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Women’s Experiences, Emotional Responses, and Perceptions of Care After Emergency Peripartum Hysterectomy: A Qualitative

Survey of Women from 6 Months to 3 Years Postpartum

Cara Z. de la Cruz, PhD, Martha L. Coulter, DrPH, Kathleen O’Rourke, PhD, P. Amina Alio, PhD, Ellen M. Daley, PhD, and Charles S. Mahan, MD

ABSTRACT: Background: Little is known of the experience and perceptions of care for survivors of emergency peripartum hysterectomy (EPH), an obstetric event that is increasing in incidence. We sought to explore women’s experiences of EPH to make recommendations for care. Methods: This qualitative study utilized purposive sampling through an online support group of women who experienced EPH. Eligible participants were at least 18 years old, had their hysterectomy at least 6 months but no more than 3 years before the interview, had a surviving infant associated with the delivery, and did not report suicidal ideation. In- depth, semi-structured telephone interviews were conducted and analyzed using Constant Comparative Analysis. Kappa statistics assessed interrater reliability for two independent coders. Results: Fifteen women participated with a mean age of 32.5 years. Most had a cesarean section, with uterine atony as the most common indication for EPH. Kappa statistics indicated near-perfect interrater agreement between two coders, ranging from .82 to .89. Seven major themes were identified: fear; pain; death and dying; numbness or delay in emotional reaction; bonding with baby; communication; and the need for information. Psychological upset occurred postpartum and was often delayed. A major finding is the need for additional follow-up visits to address the emotional after-effects and to fill in gaps in women’s understanding and memory of what had occurred. Conclusion: Understanding women’s experiences with EPH can help practitioners address not only women’s initial complications but provide needed long-term support. (BIRTH 40:4 December 2013)

Key words: emergency peripartum hysterectomy, maternal morbidity, perceptions of care, traumatic childbirth

Cara Z. de la Cruz is a Research Associate in the Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, FL, USA; Martha L. Coulter is a Professor in the Department of Community and Family Health, College of Pub- lic Health, University of South Florida, Tampa, FL, USA; Kathleen O’Rourke is a Professor in the Department of Epidemiology and Bio- statistics, College of Public Health, University of South Florida, Tampa, FL, USA; P. Amina Alio is an Assistant Professor in Commu- nity and Preventive Medicine, University of Rochester Medical Cen- ter, Rochester, NY, USA; Ellen M. Daley is an Associate Professor in the Department of Community and Family Health, College of Public Health, University of South Florida, Tampa, FL, USA; Charles S. Mahan is Professor Emeritus in the Department of Community and

Family Health, College of Public Health, University of South Florida, Tampa, FL, USA.

Address Correspondence to Cara Z. de la Cruz, PhD, Department of Community and Family Health, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd. MDC 56, Tampa, FL 33612, USA.

Accepted September 18, 2013

© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.

256 BIRTH 40:4 December 2013

Emergency peripartum hysterectomy (EPH) involves the unplanned surgical removal of the uterus post deliv- ery, typically for life-threatening obstetric hemorrhage. Postpartum hemorrhage and EPH is a public health problem because of its association with maternal mor- bidity and mortality (1–4). EPH incidence rates are increasing, and largely attributed to cesarean section rates (3–7).

Given EPH increases, its potential psychosocial rami- fications, and the need to improve care for major obstetric hemorrhage, research is needed on women’s experiences and needs (1,8–11). Only one study has examined these experiences, and none studied women’s perceptions of care (12). Therefore, this qualitative study addresses a dearth of knowledge, by providing women’s peripartum experiences of EPH, including the hospitalization and follow-up visits. Data from the per- spective of women can generate improvements in care and outcomes.

Materials and Methods

Sample

A purposive sample was selected through an English- speaking international Internet support group of EPH sur- vivors. This sampling frame provided immediate access to this rare population, ease of recruitment, and variations in experiences. Women were recruited through e-mails to the listserv. Those considered eligible were at least 18 years old, and had their EPH 6 months to 3 years before the interview. Women were excluded if their infant/child associated with EPH died, or if they reported suicidal ide- ation. Participants were chosen based on delivery status, ensuring representation of vaginal and cesarean deliveries. Recruitment continued until data saturation was reached and no new themes were elicited. Twenty-one women were contacted to participate. Six did not respond, for a participation rate of 71 percent.

Data Collection

We pilot tested the interview with women who experi- enced a difficult birth, then refined and finalized the interview guide, which covered the experience of EPH, including perceptions, thoughts, and feelings about the delivery and care received through the follow-up per- iod. We obtained verbal consent by telephone before the interview. Data collection lasted approximately 3 months, and Atlas.ti software (Berlin, Germany) was used for data management and analysis. The University of South Florida Institutional Review Board approved this research.

Data Analysis

Telephone interviews were recorded and transcribed verbatim. Constant Comparative Analysis was used for data analysis, using grounded theory (13,14). An initial codebook was created based on interview questions. These codes were applied to each interview. Emerging codes were added to the codebook and previous tran- scripts were reviewed again to incorporate new codes. Then, coded data were analyzed, isolating patterns within themes and identifying the relation to other themes. Key themes characterized the experience and sequelae of EPH.

A qualitative research consultant evaluated the inter- view guide and codebook. The lead researcher coded all interviews, and an independent coder coded 46.7 percent of interviews. Pooled Kappa statistics were cal- culated for six major parent codes, ranging from .82 to .89, indicating near-perfect inter-rater agreement (15). The final analysis and interpretation were reviewed for accuracy by the independent coder. Last, findings were presented to and validated by members of the support group. Pseudonyms are used along with quotes to pro- tect participants’ identities.

Results

Fifteen women with a mean age of 32.5 years partici- pated in the interviews. Participants were all Caucasian and married; most had a 4-year college degree; and 66.7 percent lived in the United States, 20 percent in the United Kingdom, and 13.3 percent in Canada. Among the women, 53.3 percent had EPH with their first child. The most common indication for EPH was uterine atony (66.7%), followed by placenta accreta (13.3%); 66.7 percent had cesarean sections. The aver- age maternal length of hospital stay was seven nights; 77.3 percent awoke after surgery on a ventilator and 86.7 percent were admitted to Intensive Care Unit (ICU). The two not admitted to ICU experienced delayed hemorrhage, occurring over 24 hours post delivery. All reported receiving blood transfusions.

The newborn was sent to the nursery or Neonatal ICU, and later to the maternity floor to be cared for by family until the mother was well enough to join her newborn, usually 2–4 days later. Most commonly, mother and infant were discharged after a few days together on the maternity floor. All women attended follow-up visits 6–8 weeks post discharge. Recounting experiences of postpartum hemorrhage and EPH was emotion-laden. Despite differences among participants, similar themes emerged. The following section pre- sents themes in detail; they are also depicted in Fig. 1.

BIRTH 40:4 December 2013 257

Fear

Many women reported fear or terror during the hemor- rhage, or more commonly, during the remaining hospi- tal stay. While hemorrhaging, most participants relied on others’ cues to assess the situation. Feelings of fear did not surface until baby was taken away, her partner was escorted out of the room, or personnel shouted for blood products.

A common experience was fear associated with regaining consciousness on a ventilator. Women described terrifying choking/drowning sensations, feel- ings that were intense for those alone at the time. Fear was related to not knowing what was happening, being alone, or experiencing threats to physical integrity. The manner of a practitioner had an enormous effect on the patient, as one woman expressed:

…the best thing she [obstetrician] did was when she first got there and she came over and looked at me and made me look at her and said repeatedly that I was going to be OK, and as soon as she said that, I was like, “ah, OK” and I just sort of relaxed and that’s really the last thing I remember [before I was put to sleep]. (Amber, 36 years old, first pregnancy)

One woman described her experience in ICU:

I remember all the noises, the beeps and the alarms and stuff going off and machines and monitors, and you didn’t know if an alarm going off was because it was you, or whether it was the person next door to you. I remember waking up in the middle of the night once and it was dark and there were these alarms going off and it was just horrible. [My husband] used to come and visit me in ICU and I used to beg him not to leave me. (Danielle, 43 years old, second pregnancy)

A few women experienced fear during follow-up visits: from the physical examinations the physician may perform, and fear of recalling memories asso- ciated with the hemorrhage.

Pain

Women’s reports of exceptional pain were a consistent theme. Those with vaginal deliveries seem to report more pain during the hemorrhage, even if they received pain relief during delivery. ICU stays often involved severe pain, regardless of delivery type. One woman described how pain dominated over everything else:

…she [obstetrician] started pounding on me with her fists. It was such horrible pain that I couldn’t think of anything other than the pain, and then when she said probably 5 or 10 minutes later, “We’re going to take you into surgery.” The only thought was, “I just want to be put out. I’m so looking forward to going into surgery and to be put under anesthe- sia… so that I can’t feel the pain anymore.” (Juliet, 23 years old, first pregnancy)

Experiencing severe pain was traumatizing:

…I said the epidural hadn’t worked, but she [obstetrician] didn’t believe me, I guess, even though the anesthesiologist said it didn’t work. And so she reached in and she manually tried to remove my placenta. Which is the most painful thing in the world to have happen, and to have no pain relief. It was very traumatic. Later, I couldn’t close my eyes because I would have visions of her doing that to me, even though I hadn’t seen it…I do not have fond feelings for this doctor. (Kelly, 33 years old, second pregnancy)

Hemorrhage and Hysterectomy

Hospital Recovery Follow-Up

Discharge

Fear

Pain

Death & Dying

Bonding

Delayed Emotional Response

Need to Know

Communication

Fig. 1. Themes across points of contact with obstetric practitioners for women who experience emergency peripar- tum hysterectomy.

258 BIRTH 40:4 December 2013

Death and Dying

Death and dying was a recurring theme. Most women were unaware of the situation’s severity, and that death was a possibility. In fact, a number of participants felt calm and unafraid while hemorrhaging. A few women did feel they were dying, as one participant described:

… I’m going in and out of consciousness, and I’m having a hard time staying earth-bound…I’m just talking to my hus- band and telling him, “Please make sure that you take care of our kids and let him [newborn] know that I loved him very much if I don’t make it through all of this.” I remember kind of losing it before I went into surgery, almost like leaving earth, like having an out-of-body experience. (Cheryl, 33 years old, third pregnancy)

Although many did not feel they were dying while hem- orrhaging, talking about how they nearly died or could have died was often the most emotional part of the interview.

Numbness or Delayed Emotional Reaction

Most women described feeling numb after finding out about their hysterectomy, which delayed emotional reactions such as sadness, guilt or anger. If they did have an emotional reaction immediately, it was eclipsed by gratitude and relief at surviving. While in the hospi- tal, attention focused on their physical recovery and newborn care. The emotional impact of their experience manifested much later, not often at the time of hospital- ization.

I wasn’t even thinking or worrying yet about what it meant to have had the hysterectomy. It was more about just physically recovering and getting home. (Tina, 34 years old, second pregnancy)

I sort of pushed my feelings about the hysterectomy to the back of my mind for quite a while. (Maya, 25 years old, first pregnancy)

Because of the delayed emotional reaction, being psychologically assessed in the hospital was not a good indication of psychological health.

I had a psychologist I guess it was, came and talked to me and at the time I was still…in shock from everything that hap- pened, so I was joking around with her and the sort of nega- tive impact of what had happened hadn’t hit me yet and she actually told me that I was at very low risk for postpartum depression. (Kata, 33 years old, first pregnancy)

Many participants reported that practitioners did not address their emotional needs, citing a need for psycho- logical resources before discharge, such as referrals for therapists who deal with traumatic births that could be

used after discharge. For the few given resources or referrals, they were limited or inadequate.

At follow-up, many did not yet relate emotional dif- ficulties, but were concerned with physical implications of hysterectomy. Some expressed a need to address emotional and physical issues at follow-up. They did not usually bring up the emotional impact with practi- tioners, though they may have been responsive to those concerns if probed.

She [obstetrician] also organized for a counselor to contact me, and so I arranged to go see her as well, and that’s some- thing that was offered to me rather than me having to ask for it, which was great. (Sophie, 31 years old, first pregnancy)

The emotional impact came into focus after the ini- tial excitement decreased—physical health improved, the number of visitors slowed down, and partners returned to work. They felt the emotional impact 1– 6 months post hysterectomy, typically after follow-up.

Talking to somebody in the hospital certainly didn’t help because at the time it hadn’t sank in… I know a couple of months in when I was feeling really upset about it and depressed and didn’t know what to think. I was scared to ask for help too, and…if somebody had just come along and the doctor had said, “hey, come back and see me” maybe 2 or 3 months after…they kind of just let you go at 6 weeks…and I think they should check up on you. (Juliet, 23 years old, first pregnancy)

Bonding with Infant

Participants’ infants were an integral part of their sto- ries. Because of their own health issues, all women experienced a prolonged separation from newborns, which they recalled with sadness, guilt, or regret. Some women described an urgent need to be with their baby, as one explained:

I was really worried because I’d not seen him [newborn] for so long—I’d not even held him—that I’d struggle to bond with him and I wouldn’t be able to feed him, and not only would I not be able to have the delivery I wanted, I also wouldn’t be able to feed him myself… I just couldn’t wait to hold him, almost frantic… I was worried and I feared that I wouldn’t be able to bond with him very well. (Sophie, 31 years old, first pregnancy)

Others were physically exhausted and not initially concerned for the baby, which resulted in feelings of guilt later.

All women intended to breastfeed, and some felt inadequately supported in those efforts. Nevertheless, all described breast milk coming in, though one woman’s did not until 7–8 weeks postpartum. A few women were able to breastfeed exclusively, an experi- ence that was healing and positive. Most supplemented

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with formula and felt the ability to breastfeed at all was an accomplishment. Among practitioners, however, it appeared breastfeeding endeavors were not worthwhile:

In the maternity ward the one thing that really, really bothered me the most was that they didn’t give me enough information about breastfeeding and they kind of tried to steer me away from breastfeeding, “Oh you shouldn’t bother breastfeeding you’ve gone through so much trauma. It’s not going to work and blah blah blah.” I just wish they would have just listened to my wishes and helped me out a little bit more. And I know they thought it was bad for me, but it wasn’t, emotionally anyway. (Juliet, 23 years old, first pregnancy)

On the other hand, the practitioners that were sup- portive made all the difference in efforts to breastfeed.

Women were grateful for exceptions made with respect to visitation for newborns, allowing family to provide care when participants were physically unable. When family could not care for the newborn, particu- larly in cases where the mother was transferred to higher level hospitals and her baby remained behind, women were reassured by regular updates on their infants’ well-being. Most preferred infants room in with them—this arrangement was necessary emotionally, despite the physical difficulty.

The Need for Information

Women desired information at all phases of their expe- rience. After the hysterectomy, the need for information became acute. Women wanted to know what, how, and why everything happened. Practitioners who filled in these blanks helped them accept what had occurred and gave them closure.

During the hemorrhage, knowing the procedures that were being attempted, and what outcomes were possi- ble was helpful. Because of the emergent nature of hemorrhage, signing consent for the hysterectomy was typically rushed, and most signed without a full under- standing. A few questioned the necessity of the hyster- ectomy, which created regret and resentment:

Before I knew it, I had papers shoved in my face saying, “You do understand there’s a great possibility of you needing to have a hysterectomy, we need you to sign on the bottom line.” and I kept saying, “But you’ll try everything you can to save my uterus, won’t you?” “Yeah, he’ll try, but it’s proba- bly not likely that they’ll be able to save it, so you need to sign right here.” And I just remembered signing it thinking they’re not even going to try to save my uterus… (Cheryl, 33 years old, third pregnancy)

In the hospital, the need to know what happened and what was currently happening was pressing. The lack of information available post hysterectomy was traumatizing.

I was really crying because I wanted like a human there to tell me what was going on but—but nobody was there… I hon- estly think that my intensive care stay that night was more traumatizing than what happened before. (Juliet, 23 years old, first pregnancy)

After discharge, most described an extreme need to fill in memory gaps. They questioned partners inces- santly about the events that transpired. Several women obtained medical records, and pored over them. At the time of follow-up or later, they needed the obstetri- cian’s perspective on what had happened.

I finally went back to the doc, the OB, and had set up a meet- ing with her just to have her explain to me what happened because they’d said a few things, but I never really understood exactly what happened, and that was really helpful. It was hard, but really helpful because I learned things that I had no idea about so it really helped to kind of put the pieces together and…fill in the pieces that I had missed. (Anna, 37 years old, second pregnancy)

One participant was only ready to discuss what had happened with her obstetrician 2.5 years post hysterec- tomy, when she was feeling less emotional.

Although some women experienced distress when reminded of the trauma, and avoided the hospital, for others, it may have been helpful to allow them to come back and see where everything happened, to ground their memories.

…my mind imagines one thing but I think it might be nice just to see it and see that it’s just a hospital room, it’s not some torture chamber. (Amber, 36 years old, first pregnancy)

Communication

Communication was a central theme that permeated the interviews, not only in what information to com- municate, but when and how. While hemorrhaging, many women described feeling calm, even when vaguely aware of the severity of the situation. This experience may be related to hypovolemic shock, but it appeared to be affected by the level of calm pro- jected by staff.

She [obstetrician] was just so good at getting in my face and telling me what was going on. She was very calm, but very matter-of-fact, and I never worried about it… I think that that was probably the most helpful, her attitude through it all. She wasn’t freaking out, “Camilla, you need to stay awake.” “Camilla, you are losing blood.” “Your uterus isn’t contract- ing down…you are bleeding more than usual.”… It didn’t register just how serious it was… which was good for me because I didn’t really panic, ever. (Camilla, 29 years old, first pregnancy)

260 BIRTH 40:4 December 2013

Women expressed a particular need for compassion, respect, and sensitivity in the provision of care. In addi- tion to facing their own mortality, they faced the loss of the perfect birth experience, and the loss of an organ tied to femininity and fertility. They had a need for practitioners to acknowledge feelings of grief, whether in the hospital or at follow-up.

And a lot of the attitude toward the psychological aspect had been along the lines of “just get over it”…and “we did what we had to do to save your life”… “and you need to move on with yours now.” They obviously think they were doing the right thing by me, and tried to convince me that I should enjoy my life with my daughter, and not worry about the past. They just… don’t understand what it’s like to have that taken away from you. They really don’t. (Maya, 25 years old, first pregnancy)

Women who received excellent care involving atten- tiveness, sensitivity, and compassion expressed pro- found appreciation. A few described health care practitioners becoming emotional themselves, which was supportive and meaningful.

You always have to be professional but…it’s OK to let your barriers down as a health care provider, it’s OK to say, “Oh my God, we were so scared,” “Oh my God, that was so awful…let’s talk about it together.” That was a wonderful thing. That was my experience, which was very positive… That was a very powerful thing, to feel like I was a real per- son to those people, and that they care too and that they hurt too. [Crying] (Rachel, 35 years old, first pregnancy)

Communication issues emerged about continuity of care, including the lack of an identified point person and difficulty with nursing transitions. The practitioner managing care was often not identified. The family felt reassured knowing who was in charge, which eased the exchange of information—particularly important when having information was key for the mother’s peace of mind. With constant shift changes, nurses were some- times unaware of women’s complicated delivery or hysterectomy. Participants found it unsettling to inform staff there existed no uterus to check, or no need for birth control. It was difficult to feel supported when health care practitioners did not read charts and with constant changes in personnel.

Discussion

This study exploring the experience and impact of EPH shows it is a traumatic, major life event. Our findings fill a gap in the literature about perceptions of care for EPH survivors and recommendations for care based on their experiences. Given high cesarean section rates and the concomitant increase in EPH (3–7), this study high-

lights a topic that is increasingly relevant to researchers and practitioners, who need tools to best deal with EPH.

The seven themes identified are supported by find- ings of previous qualitative studies. Research involving women who survived EPH, had traumatic or compli- cated births, or experienced childbirth-related post-trau- matic stress disorder (PTSD) found similar themes: fear; pain; the need for information; numbness; the need for compassion, attentiveness and sensitivity; and bonding and separation from newborns (12,16–18).

Another study involved experiences of near-miss maternal morbidity, in which EPH is classified (19), finding common themes of dying, fear, bonding, the need for information, and communication, particularly the need to be treated with compassion and respect (20). Women’s experiences post discharge were not studied, and women relayed anxiety about future preg- nancies (20), which is not relevant for EPH survivors who no longer can bear children. Otherwise, results closely mirror those of this study.

With respect to limitations, the sample size of 15 is small, but appropriate in qualitative research when data saturation is achieved. The use of an online support group limits the study’s generalizability, as participants were educated, Caucasian, and married. However, it is an innovative approach, providing valuable information on women’s experience of EPH across hospitals and countries. Similar studies using hospital-based sampling have found comparable themes (12,18,20), possibly because patients with rare medical conditions or experi- ences are more likely to seek peers and health informa- tion online compared with all Internet users (21).

Clinical Implications

A number of practice implications have emerged (Fig. 2). One major finding was consistent psychologi- cal upset after discharge. This finding highlights the need for providing follow-up care regularly over the first year postpartum even if the woman initially seems to be doing well.

ICU admission is a risk factor for PTSD (22). One program in select UK hospitals offers ICU survivors multiple follow-ups after discharge, and has been effec- tive in addressing physical and emotional outcomes (23). One study participant was part of this program and deemed it a major contributor to her recovery. Multiple follow-up visits should be considered in the care of EPH survivors. Study participants identified a need for at least one follow-up visit to address further concerns after the standard 6–8 week visit, as psycho- logical issues often arose at that time. Multiple follow- ups up to 2.5 years post hysterectomy may be needed

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for some women, as identified here and in a previous study (12).

Many did not experience emotional distress immedi- ately, but needed resources set up before discharge. Potential resources include referrals for therapists or online support groups specializing in trauma or birth trauma. The most relevant online group is of EPH sur- vivors, where study participants were drawn. To join, women can e-mail C.Z.d. ([email protected]) who will refer them to the current moderator.

A debriefing of events can provide support, as partic- ipants expressed a need to know what happened during the hemorrhage, what procedures were attempted, the complications that occurred during the remainder of the hospital stay, and why the hemorrhage and hysterec- tomy occurred. Practitioners can help fill in gaps in understanding or memory, which may help ameliorate symptoms of PTSD (23).

Further strategies may address women’s concerns about their hospital experience. During the hemorrhage, it is helpful if practitioners maintain as calm an atmo- sphere as possible and explain what is happening. Dur- ing the postpartum hospitalization, identifying a practitioner who is managing care, and seamless trans- fer of care between nurses is helpful. In addition, women should be assisted in bonding with their infant and breastfeeding if desired. These recommendations can be assimilated into practice quickly.

Although EPH survivors experience a life-threatening hemorrhage, limited data are available on their experi- ences and perceptions of care. This study informs practi- tioners of what the experience of EPH entails for women and families and how to best support them. Attention should be given to emotional needs, particularly in the longer term. Although postpartum hemorrhage and EPH are specific events, these recommendations may be applicable to women who experience other life-threaten- ing or traumatic childbirth complications.

Acknowledgments

Thanks to Karen Dyer, PhD, the independent coder, Jeanne Moore, MSW, MPH, who provided mental health referrals for participants needing further assis- tance, and Carol Bryant, PhD, the qualitative research consultant.

References

1. Forna F, Miles AM, Jamieson DJ. Emergency peripartum hyster- ectomy: a comparison of cesarean and postpartum hysterectomy. Am J Obstet Gynecol 2004;190(5):1440–1444.

2. Kwee A, Bots ML, Visser GH, Bruinse HW. Emergency peripar- tum hysterectomy: a prospective study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 2006;124(2):187–192.

• Project calm atmosphere when possible • Communicate what is happening • Manage pain or explain why not possible • Be compassionate and respectful

Phase I: Hemorrhage and Hysterectomy

• Identify point person to facilitate communication • Ensure seamless transfer of care between nurses • Provide early and regular contact with baby • Support breastfeeding if desired; set up with lactation consultant • Allow flexible visitation for mother’s visitors and baby’s visitors; do not

leave mother alone • Provide referrals for emotional support, even if no apparent need • Conduct debriefing of events • Manage pain or explain why not possible • Be compassionate and respectful; acknowledge feelings of grief/loss

Phase II: Hospital Recovery

• Provide miminum of one additional follow-up, and more as needed • Provide referrals for emotional support, even if no apparent need • Conduct more detailed debriefing of events • Be compassionate and respectful; acknowledge feelings of grief/loss

Phase III: Follow-Up

Fig. 2. Emergency peripartum hysterectomy: implications for practice.

262 BIRTH 40:4 December 2013

3. Sakse A, Weber T, Nickelsen C, Secher NJ. Peripartum hysterec- tomy in Denmark 1995–2004. Acta Obstet Gynecol Scand 2007;86(12):1472–1475.

4. Yoong W, Massiah N, Oluwu A. Obstetric hysterectomy: chang- ing trends over 20 years in a multiethnic high risk population. Arch Gynecol Obstet 2006;274(1):37–40.

5. Whiteman MK, Kuklina E, Hillis SD, et al. Incidence and deter- minants of peripartum hysterectomy. Obstet Gynecol 2006;108 (6):1486–1492.

6. Gould DA, Butler-Manuel SA, Turner MJ, Carter PG. Emer- gency obstetric hysterectomy - an increasing incidence. J Obstet Gynaecol 1999;19(6):580–583. Epub 2004/10/30.

7. Joseph KS, Rouleau J, Kramer MS, et al. Investigation of an increase in postpartum haemorrhage in Canada. BJOG 2007;114(6):751–759.

8. Eniola OA, Bewley S, Waterstone M, et al. Obstetric hysterec- tomy in a population of South East England. J Obstet Gynaecol 2006;26(2):104–109.

9. Skupski DW, Lowenwirt IP, Weinbaum FI, et al. Improving hos- pital systems for the care of women with major obstetric hemor- rhage. Obstet Gynecol 2006;107(5):977–983. Epub 2006/05/02.

10. Engelsen IB, Albrechtsen S, Iversen OE. Peripartum hysterec- tomy-incidence and maternal morbidity. Acta Obstet Gynecol Scand 2001;80(5):409–412.

11. Kayabasoglu F, Guzin K, Aydogdu S, et al. Emergency peripar- tum hysterectomy in a tertiary Istanbul hospital. Arch Gynecol Obstet 2008;278(3):251–256. Epub 2008/01/15.

12. Tang GW. Reactions to emergency hysterectomy. Obstet Gyne- col 1985;65(2):206–210. Epub 1985/02/01.

13. Glaser BG. The constant comparative method of qualitative- analysis. Soc Probl 1965;12(4):436–445.

14. Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant 2002;36(4):391–409.

15. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159–174. Epub 1977/ 03/01.

16. Allen S. A qualitative analysis of the process, mediating vari- ables and impact of traumatic childbirth. J Reprod Infant Psychol 1998;16(2):107–131.

17. Beck CT. Post-traumatic stress disorder due to childbirth: the aftermath. Nurs Res 2004;53(4):216–224.

18. Berg M, Dahlberg K. A phenomenological study of women’s experiences of complicated childbirth. Midwifery 1998;14(1):23– 29. Epub 1998/06/20.

19. Geller SE, Rosenberg D, Cox S, et al. A scoring system identi- fied near-miss maternal morbidity during pregnancy. J Clin Epi- demiol 2004;57(7):716–720.

20. Souza JP, Cecatti JG, Parpinelli MA, et al. An emerging “mater- nal near-miss syndrome”: narratives of women who almost died during pregnancy and childbirth. Birth 2009;36(2):149–158. Epub 2009/06/06.

21. Fox S. Peer to peer health care. Washington, D.C.: Pew Research Center; 2011 [Accessed January 15, 2013]; Available from: http://www.pewinternet.org/Reports/2011/P2PHealthcare.aspx.

22. Davydow DS, Gifford JM, Desai SV, et al. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry 2008;30(5):421–434. Epub 2008/ 09/09.

23. Griffiths J, Gager M, Waldmann C. Follow-up after intensive care. Conti Edu Anaesth, Criti Care & Pain 2004;4(6):202–205.

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