Presence of the partner in the operating room during emergency caesarean section: A scoping review

KEY POINTS Limited evidence exists regarding the presence of the partner in the operating room during emergency caesarean sections. Most parents prefer having the partner present in the operating room during emergency caesarean sections under either general or regional anaesthesia. Most arguments in the literature against having the partner present in the operating room are personal opinions. Most arguments in the literature in favour of having the partner present in the operating room are clinical findings. Healthcare staff are reluctant to allow partners to be present when general anaesthesia is used.

Introduction

Having a partner present to support the mother during labour and vaginal birth is a well established practice in most countries worldwide1 and has well documented benefits.2–5 In many countries, this is also the practice with elective caesarean sections.6 However, when it comes to emergency caesarean section, the picture is less clear. Emergency caesarean section is not how parents plan to start their life as a family, and it can be very stressful for the mother and partner. Studies find increased rates of post traumatic stress disorder,7–9 anxiety and depression following emergency caesarean section in mothers10–14 and partners/fathers.15

An emergency caesarean section is one of the most urgent medical emergencies, requiring immediate action, involving several healthcare professionals in an operating room (obstetricians, anaesthetists, midwives, etc.). Often, there is very limited time to inform the parents about what is going to happen, and they may be stressed, experiencing pain and in fear for the life of mother and infant. In this highly complex situation, is it preferable to leave the partner outside of the operating room, or is it better to let the partner accompany the mother during the emergency caesarean section?

The perceived benefits of letting the partner participate in the emergency caesarean section include improved psychological support for the mother, improved psychological coping for the partner as well as an increased possibility for early skin-to-skin contact, which could also be initiated between infant and partner, if the mother is temporarily incapacitated. On the other hand, concerns include that the partner witnessing an emergency caesarean section could increase stress for the partner and perhaps also the mother, or that the partner would behave inappropriately and thus compromise sterility or remove important attention from the mother or infant.

With this scoping review, we aim to provide an overview of the current body of evidence and opinions in the literature regarding the presence of the partner in the operating room during emergency caesarean sections.

The primary outcome of the review is: what is known about having the partner present during emergency caesarean section with general anaesthesia? Effects on the mother, the partner and the healthcare staff, in terms of experiences, thoughts and opinions, as well as effects on medical outcomes (regarding mother and infant).

The secondary outcome of the review is: what is known about having the partner present during emergency caesarean section with regional anaesthesia (epidural or spinal)? Effects on the mother, the partner and the healthcare staff, in terms of experiences, thoughts and opinions, as well as effects on medical outcomes (regarding mother and infant).

Material and methods

This scoping review was planned and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) and PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines.16,17 Please see the protocol at https://osf.io/jqwx8/ (1 October 2021). The design of the literature search strategy was based on the inclusion criteria, which were categorised according to the PCC-model (Population, Concept and Context), which is a less restrictive alternative to the PICO-model (Population, Intervention, Comparator and Outcome) recommended for systematic reviews.18

Population: this review included studies reporting on the experiences, thoughts and opinions of mothers, partners and healthcare professionals involved in emergency caesarean sections, or clinical outcomes related to the emergency caesarean sections.

Concept: this review includes studies reporting on having the partner present in the operating room.

Context: this review includes studies reporting on mothers receiving either general or regional anaesthesia for their emergency caesarean sections.

We performed a preliminary search of PubMed, Cinahl, Embase and the Cochrane Library to avoid evidence duplication but found no current or ongoing reviews concerning the presence of the partner during emergency caesarean sections.

All study designs were eligible, including not only quantitative and qualitative designs, but also, for example, letters, debate posts and so forth. Manuscripts published in English, German, Norwegian, Swedish and Danish were included.

PubMed, Embase, the Cochrane Library and Cinahl were searched, from inception to the present day (October 2021). We performed an initial limited search of PubMed and Embase to identify relevant articles. The words used in the titles and abstracts and the index terms from these articles were then used to develop a full search strategy (please see details in Table A, Supplemental Digital Content, https://links.lww.com/EJA/A772). Our search strategy aimed to locate both published and unpublished studies. The reference lists of included studies were also screened for additional relevant publications. Unpublished studies and grey literature were searched in Google Scholar.

Following the literature search, all identified studies were uploaded to EndNote20, and duplicates removed. Then studies were uploaded to the Covidence software, and duplicates were removed once more. Titles and abstracts were screened by two independent authors (HKN and TB) for relevance according to the inclusion criteria. Potentially relevant studies were retrieved and assessed in detail (Fig. 1).

F1Fig. 1:

Preferred Reporting Items for Systematic Review and Meta-analysis flowchart, literature search.

Each included manuscript was evaluated for quality of evidence, using the Mixed Methods Appraisal Tool (MMAT) developed by the Joanna Briggs Institute,19 by three authors (HKN, TB and ACB), resulting in an overall judgement of quality as very low, low, moderate or high. If content was unclear or if relevant data were missing, authors were contacted to obtain the information.

In order to thematically summarise data from the included studies, an inductive approach was used.20 Data from the studies were extracted as verbatim quotes, or in our English translation concerning studies published in other languages (German and Norwegian), by two authors (HKN and TB) using a data extraction form. These data were read and re-read several times to identify thematic similarities and patterns. Emerging patterns were organised in thematic groups. Two authors (HKN and ACB) discussed the data and emerging themes and agreed upon the final thematic groupings of the results.

Results

We identified 24 relevant titles from the literature search, including citation searching (Fig. 1). The titles covered one nonsystematic review,21 five quantitative studies,22–26 seven qualitative studies,27–33 four letters/brief descriptions of single cases,34–37 four debate posts38–41 and three conference abstracts6,42,43 (Table 1). Geographically, studies originated from the UK,6,26,30,34–37,40,42,43 the USA,22,24,41 Germany,38,39 Brazil,29,33 South Africa,27 Japan,31 Sweden,28 Norway,23 Finland,25 Spain32 and Canada.21 The studies were published between 1984 and 2020. Table 1 provides an overview of the studies included regarding design, participants, type of anaesthesia, whether the partner was present and a brief summary of results and authors’ conclusions.

Table 1 - Characteristics of included titles First author, year, country Type Design Regional or general anaesthesia Number of participants Partner present? Time to follow-up Results and conclusion Cain,22 1984, USA Journal article Cohort, restrospective questionnaire and follow-up observations in own home 19 under regional, 4 under general anaesthesia 23 volunteer couples 4 elective CS, 19 emergency. Not possible to exclude data on the four elective CS.13 fathers present, 9 wished to be, but were not allowed, 1 declined. 3 months after CS Mothers and fathers described positive feelings about having the father present during CS, and negative feeling about the fathers’ absence. Mothers and fathers had earlier and closer contact with the infant if the father was present related more positive circumstances in the hospitalisation period following surgery. At 3 months, there was no difference in parent–infant interaction except that fathers who were not present showed a little greater intensity of positive affect to their infants.Findings are described in detail in (secondary outcome, regional anaesthesia) and some are mentioned in (themes). Leach,21 1984, Canada Journal article Review, not systematic Both NA No NA Fathers are excluded from CS because of health-care professionals, who view CS as surgery, and are afraid the father will faint or contaminate the sterile field. However, these fears are unfounded, and the father should be allowed to witness the birth as only a parent can; the unconscious mother relies on him.More details can be found in Table B, Supplementary Digital Content, http://links.lww.com/EJA/A773. Svensen,23 1985, Norway (Norwegian) Journal article Retrospective cohort (defined in 1984, CS carried out in 1981–1983) Regional (epidural), and general anaesthesia 100 consecutive CS after changing routines, so epidural anaesthesia was possible, and the partner was allowed in the OR 54 CSRA, 17 of these with partners present (7 more were asked but declined; 4 wanted to be present but were not allowed).46 CSGA Not stated Mothers and fathers were positive about being present for CSRA, also in cases where resuscitation efforts were required. Complications and procedure time was alike between groups.Findings are described in detail in (secondary outcome, regional anaesthesia) and some are mentioned in (themes) Sakala,24 1988, USA Journal article Retrospective cohort General and regional 227 mothers having CS, elective and emergency, in a 10-month period in a single center 148 mothers with father present (53% emergency CS); 79 without father present (63% emergency CS) Perioperative and immediate postoperative period Regional anaesthesia was more likely to be used with father present. Clinical differences between groups (in favour of having the father present) disappeared when controlling for anaesthesia form (favouring regional anaesthesia), except higher Apgar at 5 min with father present.Findings are described in detail in (primary outcome, general anaesthesia), (secondary outcome, regional anaesthesia) and some are mentioned in (themes). Freeman,34 1989, UK Letter, description of a case NA General One couple having emergency CS Parents insisted that the father was present during CS. CS uneventful NA Large debate among anesthesiologists following the CS. A policy is being formed. Asking for inputs from others.More details can be found in Table B, Supplementary Digital Content, http://links.lww.com/EJA/A773. Russell,37 1989, UK Letter, response to Freeman 1989 NA Spinal converted to general anaesthesia One couple Father wished to remain in the OR and did so. CS uneventful. NA In favour of having the father present in the OR, both during induction of anaesthesia and during the CS, in either regional or general anaesthesia.More details can be found in Table B, Supplementary Digital Content, http://links.lww.com/EJA/A773. Gadelrab,35 1989, UK Letter, response to Freeman 1989 NA Not stated One couple Father forced his way into the OR and was present during CS. NA Describing a case of a threatening and abusive father forcing his way into the OR. Stating the partners should only be allowed in the OR at the discretion of the staff. Asking for round-the-clock hospital security staff.More details can be found in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773. Bogod,36 1990, UK Letter, opinion NA General NA NA NA Describing a change in his own preferences; now willing to allow the father to be present for CSGA, if he enters after the induction of anaesthesia, to witness the birth, and then leave with the baby and midwife.More details can be found in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773. Ceronio,27 1995, South Africa Journal article Qualitative; first unstructured, then semi-structured interview and questionnaire Regional (epidural) Five mothers, five fathers, first time parents Yes Three days and 6 weeks after CS Some mothers mentioned having the father present during CSRA as supportive. Fathers experienced stress and disappointment; found it easier to accept the CS when they understood the reasons for the procedures; did not feel excluded; felt coerced into the CS situation without feeling prepared; did not feel in control; found the OR disturbing; found support from healthcare staff to be very important.Findings are described in detail in (secondary outcome, regional anaesthesia) and some are mentioned in (themes). Paravicini,38 1996, Deutschland (German) Debate NA Regional and general NA Argues against having a partner present NA States that CS are not natural births and should not be handled as such. Having the partner present might distract the staff and disturb their concentration, and may also set a precedent for other types of surgery in the future. The father could faint or contaminate the field and should not be present.More details can be found in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773. German Society for Anesthesiology and Intensive Care Medicine,39 1999, Deutschland (German) Statement from a medical society NA Regional and general NA NA NA The responsible doctor can allow a relative to be present but is not obliged to do so. In elective CS, most often under regional anaesthesia, a partner will often be allowed. In emergency CS under general anaesthesia, a partner will not be allowed in.If the mother wishes for her partner to be present during CS, and the partner consents, he should fill out a consent form beforehand (an example is described in the document).More details can be found in table B, Supplemental Digital Content, http://links.lww.com/EJA/A773. Robinson,40 2004, UK Debate, pro NA General NA Opinion; in favour of having partners present NA Partners should be allowed in the OR during CS. Mothers wish for it and it calms her; within paediatric anaesthesia relatives are often present; difficult intubations are rare. A member of staff should support the partner.More details can be found in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773. Smiley,41 2004, USA Debate, con NA General NA Opinion; against having partners present NA Partners should not be allowed in the OR during CS. Benefits have not been documented; when the mother is under general anaesthesia, there is no reason the partner should be there; the mother would not want her husband to see her like that; the partner risks emotional trauma; staff risk legal issues; staff will perform less well; the partner might distract the staff and disturb their concentration, the partner might faint.More details can be found in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773. Tarkka,25 2005, Finland Abstract (journal article in Finnish, abstract available in English) Retrospective cohort, questionnaire Not stated 213 mothers, of whom 106 had emergency CS 83% had a support person present (most often the spouse) Not stated Mothers’ birth experiences were fairly positive and the presence of the support person during the birth was associated with mothers’ positive birth experience.Findings are described in more detail in (themes). Savage,26 2007, UK Journal article Questionnaire survey Primarily regional (epidural and spinal) ‘All (231) clinical directors in obstetrics and gynecology […] in the British Isles’ were sent a questionnaire, 68% (151) responded. Opinions on (among others) having the partner present during CS NA All consultants allowed some partners to attend, primarily when it came to CSRA; one commented ‘some colleagues have reservations if the caesarean is under general anaesthetic’. Two said that partners were not invited to emergency caesareans’.Findings are described in detail in (secondary outcome, regional anaesthesia) and some are mentioned in (themes). McIlmoyle,42 2010, UK Conference abstract Questionnaire survey Regional and general 81 staff members (36 midwifes, 25 anesthetic staff, 1 auxiliary nurse, 19 obstetric staff) Opinions on having the partner present NA A third of the anesthetic staff agreed that having the partner present during CSGA is acceptable; others were open to considering it under the right circumstances. Obstetricians are becoming similarly open; however, other members of staff, in particular midwifes, are opposed to partners’ presence during general anaesthesia.Findings are described in detail in (primary outcome, general anaesthesia), (secondary outcome, regional anaesthesia) and some are mentioned in (themes). McIlmoyle,43 2012, UK Conference abstract Questionnaire survey Regional and general 56 mothers, 53 partners (33 elective, 23 emergency CS and data cannot be separated) Not stated After CS The vast majority of mothers and partners stated that it was important for the partner to be present during CSRA and CSGA.Findings are described in detail in (primary outcome, general anaesthesia), (secondary outcome, regional anaesthesia) and some are mentioned in (themes). Lindberg,28 2013, Sweden Journal article Qualitative Not stated Eight fathers having experienced their partners’ complicated childbirth/CS that involved a postoperative stay at an ICU Some present, some not (numbers not stated) 1, 5 to 3 months after CS Main finding: ‘Fathers struggled to be recognised by the care staff as partners in their families’. Fathers who were not present for CS expressed fear, frustration, helplessness, feeling abandoned, excluded and described the waiting time as very trying. Fathers present during CS expressed appreciation for not being excluded, described family togetherness, felt able to continue their role as caregivers. Described the OR as uncomfortable, were treated well by staff and informed continuously, but did not ask for information so as to not disturb.Findings are described in detail in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773 and some are mentioned in (themes). Brüggemann,29 2015, Brasil Journal article Qualitative Regional and general Healthcare professionals, 12 nurses and five technical directors from 12 institutions No NA Healthcare staff found that OR is not a place for a companion; companions were not allowed in delivery rooms either; staff felt that companions do not have emotional and psychological preparation to participate and should not.Findings are described in detail in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773 and some are mentioned in (themes). Hugill,30 2015, UK Journal article Qualitative, and personal experiences as doctors and parents General Eight parents No Not stated All mothers mentioned the emotional significance of no one close to them or their baby being present in the OR; this was more important to them because they were under general anaesthesia. Authors speculate that there might be benefits of having the father present for CSGA but states that evidence is weak, and professional opposition can be strong.Findings are described in detail in (primary outcome, general anaesthesia) and some are mentioned in (themes). Watts,6 2016, UK Conference abstract Questionnaire survey Regional and general ‘Survey was sent to all obstetric leads in UK’. 73% response rate. Yes and no NA All units allowed partners in for regional anaesthesia; a small number of units allowed partners to be present when providing general anaesthesia. Common benefits expressed were reduced anxiety for both mother and partner, improved communication and bonding. Most frequent risk identified were staff distractions, desterilisation and partner's fainting.Findings are described in detail in (primary outcome, general anaesthesia), (secondary outcome, regional anaesthesia) and some are mentioned in (themes). Kondou,31 2018, Japan Journal article Qualitative Not stated Nine fathers present at hospital during their wives’ first childbirth No One to 6 days after CS Fathers described that they thought that doctors performed well during surgery and trusted them. During the CS, fathers feared for the life of their wives; felt anxiety while waiting. After the CS, fathers described not only relief, gratitude and pleasure, but also remaining anxiousness and fearful.Findings are described in detail in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773, and some are mentioned in (themes). Pereda-Goikoetxea,32 2019, Spain Journal article Qualitative Regional 43 mothers, 5 had emergency CS (not possible to extract data specifically on CS); 33 for second interviews No Eight weeks and 8 months after CS ‘The women considered the presence of their partners during childbirth the most important form of support’‘I wish the father could have been in the operating room’.Findings are described in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773 and some are mentioned in (themes). Maziero,33 2020, Brazil Journal article Qualitative Not stated 29 health professionals, providing direct assistance to women in labor or CS; 11 nurses, 9 doctors and 9 nursing technicians Investigates healthcare professionals’ reasons for not having the partner present NA Reasons for not having the partner present were that the partner might distract the staff and disturb their concentration, does not understand what is happening, an OR is not an adequate environment. Staff state that the partner should not be allowed in for high-risk pregnancies or emergencies. Authors’ conclusions are that having a partner present during labour and delivery is a booster for the adoption of other good practice; it is essential that hospitals establish a guarantee of a companion for all women, including during complicated births and caesarean sections.Findings are described in detail in Table B, Supplemental Digital Content, http://links.lww.com/EJA/A773 and some are mentioned in (themes). An overview of all the included titles is presented. Manuscripts describing original clinical findings (qualitative and quantitative studies) are described in more detail in Tables 3–5. Manuscripts not describing clinical findings (letters, debate posts and nonsystematic reviews) are described in more detail in Table B in Supplemental Digital Content, https://links.lww.com/EJA/A773. CS, caesarean section (this is only used in the meaning ‘emergency caesarean section’ as studies concerning elective caesarean sections were not included); CSGA, caesarean section under general ’Wang; CSRA, caesarean section under regional anaesthesia (epidural or spinal); OR, operating room.

The quality of evidence was assessed for all titles (Table 2 and Table C, Supplemental Digital Content, https://links.lww.com/EJA/A774). Debate posts and letters/brief descriptions of single cases were rated as having very low quality of evidence. The MMAT tool19 was used to evaluate all manuscripts containing original clinical data. We tried to contact several authors to obtain more information and data, but this was unsuccessful (see Table D, Supplemental Digital Content, https://links.lww.com/EJA/A775).

Table 2 - Quality assessment First author, year, country Type Quality of evidence Cain,22 1984, USA Journal article, retrospective cohort with follow-up observations Low Leach,21 1984, Canada Journal article, review (not systematic, published under the theme ‘thoughts and opinions’) Very low Svensen,23 1985, Norway (Norwegian) Journal article Low Sakala,24 1988, USA Journal article, retrospective cohort. Low Freeman,34 1989, UK Letter, description of a case Very low Russell,37 1989, UK Letter, response to Freeman 1989 Very low Gadelrab,35 1989, UK Letter, response to Freeman 1989 Very low Bogod,36 1990, UK Letter, opinion Very low Ceronio,27 1995, South Africa Journal article Moderate Paravicini,38 1996, Deutschland (German) Debate Very low German society for Anesthesiology and Intensive Care Medicine,39 1999, Deutschland (German) Statement from a medical society Very low Robinson,40 2004, UK Debate, pro Very low Smiley,41 2004, USA Debate, con Very low Tarkka,25 2005, Finland Abstract (journal article only available in Finnish and can, therefore, not be evaluated; abstract available in English). Retrospective cohort, questionnaire. Very low Savage,26 2007, UK Journal article, national questionnaire survey Moderate McIlmoyle,42 2010, UK Conference abstract, survey of healthcare staff's opinions Low McIlmoyle,43 2012, UK Conference abstract, survey of parents’ opinions Low Lindberg,28 2013, Sweden Journal article, qualitative study Moderate Brüggemann,29 2015, Brasil Journal article, qualitative study Moderate Hugill,30 2015, UK Journal article, qualitative study and personal experiences and opinions Low Watts,6 2016, UK Conference abstract, national questionnaire survey Low Kondou,31 2018, Japan Journal article, qualitative study Moderate Pereda-Goikoetxea,32 2019, Spain Journal article, qualitative study Good Maziero,33 2020, Brazil Journal article, qualitative study Moderate Included studies were evaluated on study level based on the MMAT tool19 from the Joanna Briggs Institute for scoping reviews and judged to be of very low, low, moderate or good-quality, overall. See supplement material for details on risk-of-bias evaluation for each study (MMAT for all manuscripts containing a description of clinical investigations).

Content data were extracted from the studies according to the outcomes and thematically summarised. Overall, contents were divided into either ‘pro’ or ‘con’ as regards having the partner present during emergency caesarean section (Table 3).

Table 3 - Themes and Outcomes based on original clinical research, marked as [finding], or opinions, marked as [claim] Con Theme Quotes The OR is only for surgery ‘Health-care professionals who persist in viewing a caesarean birth as first, and only, surgery’ [claim] Leach 198421‘An OR is only for surgery, not “family care”‘ [claim] Paravicini 199638 The OR is an unpleasant environment ‘A claim is that the OR is not a place for a companion’ [claim] Brüggemann 201529‘[Fathers] found the theatre, clothes, temperature and the prospect of blood disturbing and contributing factors to their raised anxiety’ [finding] Ceronio 199527‘The smell in the OR, or wearing a facemask is difficult for the partner’ [claim] Paravicini 199638‘experiencing the operating room as an uncomfortable, scary environment’ [finding] Lindberg 201328‘Some claim that the environment is not adequate’ [claim] Maziero 202033 Wish to protect the integrity of the mother ‘Some and perhaps many women would choose not to have their partners see them intubated and paralyzed under general anaesthesia’ [claim] Smiley 200441‘Purported reasons for fathers continued exclusion include staff perceptions that men do not want to see their partner “like that”’ [claim] Hugill 201530 A CS is not a normal birth ‘A caesarean section is a pathological process, as opposed to the natural birth’ [claim] Paravicini 199638‘It is similarly rather silly to try to pretend that one can treat a surgical procedure under general anaesthesia as if it were a normal, “natural” birth’ [claim] Smiley 200441 Fear that the partner will disturb the concentration of the staff ‘His exclusion has been justified with concerns that he might faint, contaminate the sterile field or violate another patient's privacy’ [claim] Leach 198421‘I found the induction of general anesthetic stressful’ [finding] Russell 1989‘The staff completed the operation without mishap in an atmosphere of increasing menace and threat of assault’ [finding] Gadelrab 198935‘He risks contaminating the sterile area or otherwise harm his wife’ [claim] Paravicini 199638‘the very real possibility that the anesthesiology-surgical team will perform less well under the observation of the woman's partner’ [claim] Smiley 200441‘Most frequent risk identified were staff distractions, desterilisation of equipment and partners fainting’ [claim] Watts 20166‘The companion interferes during the professionals’ procedures, besides not being able to understand what is happening’ [claim] Maziero 202033 Mother under general anaesthesia is not ‘present’ ‘A woman who has delivered a child under general anaesthesia cannot experience the birth, determine the health or sex of the infant, or welcome it into the world’ [claim] Leach 198421‘There is no way for the family to share the moment when the mother is not present’ [claim] Smiley 200441 Medico-legal complaints ‘Someone who witnesses an injury to a loved one can sue for and collect damages for the emotional trauma of being present when the event happened’ [claim] Smiley 200441‘I feel that this [asking the partner to leave] is mainly because of the medico-legal consequences if matters go wrong’ [claim] Robinson 200440‘Having the father in the OR could turn into a legal right, so he would also demand (and call for an attorney) to be present the next time, and the ‘movement’ to allow lay people in the OR will spread to other specialties’ [claim] Paravicini 1996

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