Problem

Communication is acknowledged by the General Medical Council as a principal domain in the duties of a doctor.1 The National Health Service highlights that improved communication with patients increases satisfaction with care and leads to improved outcomes.2

Communication is central in obstetric practice when discussing mode of delivery after caesarean-section. There is a continued global drive to decrease caesarean-section rates and promote vaginal birth after caesarean-section (VBAC).3 Dedicated antenatal clinics, supporting women through the informed decision-making process on mode of birth after a primary caesarean delivery, has been found to improve VBAC attempt rates.4 5

The overarching aim of this work-stream was to review why patients chose their intended mode of delivery in the Royal Jubilee Maternity Hospital (RJMH) Belfast. The National Health Service recognises that involving patients often improves efficiency in design and joining up services, in this case, between initial and subsequent gestations.6

RJMH, is a tertiary maternity unit with 5500 deliveries annually. Elective caesarean sections are undertaken in the elective theatre suite while emergency caesarean sections occur on delivery suite. Postoperatively, all share the same postnatal wards, remain as inpatients on average for 2 days and are discharged with community midwife involvement. General practitioners (GP) review at 6 weeks post partum. Standard practice debriefing after caesarean section occurred verbally, shared between the operator and the junior medical staff on the postoperative ward. RJMH ‘Birth Choices’ antenatal clinic is where women with previous caesarean-sections receive their antenatal care in subsequent pregnancies. A multidisciplinary team of obstetricians and specialist midwives discuss the options of VBAC and elective repeat caesarean-section (ERCS).

Anecdotal evidence and staff perception suggested patients who returned in a subsequent pregnancy had little knowledge about the indication for their surgery or their suitability for VBAC. This lead to a lengthy antenatal process discussing previous events and the option of VBAC when the patient had already formulated their perception of events and intended mode of delivery. Patients frequently could not recall postoperative discussions. Some cited different information given by different care providers, causing patient distress. The project team felt that this hindered women in making informed decisions and that discussion in subsequent pregnancy was information given ‘too late’. The team believed improving communication at the time of initial caesarean-section would be beneficial. Different care providers giving conflicting information to women, highlighted poor inter-professional communication regarding VBAC and its safety profile.

Our baseline survey, designed from patient identified themes, reported that 20% of women gained ‘clarity’ with the information provided to them about their operation. Patients also identified GPs as the most common healthcare provider to seek advice from regarding suitability for VBAC. The project intended to create a robust way in which to measure and improve patients’ clarity regarding the information they were given.

We aimed to improve ‘full clarity’ from 20% to 30% within a 6-month project time period. This modest figure was chosen as a patient’s perception of ‘clarity’ may not be achievable in the immediate postnatal period due to competing demands on their attention. We introduced small changes that would not impact on workload and had a short time frame to implement these. The project aimed to provide consistent information to GPs.

Background

Factors influencing women’s decision on mode of birth are multifactorial. While the health of both mother and baby is reported as a major determinant in deciding mode of delivery, natural experience, recovery time, avoidance of pain and convenience of timing a planned birth were other factors reported in the literature.7 Medical advice was one of the biggest influences on women’s choice shown in a recent Swiss study.7 The issue of ‘safety’ was a predictor to decrease the probability of choosing VBAC.7 While both VBAC and ERCS have low maternal and neonatal risks,8 information on safety given by care providers may emphasise elective caesarean-section as a ‘safe’ option.7 Fenwick et al concur that medical advice emphasising the safety of caesarean-section was associated with women’s decision for a repeat caesarean-section.9

Women have identified that they often receive contrasting information about mode of birth options.10 A consistent confident attitude regarding VBAC by the healthcare provider is important to women.11 Clinicians in countries with high VBAC rates agree that strengthening women’s trust that VBAC is a viable option, is an important aspect in why women choose VBAC.12 Early information about the initial caesarean-section, the reason why it occurred and suitability of VBAC is important to women.11 13 Debriefing as to why the caesarean-section was required and information on VBAC was requested ‘as soon as possible’.11A Canadian study showed that women’s decision-making process commonly began during the interpregnancy interval and would benefit from decision support as early as immediately following primary caesarean-section. In some cases, support was required before patients would contemplate a future pregnancy.13 In this regard we may be failing some patients who, without adequate information given at the time of caesarean-section, may never embark on subsequent pregnancies and do not feature in our service again.

Verbal information was preferred, but leaflets were also important. In the absence of information from care providers about their first birth, participants relied on personal knowledge from their caesarean experience which risks inaccuracy, and information from peers and the internet which may not be specific to their clinical situation.13 The National Institute of Clinical Excellence (NICE) recommend both verbal and printed information be available to these women.14

Shared decision making and empowering the women to make their own choice was another strong theme in recent studies.11 15

Baseline measurement

To confirm a need for change, a focus group of five women identified their information needs. While the team’s aim was to impart information regarding VBAC, women highlighted they knew little about indication and complications of their surgery. Using the themes of indication, complications and impact on future delivery, we then surveyed 25 women at day 1–2 postcaesarean-section in December 2016 (figure 1). Women were randomly selected representing both elective and emergency caesarean-section. 20% of women achieved ‘clarity’ with the information in all four areas.

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Figure 1

Patient clarity survey questions. Only ‘clear’ answers were counted as a positive response.

Preceding this project, debriefing after caesarean section did not consistently meet NICE guidance. It occurred verbally and sporadically, shared between the operator and junior medical staff on the postnatal ward. Consultant obstetricians and senior obstetric trainee operators, reported barriers to postoperative patient debriefing. They discussed that job requirements caused inconsistent availability to debrief women the following day. Often their debrief occurred immediately postoperatively in the recovery room. The operators believed that junior doctors also debriefed postnatally as part of their standard day 1 review. There was no documentation of these interactions. A focus group of six junior doctors expressed barriers to debriefing included time restraints to review detailed intra partum notes and lack of confidence in what to discuss. If suitability for VBAC was not written in the operative note, junior doctors would not broach this. Women surveyed felt discussion immediately after delivery was suboptimal, as they were unable to recount the information. Hunger, emotion, tiredness and the attention the new baby required were cited as reasons for this. They proposed patient specific written information be available so that they could revisit these points at a date suitable to them.

When discussing suitability for VBAC, we asked women in the baseline survey who they would ask for advice regarding this. While some mentioned family members and obstetricians, 13/25 reported asking their GP and others were unsure who to ask. A focus group of seven GP’s within the Belfast catchment area responded to our survey. Their responses showed that while they were infrequently asked to clarify information regarding obstetric surgery, they would not feel confident in discussing these issues and had poor access to information from secondary care. An example debrief template met with positive feedback with all agreeing that it would be beneficial in their job. We invited the community midwifery team to participate but failed to achieve a response within our 6-month period.

The project focused on the introduction of patient specific written information to assist both patient and GP in the debriefing process and teaching for junior doctors on debriefing. Data collection occurred weekly and included type of caesarean section, grade of operator, documented debrief by operator, debrief form completed and documented debrief by junior doctor. Our outcome measure was the patient clarity score using the original survey questions. We evaluated if improvement was secondary to the written information by reviewing form uptake with weekly analysis. We also reviewed evidence of debriefing in the notes by junior doctors on a monthly basis.

Design

The improvement team involved a lead senior obstetric trainee, two consultant supervisors, two junior obstetric trainees and midwifery team leaders in each clinical area involved in the care of patients with caesarean-sections in RJMH. Involvement of the ‘Specialist Trainee Engaged in leadership Programme’ within the Belfast Trust gave added multidisciplinary experience and guidance to the quality improvement process. The project was registered with the local quality improvement department and as such did not require ethical approval.

Baseline data was collated and discussed. A patient pathway identified all care providers that interacted with these patients. Barriers to clear consistent patient information were addressed. Appraisal of all suggested interventions included cost effectiveness, ease of implementation and patient benefit. The team agreed interventions which were beneficial and achievable. The project focused on; promotion of debriefing as a significant aspect of care, introduction of a debrief form and education of junior doctors in methods of debriefing. We assumed slow uptake of new documentation and focused a number of Plan Do Study Act (PDSA) cycles on project promotion and highlighting the benefits to physicians. Baseline results were presented at the department meeting to include the wider team in development of the project and promote its implementation. Patient experiences from the December survey were used to highlight the difficulties women have retaining verbal information and the importance of written information in empowering patients to understand events.

Strategy

PDSA cycles implemented interventions and measures identified their impact. As both elective and emergency cases were recovered in the same postnatal ward, interventions were implemented for both caesarean-section types to avoid confusion for postnatal staff. Weekly data collection and review captured 10 cases of adequate emergency and elective operation mix. Anonymised data included type of caesarean-section, grade of operator, documented debrief in clinical notes by operator, debrief form completed and documented debrief by junior doctor on day 1 postoperatively. These markers identified process measures, where implementation was successful and what operator groups required more project promotion. In patients who had the debrief form completed, a repeat clarity survey was undertaken. We chose this method because we wanted to identify whether implementation of the form changed clarity scores compared with baseline results. We also identified degree of successful form implementation. We reviewed debrief documentation in the patients notes on a monthly basis. We introduced junior doctor teaching and promotion of the importance of debriefing to affect change.

Lessons and limitations

The project aimed to improve communication between obstetrician and patient after caesarean-section. One issue was the limited documentation of the debriefing process at baseline as this routinely occurred verbally. After promotion and staff education, documentation of the debriefing increased in the maternity notes but this may have occurred as frequently before intervention but without documentation. Improving patient clarity scores, however, would suggest that the project did bring communication to the fore.

A limitation of study design was obtaining clarity scores only in those who received the debrief form. We felt this was appropriate as we knew baseline data showed low clarity scores with previous methods. This collection method identified that the intervention improved this score. We understood uptake of the form would initially be challenging so wanted to quickly assess whether this intervention was worth promotion. We used these results to encourage staff buy-in to using the form. Our results however, reflect clarity scoring for perfect usage of the form which requires a longer time scale to embed into routine practice.

A lesson learnt by our team was to engage senior managerial team members early. Our failure to realise this caused delays when our redrafted form required printing and encountered problems. The ‘Specialist Trainee Engaged in leadership Programme’ team, provided experienced staff to educate us on these quality improvement points. This resource provided by the Belfast Trust was invaluable to the success of the project. The delay in printing the form’s second draft, and its late introduction, limited comprehensive review of its success within the 6-month project timeframe. Another learning point was the importance of involving the whole healthcare team. The midwifery area leads proved invaluable in encouraging the clinical staff in each area to participate and create change.

Time limitation had its strengths and weaknesses. While weekly review prompted fast action, the speed with which interventions were introduced caused difficulty in assessment of which cycles produced the greatest benefit. Grass-root feedback suggested it was the consistent promotion of the project by multiple techniques that increased awareness and engagement of staff. Our project time period avoided the junior doctor changeover date which creates difficulties in maintaining progress in any intervention. To improve sustainability, we created a permanent staff champion to promote the project in the long-term and embed it into practice. We aim to repeat similar data collection to ensure the intervention is sustained. The 6-month period does not identify long-term advantages of the project. At a later date, when the new debrief process is embedded into practice, we aim to review how this has benefited primary care doctors and whether it impacts on women’s birth choice in subsequent pregnancy. It is anticipated that further positive outcomes will be seen when women subsequently return to maternity services with a clearer understanding of previous events and will lead to informed decision making.