The document discusses the implementation of an enhanced recovery care pathway for elective caesarean sections, which has led to a significant increase in the percentage of patients being discharged on day one, from less than 1% to 15-20%. Key changes included preoperative counseling, carbohydrate loading, non-opiate analgesics, and improved postoperative care, all contributing to good patient outcomes without increasing readmission rates. Future developments aim to apply these strategies to emergency caesarean sections and enhance practices such as skin-to-skin contact and delayed cord clamping.

1. Next day discharge following
elective caesarean section using
Enhanced Recovery Care
Pathways.
Ian Wrench (Consultant Anaesthetist)
Andrea Galimberti (Consultant Obstetrician)
Jan Hall (Midwifery Sister – Postnatal ward)
Julie Humphries (Midwifery Sister – Postnatal Ward)

2. Structure of talk:
 Rationale for introduction of enhanced
recovery for elective caesarean section
 Patient survey
 Multidisciplinary group
 Changes made to pathway
 Results
 Conclusions and future direction

3. Rationale
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QIPP programme - £20billion savings
NICE “…women who are recovering well, are apyrexial and do not have
complications following CS should be offered early discharge (after 24 hours) from
hospital and follow-up at home, because this is not associated with more infant or
maternal readmissions.”

Evidence from other specialties that enhanced
recovery programmes improve outcomes:
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Colorectal
Urology
Orthopaedics
Gynaecology
Hepatobiliary
etc

4. •
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Less than 1% of patients leaving on Day 1 (24-48hrs)
Average length of stay = 2.45 days

5. Enhanced recovery
 In general terms the most important aspects
of an enhanced recovery programme are:
Reduction in the stress response to surgery

Excellent perioperative nutrition
 Postoperative pain relief that doesn ’t rely on
strong morphine like pain killers
 Rapid postoperative mobilisation

A co-ordinated perioperative care pathway
designed and managed by a multidisciplinary
team.


6. Patient survey – 58 patients, day 1 or day 2 following
elective caesarean section. S. Aluri, R. Pothireddy, C
Anderson, I Wrench

7. Planning for earlier discharge post
elective caesarean section.
Multidisciplinary team:
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Anaesthetists
Midwives
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Post natal sisters
Community midwives
Senior midwifery
Breast feeding team
Obstetricians
Pharmacist
Patient representative
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Six months planning
New periop’ pathway
Publicising
Getting consensus

8. What changes did we
introduce?

9. What changes were made?
 Patient selection

All patients have the new interventions –
selection happens post surgery according to
how the patient is recovering
 Preadmission counselling

Patients are given a leaflet telling them what
needs to happen pre-discharge

10. You are going to have a planned
(elective) caesarean section. Usually
you will stay in hospital for at least
two days but some women may go
home the day after the operation if
their recovery is going well. Below is
some information about what needs
to have happened before you can go
home.
NEW WORDING:
You are going to have a planned (elective)
caesarean section. If your recovery is
going well you may go home the day after
the operation. Below is some information
about what needs to have happened
before you can go home.

11. What changes were made?
 Carbohydrate loading prior to surgery

All patients (except diabetics) get flat lucozade
before theatre

12. What changes were made?
 Keep patient warm

in theatre
Active warming encouraged (S.Aluri, M.Berwetz,
M.Walters, M.Woolnough)

13. What changes were made?
 Avoidance of fluid overload in theatre

Usually fluid management is simple – no large
fluid shifts
 Surgical technique - short incisions/ no
drains

Already have horizontal incision with drains
rarely used.

14. What changes were made?
 Non-opiate oral analgesics/ NSAIDs
where possible postoperatively
New oramorph regime introduced – service
evaluation shows it to be effective

TTO’s prescribed in theatre so that this isn’t a
problem to organise later

 Prevention of postoperative nausea and
vomiting

No changes made – rarely prevents discharge

15. New Oramorph regime:
C.Meer, B.Kasa, R.Goyal
 Formerly parenteral regime with
subcutaneous cannula – service evaluation
of 67 patients:
79% - not used

63% - Pain or erythema

39% - taken out as uncomfortable

 Change to hourly oramorph regime – service
evaluation of 128 women:
94% rated pain control good or excellent (as
before)

98% of midwives – less work (oramorph not
controlled drug – one qualified only)


16. What changes were made?
perioperative oral intake:
 No restriction on preoperative fluids
Clear fluids up to two hours preop’ (includes
lucozade)
 Food up to 6 hours preop ’

 Early intake of fluids and food
postoperatively

Well established guidelines – clear fluids up to
one hour then whatever they want in terms of
food and fluid

17. Perioperative oral intake data:
R.Kaur, S.Glover, L.Powell, A.Philips, H.Roberts, S.Gowri

18. What changes were made?
The neonate
 Breast feeding
Problems with breast feeding commonly delay
discharge
 Skin to skin contact at birth between mother and baby
improves breast feeding rates – low rates in theatre
 New initiative to encourage this in theatre

 Delayed cord clamping
Increases the amount of blood going to the newborn
from the placenta

Increases blood haemoglobin levels
 Should improve neonatal recovery
 Obstetricians have instituted a new protocol for this
and it is being used


19. Postoperative management:
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Postoperative mobilisation
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Spinal anaesthesia takes 4 to 9 hours to wear off
8 hours post op is in the evening for most
Fewer staff then - ?safe to mobilise?
Patients ambivalent about early mobilisation
Elected to mobilise day after surgery as before.
Removal of urinary catheters

No change – removed on mobilising as before

23. Telephone service evaluation:
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19 women were followed up by telephone on
discharge
100% reported they were able to do daily
activities
96% reported feeling ‘back to normal’
82.3% reported no pain.
76.5% breastfeeding rate; 100% reported no
problems at all in looking after the baby
No readmissions or problems reported in women
or neonates discharged on day 1

24. Summary
 Enhanced recovery successfully
introduced for elective caesarean section
 15 - 20% of patients leave on day one

Previously around 1%
 No increase in readmission rates
 No evidence of problems in the
community

25. Future developments

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Apply to emergency caesarean sections
Increase uptake of skin to skin and delayed cord
clamping in theatre
Patient self administration of postop’ analgesia

Successful application for funding for lockable
bedside cabinets