Abstract
Cesarean sections (c-sections) are the most commonly performed surgery in the United States, and the country is currently facing a maternal health crisis. Surprisingly, women do not receive rehabilitation services to support the acute stages of c-section recovery. When someone undergoes a knee or hip replacement, it is standard practice for the physician to order home health services, including occupational therapy, for a client before they are discharged from the hospital. The role transition to motherhood, which requires the provision of newborn care, physical limitations after surgery, and the associated mental health changes position occupational therapy practitioners as professionals who can provide essential services to mothers after a c-section. In this column, we argue for occupational therapy practitioners’ important role in serving women in the home environment immediately after a c-section and provide a tangible action plan for implementing these crucial services to improve maternal health outcomes. This column gives a voice to the often-invisible struggles of mothers suffering in silence in the acute postpartum stage of c-section recovery in the hope of bringing positive change to maternal health outcomes through the provision of skilled occupational therapy services.
This column gives a voice to the often-invisible struggles of mothers suffering in silence in the acute postpartum stage of c-section recovery in the hope of bringing positive change to maternal health outcomes through the provision of skilled occupational therapy services.
Rates of cesarean sections (c-sections) in the United States have risen significantly in the past 25 yrs; in 2021, they accounted for 31.2% of all births (Osterman et al., 2023). According to Sung et al. (2024), more than 1 million c-sections are performed yearly in the United States, making it the most common surgery. Despite the rise in the prevalence of this surgery, there continues to be no consistent evidence for recommendations regarding the recovery and resumption of daily activities for women after discharge from the hospital (Ali et al., 2020). There is also an “absence of a high-quality outcome measure to assess recovery” for women who have undergone c-sections (Sharawi et al., 2019, p. 1452). As a result, we conducted a review of practice guidelines from the American College of Obstetrics and Gynecology; the Centers for Medicare & Medicaid Services (CMS); and the Occupational Therapy Practice Framework: Domain and Process (OTPF–4; American Occupational Therapy Association [AOTA], 2020). We also conducted an in-depth review of MEDLINE Ultimate, PubMed, Google Scholar, and CINAHL.
In 2022, the White House published a document confirming that “the United States is facing a maternal health crisis” (p. 3) as evidenced by the fact that it has the highest rate of pregnancy-related deaths among all developed nations. More specifically, in the early postpartum period after a c-section there are serious potential complications that can lead to death if not urgently treated. These include wound infections, puerperal sepsis, chest infections, hemorrhages, deep vein thrombosis, and perinatal mental health disorders (Ali et al., 2020; Podvey, 2018; Postpartum Support International, n.d.; Xu et al., 2017). When women are discharged without a plan for continuation of care in the home, they may not have the support needed to detect and properly address life-threatening complications (Martin et al., 2014).
Occupational therapy practitioners work under physician orders to provide skilled interventions to clients to address barriers to optimal occupational performance (AOTA, 2020). Occupational performance refers to the complex and dynamic relationship among the person, environment, and occupation that leads to function (Baum & Law, 1997). Occupations are activities people want to do, need to do, or are expected to do that occupy time and bring meaning and purpose to life (AOTA, 2020). As detailed in the OTPF–4 (AOTA, 2020), occupations are categorized as activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation. In the home health setting, occupational therapy practitioners focus primarily on occupations that are negatively affecting a client’s ability to remain safely and independently in the home environment.
After childbirth, women experience significant changes in their life roles, occupations, occupational performance, and health. The female body goes through many physical changes and physiological hormonal rebalancing in the postpartum period that can wreak havoc on emotional well-being and mental health (Petersen et al., 2020). Newborn care is also extremely demanding, especially in the first weeks of life. In a 24-hr period, newborns eat at least 8–10 times and require diaper changes at each feeding (at a minimum).
Women who have c-sections often experience difficulties with performing ADLs, IADLs, health management, newborn care, and rest and sleep, as supported by a comprehensive literature review (Xia et al., 2023). The logical conclusion is that incorporating home health occupational therapy practitioners into the treatment team after a c-section will lead to improved physical, mental, and emotional outcomes for women and subsequently decrease the risk of life-threatening complications associated with the maternal health crisis. There is a call to action for home health occupational therapy practitioners to provide services to women recovering from a c-section.
The Argument
C-Sections
In response to the maternal health crisis, the field of obstetrics has encouraged Enhanced Recovery After Surgery (ERAS) principles to be implemented for c-section surgery. ERAS is “an evidence-based, multidisciplinary approach to improving surgical care in the perioperative period” (Ogunkua & Duryea, 2021, p. 16) that has been used in other fields of medicine for years (Meng et al., 2021). Enhanced Recovery After Cesarean (ERAC) was introduced in 2018 and is aimed at improving women’s postoperative experiences while also decreasing life-threatening complications that increase morbidity and mortality rates (Meng et al., 2021; Ogunkua & Duryea, 2021). Improving perioperative experiences in the hospital is a very important step in the right direction to better care for women, but there continues to be a lack of support in the home environment after discharge (Conceição et al., 2020). Occupational therapy practitioners can perfectly support the ERAC initiative and are uniquely equipped to provide therapeutic care for mothers who are recovering from c-section surgery while simultaneously caring for their newborn in the home environment.
More specifically, Conceição et al. (2020) indicated that “after cesarean surgery, women have greater negative repercussions on occupational performance when compared with women [who have] had vaginal delivery” because of unique physical, mental, and emotional challenges (p. 122). Occupational performance is notably affected by incision pain and low back pain. Low back pain is a common complaint among women who have had c-sections because the incision through the abdominal wall further weakens and damages core muscles (Nayyab et al., 2021). In addition, there is evidence to support an increase in perinatal mental health disorders after c-sections, which may further negatively affect occupational performance and safety for mother and baby (Podvey, 2018; Postpartum Support International, n.d.; Xu et al., 2017). Typical activity precautions for women after a c-section include no heavy lifting, sexual intercourse, stair negotiation, or driving until cleared by their obstetrician/gynecologist (OB/GYN), although, as previously mentioned, there is no standard, evidence-based protocol for best-practice recovery. A consultation with Dr. Jerry Skuthan, a 3rd-yr OB/GYN resident, indicated that the variability in women’s body structure, coupled with the position and size of the baby, contributes to the inconsistencies and lack of a standardized best-practice recovery plan (J. Skuthan, personal communication, April 14, 2023).
It is important to note that after c-sections, women are not medically cleared to drive, typically require the assistance of another person, and may require modifications for stair negotiation, qualifying them for homebound status and justifying the need for home health services under CMS (2021) guidelines. Despite the justification of homebound status and the aforementioned barriers to occupational performance women experience, it is surprisingly not standard practice for OB/GYNs to order home health care for women after c-sections. Slootjes et al. (2016) argued that occupational therapy practitioners are necessary members of interdisciplinary maternal health teams because of their specific training to provide client-centered care while addressing occupational performance issues. Creating the opportunity for occupational therapy practitioners to provide support to women in the home environment after a c-section will positively affect recovery experiences and improve overall health outcomes.
Rehabilitation in C-Section Recovery
In recent years, there has been an increase in research addressing the role of physical therapists (PTs) in outpatient postoperative c-section recovery (Stone et al., 2021); however, according to Fernandes (2018), there is “a paucity of evidence regarding occupational therapists’ role in perinatal care” (p. 1). PTs typically address low back pain, core rehabilitation, scar management, and pelvic floor dysfunction in the c-section postpartum population with services not commonly provided in the home. Although there is overlap between PTs’ and occupational therapy practitioners’ scope of practice to provide biomechanical interventions, PTs are not trained to meet the additional mental, emotional, and occupational performance needs that often complicate c-section recovery. Occupational therapy practitioners specialize in providing skilled therapeutic services to address and manage mental, physical, and emotional health challenges that affect occupational performance (AOTA, 2020). They also are experts at task analysis, environmental assessment, and providing modification recommendations to increase optimal function in the home. Because of occupational therapy practitioners’ holistic treatment approach and skill set, maternal health and wellness fall directly within their scope of practice (AOTA, 2020; Fernandes, 2018). Developing a consistent, evidence-based rehabilitation approach to care for women after a c-section in the home environment is essential, and occupational therapy practitioners are crucial members to include on the multidisciplinary care team (Conceição et al., 2020; Fernandes, 2018; Podvey, 2018; Slootjes et al., 2016).
Women’s Perceptions
Recent domestic and international qualitative studies have captured women’s lived experiences throughout their planned c-sections. The information gathered in these studies, although limited and subjective, further magnifies the need for improved c-section recovery care to include occupational therapy practitioners. For example, Thirukumar et al. (2021) reported that women’s overall negative experiences during recovery from c-sections are due to limited support and inadequate preparation. Similarly, Xia et al. (2023) outlined that women would like to have better antenatal education, discharge teaching, pain management education, and postdischarge support with individualized follow-up planning. Sidar and Skuthan (2024) argued for the importance of occupational therapy practitioners on the hospital multidisciplinary acute postpartum care team to prepare mothers for a safe transition to their home environment. Occupational therapy practitioners providing services in the home environment are then able to provide a continuation of care in the home to address the aforementioned problem areas identified by women who have undergone c-sections through a personalized, client-centered treatment program.
A Tangible Action Plan
Because of the occupational therapy practitioners’ unique qualifications and the aforementioned needs of women recovering from c-sections (Thirukumar et al., 2021; Xia et al., 2023), there is an overwhelming need to create evidence-based programs and provide support to women who have had this surgery (Conceição et al., 2020; Fernandes, 2018; Podvey, 2018; Slootjes et al., 2016). Home health occupational therapy practitioners are particularly well positioned to provide services for women recovering from c-sections because of their training in providing home-based services and the homebound nature of the early postpartum period. Home health occupational therapy practitioners have the opportunity to collaborate with their employers and OB/GYN practices to initiate the referral process for the provision of skilled occupational therapy services for women after discharge to their home environment. It is important that OB/GYNs understand the vital role home health occupational therapy practitioners play in the recovery process of women immediately after a c-section so they can initiate the referral before a woman is discharged from the hospital.
In typical c-section recovery, the first 6–8 wk postpartum are considered to be the acute stage of healing, when women have the most physical restrictions and need for assistance. Therefore, home health occupational therapy services would be most beneficial immediately after hospital discharge and until the client is cleared by their OB/GYN to resume all activities. An occupational therapy evaluation in the home environment should include, but is not limited to, a client interview to build an occupational profile, an environmental assessment of the home, a mental health screening, an evaluation of the incision and a screening for signs of infection, the provision of basic modifications for safe ADL completion, discussion of patient questions and concerns, and the creation of a client-centered plan of care. If any concerns or problem areas fall outside the scope of occupational therapy, additional professionals may be added to the patient’s plan of care.
Follow-up visits should be specifically tailored to the client’s needs; however, general treatment areas in the early c-section postpartum period include, but are not limited to, ADL and IADL adaptations, breathwork, stress management, core rehabilitation, scar desensitization, proper body mechanics for functional movements, energy conservation education, and nonpharmacological pain management strategies. Occupational therapy practitioners often are already providing services to support co-occupations for the mother and child in neonatal intensive care units (NICUs; Cardin, 2020), including adapted feeding positions and routines. Home health occupational therapy practitioners can continue and expand on provided interventions in the NICU to contribute to continued occupational success for mother and baby, for example, assisting the family with an environmental setup for needed supplies at the appropriate height and a supportive seating position and body mechanics for mother and baby for feeding success. Screenings for perinatal mental health disorders and client interviews are pertinent at every follow-up visit because symptoms can develop at any time during the first postpartum year (Petersen et al., 2020; Postpartum Support International, n.d.). Occupational therapy practitioners should be in consistent communication with the client’s OB/GYN, and any other practitioners involved in the client’s care, to ensure that the mother is supported and to reduce the risk of postsurgical complications. When a woman is discharged from home health, ideally the wound has healed and she is returning to her prior level of functioning. We recommend that all women transition to outpatient pelvic floor therapy to continue healing.
Women’s early postpartum recovery experiences after c-sections would be greatly improved if they were offered skilled, client-centered occupational therapy home health services after hospital discharge. Occupational therapy’s scope of practice integrates maternal mental health, role transitions, medical and pain management postsurgery, emotional well-being, and occupational performance barriers to ADLs, IADLs, and the co-occupation of mothering. This makes occupational therapy practitioners excellent clinicians to address the needs of women after c-section (AOTA, 2020). It is time for the U.S. health care system to take better care of mothers and implement tangible solutions to end the maternal health crisis.