Leading change

Midwives at University Hospitals of Leicester NHS Trust (UHL) led the development and implementation of an enhanced recovery pathway for women having caesarean sections within the Trust’s two maternity service sites, as well as a standalone birth centre and a homebirth team. This change has led to better use of resources, experiences and outcomes for women using the services.

Where to look

UHL are committed to providing excellent care, and in 2016-2017 between Leicester General Hospital and Leicester Royal Infirmary there were in excess of ten thousand births. Before the change the Trust utilised standardised pathways for caesarean section births which included a minimum of two days observation before a woman could be discharged home.

Enhanced recovery pathways have been successfully utilised in a number of surgical placements including caesarean sections (Wrench et al 2015) within hospitals in England. The team recognised unwarranted variation in practice in the length of stay days and an opportunity to review pathways and guidance in use at the Trust, to ensure practice was both evidence-based as well as meeting individual women’s needs.

What to change

Through comments from the Trust’s friends and family questionnaire, midwives identified dissatisfaction amongst some women having caesarean sections with the standardised 2 day post-operative stay in the Trust’s clinical pathways, when they felt well enough to go home sooner. Enhanced recovery although a new approach to the care of patients following a surgical procedure, supports good quality care provision, before, during and after an operation. In the case of c-sections it allows women the benefit of reduced risks of post-operative complications and an earlier return to normal activities (NHS 2016).

For the midwives within LGH there was an opportunity to reduce the variation in unnecessary 2 day stays and in-patient experience by adopting an evidence-based enhanced recovery pathway.

Enhanced recovery is a modern, evidence based approach where different members of the hospital and primary care team work together in order to ensure that the patients are:

• in the best possible condition before their operation,
• better prepared for their hospital stay and
• able to feel better sooner after their operation.

In hospital sites where enhanced recovery is the norm, they have reported significant improvement in:

• patient experience,
• clinical outcomes and
• professional relationships/teamwork.

An Enhanced Recovery Pathway aims to enable quick recovery from surgery through advanced preparation for early normalisation (Wrench et al 2015).  It can assist new mothers to recover from their caesarean section by ensuring:

• reducing pain with good anaesthetic techniques, medication and using minimally invasive surgical techniques where appropriate,
• reducing immobilisation by encouraging activity and removing drips, drains and catheters as early as possible, and
• reducing post-operative nausea and vomiting with good fluid balance control and medications.

The new pathway also ensured that through the use of dedicated enhanced recovery staff, where there were complications, additional complexities or other risk factors, staff were supported to appropriately assess patient needs, seek additional support and tailor recovery management plans as needed.

How to change

The UHL Ward Matron, Manager and midwife initially visited a maternity unit in the north of England where they had an established post-operative enhanced recovery pathway in place. The positive impact of this new approach meant the team were confident this was a feasible approach for UHL, which would improve both the experiences and outcomes of women using their services.

Midwives introduced the concept to relevant boards and groups at UHL before beginning roll out education and training as well as the pathway itself within the maternity services. The new pathway now means that women who are booked for an elective caesarean section, immediately have the information from their community midwife that their stay in hospital will be reduced, if all is well following surgery. All information is aimed to help the woman and their family prepare for the surgery and ensure they have all the information for the recovery. Preparation for surgery now means that women are ‘nil-by-mouth’ for shorter periods, they are given carbohydrate drinks prior to the surgery, and they are given a snack one hour after surgery and moved from theatre recovery to the post-natal ward. This ensures they remain well-nourished and hydrated, which supports effective wound healing and maintenance of energy levels following the operation.

Adding value

Better outcomes – The women using the new pathway have responded positively and have embraced opportunities to mobilise early, which has in turn reduced complications following surgery. Within a four-month period 67% of women were able to be safely discharged home after 24 hours of their elective section, which is extremely positive, as it means separation from their families is reduced as their hospital stay is shorter. Patient flow through services has been improved without an increase in readmission rates or the occurrence of any serious incidents.

Better experience – Enhanced recovery at UHL has made a huge impact on the service and it has improved patient experience. Women feel more empowered, that they are planning their recovery in advance and they are normalised far quicker once arriving on the ward. Women thrive in being part of their care planning and get home quicker. It has lifted staff morale as the areas have needed to come together and work more cohesively with each other.

Staff have also responded positively regarding the new way of working, reporting they feel more empowered and supported to provide high quality, holistic care to the women they care for and their families.

Better use of resources – The impact of the new way of working on resources has also been positive with reduced lengths of stay improving the services capacity so this can be used for those who need additional care or attention. Additionally, complaint levels have dramatically reduced which has freed up staff time for direct care and other duties.

Challenges and lessons learnt for implementation

Preparation is key in educating and supporting staff to change practice, time should be set aside to do this thoroughly.

It was important that community staff are involved in projects such as this as they have a key role in preparing woman psychologically during the antenatal period.

Good multi-disciplinary relationships were vital to ensure all the elements of the pathway came together.

Due to the success of this work UHL are looking to roll the pathway out to women who have had an emergency section as well as an elective and are sharing their practice and learning with other maternity services locally.

For more information contact

Joan Morrissey – Midwifery Matron
University Hospitals Leicester
Joan.morrissey@uhl-tr.nhs.uk