Abstract
Lower segment cesarean section (LSCS) is a safe mode of delivery and has definite indications. However, at times, patients do not accept the advice to undergo elective or emergency LSCS, as appropriate. This leads to avoidable complications and cost. This communication discusses the style and salient features of counseling patients to understand and accept LSCS, as part of informed consent-taking. This discussion is geared towards obstetric care providers who encounter LSCS hesitancy in spite of having explained the indication(s) for surgery.
Keywords: Labor, delivery, consent taking, patient-centered care, obstetrics
Prevention of disease, and promotion of health, is an integral part of health care services. The concept of prevention has gained traction in recent decades, and various levels of prevention have been described in literature.1
Quinary prevention is defined as “Policies, conditions, actions and measures, that inhibit the emergence and establishment of processes and factors, that increase the risk of communication of inappropriate information, related to health, disease prevention or management, and/or that minimize the risks of communicating any such inappropriate information, hence minimizing the effect of such misinformation on the progression or development of disease at any stage during its natural history”.2
A simpler definition of quinary prevention is as follows: “Means of preventing health-related hearsay or misinformation, or its ill effects on the health of individuals.”2
QUINARY PREVENTION IN OBSTETRICS
The framework of quinary prevention has been discussed in the context of chronic diseases,3,4 but is equally applicable to acute health care settings. In obstetrics, we encounter many misconceptions, especially related to lower segment cesarean section (LSCS), its necessity, and its advantages. This leads to a situation of LSCS hesitancy,5 where patients decline or delay consent for surgery. Lack of timely decision, and timely intervention, may have negative effects on the health of both mother and baby.
In this opinion piece, we list the various myths and misinformation related to LSCS as a mode of delivery and discuss how to tackle them. The quinary prevention framework improves patient provider communication and information sharing, thus enhancing the quality of obstetric care (Table 1).
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Table 1. Quinary Prevention and LSCS: Content of Communication
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Myths regarding LSCS
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Accurate information: quinary prevention
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Related to necessity
· LSCS is advised for financial reasons, not for health
· LSCS is advised for the doctor’s convenience
· LSCS is advised because the doctor is unable to perform instrumental delivery
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LSCS has clear cut indications, which can be classified as elective, emergent and urgent. These indications are based upon evidence and outcomes.
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Related to safety
· LSCS is associated with increased risk of adverse maternal outcomes
· LSCS is associated with increased risk of adverse fetal outcome
· LSCS leads to long-term maternal ill health, e.g., backache
· LSCS leads to long-term ill health in the child
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LSCS is an intervention which protects and promotes maternal, fetal and long-term health. Explain potential adverse outcomes of prolonged or difficult labor.
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Related to tolerability
· LSCS calls for long-term bed rest
· LSCS doesn’t allow the mother to breastfeed
· LSCS doesn’t allow one to plan the next pregnancy
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With simple postoperative rehabilitation, the mother can resume normal activities. Breastfeeding is easily possible after LSCS.
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Related to social desirability
· LSCS means that the mother is “less feminine” than women who have had a normal vaginal delivery
· LSCS means that the mother is “less strong" than women who have had a normal vaginal delivery
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LSCS does not mean that one is “less feminine”. Body self-image should not be linked to mode of delivery.
Involve the husband while explaining the anatomy and physiology of parturition, as well as impact of prolonged or difficult labor on the female genital tract.
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Related to affordability
Post-LSCS maternal and newborn care is expensive
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If planned during working hours, the cost of LSCS can be minimized. Timely LSCS reduces the cost of long-term care of mother and neonate. Discuss options regarding place of delivery.
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While Table 1 is not exhaustive, we feel that it provides a comprehensive overview of the various myths that one may encounter during obstetric practice. Table 2 also shares a pragmatic way of dispelling these myths, in patients, and in the community at large.
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Table 2. Quinary Prevention and LSCS: Communication Style
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· Ask about concerns and complaints fears and feelings, doubts and distress. Acknowledge and appreciate the patient’s point of view, and the efforts she has made to take care of her health.
· Accept her view point as being rational, and then offer an alternate viewpoint based upon scientific knowledge.
· Address and analyze the reasons behind these thoughts, beliefs and emotions.
· Articulate and repeat the information in a variety of words in the patient’s language.
· Avoid argumentative or aggressive language, while continuing to engage the patient.
· Allow the discussion to continue at a later date or time, if appropriate.
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SUMMARY
Quinary prevention encourages obstetric care providers to enquire regarding specific myths related to LSCS, and address them appropriately. The rubric that we share provides a framework to classify and address the confusion that surrounds LSCS. Handling these challenges is as much an integral part of obstetrics as conducting deliveries: both contribute equally to safe motherhood.
REFERENCES
- Magnani JW, Mujahid MS, Aronow HD, Cené CW, Dickson VV, Havranek E, et al; American Heart Association Council on Epidemiology and Prevention; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Peripheral Vascular Disease; Council on Quality of Care and Outcomes Research; and Stroke Council. Health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: a scientific statement from the American Heart Association. Circulation. 2018;138(2):e48-74.
- Kalra S, Kumar A. Quinary prevention: defined and conceptualized. J Pak Med Assoc. 2019;69(12):1765-6.
- Dutta D, Arora V, Dhingra A, Das AK, Fariduddin M, Shaikh K, et al. Quinary prevention in diabetes care: need for multidisciplinary approach. Clin Epidemiol Glob Health. 2021;11:100757.
- Kishor K, Bisht D, Kalra S. Cardiovigilance in atrial fibrillation–Primordial to quinary prevention intervention. Euro J Arrhythmia Electrophysiol. 2019;5(2):77-81.
- Kalra B, Sharma A, Dhingra K, Agrawal S. Addressing lower segment cesarean section hesitancy: a patient-centered, pragmatic communication guide. Ind J Clin Pract. 2022;33(3):34-6, 38.