RAJIV GANDHI UNIVERSITY OF HEALTH

SCIENCES
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION

NAME OF THE
CANDIDATE AND
ADDRESS

KAVITHA .M.C
Ist YEAR MSc. NURSING STUDENT,
N.D.R.K. COLLEGE OF NURSING
B.M. ROAD HASSAN, KARNATAKA.

NAME OF THE

N.D.R.K.

INSTITUTION

HASSAN, KARNATAKA.

COURSE OF STUDY

MASTER OF SCIENCE IN NURSING

AND SUBJECT
4

DATE OF ADMISSION

COLLEGE OF NURSING, B.M. ROAD,

(OBSTETRICS & GYNECOLOGICAL NURSING)

07.07.2010

TO THE COURSE
5

TITLE OF THE TOPIC

EFFECTIVNESS OF EARLY AMBULATION

ON OCCURRENCE OF DEEP VEIN THROMBOSIS
AMONG CAESAREAN MOTHERS IN SELECTED
HOSPITALS, HASSAN, KARNATAKA.

5.1

STATEMENT OF THE
PROBLEM

A STUDY TO ASSESS THE EFFECTIVNESS

OF EARLY AMBULATION ON OCCURRENCE OF
DEEP VEIN THROMBOSIS AMONG CAESAREAN
MOTHERS IN SELECTED HOSPITALS, HASSAN,
KARNATAKA.

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION
The moment of child is born, the mother is also born. She never existed before.
The women existed, but the mother, never. A mother is something absolutely new. 1
- Rajneesh
Motherhood is the most sacred and greatest boon that god has bestowed upon a
woman. A woman becomes a complete woman when she becomes a mother. Being a
mother involves some great sacarifies on the part of a woman. To give birth in itself is a
painful process and rearing a child involves no less trouble. But a mother finds unique
pleasure in it. 1
Childbirth is a common event which occurs in womens life. This experience of
child birth is beyond the physiological aspects. This experience influences a womans self
confidence, self esteem and view of life. It can be one of the influential experiences for a
woman. 1
Caesarean section is an operative procedure where by the fetuses is delivered
through an incision on the abdominal and uterine walls.
Infection like endomyometritis, wound infection or dehiscence, thromboembolic
complications, abdominal wall haematoma, breast engorgement and urinary tract
infection are very common among post operative caesarean mothers.Post operative care
for caesarean woman is monitoring for evidence of uterine atony, excessive vaginal or
incisional bleeding & oliguria. 2
One of the major and common complications during puerperium is Deep vein
thrombosis. Therefore in order to prevent the thrombosis women should be advised to
get out of bed as early as possible following delivery7.
For most of the woman 8-12 hours of rest is enough following delivery. She is
able to feed the baby, move out of bed & go to toilet. Now a days early ambulation is
followed because of the advantages like, it provide a sense of wellbeing, reduces bowel
and bladder complications, facilitate uterine drainage& involution, reduces puerperal
venous thrombosis& embolic phenomenon.23

Early ambulation does not mean return to normal activities, she should avoid
strenuous work like lifting, staining and pushing heavy things and this should be
restricted for at least 6 weeks.The mother is encouraged to be out of bed as soon as
possible following delivery unless there are contraindications.3
Women who had local, epidural or caudal anesthesia during delivery can ambulate
as soon as they feel able. If the mother had intrathecal subarachnoid spinal anesthesia, she
should remain flat in bed for at least 8 hours before ambulating. This helps to prevent
leakage of spinal fluid through the needle puncture site in the dural membrane, reducing
the incidence of post spinal headache. This recumbent position must be maintained while
taking fluids & interacting with the newborn.4
The first time the mother gets up she should dangle her legs over the side of the
bed for a few minutes. The nurse assesses her status, checking for dizziness or weakness.
She is then assisted to stand, and then walk a few steps to determine balance. The nurse
accompanies her to the bathroom or chair and remains close at hand to give immediate
assistance if the mother becomes weak or faint4.
It is important that the nurse explain purpose & the value of early ambulation to
the mother or other decision makers. Activity should be gradually increased according to
the mothers strength.

6.2. NEED FOR THE STUDY

Motherhood is the neither a duty nor a privilege, but simply the way that
humanity can satisfy the desire for physical immortality & triumph over the fear of
death.1
-

Rebecca west

Delivery of the baby by the surgical incision of the mothers abdominal wall &
uterus has a long history although it is only in the last century that the procedure of
cesarean section has carried any realistic expectation of maternal survival. Caesarean
section is the most common operation performed on women in worldwide2.

Complications of the birth process may affect either the mother or the infant. Where
as the risk of complications for the mother is somewhat greater in a cesarean birth than in
a vaginal birth, the risk of complications for the infant is greater from vaginal birth than
from cesarean birth. Moreover, the type and severity of complications from each method
of birth differs for both the mother and the infant. Complications of cesarean birth for the
mother during the operative procedure include adverse reactions to anesthetic agents,
injury of abdominal organs and hemorrhage from the surgical incisions; and after the
procedure, pneumonia, urinary or wound infections, and blood clots in the legs, abdomen,
or lungs. The most common long-term complication of cesarean birth is the risk of
rupture of the uterine incision in a subsequent pregnancy, and the consequent increase in
risk of future pregnancies having to be delivered by cesarean5.
Complications occurs in less than 10 percent of cases, but these complications can
include an infection of the incision, urinary tract or tissue lining the uterus (endometritis)
& major complication is deep vein thrombosis2.
Caesarean section now accounts for about 25% of all births in the in the United
States. The chance of dying from a caesarean section, which is a major abdominal
surgery, is about 20 out of 100.000. Although this is not exceptionally high, it is higher
than the chance of dying from a vaginal delivery24.
During the recovery period the immediate care involves, the vital signs will be
monitored carefully & the firmness of uterus will be periodically checked. The best
advice for recovery is to begin to move as quickly as possible. One of the biggest
milestones in the hospitals will be the first walk. It is important to walk as soon after
surgery as possible to help prevent deep vein thrombosis (DVT) 6 .
At the beginning of 20 th century, venous thrombosis was a major complication
during puerperium. It occurred in almost 8 out of 1000 postnatal women & was fatal in
about a third of the cases. Around 1900 women were told to stay in bed until the 28 th day,
Nowadays women are advised to get out of bed as early as possible in order to prevent
thrombosis7.
In 1977 an English obstetrician, by the name of Charles white, in his treatise, on the
arrest of puerperal fever, recommended early mobilization after delivery. Around 1900,
German gynecologists started early mobilization. This was based on the finding of

Kustner women after childbirth, so he decided to encourage women to get of bed at an

early stage. He found less fever in these women. Moreover, he did not find any deep vein
thrombosis in 600 women who were mobilized on the first day after delivery, when eight
cases would have been expected8.
A collaborative study done by the Indian Council of Medical Research (ICMR) in
the 1980s showed a caesarean section rate of 13.8 percent in teaching hospitals since
caesarean section is one of the most frequently performed operations to the safety of
mother or baby. At the same time we need to recognize that caesarean surgery
significantly increase the death of a women (Gaskin, 290)
Overall, the risk of maternal death from a caesarean birth (4 per 10.000 births) is
four times greater than vaginal birth (1per 10.000 births) 9.
A prospective cohort study was conducted in US on the incidence of deep vein
thrombosis in women undergoing caesarean delivery. Venous thromboembolism (VTE) is
one of the leading causes of maternal mortality in the United States. Caesarean delivery is
a known risk factor. This study was to determine the incidence of deep vein thrombosis
(DVT) post caesarean delivery. Of the 194 patients who consented to study participation,
only one participant developed DVT after caesarean delivery, giving an overall incidence
of 0.5 %( 95% CI, 0.1 to 2.8%). They found the DVT rate after caesarean delivery to be
0.5%.22
So many studies showed that early ambulation has advantages like it create a sense
of wellbeing, reduces deep vein thrombosis, help for involution of uterus, reduces bowel
and bladder complications etc. It does not require any special training, method of practice
is easy, and no need of special supervision & it is a cost free method. So I have selected
this as my research topic to enhance the knowledge of women regarding the effectiveness
of early ambulation on post operative days.

6.3 STATEMENT OF PROBLEM

A STUDY TO ASSESS THE EFFECTIVNESS OF EARLY
AMBULATION ON OCCURRENCE OF DEEP VEIN THROMBOSIS AMONG

CAESAREAN

MOTHERS

IN

SELECTED

HOSPITALS,

HASSAN,

KARNATAKA.

6.4 OBJECTIVES OF THE STUDY

1.

To assess the occurrence of deep vein thrombosis in experimental group.

2.

To administer the early ambulation on experimental group.

3.

To assess the occurrence of deep vein thrombosis in control group.

4.

To compare the occurrence of deep vein thrombosis between experimental and

control group.

5.

To associate the selected demographic variables with the occurrence of deep vein
thrombosis in experimental and control group.

6.5 HYPOTHESIS
NULL HYPOTHESIS
H0: There will not be a significant difference in the occurrence of Deep vein thrombosis
(DVT) between experimental and control group.
RESEARCH HYPOTHESIS
H1: There will be a significant difference in the occurrence of Deep vein thrombosis
(DVT) between experimental and control group.
H2: There will be a significant association between occurrence of deep vein thrombosis &
selected demographic variable in experimental and control group.

6.6 ASSUMPTIONS:-

1.

Early ambulation provides a sense of wellbeing for caesarean mothers.

2.

Early ambulation promotes the circulation and reduces the risk of thrombophlebitis.

6.7 OPERATIONAL DEFINITIONS

1. ASSESS
It is an activity to estimate the outcome of early ambulation in terms of reduction
of deep vein thrombosis.

2. EFFECTIVNESS
In this study it refers to the extent to which early maternal ambulation after
caesarean birth helps in reduction of deep vein thrombosis.
3. DEEP VEIN THROMBOSIS
It refers to a thrombosis (blood clot) of the leg veins of the mother within 7 days
of delivery as assessed by Homans sign. (Homans sign is exhibited by the presence of
calf muscle pain during the dorsiflection of the foot).
5. MOTHERS
It refers to women in age group of 20-35 years who have undergone
caesarean section and has no complications of pregnancy and child birth.
6. EARLY AMBULATION
It refers to the mother is encouraged to be out of bed as soon as possible (10-24
hours) following delivery who were given general and spinal anesthesia. The mothers are
made to sit on the bed after 10 hours of delivery for 5 minutes and should dangle her legs
over the side of the bed for a few minutes. They are checked for dizziness, headache,
uneasiness & nausea. Those who do not exhibit the above symptoms are made to stand
with support for 2-3 minutes then walk a few steps to determine balance with support and
then ambulated in the ward with support for 15 minutes for every 2 hours.(Mothers with
headache, nausea & uneasiness will be given complete rest until 24 hours of delivery).

6.8CRITERIA FOR SAMPLE SELECTION

Inclusion criteria

1. Mothers who have undergone for caesarean section.

2. Mothers who are in the age group of 20-35 years.
3. Mothers who are present at the time of study.

Exclusion criteria

1. Mothers who have undergone for complicated caesarean section.

2. Mothers who develop headache, uneasiness and nausea within 24 hours of surgery.
3. Mothers who are not present at the time of study.

6.9 LIMITATIONS OF THE STUDY

Study is limited to:
1. Mothers who have undergone for caesarean section age between 20-35 years
2. Study period 4-6 weeks
3. Sample size 80

6.10 SIGNIFICANCE OF THE STUDY

This study signifies that the importance of promoting a sense of wellbeing after
caesarean section.

6.11 CONCEPTUAL FRAME WORK

Conceptual framework based on the IMOGENE M. KING THEORY is planned
for this study.

6.12 REVIEW OF LITERATURE

Review of literature is a key step in research process. Review of literature refers
to an extensive, exhaustive and systematic examination of publications relevant to the
research project .Before any research can be started whether it is a single study or an
extended project, literature reviews of previous studies and experiences related to
proposed investigations should be done. One of the most satisfying aspects of the
literature review is the contribution it makes to the new knowledge, insight and general
scholarship of the researcher.
A study was conducted in USA on Thromboprophylaxis after cesarean delivery: A
decision analysis; To compare 4 strategies for managing patients after cesarean delivery.
Using decision analysis, we compared universal subcutaneous (SC) heparin prophylaxis,
heparin prophylaxis only for patients with a genetic thrombophilia, use of pneumatic
compression stockings (PCS), and no thromboprophylaxis. Conclusion was use of
pneumatic compression stockings (PCS), after cesarean delivery is the strategy with the
lowest number of adverse events. Universal prophylaxis with SC heparin is associated
with an excess risk of HIT-induced thrombosis and bleeding per venous
thromboembolism (VTE) prevented compared with PCS use. Until future studies are
completed, postcesarean thromboprophylaxis with PCS should be used if the clinician
elects to provide prophylaxis10.
A study was conducted in UK on prevention of venous thromboembolism in
pregnancy; venous thromboembolic complications (VTE) are leading causes of maternal
mortality in the developed World. The common risk factors for VTE in pregnancy are:
age over 35 years; obesity; operative delivery; thrombophilia; as warfarin is unsuitable
for use in pregnancy because of problems with embryopathy and risk of fetal bleeding,
optimal thromboprophylaxis in pregnancy centers on the use of low-molecular-weight
heparin (LMWH). LMWH's, such as enoxaparin and dalteparin, have clinical and
practical advantages compared with unfractionated heparin in terms of improved safety
and patient convenience with once daily dosing for the majority of women. Thus LMWH
is now the agent of choice in pharmacological thromboprophylaxis in pregnancy11

A study was conducted on Venous thromboembolism in obstetrics &

Gynecology; The diagnosis of venous thromboembolism can present a clinical challenge.
Using D-dimer testing and spiral or helical computed tomography scans has simplified
the diagnosis of venous thromboembolism. In addition, the use of low molecular weight
heparin has become widely accepted in the prevention and treatment of venous
thromboembolism. However, further studies are needed to determine optimal prevention
and treatment strategies, particularly in the obstetric population12.
A study was conducted in university of California on The epidemiology of venous
thromboembolism; Venous thromboembolism (VTE) occurs for the first time in
approximately 100 persons per 100,000 each year in the United States, and rises
exponentially from <5 cases per 100,000 persons <15 years old to approximately 500
cases (0.5%) per 100,000 persons at age 80 years. The time of year may affect the
occurrence of VTE, with a higher incidence in the winter than in the summer. One major
risk factor for VTE is ethnicity, with a significantly higher incidence among Caucasians
and African Americans than among Hispanic persons. Overall, approximately 25% to
50% of patient with first-time VTE have an idiopathic condition, without a readily
identifiable risk factor. Early mortality after VTE is strongly associated with presentation
as PE, advanced age, cancer, and underlying cardiovascular disease13.
A prospective, controlled, randomized study was done to compare the effect of
early and late ambulation in hospitalized patients with acute myocardial infarction. All
patients surviving longer than the first five days were studied; 64 patients were mobilized
on day six and discharged on day 12, and 65 were mobilized on day 13 and discharged on
day 19. Follow-up observation lasted from six to 52 weeks.

Of patients without

complications until day six, eight out of 32 in the early and 16 of 35 in the late groups
manifested complications during the follow-up period (p < 0.05). Of those who had
complications before day six, seven of 32 and 26 of 30 still had or acquired new
complications until last seen (p < 0.0001). The number of serious complications in the
two groups was eight and 24 respectively (p < 0.001). We conclude that early ambulation
is beneficial irrespective of complications on admission14.
A study was conducted on early activity on the prevention of venous thrombosis
after cesarean section; pregnant women are at high risk of venous thrombosis, obstetrics
and gynecology after China reported that the incidence of venous thrombosis was 2.6%.

In order to investigate the prevention of venous thrombosis and effective preventive

measures, conducted the study. Maternal bed rest after a long time associated with venous
blood flow is slow, so the risk of increased incidence of DVT. using early postoperative
passive and active movement of both lower extremities, early postoperative ambulation,
early nursing intervention into the whole fluid can effectively prevent the occurrence of
DVT, its measures for simple, effective, safe and worthy to be popularized15.
A study conducted on Early Ambulation after the Surgical Treatment of
Idiopathic Scoliosis; From January 1968 through June 1970, 106 consecutive patients in
the age range from twelve to twenty years had surgical treatment of their idiopathic
scoliosis under the same management regimen. Early ambulation after surgical treatment
of scoliosis the cast and the rib cage on the convex side of the curve. This can be
prevented by maximum pressure and molding about the localizer strap during cast
application. Roentgenograms made at the stages mentioned seem the only way to
promptly recognize losses of correction accurately and to direct appropriate treatment to
regain correction16.
The study was undertaken to estimate the incidence of venous
thromboembolism in pregnancy & puerperium to identify risk factors for pregnancy
related venous thromboembolism. A register based case control study with 613,232
pregnancies from 1990-2003 in 11 Norwegian countries. Medical records for eligible
cases were revisited & relevant medical data were transferred to a specific case report
form. The diagnosis of venous thrombolism was based on strict criteria. Data were
analyzed by chi 2 test & forward stepwise logistic regression. In total, 615 cases were
detected the incidence of venous thromboembolism17.
In Czechoslovakia, Dvorak performed a study in 1977 on the effects of early
ambulation after delivery, from 1955 to 1964, 9774 women were kept in bed for 6 weeks.
Two percent of them experienced a venous thrombosis: 0.09% a pulmonary embolism,
0.66% a deep venous thrombosis and 1.34% a superficial thrombophlebitis. From 19701975, 10235 women were mobilized within 24 hours after delivery. No deep vein
thrombosis or pulmonary embolisms occurred, while only 0.34% of the women got a
thrombophlebitis. However, as with the other studies, no corrections for other changes in
practice, such as anticoagulation therapy, were taken into account18.

A study was conducted on maternal death in the 21st century: causes, prevention,
and relationship to cesarean delivery. Objective was to examine etiology and
preventability of maternal death and the causal relationship of cesarean delivery to
maternal death. Leading causes of death were complications of preeclampsia, pulmonary
thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease.
Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed
preventable (17 by actions of health care personnel and 10 by actions of non-health care
personnel).Suggesting that the number of annual deaths resulting causally from cesarean
delivery in the United States is about 2019.
A study was conducted on deep venous thrombosis during pregnancy and after
delivery: indications for and results of thrombectomy. Pregnancy and the puerperium are
time periods of an increased risk for venous thromboembolism. Anticoagulation therapies
with heparin or thrombectomy are treatment options. In the current literature, these
options are discussed controversially. The AVF was ligated 3 to 6 months later. Follow-up
with duplex ultrasound scan, photoplethysmography, and strain-gauge plethysmography
was completed in 87 women. : In experienced hands, venous thrombectomy is a safe
method to prevent pulmonary embolism and postphlebitic syndrome in women during
pregnancy and the puerperium. The frequency of a severe postphlebitic syndrome after
our surgical approach is lower than the rates published for anticoagulation treatment
alone20.
A study was conducted on

Immobilization and the risk of venous

thromboembolism. A meta-analysis on epidemiological studies; the aim of this work was

to estimate the risk of VTE in medical bedridden patients by a systematic review and a
meta-analysis. Results: 43 studies were included (24181 patients). Publication bias was
only observed in one subgroup. A conclusion was among medical patients,
immobilization increases the risk of VTE. Nevertheless, a specific role of underlying
conditions cannot be excluded.21

7. MATERIAL AND METHODS OF STUDY

7.1 SOURCES OF DATA
Mothers who have undergone for caesarean section in selected hospitals. Hassan

7.2 METHOD OF DATA COLLECTION

1. Research design:
Quasi experimental with post test only design.
No randomization

---

01

01

KEYS:E- Experimental group

C- Control group
X- Intervention (early ambulation)
01- Observation of deep vein thrombosis

2. Research setting: The post operative room of selected hospitals, Hassan, Karnataka.
3. Population:
Accessible population: Entire mother who have undergone for caesarean section
at hospitals. Hassan, Karnataka.
Target population: Selected mothers who have undergone for caesarean section
at selected hospitals, Hassan, Karnataka.
4. Sample: Mothers who fulfilled the inclusion and exclusion criteria are the samples,
Hassan, Karnataka.

5. Sample size: 80 mothers who have undergone for caesarean section of selected
hospitals, Hassan, Karnataka.
6. Sampling technique: Non probability convenient sampling technique.
7. Collection of data-Data will be collected through interview schedule and
observational method. A semi structured questionnaire is planned to collect the
background variables which includes maternal and demographic variable. Assessment
tool is prepared for measuring the deep vein thrombosis (Homans sign).

8. VARIABLES
Independent variable:- Early ambulation.
Dependent variable:-Deep vein thrombosis.
Extraneous variables:- Age, parity, education, religion, type of operation & type of
anesthesia.

9. PLAN FOR DATA ANALYSIS

Descriptive statistics
Descriptive statistics include percentage, frequency, mean and standard deviation

Inferential statistics
It include paired t-test with chi- square test and ANOVA f test for the
assessment of deep vein thrombosis and to associate the socio demographic variable is
planned .

10. PILOT STUDY

10% of sample size is planned for the pilot study.

11. ETHICAL CONSIDERATION

1. Does the study require any intervention to be conducted on caesarean mothers?
Yes
2. Has ethical clearance been obtained from your institution?
Yes
3. Has the consent been taken from selected hospitals?
Yes

12. LIST OF REFERENCES (VANCOUVER STYLE)

1. www.quotegarden.com/mothers.html
2. http://www.answers.com/tpic/cesarean section
3.

http://www.ignou.ac.in/edusat/BNS/bns-103-1/103-1.5.pdf

4.

Reeder, Martin, Koniak, Griffin, Maternity nursing.18 th edition. Lippincott Page

no.678-679

5. Bowes, Watson, Jr. clinical aspects of normal and abnormal labor. In Robert Creasy
and Robert Resnik., maternal- fetal medicine, 4th edition. Philadelphia: Saunders,
1999
6.

http:// pregnancy.about.com/cs/cesareansection/a/after csec.htm

7. Ashton WE, McGlinn JA. Essentials of Obstetrics: Arranged in the Forum of

Questions and Answers Prepared Especially for Students of Medicine. Philadelphia
and London: WB Sanders, 1911.
8. Rotstein ML. Getting patients out of bed early in the puerperium. JAMA 1944;
125: 838-40.
9. Hankins, Gary, Steven Clark, Gary Cunningham, and Larry gilsrap. cesarean
section. In operative obstetrics. Norwalk, CT: Appleton and Lange, 1995.
10. Quiones

JN,

James

DN,

Stamilio

DM,

Cleary

KL,

Macones

GA.

Thromboprophylaxis after cesarean delivery: A decision analysis; Obstet Gynecol.

2005 Oct; 106(4):733-40
11. Greer IA.; prevention of venous thromboembolism in pregnancy; Eur J Med Res.
2004 Mar 30;9(3):135-45.
12. Krivak TC, Zorn KK. Venous thromboembolism in obstetrics & Gynecology;
Obstet Gynecol. 2007 Mar; 109(3):761-77.
13. White R H; The epidemiology of venous thromboembolism; Circulation. 2003 Jun
17;107 (23 Suppl 1):14-8.
14. Abraham S. Abraham, M.D., M.R.C.P., Yitzhak Sever, M.D., of Early Ambulation in
Patients with and without Complications after Acute Myocardial Infarction; N Engl J
Med April 3, 1975 ; 292:719-722
15.

Lu Li, Yong-Cheng Liu. Pelvic deep venous thrombosis after surgery of causes.
[J]. Journal of Surgery .1996:397-399.

16. Minneapolis, Minnesota, and Robert b. winter, M.D. @, st. Paul, Minnesota early
ambulation after the surgical treatment of idiopathic scoliosis. University of
Minnesota hospitals and the Fairview hospital, Minneapolis, and the Gillette
children's hospital, St. Paul November 23, 2010 1973; 55:1003-1015.
17. Jacobsen AF, Skjeldestad FE, Sandset.PM. Incidence & risk patterns of venous
thromboembolism in pregnancy & puerperium- a register based case control study.
Am J Obstet Gynecol. 2008 Feb; 198(2):233.el-7.Epub2007 Nov 12.
18. Dvorak V, Novotny A. Prevention of thromboembolism in the puerperium. Cesk
Gynekol 1977;42: 697-8.
19. Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal
death in the 21st century: causes, prevention, and relationship to cesarean delivery.
Am J Obstet Gynecol. 2008 Jul; 199(1):36.e1-5; discussion 91-2. e7-11. Epub 2008
May 2.
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during pregnancy& after delivery: indications for results of thrombectomy. J vasc
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21. P. Pottier J.B. Hardouin S. Lejeune P. Jolliet B. Gillet B. Planchon , Immobilization
and the risk of venous thromboembolism. A meta-analysis on epidemiological
studies; Department of Internal Medicine. Nantes University-Hospital Center. Place
Alexis Ricordeau; Received in revised form 27 April 2009.
22. Winnie W. Sia, Raymond O.Powrie, Ann B. Cooper, Lucia Larson: The incidence of
deep vein thrombosis in women undergoing cesarean delivery, volume 123, (3),
January 2009, pages 550-555.
23. Bobak, Lowdermilk, Jensen, Maternity nursing 4th edition, Mosby publication,
Philadelphia; 1995.
24. D.Ashley Hill. MD: cesarean section procedure. Florida hospital, Family practice
residency. Orlando, Florida.