Clinical Feature
Journal of Perioperative Practice
The introduction of an enhanced
recovery pathway for elective
caesarean sections
Susan Pirie1 and Julie Mulliner2
Abstract
This article will focus on the establishment of an enhanced recovery pathway (ERP) for women undergoing elective
caesarean section in a busy maternity unit. It will consider the background to this project, the impact on services and the
improvements in service that have been achieved as well as the challenges that have been experienced in this process.
Keywords
Enhanced recovery pathway / Caesarean section / Service improvement
Provenance and Peer review: Invited contribution; Peer reviewed; Accepted for publication 24 November 2017.
Introduction
The ERP or `fast track' pathways originated in Denmark
in relation to the care of patients undergoing colorectal
surgery, an approach which was pioneered by Henrik
Kehlet (Kehlet 1997). Enhanced recovery is a model of
care which aims to maximise the recovery of patients
from major surgical interventions by implementing a
range of measures including preoperative education,
effective pre-assessment and management of the
patient, maintaining hydration, effective analgesia and
management of postoperative nausea and vomiting and
early mobilisation (Kerr et al 2017).
The aim of an ERP is to reduce the effect of stress on the
body, which is caused by the surgical intervention and to
facilitate a safer and earlier discharge from hospital,
thus reducing overall costs (Foss & Barnard 2012, White
et al 2013).
Background
In 2015, it was noted that there were a number of issues
relating to the management of women undergoing an
elective caesarean section in Aberdeen Maternity
Hospital. A decision was made to audit the experience of
women undergoing this procedure and an audit
questionnaire was devised. The questionnaire related to
the pre, intra and postoperative experience of women
undergoing this procedure. This was then given to all
women undergoing elective caesarean section in the
period 8th June - 3rd July 2015. A response rate of
2018, Vol. 28(3) 46–50
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DOI: 10.1177/1750458918755964
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61.5% was achieved from this questionnaire (McRobbie
et al 2016).
The audit confirmed that there were a number of issues
affecting the women's birth experience, that some of
these issues were impacting on the quality of the service
and that there was a high level of frustration within the
multi-disciplinary team.
The audit highlighted the following issues:
• Issues with the booking system
• Inappropriate and late operating lists
• Lack of consistency with admission times
• Delays in the operating list due to the lack of consis-
tency of admission times and/or inappropriate list
order
• Prolonged periods of fasting
• Delays in the list could also create issues with the
neonatal unit, as there was greater potential for
admission to the unit later in the day, creating prob-
lems with safe management and staffing for the unit
• Poor levels of patient satisfaction.
1
Senior Charge Nurse, Theatres, Aberdeen Maternity Hospital, NHS
Grampian
2
Clinical Nurse Manager, Theatres, Women and Children’s Directorate,
NHS Grampian
Corresponding author:
Susan Pirie, Aberdeen Maternity Hospital, NHS Grampian, Cornhill Rd,
Aberdeen, AB25 2ZL, United Kingdom of Great Britain and Northern
Ireland.
Email: susan.pirie4@nhs.net
Pirie and Mulliner
In view of the above findings and a desire to promote
evidence based care, the perioperative team then
considered how an ERP could be introduced to the
elective caesarean section service with the aim of
improving the patient experience. This involved looking
at many elements of the perioperative journey and
implementing changes to facilitate an ERP.
Booking/pre-assessment services
The booking system for elective caesarean sections was
found to be in need of streamlining, in order to improve
services to women. Improvements in the referral system
for elective surgery included the introduction of
appropriate pre-assessment appointments in a
dedicated clinic for women undergoing for elective
caesarean section. The operating lists began to be
populated 2-3 weeks in advance using the OPERA
Theatre Management System, so that it became
possible to preliminarily anticipate perioperative
requirements.
Each Friday, a caesarean section clinic was held, which
was led by a consultant anaesthetist. At this clinic
women were reviewed and allocated a date for their
elective caesarean section. Previously women had been
allocated a date for elective surgery months in advance,
which could and did give rise to dissatisfaction if the
date was then changed. Under the revised system,
women were given a date with the proviso that it
might be subject to change. Women were assured
that every effort would be made to honour this date,
but that it could not be guaranteed. This gave women
an opportunity to discuss their procedure and any
concerns that they may have with the anaesthetist
and also allowed for more effective planning of the
women's care.
The importance of preoperative assessment for all
patients is an established element of perioperative
practice (AAGBI 2010, AAGBI 2013, RCoA 2017).
Another element of the booking process that was
considered was the standardisation of the admission
process on the day of surgery. The current system had
wide variations in admission times and an adhoc
allocation to the wards for pre and postoperative care.
As part of the ERP it was decided that all women for
elective caesarean sections would be admitted to
one ward only, in order to provide consistency and
continuity of care. This would enable staff to become
familiar with these processes and introduced
consistency for the multi disciplinary team. It was
decided to streamline the admission times so that the
first two patients on the operating list would arrive for
07:30 hours, and subsequent patients would arrive from
10:00 hours.
47
Operating list
The current system was identified as inefficient and
therefore ripe for improvement. Some of the more
common issues that the review identified were as
follows:
• Theatres were set up in relation to the list order, prior
to the surgical briefing at 08:30, but changes to the
list order at this briefing could lead to repetition of
this work.
• The women allocated to be first and second on the
operating list may have been given a later admission
time and so were not ready for theatre at the allotted
times.
• Inadequate communication of patients' needs could
lead to delays whilst additional equipment or patient
information was sought.
• There were a number of staff involved in the admis-
sion of women preoperatively and different interpre-
tations of how the patient should be prepared for
theatre.
In order to improve efficiency in the operating list order it
was agreed that each Thursday the operating list for
elective caesarean sections for the following week would
be reviewed by both a consultant anaesthetist and an
obstetrician.
The purpose of this review was to identify an appropriate
order for the list. For example, where it was anticipated
that a baby may require admission to the neonatal unit
(NNU), the patient would be accommodated early in the
list, thereby facilitating an admission to the unit at an
appropriate time for their resources. In addition, the
need for cell salvage could be identified and a technician
booked to support this process. Other issues to be
considered were related to the women's previous history,
such as the presence of abdominal scars from previous
surgery, obstetric history and any other pertinent factors.
Following this initial process, the list order for each day
would be reviewed following the caesarean section clinic
on Friday and then finalised. Any adjustments made to
the list would then be entered onto the Opera theatre
management system, so that all staff would be aware of
the forthcoming lists, and it was anticipated that
potential delays could be reduced.
There is a recommendation that finalised operating lists
should be published 16–24 hours in advance of the
operating session (AfPP 2016). It is also recognised that
alterations should be kept to a minimum (AfPP 2016).
The implementation of the processes outlined above has
significantly reduced the need to alter the operation lists
after they have been finalised. In addition, it enables
members of the multidisciplinary team to have
knowledge of the workload for the following week.
48
Admission processes
The current admission processes were very dependent
on the perioperative knowledge and skills of the midwife
involved. The midwife would be identified from the
workload of the ward and therefore more than one
midwife could be involved in the admission process. The
audit that was undertaken had highlighted some of the
issues and others were identified when the patient
arrived in theatre and was being checked in by a
perioperative nurse or ODP. Some of the issues that
were identified were as follows:
• Elements of patient preparation had been missed eg
current patient weight, no up to date blood results,
lack of TED stockings.
• Any issues that were identified during the admission
process were not communicated appropriately and/or
in a timely manner.
• Significant delays were occurring in getting the
women to theatre.
It was decided therefore, that one midwife would be
allocated to admit the woman to the ward and to then
accompany the woman on her perioperative journey. It
was anticipated that this would lead to more consistency
in the care of these women and also provide a degree of
confidence and continuity for the woman at this point in
her pregnancy and birth. A comparison of feedback from
women using the services before and after the changes
were introduced has provided anecdotal evidence that
some women do feel that they have greater continuity
of care.
In addition to the above, it was recognised that women
were being admitted to the wards on an ad hoc basis
and that this was also contributing to some of the
dissatisfaction with the women's experience of the
elective caesarean section service. In order to address
this, it was decided that all women would be admitted to
one ward only and that they would return to this ward
postoperatively. Standardised admission times were
also identified and introduced.
However, it soon became apparent, that the admission
of all patients to one ward was not sustainable for the
ward concerned. The admission processes were
reviewed again and a decision to admit patients to both
wards was made. Admission times were agreed to be
07:30 for the first two women scheduled on the
operating list and then 10:00 for all remaining patients.
Fasting
An area of perioperative practice that has benefitted
from the implementation of evidence based practice is
the optimisation of preoperative fasting (RCN 2013). It is
now accepted that a fasting period of six hours for food
and two hours for clear fluids will enhance the woman's
Journal of Perioperative Practice 28(3)
perioperative experience (RCN 2013). It is hoped that
the days of routinely fasting patients from 22:00 or
00:00 on the night before surgery are long gone.
It was identified that there was a degree of variation in
the approach to fasting periods for women undergoing
elective caesarean sections. Prolonged fasting is linked
to an increase in the need for postoperative nausea and
vomiting care (Mardell & Bothamley 2005, Khoyratty et
al 2010, Roberts 2013). One of the benefits of an ERP is
that of reduced fasting times (Ralph 2017). The
perioperative team, with some involvement from the
anaesthetists, therefore undertook a review of existing
practices relating to preoperative fasting to confirm
anecdotal evidence. This then led the perioperative
team to develop and implement a revised fasting
protocol for women undergoing elective caesarean
sections.
The wider maternity team was actively engaged to
ensure that there was a better understanding of the
fasting process and of the detrimental effects of
prolonged fasting. As part of this process, high energy
drinks were introduced as there is evidence to show that
the provision of these drinks contributes to an enhanced
recovery (Hausel et al 2001, Khoyratty et al 2010,
Kelliher et al 2011).
Anaesthesia and analgesia
There has been minimal change in relation to the choice
of anaesthesia and analgesic regimes following the
review of practice.
Most women undergoing elective caesarean section will
opt for a regional anaesthetic and therefore some of the
issues relating to general anaesthesia are eliminated.
However, there are a few occasions when it is necessary
to proceed to a general anaesthetic, perhaps because
regional anaesthesia is unsuccessful or the clinical
situation changes and a general anaesthetic becomes
necessary. The use of regional anaesthesia contributes to
an effective management of postoperative analgesia and
can also be linked to a reduction in postoperative nausea
and vomiting. In line with NICE guidance relating to
normothermia, all IV fluids are prewarmed (NICE 2008).
Effective management of postoperative analgesia and
postoperative nausea and vomiting is a key
recommendation of a successful ERP (Kelliher et al
2011). Unless contraindicated by the women's medical
history, a diclofenac suppository would be administered
following surgery and before being moved to the
postoperative recovery unit.
All women would be prescribed with appropriate
postoperative analgesia and would be followed up
postoperatively by the anaesthetist to ensure that the
woman is comfortable postoperatively.
Pirie and Mulliner
Effective postoperative analgesia is an essential
element of an enhanced recovery programme (Foss &
Bernard 2012, White et al 2013). Although there has
been little if any change in the analgesia routine for
women undergoing elective caesarean section, the
review highlighted a need to refresh the preoperative
information that women received.
The importance of preoperative information in relation to
improved recovery and pain management has been
demonstrated (Keliher et al 2011). Although the Friday
clinic had been running for some time, it was identified
that the women were not receiving any written
information about their elective caesarean section.
It was recognized that the Friday clinic, provided an
opportunity for the women to discuss their concerns and
analgesia options and work was undertaken also to
develop effective information leaflets for elective
caesarean sections. Once these leaflets were completed
and agreed, they were given to women at this clinic. This
practice has been well received and has been linked to a
noticeable improvement in the management of
postoperative pain. The importance of effective
preoperative information has been identified as a
measure to reduce postoperative pain and anxiety
(Foss & Barnard 2012).
Early mobilisation
Another element of a successful ERP is that of early
mobilisation (White et al 2013, Corso et al 2017). It has
long been recognized that the presence of an indwelling
urinary catheter can impede early mobilization (Keliher
et al 2011). The use of urinary catheters in women
undergoing elective caesarean sections was reviewed
(Keliher et al 2011) and a discrepancy in postoperative
management of urinary catheters was identified. In order
to address this, a standardised time frame of removing a
urinary catheter 24 hours after surgery was introduced
to encourage early mobilisation.
However, ongoing review of this element of the women's
care identified that this timescale was impacting on
early mobilisation and the timescale was reduced to 12
hours (Keliher et al 2011, White et al 2013). It was then
identified that most women were having a catheter
removed in the evening or overnight, depending on the
time of their surgery, and therefore this was having little
if any impact on early mobilisation. The timescale for an
indwelling urinary catheter was again reviewed and
reduced to 6 hours. This has been found to be an
effective measure in encouraging early mobilisation.
Patient experience
There was an increased awareness of the psychosocial
needs of women and their partners, when undergoing
an elective caesarean section. At the time of the review,
no photographs were allowed in theatre and birthing
49
partners were not allowed into theatre until the spinal
anaesthetic was deemed to be successful. It was felt
that these restrictions were not facilitating the most
positive experience for both the women and partner and
so, after discussion and agreement with the multi-
disciplinary team, it was agreed that birthing partners
should be able to support the women during the
intervention of spinal anaesthesia. This practice that has
greatly enhanced patient experience and satisfaction.
The presence of birthing partners is an accepted
element of obstetric care (AAGBI 2013).
The issue of photography in the operating theatre was
also perceived to be an issue for women undergoing
caesarean section procedures in theatres at Aberdeen
Maternity Hospital. The historic culture within obstetric
theatres had prevented these special moments being
captured. Through patient centered working as part of
this project, we reviewed our beliefs and developed a
process that could facilitate these important moments
of family life. The matter was fully discussed with staff
and support provided to facilitate this change in
practice. The introduction of the enhanced pathway for
women undergoing elective caesarean section has
provided the multidisciplinary team with a platform to
continue our journey forward with the integration of
theatre experience into the women centered care ethos
we wish to provide for service users.
Conclusion
The change in practices have been welcomed by
patients and their birthing partners, who now report a
much more positive experience of elective caesarean
section procedures. There was initially some resistance
from members of the multidisciplinary team involved in
the care of women undergoing elective caesarean
section, but these changes are now accepted practice
and actively encouraged by all staff.
The introduction of a dedicated theatre midwife to admit
the women on the day of surgery and be involved with
their care until entering the recovery room has proved to
be a great success that has on occasions exceeded
expectations.
The changes that have been made have contributed to a
better flow of patients through theatre, which in turn has
increased theatre efficiency. In addition, there has been
a more cooperative approach to the WHO safer surgery
checklist in relation to a more effective surgical briefing
and surgical pause (Time Out) process which has
contributed to improved patient safety.
Overall, the review of patient care for women undergoing
elective caesarean sections has led to sustainable
improvements in the service provision to these women.
The services remain under review and it is anticipated
that further improvements can be identified and
50
implemented to further enhance the care of all women
utilising perioperative services in the maternity hospital.
No competing interests declared
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