CHAPTER I.

INTRODUCTION

Surgery is one of the most ancient arts in the world. Any type of surgery is
stress to the patient. It becomes even more stressful when the vital organs are
involved in the surgery. Some of the patient may respond with expression of
helplessness, security and isolation due to discomfort, pain and fear of breaking
stitches (Watson, 2001).
Early walking after surgery is one of the most crucial things to do to prevent
problems. But during the post-operative setting, patients are often burdened by their
condition that reduces their ability to ambulate. C-section in the Obstetric Unit is one
of the most frequent major surgeries being performed nowadays. It evokes world-
wide concern because of its steady increase coupled with lack of consensus on the
appropriate CS rate and the associated short and long term risks and costs. And
introduction of early ambulation though preoperative motivational teaching could
probably cut not only the risks for complication but also healthcare costs.
Pre-operative care is a preparation and management of patient prior to surgery.
It includes physical, psychological and legal preparation. The patients who are
physically and psychologically prepared for surgery tend to have better surgical
outcome. (KG., 2006 October). And as part of Health care team, it is an obligation to
make the patient’s welfare the first consideration during surgical experience.

1
A. Background of the Study
Preoperative teaching is very important to ensure a positive experience on the
client. Numerous research studies have supported the value of preoperative
instructions in reducing both the incidence of postoperative complications and the
length of stay in the hospital. The clients learning needs, level of anxiety, and the
fears about surgery are assessed individually so that an individualized teaching plan
can be formulated.
Global incidence of post-operative respiratory complications were 11.7
percent, global mortality in surgical patient ranges from seven to eight percent and out
of all cases, pneumonia contributes 10 to 28 percent. In United States, elective
abdominal surgery were 5075, the incidence of respiratory complications were 10.4
percent most frequent is pneumonia (52.5 percent), overall mortality due to the
respiratory complication were seven and half percent and 27.8 percent morbidity
related to respiratory complications. (Lawrence VA, 1995), (Pedersen T., 1994). In
India the incidence of respiratory complications following upper abdominal surgery is
20-25 percent and following lower abdominal surgery five to 10 percent (Deodhar
SD, 2010 Aug).
Caesarean section is one of the highest incident surgery nowadays associated
with most of maternal mortality and morbidity cases. According to the latest data
from 150 countries, currently 18.6% of all births occur by CS, ranging from 6% to
27.2% in the least and most developed regions, respectively. Latin America and the
Caribbean region has the highest CS rates (40.5%), followed by Northern America
(32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%).
Abdominal adhesions are associated with increased postoperative
complications. The rate of adhesions after abdominal surgery was 54 %, and was
66 % after gastrointestinal surgery, 51 % after obstetric and gynaecological surgery
and 22 % after urological surgery.
Occurrence of pneumonia challenges the medical management of patients who
have undergone surgery, and is associated with significant mortality and morbidity.
The variables associated with postoperative pneumonia were: [Preoperative] age >50
years, Glasgow Coma Scale (GCS) at presentation <15; [postoperative] duration of
surgery >3 hours, GCS <15 after complete reversal from anaesthesia, duration of
intubation in the postoperative period >48 hours, tracheostomy, postoperative
ventilation, intensive care unit (ICU) stay >5 days.

2
B. Statement of the Problem

The study aims to determine the effect of preoperative teaching on early

ambulation among postoperative Caesarian Section patients.

1. What is the level of performance on pre-ambulation tasks (deep breathing

and coughing exercises, leg exercises, turning to sides) among post
Cesarean Section patients who received an individualized structured
teaching preoperatively?

2. Which among the pre-ambulation tasks (deep breathing and coughing

exercises, leg exercises, turning to sides) are appropriately performed by
the patients?

C. Significance of the Study

Numerous research studies have supported the value of preoperative

instructions in reducing both the incidence of postoperative complications and the
length of stay in the hospital. Early ambulation is found out to have the utmost benefit
for early recovery. The research study is specifically significant to elective patients
who have undergone surgery on OB unit.

Furthermore, the study will be beneficial to the following:

To the Patients. This study will be beneficial to the patient to be able to

identify the effects and benefits of early ambulation in preventing post-operative
complications. Ultimately, the patient will be able to attain a positive health outcome
such as optimal well – being, personal fulfilment, and productive living.
To the Nurses. This study will help the nurses promote pre-operative
teachings as means of health promotion as well as prevention of possible post-
operative complications to patients under their care.
To the Nursing Profession as a whole, the study will be able to provide
additional knowledge in the Nursing Practice, Nursing Education, and Nursing
Research. The study will incorporate current findings on the effects of early
ambulation in preventing post-operative complications.

3
D. Scope and Delimitation

This study was conducted in a tertiary government hospital in Zamboanga

City. Obstetric clients who have undergone CS (elective) were included in the
individualized structured teaching for two sessions for 35 minutes per session; first
session was when patient was already transferred to ward, second was before
transporting patient to Operating Room.

4
 CHAPTER II

A. Related Literature
A cesarean birth occurs through an incision in the abdominal wall
and uterus rather than through the vagina. There has been a gradual
increase in cesarean births over the past 30 years.
Recent statistics from 150 countries shows a global C-section rate of
18.6% of all births – almost 1 in 5 women around the world will give birth via c-
section. Data from 121 countries shows between 1990 and 2014, the global
average c-section rate increased by 12.4. Ranging from 6% to 27.2% in the least
and most developed regions, respectively. Latin America and the Caribbean
region have the highest CS rates (40.5%), followed by Northern America (32.3%),
Oceania (31.1%), Europe (25%), Asia (19.2%) and Africa (7.3%).
Early ambulation following a surgical procedure is a central concept in fast-
track surgery according to Enhanced Recovery after Surgery protocols. Although
a shorter hospital stay is reported to be a benefit of perioperative rehabilitation, its
effect on patient metabolism has not been fully explored.
A study has been conducted to determine the patient’s level of performance of
the pre-ambulation tasks, that is the nature or quality of his performance
determined on the basis of four criteria: a. Time Interval, b. Prompting Required,
c. Assistance Required, d. Frequency of Performance.

Components of Preoperative Teaching

Information provided to the client before the client surgery should be geared to
individual needs. This information can be 1. Sensory 2. Psychosocial or
3. Procedural.

Sensory information addresses the sights, sounds and feel of the operating
room. Instruct the client that the operating room and skin preparation fluids
will be cold but that warm blankets are available.

5
Psychosocial information involves coping abilities and worries about family
and similar concerns.

Procedural Information details activities during the preoperative period and

postoperative care. It includes information that the client needs to know and
wants to know is going to happen.

The client’s role in postoperative care is taught before surgery. The

nurse provides instructions on 1. Deep breathing 2. Coughing 3. Turning
4. Ambulating and 5. Pain control and the client’s learning of some of these
procedures is validated by return demonstration

Deep Breathing Exercises – to help prevent postoperative surgical

complications, careful preoperative instructions and practice in deep-breathing
and coughing exercises should be completed and reinforced.

Coughing Exercises- coughing removes retained secretions from the bronchi

and larger airways. Coughing may be painful and analgesia may be required.

Turning Exercises - Preoperative clients also need to practice turning sideto

side, using the bedside rails to assist movements. Turning helps to prevent
venous stasis, thrombophlebitis pressure ulcer formation, and respiratory
complications.

Extremity Exercises - Post operative extremity exercise helps to prevent

circulatory problems such as thrombophlebitis.

Ambulation- Ambulation should be encouraged whenever appropriate, as it

helps to prevent many postoperative complications.

Pain Control- Uncontrolled pain is a common concern among postoperative

clients. It is important to reassure clients that pain will and can be controlled
after surgery.

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 Equipment- Whenever possible, explain about the equipment that will be used
during the preoperative period.

B. Conceptual Framework

OB Patients for
Elective CS

Pre operative structured teaching on

pre ambulation tasks

 Deep Breathing and coughing

exercises
 Leg exercises
 Turning to sides

Level of performance on pre ambulation

tasks following the criteria

 Time interval
 Prompting required
 Assistance Required

(Reference:”Effects of Pre-operative Instruction About

Early Ambulation on Patients’ Post-operative
Performance of Selected Pre-Ambulation Tasks” by

Figure 1.0 Conceptual Framework. The framework shows a group that will undergo C-
Section. This group will be given a structured preoperative teaching on three tasks( deep
breathing and coughing exercises, leg exercises, turning to sides) Post-CS, they will be
evaluated as to the performance of the teachings provided prior to surgery under the same
tasks following the three criteria.

Conceptual Framework
The framework shows providing individual health teaching about three tasks
of perambulation to subjects who will undergo primary Caesarean Section
preoperatively. It aims to describe the effect of health teaching on the subjects

7
postoperatively utilizing the three criteria as basis for evaluation of their performance
of perambulation task.

C. Operational Definition

Caesarian Section (CS). Use of as surgery to deliver one or more babies

Gravida. Refers to the number of times a woman has been pregnant, regardless of
whether the pregnancies were interrupted or resulted in a live birth

Indication for procedure. Reason as to why the patient needs to undergo

caesarean section

Level of Performance. Nature or quality of performance determined on the basis

of three c criteria:

Time interval. The time which elapsed from first post-operative hour to the
time when
the first complete performance of a task made

Prompting required. Whether the post-operative nurse’s verbal comments or

reminder was necessary to make the patient start the complete performance of
the task

Assistance required. Whether the patient required the nurse’s or significant

other’s physical assistance in carrying out the complete performance of the
task

Obstetric-Surgical patient. Patients admitted with conditions associated with

childbirth and who are indicated for an elective Cesarean Section

Pre-ambulation tasks. Activities done to prepare patient physiologically prior to

ambulation

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 Deep Breathing Exercises. Breathing that is done by contracting the
diaphragm, a muscle located horizontally between the thoracic cavity and
abdominal cavity
Breathing in through nose and breathing out through pursed lips

Leg Exercises. Activity of exerting muscles in various ways to keep fit

Straight leg raises, ankle pumps, knee bends for 10 sets each

Turning to sides. Changing position in bed every 2 hours to help keep blood
flowing

Preoperative Teaching/ Preoperative Instructions. A structured individualized

teaching provided to patient before undergoing surgery, specifically on the selected
three pre-ambulation tasks

Pre-operative Stage. Time before a surgical operation

Primary Caesarean Section - First time to undergo delivery of a baby through

surgery

Post-operative stage. Time after the surgical operation

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 CHAPTER III: METHODOLOGY

A. Research Design

The study employs a single group post-test, descriptive design since it

involves only a group of subjects upon which a variable is tested, without any random
pre-selection processes.The explanatory variables were pre-operative structured
individualized teaching on early ambulation (independent variable) and the
respondents’ level of performance of the pre-ambulation tasks (dependent variable).

B. Research Locale:

The study was conducted in Obstetrics Unit in one of the tertiary

hospitals in Zamboanga City.

C. Sampling Design
Purposive Sampling technique was utilized to select the participants of the
study. The researcher selected 10 participants with ages 18-29 years old, 5 of which
had undergone Caesarean Section for the first time, and the other 5 had repeat
Caesarean Section with gravida 4 at most. The patients were scheduled one to two
weeks prior the procedure, had no other medical problems or mental incapacities and
able to comprehend directly the purpose of the study, and was under the type of
anesthesia which is the Regional Anesthesia, Sub-arachnoid Block. It was focused on
the pre-ambulation tasks performance right after the time of the surgery. It excluded
those that have major complications before and after the operation like patients who
had cardiac and pulmonary problems, massive blood loss, shock and respiratory
complication.

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D. Data Gathering Tool
The researcher utilized a questionnaire designed to gather information on the
pre-operative patients, which included information on the number of pregnancy
(gravida), age of the patient, Last Menstrual Period, Age of Gestation, Indication for
procedure, Admitting diagnosis, medical history, family medical history, whether the
patient has undergone other surgical procedures, level of understanding of the pain
scale (Wong-Baker pain scale).
After gathering data about patient’s personal profile, structured individualized
health teaching was conducted with the use of video presentation on how to do the
selected three pre-ambulation tasks.
The third part of the questionnaire included researchers made questionnaire as
adopted from a criteria made by Raquel P. Caña on her research study entitled
“Effects of Pre-operative Instruction about Early Ambulation on Patients’ Post-
operative Performance of Selected Pre-ambulation Tasks”

E. Validity and Reliability

The questionnaire made by researchers was developed from the concepts that
was stated in the review of literature. The statements in the questionnaire are made
simple for easy comprehension and would assure a content and concurrent validity if
applied in the respondents.

F. Data Gathering Procedure

The Primary mode for data gathering was through observation and
questionnaire. The researchers were non participant observers on evaluation of the
patient’s performance of pre-ambulation tasks.
The tool was comprised of time and day of post-operative and post-
anaesthesia period. Evaluation of the pre-ambulation tasks began from the 1st hour of
post anaesthesia period, continued on 1st post op day until the discharge period
depending on when the patient was able to accomplish the pre-ambulation tasks as

11
one of the criteria on the evaluation tool which is the “Time Interval” (whether the
patient was able to do the task within 8 hours, 16 hours and 24 hours post-
operatively).
Other data gathered were number of pregnancy (gravida), parity, age of
gestation, age of the patient, last menstrual period, admitting diagnosis, indication for
procedure, family history of diseases and surgical history.
After seeking permission from the hospital of choice, 10 preoperative CS
patients were given structured preoperative teaching individually. The lecture
included definition of Caesarean Section, indications, complications, and the three
pre-ambulation tasks; Task A includes Deep-breathing and Coughing Exercises,
Tasks B- Leg Exercises and Task C- Turning to Sides. Video presentation on how to
perform the three pre-ambulation tasks properly was shown to patients as well. It also
included the importance of early ambulation including the possible course of CS. The
evaluation of pre-ambulation tasks was made after the C-section utilizing a tool
developed by Raquel P. Caña based on the three criteria: Time interval, Prompting
required, Assistance Required. Each criterion had scores of 1 to 3.
For the criterion Time Interval, a score of 1 was given to those who performed
the tasks within 17-24 hours post-operation, 2 for those who performed the tasks
within 9-16 hours post-operation and 3 for those who did the tasks within 8 hours
post-operation.
For the criterion of Prompting Required, a score of 1 was given to those who
performed the tasks after being reminded for 4 or more times in 8 hours by the nurses,
a score of 2 for was given to those who were reminded once to three times in 8 hours
to perform the tasks, and a score of 3 was given to those who performed the selected
three pre-ambulation tasks without being reminded by the nurses.
For the criterion Assistance Required, a score of 1 was given to those who
performed the tasks with full assistance from the nurses and/or significant others, a
score of 2 for those who needed minimal assistance and a score of 3 was given to
those who performed the three selected pre-ambulation tasks without the assistance of
nurses and/or significant others.

G. Data Analysis
To examine the research question, the data collected from the respondents was
measured utilizing Measure of Central Tendency which is Mean to calculate the

12
frequency and the average that the data occurred in the study which allowed the
researcher to assess the performance of the subjects with the three criteria as its basis.
The method was chosen since the data are discrete.
Ethical Consideration
The following ethical issues were kept under consideration during the research
process and aftermaths:
 Determining the problem statement has ensured that the research
benefited the individuals being studied and ensured that the participants
were not marginalized or disempowered at any step.
 The purpose of study was made clear and simple to be easily understood
by the readers as well as the respondents thus avoid any ambiguity at any
end.
 Precisely yet comprehensive information (Debriefing) were provided to
respondents in order to make them clear about all aspects, objectives and
outcomes of the research.
 Informed consent was secured from respondents after thoroughly
explaining the research process.
 While anticipating the data collection, the well-being of the respondents
was ensured through securing their right to participate and withdraw at
any time voluntarily.
 Data collected about participants’ information were kept confidential.

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 CHAPTER IV
PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA

The implementation of the study began by determining respondents who are

for elective Primary and Repeat Caesarean Section. The purpose and procedure of the
study was explained to the respondents, prior to securing their consent to participate
in the research process.
Once consented, the researchers conducted health teachings on the
respondents discussing about Caesarean Section, its indications, possible post-
operative complications, importance of performing the three selected pre-ambulation
tasks, and video presentation were shown on how to perform the tasks properly.
Pamphlets containing the lecture discussion were also given to respondents.
The lecture discussion was conducted once the respondents arrived at the ward
and prior to their transportation to Operating Room.
Evaluation started once the respondents were transported back to ward
following a Caesarean Section. Evaluation was made by the researchers through
observation.
The results imply that primary Caesarean Section patients were more
compliant in accomplishing the selected three pre-ambulation tasks than repeat
Caesarean Section patients in terms of the first criteria which is Time Interval, while
majority on both groups were able to perform the tasks without prompting and
assistance required from the nurses and/or significant others.
The implications made were based on the results shown in the tables.

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15
 Table I shows the results of respondents who had Primary Caesarean Section.
It shows that out of 5 respondents, 4 or 80% were able to do Deep Breathing
Exercises within 8 hours post-operation, and all of them or 100% were able to do the
task without prompting and assistance by healthcare workers and significant others.
For the Leg Exercises, 3 out of 5 respondents or 60% were able to do the task
within 8 hours post-operation while 2 or 40% have done the task within 9-16 hours
post-operation, but 100 of them did it without prompting and assistance required from
healthcare workers or significant others.
Out of the 5 respondents, 4 or 80% were able to perform Turning to Sides
within 9-16 hours post surgery and only 1 or 10% was able to do the task within 8
hours post-operation; 1 or 10% also required prompting at intervals while the other 4
or 80% need no reminding to do the task; three or 60% were able to do the task with
some assistance from healthcare worker while the remaining 2 or 40% were able to do
the task alone.

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17
 Table II shows the results of respondents who had repeat Caesarean Section. It
shows that out of 5, 2 or 40% were able to do Deep Breathing Exercises within 8
hours and also another 40% have done the task within 17-24 hours while the
remaining 1 or 10% did it within 9-16 hours post-operation. One or 10% needed to
always be reminded to do the task, also another 10% required occasional prompting
while the remaining 3 or 60% need no prompting from healthcare workers or
significant others to do the task, All of the respondents or 100% were able to do the
task without others’ assistance.
For the Leg Exercises, 4 or 80% were able to do the task within 9-16 hours
post-operation, while the remaining 1 or 10% was able to do it within 8 hours post
surgery. One or 10% needed some prompting while the other 4 or 80% need not to be
reminded to do the task, Three of 60% were able to perform the task with some
assistance from others while the remaining 2 or 40% were able to do it on their own.
Out of the 5 respondents, 1 or 10% were able to turn to sides within 24 hours
post-operation, 3 or 60% were able to do task within 9-16 hours post-operation while
1 or 10% did it within 8 hours post-operation. Four or 80% of them needed to be
reminded sometimes to perform the task while the remaining 1 or 10% did it with no
prompting at all. Three or 60% were able to do the task with minimal assistance from
others while 2 or 40% were able to do it on their own.

18
19
 Table III shows the results of both respondents who had primary and repeat
Caesarean Section. It shows that majority of the respondents were able to perform the
three selected pre-ambulation tasks within 16 hours post-surgery, with no reminder
and assistance needed from the nurses and/or significant others.

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 CHAPTER V. SUMMARY, CONCLUSION, RECOMMENDATION

Summary
After conducting pre-operative teaching on obstetric-surgical patients,
majority of primary Caesarean Section respondents were able to do Deep Breathing
Exercises and Leg Exercises within 8 hours post-operation without prompting and
assistance required from healthcare workers and significant others. While most of
them were able to turn to sides within 9-16 hours post-operation without prompting
needed and with minimal assistance from others.
On the other hand, among the repeat Caesarean Section respondents, majority
did Deep Breathing Exercises without prompting and assistance required within 8
hours post-operation. Most of them performed Leg Exercises within 9-16 hours post
surgery without prompting required and with minimal assistance. Most of the repeat
Caesarean Section patients also were able to turn to sides within 8 hours post-
operation with occasional prompting and minimal assistance from healthcare workers
and significant others.

Conclusion
Based on the results shown, researchers conclude that conducting pre-
operative teaching to patients improved their level of performance on the three pre-
ambulation tasks.
Most of the primary Caesarean Section respondents were able to perform the
pre-ambulation tasks without the necessity of prompting them and assisting them in
doing so. Consequently, they were rated as 3 compared to the ratings of repeat
Caesarean Section respondents based on the tool utilized.
We can also conclude that among the pre-ambulation tasks, the deep breathing
exercises are correctly performed by almost all respondents. Both primary and reapeat
Caesarean Section respondents were able to perform deep breathing exercises without
any assistance necessary. Thus, they are rated a score of 3.

Recommendation

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 The results of the study provide information on accomplishment of the three
pre-ambulation tasks to respondents with pre-operative teaching. Due to small sample
size and only a selected area of implementation, the researchers recommend further
study and larger sample size in implementing the study with use of experimental and
control group to determine whether there exist a significant difference in respondents’
performance with those having pre-operative teachings compared to those with none.

22
References

http://www.americanjournalofsurgery.com/article/0002-9610(50)90418-
1/abstractmed-surg. suddarth

https://www.medscape.com/viewarticle/500887_5Preparing Your Patient for

Surgery

Linda M. DeLamar, CRNA, MSN, MS

Topics in Advanced Practice Nursing eJournal. 2005;5(1) 

https://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_04.pdf

Trends in Cesarean Rates for First Births and Repeat Cesarean Rates for Low-
Risk Women: United States, 1990–2003

https://www.babycenter.com/0_c-sections-giving-birth-by-cesarean-
section_160.bc

https://emedicine.medscape.com/article/263424-overview

https://www.ncbi.nlm.nih.gov/pubmed/23657643

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3604814/

What to Expect: Deep Breathing, Coughing, and Moving after Abdominal

Surgery: https://myhealth.alberta.ca/Alberta/Pages/deep-breathing-coughing-
after-abdominal-surgery.aspx

23
 5 Benefits of Deep Breathing Exercises:
https://www.livingthenourishedlife.com/5-ways-youll-benefit-from-daily-
deep/

APPENDICES

SURVEY TOOL

I. Personal Profile

Name:
Age:
Last Menstrual Period:
Age of Gestation:
Gravida:
Para:
Admitting Diagnosis:
Indication for Procedure:
Family History of:

Pulmonary Problems ( )YES, specify_________________ ( )NO

Cardiac Problems ( )YES, specify _________________ ( )NO
Allergies ( )YES, specify_________________ ( )NO

Previous Surgical Procedure:

Date and Time of Operation (Caesarean Section):

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Part II. An Observation Guide on the Pre-ambulation Tasks

On the scale of 1 to 3, rank the performance of each participant in

accomplishing the pre-ambulatory tasks following the respective legends for the three
criteria

TIME PROMPTING ASSISTANCE

TOTAL
TASKS INTERVAL REQUIRED REQUIRED
1 2 3 1 2 3 1 2 3
A. Deep
Breathing and
Coughing
Exercises
B. Leg Exercises
C. Turning to
Sides
1 - Always (4 or
more times in 8
1 - 24 hours post- hours)
1 - With assistance
surgery 2 - Sometimes (1-3
2 - With minimal
2 - 16 hours post- times in 8 hours)
LEGEND assistance
surgery 3 - No reminder
3 - Without
3 - 8 hours post- from the nurse
assistance
surgery needed to initiate
the performance of
the task

25
 SURVERY TOOL

III. Health Teaching

Structured health teaching will be conducted to patients individually for about

35 minutes each following the time-allotment per topic to be discussed on health
teaching plan which include definition of Caesarean Section, indications, post-
operative complications, with emphasis on importance of the three pre-ambulation
tasks in the form of lecture discussion, with the use of video presentation on how to
correctly perform the three pre-ambulation tasks: a. Deep breathing and coughing
exercises, b. Leg exercises, c. Turning to sides.
After which, patients will be evaluated post-operatively on their performance
in accomplishing the three pre-ambulatory tasks based on the adopted criteria made
by Raquel P. Caña which includes Time interval, Prompting required, and Assistance
required.

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27