Obstetric Enhanced Recovery

1. Obstetric Enhanced Recovery
D.Marshall (ST3)
B.Saeed (ST4)
E.Faheem (CF)
R. Zill-e-Huma (Consultant Obstetrician)
Melissa Kitching ( Consultant Anaesthetist)

2. Benefits of enhanced recovery pathway
• Evidence-based
• Reduced hospital stay after CS without increase in complications: standard 2nights →
1night
• Improved psychosocial experience
• Improved postnatal experience
• Reduction in maternal and neonatal nosocomial infections
• Improved departmental capacity and flow

3. Description of obstetrics ER programme
Local guideline:
Enhanced Recovery for Women following Caesarean
Section
Inclusion criteria:
• Women with an otherwise low risk pregnancy
undergoing ELSCS
• No significant medical co-morbidities
• Anticipated uncomplicated surgery and recovery
Exclusion criteria: Antenatal/Intrapartum/postpartum
• HTN, Diabetes, praevia ,pre-term, Hb<104,
safeguarding concerns, medical co-
morbidities/MOH/adhesions etc.
• Identification of cases in ANC by obstetric staff but
can be recruited from other clinical areas including
day of caesarean section
• Provision of information leaflets
• Sticker on consent form; tick if leaflet given
• Record in caesarean section diary, pre-anaesthetic
appointments booked. Indicate on booking if for ER
• Ideally should be first on list or performed before
4pm
• Process explained again at pre-assessment
appointments.

4. Obstetric ER programme
• Encourage to purchase a high-calorie bottled drink and drink
200mls by 0700hrs on the day of the operation.
• To give information about self-medication and purchase a
week’s supply of analgesia taking into account the method of
feeding and any allergies or interactions with other
medications.
• Pre-caesarean safety huddle and identification of cases.
• Discharge medications, including thromboprophylaxis, should
be prescribed by operating obstetric team whilst in theatre
which will be dispensed by the ward pharmacist.
• Early mobilization should be encouraged. Aim for 4 hours
postoperative.
• Removal of the urinary catheter once a woman is mobile
after a regional anaesthetic. Ideally should void within 6
hours of delivery or following removal of indwelling urinary
catheter.
• If the blood loss was ≥ 500mls or if the woman is
symptomatic a full blood count should be performed at
0600hrs. Blood can be taken from 1800hrs onwards on the
day of surgery if surgery completed in the morning, to be
ready for review prior to discharge.
• Enhanced Recovery women should be a priority for the
neonatal and audiology teams performing baby checks.
• Midwifery led discharges.
• Discharge will aim to be within 24-36 hours post-surgery

5. Purpose of Audit
• To evaluate adherence to guideline
• To determine any barriers to implement Obstetric ER
programme

6. Methods
• Retrospective audit
• 30 cases in 1st August 2019-1st October 2019
• Collection of data using ELSCS book
• Review of notes

7. Standards
• Identification of cases; suitability before and after CS
• Documentation of ER: use of stickers and leaflets
• Timing of CS
• Reason for CS delay
• TWOC timings
• Length of stay
• Discharge delays

8. Results
Parameters Results Audit compliance with
guideline (%)
Inclusion criteria 28 cases
ER care
2 case unsuitable; (chronic HTN,
anaemia)
93.3%
Post surgery exclusion 1 case should have been
removed from pathway
Causes :
1. MOH
97%
Stickers 77% 13% Sticker not present/completed 77%
Information leaflets 63% 37% Not indicated on sticker/not
present in notes
63%
Timing of CS (CS started before
16:00)
80% 80%
Discharged 24-36 hrs 63 % 63 %
Timings of TWOC 18 hours Average time by 6-8am the next day
1x failed TWOC 0%
TTO complete in theatre 32% 32%

9. Reason of delay in discharge- 36.6% cases
27%
37%
9%
9%
9%
9%
Unknown
Pain control
Ileus
Blood patch
Nicu admission
IV ABX

10. Have we improved since last year ?
Parameters 1st audit Nov 2018; compliance
with guideline %
Re-audit Nov 2019; compliance
with guideline %
Inclusion criteria 96% 93.3%
Post surgery exclusion 100% 97%
Stickers 17% 77%
Information leaflets 0% 63%
Timing of CS 66% (before 12pm) 80% (before 4pm)
Documentation of delay in CS 0% 0%
1 night stay 63% 63%
Catheter out (average no of hours post CS) 19 hrs 18 hrs
Re-admissions None None

11. Conclusion
• Improvement in evidence of recruitment by using stickers which also
captures information of handing out leaflets
• 80% of ER identified cases were performed before 4pm
• 7% of cases not identified appropriately
• 1 case no documentation of exclusion from ER pathway following
MOH
• Only 32% completion of TTO’s in theatres
• No improvement in documentation of delay in ER cases
• No improvement in number of cases discharged after 36 hours
• No improvement in number of cases offered TWOC in timely fashion

12. Recommendations
• To improve completion of TTO in obstetrics theatres.
• To improve documentation of reason of delays in performing cesarean section
before 4pm in previously identified ER cases in maternity notes.
• Adherence with guidance on inclusion and exclusion criteria
• Improvement required to perform TWOC in postnatal wards in a timely fashion
• Improve staff engagement and reminder of policy through maternity forums
• Re-audit 1 year