A Multiple Methods Research Program Examining Enhanced Recovery Care with Next-Day Discharge for Elective Caesarean Section

Abstract

Enhanced recovery care for surgery has been increasingly applied for caesarean section. Programs of enhanced recovery aim to ‘fast-track’ convalescence by including antenatal preparation and education, and improved intrapartum and postnatal care such as encouraging mobility, early cessation of fasting and criteria-led hospital discharge. Given this improved care, enhanced recovery is associated with or includes an early discharge. A health service in South Australia is the first to implement an enhanced recovery care pathway for caesarean section in Australia called Enhanced Recovery after Elective Caesarean Section (EREC). EREC includes a next-day discharge with home midwifery and Mothercarer support. This program of research used multiple methods to better understand enhanced recovery care with next-day discharge after elective caesarean section. The results are discussed in terms of implications for future similar programs in this and other clinical contexts. Study 1 was a mixed methods systematic review synthesising women’s experiences and psychosocial outcomes with early discharge after caesarean section. Eight studies were identified reporting on: satisfaction, mental well-being, infant feeding, and pain. This study found no clear negative impact on women’s psychosocial outcomes and experiences. Several characteristics of care such as home midwifery were associated with more positive outcomes. Study 2 was a qualitative paper examining the experiences and perspectives of 11 women on the EREC pathway who had an early discharge. Using thematic analysis, major themes identified were: women’s general experience of an enhanced recovery care pathway, their experiences at home, and support at home. All women interviewed were satisfied with the EREC pathway and home recovery. Certain aspects of care were essential to a positive experience such as social support, support from staff, and home midwifery care; well managed pain relief, information, and reassurance of longer hospitalisation if required. Study 3 addressed anecdotal reports from midwives who reported that a large percentage of women assessed as eligible for EREC were not discharging the next-day, and therefore not completing the pathway as expected. This was suggested to be primarily due to psychosocial reasons. A prospective cohort study was developed and found that 62% of women did not go home the next-day, and identified that the two most common factors were for medical and obstetric reasons rather than psychosocial reasons. This study also identified antenatal demographic and biopsychosocial characteristics of women on the EREC pathway and described women’s antenatal satisfaction with preparation for EREC, preferences for postnatal care, and perception of support for EREC by hospital staff and family. Finally study 4, was a qualitative study applying thematic analysis to explore the experiences and perspectives of 23 healthcare providers (5 doctors and 18 midwives) who had occupational experience with the EREC pathway. Major themes identified were: EREC is more than just early discharge; experiences with the EREC process; woman-centred care; staff engagement with EREC, and the impact of EREC within the health system. This qualitative study found that staff were generally accepting of enhanced recovery care. Although, staff identified specific challenges such as early discharge, and the perceived lack of choice for women, as all eligible women were automatically included on the EREC pathway. Staff identified components that assisted with the integration and acceptance of EREC such as education, communication of the evidence, the inclusion of home support, and clinical flexibility. Organisational considerations such as having enough clinical time, clear guidelines and protocols, and clear staff roles were also discussed. Overall, the findings indicated that implementing enhanced recovery care with nextday discharge should be thoughtfully considered in other maternity services, given the benefits of this model of care. However, a combined package of care similar to the one included in the EREC pathway is required. This package of care should include appropriate screening and eligibility criteria, preparation and antenatal education, well-defined discharge processes, and home support. This work has also identified that staff require support to integrate change into practice.