Fast-track pathway for elective caesarean section: a quality improvement initiative to promote day 1 discharge.

Enhanced recovery after surgery (ERAS) aims to improve perioperative care, hasten recovery to the normal physiological state and shorten length of stay (LoS). There is evidence that ERAS programmes following elective caesarean section (ELCS) confer benefit through faster return to physiological state and reduced LoS for mother and baby. Baseline audit of ELCS in 2013 revealed a mean LoS of 3 days. We piloted an ERAS discharge pathway promoting day 2 discharge, which rose from 5.0% to 40.2%. 19.2% of women went home on day 1. Many women fed back that they would prefer day 1 discharge. We hypothesised that a day 1 discharge pathway for low-risk women could benefit both women and services at our maternity unit. From October 2015, we developed a 'fast-track pathway' (FTP) using a Plan-Do-Study-Act approach. Between October 2015 and April 2016, we prospectively audited clinical outcomes, LoS and maternal satisfaction from all women placed on the FTP. We held regular multidisciplinary team meetings to allow contemporaneous analysis. Satisfaction was analysed by Likert scale at postoperative surveys. Women were identified in antenatal clinic after meeting predefined low-risk criteria. 27.3% of women (n=131/479) delivering by ELCS entered the FTP. 76.2% of women on the FTP were discharged on day 1. Mean LoS fell to 1.31 days. 94.2% of women who established breast feeding at day 1 were still breast feeding at 7 days. Overall satisfaction at day 7 was 4.71 on a 5-point Likert scale. 73.1% of women reported good pain control. Additional financial savings are estimated at £99 886 annually. There were no related cases of readmission. Day 1 discharge after ELCS is safe and acceptable in carefully selected, low-risk women and has high satisfaction. There may be resultant financial savings and improved flow through a maternity unit with no detected adverse effect on breast feeding, maternal morbidity or postnatal readmissions.

Woman-Centred Induction of Labour (the WOCIL project).

Induction of labour (IOL) is a common obstetric intervention. 32% of women are induced per year in our obstetric unit. We were experiencing delays in starting IOLs due to unit activity, protracted inpatient stay and dissatisfaction among staff and service users. We used quality improvement (QI) methodology to identify inefficiencies and root causes and used a bottom-up approach in planning improvements. After optimising our IOL processes, we introduced misoprostol vaginal insert (MVI) as it was faster acting than traditional dinoprostone. We compared 207 women who had MVI with 172 women who had dinoprostone prior to MVI introduction. There was a reduction of IOL start to delivery time, from a mean of 30 hours to 21 hours. Fewer women required oxytocin and of those who did, required oxytocin for fewer hours. We also found a reduction in caesarean section rates in women undergoing IOL, statistically significant in nulliparous women (41%-25%, p=0.03). There was a higher uterine tachysystole and hyperstimulation rate with MVI use and introduction should be accompanied by education of staff. We did not find any increase in neonatal admissions, maternal haemorrhage or other serious adverse events. In summary, MVI is a useful drug in helping high volume units with high IOL rates, reduced bed occupancy and improved flow of women. We would recommend a holistic QI approach to change management, as safe use of the drug requires optimisation of the IOL processes as well as staff engagement, due to rapid flow of women through the IOL pathway and increased hyperstimulation rates.

Attitudes towards attrition among UK trainees in obstetrics and gynaecology.

Physician dissatisfaction in the workplace has consequences for patient safety. Currently in the UK, 1 in 5 doctors who enter specialist training in obstetrics and gynaecology leave the programme before completion. Trainee attrition has implications for workforce planning, organization of health-care services and patient care. The authors conducted a survey of current trainees' and former trainees' views concerning attrition and 'peri-attrition' - a term coined to describe the trainee who has seriously considered leaving the specialty. The authors identified six key themes which describe trainees' feelings about attrition in obstetrics and gynaecology: morale and undermining; training processes and paperwork; support and supervision; work-life balance and realities of life; NHS environment; and job satisfaction. This article discusses themes of an under-resourced health service, bullying, lack of work-life balance and poor personal support.

Improving induction of labour - a quality improvement project addressing Caesarean section rates and length of process in women undergoing induction of labour.

Induction of labour (IOL) in maternity care is often not an area of priority in maternity services, which often results in protracted delays, a poor patient experience, and patient complaints. Caesarean section (CS) rates among women undergoing IOL at this inner city district general hospital were noted to be higher than other units nationwide. We collected pre and post-intervention data of the following outcome measures: time taken to administer prostaglandin after arrival, time taken to achieve established labour, mode of delivery, and user satisfaction scores. Our introduction of a dedicated IOL Suite, promotion of out-patient IOL, use of a single administration prostaglandin (as opposed to traditional six hourly prostaglandin), widespread staff engagement and rolling audit has resulted in positive change in the maternity unit. CS rates for women undergoing IOL have been reduced from 29% to 22% (p=0.05), time taken to administer the induction medication has decreased from 6.3h to 2.7h (p=0.0001), and out-patient induction rates have increased from 3% to 33% (p=0.001). We have achieved a reduction in the overall length of in-patient stay. We have also received positive feedback from both staff and patients. We used a bottom-up approach, engaging frontline staff in problem identification and pathway design. Our staff engagement questionnaire showed other benefits such as increased staff morale as a result. Collection of simple performance data and sharing of this in real time with staff acts as a valuable tool for acceptance of change and continuous improvement. Communicating plans to a large body of people is important in ensuring the success of an intervention. Staff showing disengagement may require specific detailed information to allay their concerns. Following initial successes, ongoing vigilance, and collection of audit data is key to sustaining any improvement.

Pulmonary edema in pregnancy and the puerperium: a cohort study of 53 cases.

OBJECTIVE: To describe the etiology and obstetric outcome in women presenting with pulmonary edema during pregnancy and the puerperium. As a secondary objective, we evaluated the utility of echocardiography in the investigation and management of such women. METHODS: Retrospective case note analysis of 53 cases of pulmonary edema that resulted in severe respiratory distress and admission to intensive care. The study population were women accessing obstetric care at a tertiary referral center in South Africa. RESULTS: Cases were classified as cardiac (6/53; 11%), hypertensive (44/53; 83%), or septic (3/53; 6%), depending on the underlying cause for pulmonary edema. There were significant differences in the mean ejection fraction at echocardiography for cardiac vs. non-cardiac groups (26% vs. 55%, P=0.0001), as well as the presence of valvular stenosis or regurgitation (5/6 vs. 8/30, P=0.016). Women in the non-cardiac group were more likely to present earlier and require earlier delivery than in the cardiac group (median gestation at delivery 35 weeks vs. 38 weeks, P=0.0106) and mothers in the cardiac group were more likely to die (2/6 vs. 1/47, P=0.031). Cesarean delivery was performed in 85% of cases. CONCLUSIONS: Hypertensive illness is the most common underlying etiology in the development of pulmonary edema. Transthoracic echocardiography is a non-invasive investigation that can be carried out at the bedside and is a useful diagnostic tool in pulmonary edema occurring in pregnancy and the puerperium. Knowledge of ejection fraction is an important diagnostic tool to differentiate the underlying causes and to guide management.