of physiotherapists (2) to identify the physiotherapy management strategies of women postCSD; (3) to identify the complications currently being addressed by physiotherapists in women post CSD, (4) to determine referral to other members of the multidisciplinary team by the physiotherapists and the advice given to the women on discharge.

MethODs
The study utilized a quantitative, cross sectional, descriptive survey design to determine the current management stra tegies employed by physiotherapists in the treatment of women postCSD. It was conducted in 2012 at four public hospitals in KwaZuluNatal using pur posive sampling. The hospitals were selected on the basis that they were tertiary and/or regional hospitals, had a high obstetric and gynaecological patient turnover, and serviced a wide range of areas within the province. The study population consisted of all phy siotherapists (N = 37) employed by the respective hospitals.
A selfadministered, anonymous ques tionnaire was developed based on avai lable literature (Mantle et al, 2006;Pasquina et al, 2006;HaySmith et al, 2009). The survey questionnaire was divided into four sections to address the study objectives; Section A: demo graphic details of the participants, Section B: the number of patients post

ResUlts
A response rate of 84% (N=31) was achieved, and the mean age of the participants was 32 years (SD±4.65). There were more females (n=28) than males (n=3). Of the participants, 45% (n=14) had 37 years of experience, 26% (n=8) had 8-12 years of experience and 29% (n=9) had 13-19 years of experience in Physiotherapy. In terms of postgraduate education, 96.7% (n=30) do not have any postgraduate degree(s) in Physiotherapy.
Of the 31 participants, 68% (n=21) had treated postCSD patients, 6% (n=2) were unsure if they had treated post CSD patients and 26% (n=8) had not treated postCSD patients in 20112012. The selfreported number of patients treated following CSD by the partici pants varied, with a median of five and an interquartile rage of 0-15. The most common reason reported by the par ticipants for not having treated a CSD patient in the past year was that they had not been on an obstetric and gynae cology rotation (29%; n=9); other rea sons are presented in Figure 1.
The mean number of physiotherapy treatment sessions rendered for each patient was 3.52 (SD±1.09), with the average treatment time being 15-30 minutes (67.7%; n=21). The year of undergraduate completion did not affect the average time spent treating a patient postCSD (p=0.35). The average treat ment time spent with a patient was also similar, irrespective of whether or not the participant treated a patient postCSD (p=0.38) in 20112012. Various moda lities were selected by physio therapists for treating patients' postCSD. All of the participants (N=31) selected mobi lization as a treatment technique for postCSD patients. For this study, the term mobilization is defined as "the process of reestablishing the ability to move between postures (for example sit to stand), maintain an upright posture, and to ambulate with increasing levels of complexity (speed, changes of direc tion, dual and multitasking)" as per the NICE clinical guideline124 (2011). Other modalities selected are described in Figure 2.
Treatment modalities selected by the participants were similar regardless of when the participants graduated (Table  1). Percussion was the only modality selected most frequently (p=0.01) as a treatment choice by those who had treated postCSD patients in the past year compared to those who had not (Table 1).
Forty five percent (n=14) of physio therapists mentioned that they treated other complications following caesa rean section and are shown in Figure 3.
Of the 31 participants who had and had not treated postCSD patients in the past year, 19.4% (n=6) referred them to

DiscUssiON
The results from the study suggest that the current physiotherapy management strategy for women postCSD is based mainly on the doctors' referral, as doctors are only referring postCSD patients who they deem necessary for physio therapy. Therefore, other complications and potential complication as a result of the CSD procedure that should be identified by physiotherapists are not always addressed. The physiotherapy management stra tegies selected for patients' postCSD were similar, irrespective of the year of qualification and whether partici pants had treated patients postCSD or not during the previous year (Table 1). It can therefore be concluded that physio therapists are not modifying their manage ment strategies to meet the spe cialized needs of postCSD patients, but are using standard treatment routines. This may be due to the fact that none of the participants had received any specia lized postgraduate training in postCSD management. It suggests that physiotherapists depend on their under graduate knowledge and have not changed their management strategies to include recent evidence based research. Globally, physiotherapists are required to keep abreast with new information and incorporate evidence based research into their clinical practice (French and Dowds, 2008). The results of this study are similar to a review by Schreiber and Stern (2005), which suggested that physiotherapy management was not based on research, but rather on anec dotal and undergraduate information. Furthermore, a study by Stevenson and Lewis (2004) showed that although physiotherapists were in favour of evi dence based research, they were reluc tant to change their practice.
Anecdotal information from the hos pitals used in this study indicates that some perform over 2000 caesarean sec tions per annum out of a total of 8400 births. With the study by van Ham et al, (1997) indicating that 36% of CSD women have complications and could require physiotherapy treatment, the low mean number of patients (mean=5) being treated by the participants demon strates a low level of referral from obstetricians. There is evidence that physiotherapy can successfully treat post partum problems postCSD such as pelvic floor dysfunction and lower back pain (Britnell et al, 2005), and that inhospital prophylactic treatment should also be rendered. What is note worthy is the main reason selected for not having treated a patient postCSD was not having been on that particular clinical rotation, with only one par ticipant selecting "lack of referral from a doctor" (Figure 1). This indicates that obstetricians and gynaecologists are only referring patients who they deem necessary for physiotherapy. This is supported in the study by the mean number (mean=3.52; SD=±1.09) of treatment sessions rendered for a patient postCSD. This is a high number of physiotherapy treatment sessions for uncomplicated postCSD patients, as they are considered for discharge on day three postoperatively (South African Department of Health, 2007). Thus, the other reason for nonreferral could be that uncomplicated postCSD patients who would benefit from prophylactic treatment are not being referred for physiotherapy because doctors are un aware of the services physiotherapists render.
Participants in this study selected res piratory modalities (Figure 2) as part of their management strategy for patients' postCSD. Although there is minimal evidence in the literature reporting on respiratory complications following an uncomplicated pfannenstiel incision for a caesarean section, participants stated that respiratory complications (16%) was one of the main problems they  (Figure 3). This was followed by pain (13%) and muscle weakness (13%), while three participants men tioned lower back pain and sciatica, and two mentioned treating urinary incontinence as an added complication. The results suggest that obstetricians and gynaecologists at these hospitals mainly refer patients with respiratory complications for physiotherapy, indi cating misconceptions regarding the ser vices rendered by physiotherapists for patients' postCSD. This is despite the role and influence of physiotherapy in obstetric and gynaecological conditions being established more than five decades ago (Mantle et al, 2006) Freeman et al, (2000 advised that in order for patients to be referred to other members of the multidisciplinary team, health care professionals need to understand each other's role and contribution towards patient care. Participants in this study indicated that they did refer patients to other members within the multidisci plinary team, with only one providing a reason for referral which was "to doc tors, patient had severe abdominal pain swab was left in the patient". This demonstrates the importance of commu nication and understanding each other's role when working as part of a team. Advice on discharge was given to most of the patients, but only five (16%) participants specified pelvic floor exer cises and nine (29%) specified back care and ergonomics as a home program. However, the literature indicates that in terms of potential problems following a CSD, urinary incontinence was preva lent (Chin et al., 2005) and lower back pain was frequently underreported (Wang et al, 2004;Morgren and Pohjanen, 2005). Studies have shown the bene fit of a specific home exercise program for urinary incontinence (Haddow et al, 2005) and non-specific lower back pain (Kuukkanen et al, 2007) in postCSD patients.

cONclUsiON
The Physiotherapy profession needs to educate obstetricians and gynaecolo gists about the role and effectiveness of physiotherapy techniques in patients' postCSD. Scholes and Vaughan (2002) stated that interprofessional education is thought to improve collaboration between the members of the multi disciplinary team which will result in more effective and efficient team work. This could include interprofessional education workshops on the role of physiotherapy within the multidiscipli nary team treating women postCSD to increase referrals for treatment.
The lack of advice on pelvic floor and lower back exercises as prophy lactic treatment in postpartum home programme(s) suggests a gap in aware ness of the prevalence and types of complications that may arise postCSD by the physiotherapists. Physiotherapy courses that provide additional training using evidence based practice manage ment practices for CSD patients would enable practitioners to provide more appropriate treatment. More research by the physiotherapy profession is also needed to identify the standard physio therapy treatment needed by postCSD women.
The study demonstrated the need for improvements in the role, effective ness and influence of physiotherapists in their management strategy of post CSD patients. Greater awareness by the referring clinicians of the conditions that physiotherapists can treat postCSD will not only strengthening their role within the multidisciplinary team, but assist more women who would benefit from additional treatment.