Preoperative anxiety is a common and prevalent phenomenon in most patients undergoing the surgery [1] and it a problem associated with preoperative care in patients. People usually experience high levels of anxiety during the first surgical experience [2]. The main causes of preoperative anxiety include the possibility of delay in surgery (69.6%), worry about surgical mistakes and injuries to patients (64%), lack of attention from the staff (63.2%), and fear of anesthesia complications (58.4%) [3].
The prevalence of anxiety is different depending on the type of surgery; however, it is reported to be from 60% to 92% in patients with non-selective or emergency surgery [4-5]. The problems associated with preoperative anxiety in patients include increased dosage of drugs for induction of post-operative anesthesia and anti-pain [6], difficulty in accessing the vein, increased pain intensity, postoperative nausea and vomiting, long stay in recovery, and an increased risk of infection [7-9].
Cesarean section is a highly prevalent surgery that is mostly performed with the help of spinal or epidural anesthesia. Spinal anesthesia is commonly used in the cesarean section [10-11]. spinal anesthesia  is the most important and common causes of nausea and vomiting and are exacerbated by hypotension, visceral manipulation, vagal stimulation, intravenous drug use, and psychosocial factors [12]. Postoperative nausea and vomiting are the most common post-surgical complications after pain and hypotension in the cesarean section and are observed in more than 66% of patients in spinal cesarean section [2]. This disorder causes dehydration, water and electrolyte imbalance, stomach contents aspiration, pain in the operation site, impairment of recovery, increased cost of treatment, and patient dissatisfaction [13].
Preoperative anxiety is a factor influencing postoperative nausea and vomiting [13-15]. Anxiety makes the patients susceptible to postoperative nausea and vomit by decreasing the pH of stomach content and increasing its volume [16-17]. Even though the relationship between preoperative anxiety and postoperative nausea and vomiting has been investigated in some studies such as that conducted by Ghanei Gheshlagh et al. [18], the effect of anxiety on patients’ nausea and vomiting has been less considered in terms of such aspects as patients’ anxiety type (in terms of state and trait anxiety) and anxiety before or after surgery.
The best and most appropriate treatment for nausea and vomit complications can prevent more severe complications since these can affect maternal and fetal health and cause complications, such as increased hospital stay and costs, as well as patient discomfort and dissatisfaction. Therefore, the present study can contribute to the development of useful therapeutic protocols for patients.
 
Objectives
The present study aimed to investigate the impact of anxiety on nausea and vomiting caused by spinal anesthesia before and during the cesarean section.
 
Materials and Methods
The present descriptive-analytical study was conducted on 100 candidate patients undergoing cesarean section at Fatemieh Hospital in Hamedan, Iran, in the summer of 2016. Patients were selected using a convenience sampling approach. The inclusion criteria included pregnant women in the age range of 18-45 years who volunteered for a cesarean section; willingness to participate in the study along with reading and writing ability; physical status 1 or 2 according to the American Society of Anesthesiologists; and the willingness to undergo spinal anesthesia.
However, those with a history of nausea, vomiting, motion sickness, psychiatric illnesses, and smoking and drug addiction were excluded from the study.
Initially, the researchers explained the process of the study to the participants. Afterward, the participants were asked to complete questionnaires after written informed consent was obtained from them and they were assured of the confidentiality of their information. Patients were admitted to the emergency department and underwent full monitoring including noninvasive blood pressure, electrocardiogram, and pulse oximetry after they completed the anxiety and admission questionnaires in the operating room. Afterward, patients received 500 cc of Ringer’s lactate solution as the preload. The selective spinal anesthesia for patients was performed in the sitting position with 2cc of Bupivacaine 0.5% and 2.5 μg of Sufentanyl using spinal needle 25 (orange) through the lumbar intervertebral space 5-4 [NPSoft1]. Patients immediately sat after the spinal anesthesia, and the surgery began after ensuring about the high level of anesthesia (anesthesia level T4). The type of operation and its procedure as well as the type of drug used for anesthesia were the same for all the patients. The patient would be excluded from the study if the surgical procedure changed for any reason, such as excessive bleeding and/or the need for a hysterectomy, or in case the patient showed severe symptoms of anxiety before surgery.
Data collection was carried out using a demographic characteristics form for gathering such information as age, education level, gestational age, and cesarean section count, as well as the presence or absence of nausea and vomiting. The preoperative anxiety was also assessed using Spielberger’s state-trait anxiety inventory.
 
Spielberger state-trait anxiety inventory (STATE)
This 40 items tool consists of questions (n=20) related to state anxiety (expressing emotions when completing the questionnaire) and questions (n=20) concerning trait anxiety (expressing perpetual negative emotions). Scoring was based on a 4-point Likert scale. The total score of both state and trait anxiety scales ranged from 20 to 80. The validity and reliability of the Persian translation of this questionnaire were approved [19]. In the present study, the reliability of this tool was confirmed through Cronbach’s alpha which was measured at 0.86 and 0.73 for the state anxiety and trait anxiety, respectively.
 
Visual Analogue Scale (VAS)
Intraoperative anxiety was evaluated and recorded using the VAS after postpartum and the severity of the anxiety was indicated by a number from zero (no anxiety) to 10 (maximum anxiety). The VAS is a standard tool that has been utilized in various studies to measure anxiety [20-21].
The presence or absence of nausea and vomiting were evaluated and recorded in patients during the operation (from the time of anesthesia to the end of surgery) and stay in the recovery room. Metoclopramide was used for patients with nausea and vomiting as prescribed by an anesthetist. The obtained results were analyzed using SPSS (version18) through Chi-square test, and independent t-test. A p-value less than 0.05 (P<0.05) was considered statistically significant.
 
Results
The study was conducted on 100 patients in the age range of 18-43 years as candidates for the cesarean section. Table 1 presents some demographic characteristics of the patients.
Table 2 presents the relationships between the state anxiety and nausea and vomiting in patients at the preoperative stage. The results indicated that there was no significant relationship between the state of anxiety and nausea with vomiting in patients.
Table 3 presents the relationship between the trait anxiety and nausea with vomiting in patients at the preoperative stage. The results indicated that there was a significant relationship between the trait anxiety and nausea in patients; however, no significant relationship was observed between the trait anxiety and vomiting.
The independent t-test was used to determine the relationship between intraoperative anxiety and nausea and vomiting in patients (Table 4). The results indicated that there was no significant difference between patients with nausea or vomiting and those who did not have nausea or vomiting, in terms of the anxiety level.
 
Table 1. Examination of patients in terms of age, gestational age, cesarean section, and delivery

 
Table 2. Correlation between the state anxiety before the operation and nausea and vomiting

 
Table 3. Correlation between the trait anxiety before operation and nausea and vomiting

 
Table 4. The results of independent t-test