Janine McKnight-Cowan

Promoting Five Guide as a tool to enhance caesarean section recovery

Background

More than a quarter of all babies born in the United Kingdom are delivered by caesarean section (1).

NICE guidelines in the UK suggest that general postnatal care of women who have had a caesarean section should be provided with ‘specific care related to recovery after their caesarean section, and care related to the management of other likely complications’ (2).

As health care professionals we are ideally placed to deliver health messages and explore what health information works better for patients and is more appropriate, more specific, and what is essential ‘post-operative’ information (3).

In the current NHS Choices Your Health ‘Recovering from a caesarean section’ leaflet, also available online, women are informed to, ‘take things easy’ for a few weeks (4). In addition, the leaflet includes information on recovery in hospital, on how to look after a wound, how to control the pain and any bleeding, and how to ‘return to normal activities’. There is advice on when and who to seek advice from but, there is no mention of asking advice from your health visitor. Only the midwife and GP. 

open palm

The Five Guide tool is a 3D narrative explanation which, at any time, before or after caesarean section, can be used to support a woman by providing a consistent health message. Health visitors care for women antenatally and postnatally in the transition of care between acute and community sector, looking after women who are surgically delivered. This tool will assist the clinician to explain visually the reason behind ‘the take things easy’ narrative. It does this by the simple 3D use of the clinician’s own hand to help explain and create a visual anatomical picture of her own abdominal healing, and additional health promotion.
 

As Five Guide is a visual tool with its own thumb to little finger message. It is best explained quite simply:

  • The clinicians own hand, held with fingers spread, represents the five layers healing as a result of a C-section
  • The thumb is layer one and is the skin wound
  • The index finger is layer two the fat layer
  • The middle finger is layer three the separation of the abdominal muscles
  • The ring finger is layer four, the separation of the peritoneum
  • The little finger and fifth layer is the womb 

The representation of each layer as a visual window on recovery allows women to become in tune with their body. Family-centred care is more than understanding breast feeding, attachment, bonding and getting to know your baby. Five Guide gives women that visual moment to become in tune with what they feel and how they will then understand why they need to 'take it easy'.

 

The Five Guide tool is a 3D narrative explanation which, at any time, before or after caesarean section, can be used to support a woman by providing a consistent health message 

 

In a simple ‘plan, do, study, act’ (PDSA), the findings clearly reflect a powerful set of results where improvement in public health care can be beneficial to:

  • Health visitors by delivering a continuum of care between maternity hospital and community
  • Patients through feeling empowered in their post-surgical recovery by hearing and seeing a visual recovery narrative that is transferable between hospital and community staff
  • The public by being exposed to a new quality standard that is based on feedback from service users, professional feedback, quality always review, and independent inspection by NMC, NICE, and NHS Choices. Making Every Contact Count is thus embedded into practice and delivery of care, allowing a health visitor to make a difference on an individual level, the patient would then have the tools to stay well following the delivery of Five Guide message (3).

In summary, this innovative and sustainable visual project is all about providing improvement needed in service delivery as assurance not reassurance.

Aims and objectives

  •  To understand the experiences of health visiting staff, delivering caesarean section recovery information at a new birth visit
  • To understand if women had received any information after their caesarean section
  • To raise awareness in Derbyshire locality health visiting group of Five Guide as a tool to enhance their knowledge and delivery of care to women who have had caesarean section delivery
  • To identify any quality issues with current delivery of care to post surgically delivered women 


NICE guidelines in the UK suggest that general postnatal care of women who have had a caesarean section should be provided with ‘specific care related to recovery after their caesarean section, and care related to the management of other likely complications’

c section portrait
More than a quarter of all babies born in the United Kingdom are delivered by caesarean section

Activity to date

The project activity following submission to RCN meant a tight period was ahead of the project lead. With support from RCN mentor the PDSA cycle was implemented. Following consultation with Derbyshire Community Healthcare Services NHS Foundation Trust’s (DCHS) research and innovation team, it was agreed a service review at local level would be implemented.


To achieve the aims and objectives highlighted above, I carried out:

  • A patient experience survey
  • Staff pre-training questionnaire 
  • Five Guide training 
  • A reflective review questionnaire for staff, after delivery of Five Guide with women

This project was targeted at two south Derbyshire locality health visiting teams, which included a total of 15 health visitors. The project was given full support by service leads.

Between September and November 2017, 15 respondent health visitors received a pre-training questionnaire and a visual training on Five Guide caesarean section surgery and recovery. Health visitors provided feedback to the project lead, including the patient experience on the service their patient had received. This also included client and staff comments following Five Guide tool training and delivery. 

 

Five Guide gives women that visual moment to become in tune with what they feel and how they will then understand why they need to 'take it easy'


During this time, a total of 14 women (nine who had received emergency sections and five who had a planned section) provided feedback, including the information and the format of their education from the hospital or midwife, if it had occurred. Women were also asked about which information they were most likely to remember following exposure to Five Guide tool, as well as their opinions about it.

Five Guide video

The Five Guide tool is a 3D narrative explanation which, at any time, before or after caesarean section, can be used to support a woman by providing a consistent health message.

Outputs to date

The PDSA tool was useful for documenting a test of change presumed by the project lead. Carrying out the test (do) and observing and learning from the consequences (study) have determined the lessons learned (change).

Outputs included:

  • All 15 health visitors had not received any specific training on how to care for women in the community following C-section delivery
  • Only two health visitors had either an obstetric/midwifery clinical background. A total of 13 had no experience of the surgery or recovery impact
  • None of the 15 health visitors had ever seen the NHS Choices, or NICE guidelines for Recovering from a caesarean section information sheet
  • Levels of care offered to women varied from universal care (low level) to universal plus care (higher short-term care) following C-section delivery. There is no current guideline to reflect care that should be offered to women
  • All 15 health visitors noted that Five Guide was a ‘very effective and important tool they will continue to use with women recovering from C-section’. Comments included: “Visual, always at hand”, “Powerful and easy to remember”, “Each time I now use it, it reminds me every woman needs to hear the same information”
  • Women were asked to compare the information they had received prior to the health visitor’s visit. One woman had no information prior to discharge, two had had verbal information but could not remember it. A total of 11 women felt that Five Guide had been the most beneficial information they had received. Comments include: “I wish I had known this 12 days ago”, “Each time she goes to try to hoover, I remind her by holding up my hand, she has five layers healing”.
 

Lessons learned

Following some time analysing the findings and collating the many number of professional and client comments, it became very clear that the rhetoric of NICE guidelines and NHS Choices paperwork, is not a reality in reaching the very person who matters - the woman who has had a surgical delivery.

Without investment in developing this simple cost-effective, creative and visual innovation, the standard and quality of practice across the country as well as locally is compromising women who are surgically delivered. Health professionals and their women have received health education and information that works more appropriate, easy to deliver and remember more specifically, what is essential ‘post-operative’ information. 

 

Without investment in developing this simple cost-effective, creative and visual innovation, the standard and quality of practice across the country as well as locally is compromising women who are surgically delivered 

 

Creating this real sustainable legacy of visual communication is vital for the benefits of nurses, midwives’ health visitors, general practitioners and obstetricians, as this tool is transferable to their disciplines. The Five Guide also creates an opportunity for a consistent sustainable and important health message to reach all women and their families, ensuring that health professionals do protect women’s physical, social and psychological needs, and that they are assessed and responded to, by promoting their wellbeing and preventing ill health (5).

  

The Five Guide also creates an opportunity for a consistent sustainable and important health message to reach all women and their families, ensuring that health professionals do protect women’s physical, social and psychological needs, and that they are assessed and responded to, by promoting their wellbeing and preventing ill health 
 

Because of the impact and findings of this study, service managers within the health visiting teams have highlighted the need to develop a workforce training video of Five Guide. Filming is planned in the near future. 

open book

midwife close up
As health care professionals we are ideally placed to deliver health messages and explore what health information works better for patients and is more appropriate, more specific, and what is essential ‘post-operative’ information

Reflections on impact

The most profound impact this project has had on the author is that this simple tool reflects the three core components of Making Every Contact Count (MECC) (3). These are:

  • Staff are ready to deliver the message
  • Patient is enabled to empower their own recovery
  • Organisational readiness to change in order to develop

 Reflective narrative from health visitors includes comments such as:

  • “Just so simple to remember and use, before I had picked up what to say from my mentor”
  • “My lady was a diabetic and until I used Five Guide she had not told me she had a wound infection”
  • “I came from a mental health nursing background, I had no surgical experience”
  • “I had no idea the uterus was sutured outside of the abdominal wall, or that there was internal healing”
  • “Visual health promotion is great, no leaflets to order”
  • “Using your hand to describe recovery was very powerful when used in front of the woman’s partner, suddenly he became more attentive to her”
  • “I have used Five Guide many times now and the effect it has on empowering women is amazing, I feel pretty good knowing I’ve made a difference”

midwife

Some of the reflective narrative comments from women included:

  • Husband: “Each time she tries to hoover or clean up, I can remind her she has five layers healing and not just her skin wound”
  • Son: “I like helping mum recover, she needs help with shopping bags for a while”
  • Woman: “Third section, why wasn’t I told this before?”
  • Woman: “Every woman needs to know this, sooner”
  • Woman: “Now I realise why not getting pregnant again too soon is safer for me and a baby”

These along with the many more comments from staff (service providers) and women (service users) are powerful quality measures and were shared with the quality people team and quality services team within the organisation. The data represents South Derbyshire and cannot be generalisable to all NHS services, but the information collected is a quality evaluation to the specific clinical client needs of maternity care post operatively, and those health visitors expected to provide that care.

Another measure of the impact of the Five Guide is that all health visitors who took part are still using the Five Guide tool.

Update February 2018

The Five Guide has been nominated as a finalist in the Journal of Health Visiting, Education in Health Visiting Awards

The video has been filmed.

The Way Forward 

Five Guide Tool is transferable to other disciplines such as:

  • Midwives
  • General practitioners
  • Obstetricians
  • Maternity support workers
  • Breastfeeding support workers
  • Partners/husbands/carers

This cost-effective 3D tool is about providing people with the knowledge on their recovery. A clinician who does not have the expertise cannot impart the information. The project needs to be implemented more widely and its potential to be used in abdominal surgical procedures is recognised.

Five Guide, as a 3D innovative tool, simply uses an anatomical visual to explain internal body repair and there are many avenues to disseminate it such as:

  • Health Education England - MECC
  • NHS Improvement
  • NHS Choices Your Health, Your Choice
  • NICE Guidelines
  • Care Quality Commission
  • Further publications

More exciting is that this project reflects the very essence of the RCN Centenary Awards. It is practice that has 'gone under the radar’ and now it needs to be developed to communicate the value it has in caring for patients and educating staff. 

 

Sustaining momentum 

Five Guide has already been imbedded in 15 health visitors and they are using the tool each and every time they care for a surgically delivered woman. Women who have been part of the project are passing on this health message to their family.

 

The Five Guide creates an opportunity for a consistent sustainable and important health message to reach all women and their families, ensuring that health professionals do protect women’s physical, social and psychological needs, and that they are assessed and responded to, by promoting their wellbeing and preventing ill health 

 

The workforce development video is a priority from this stage of the project, as we now have a published review, and this will give quality kudos for funding. The video would go live and be shared with Health Education England (HEE) for dissemination and training.

If the project is selected for further development, there is the potential to increase the scope of the project to a wider audience and hopefully embed it as a standard in practice.