Improving Patient Safety and Experience with C-section Delivery in a Community Hospital with Skin-to-Skin in the Operating Room
Summary
Prior to this fellowship, the organization did not offer any skin-to-skin opportunity for obstetrical care patients during C-section births. Midwifery clients however do have the opportunity to participate in skin-to-skin as the primary midwife is able to assist with the procedure. Due to a lack of nursing staff and unit culture, this simple yet highly beneficial best practice has been left by the wayside. This project has sought to understand the current culture and barriers to implementing this best practice, eliminate those barriers and to improve patient experience and satisfaction with their operative birth. Safety has also been prioritized by engaging with key stakeholders to create an agreeable procedure. In the initial stages of the fellowship, I was able to interview several patients who had C-section births and found that patients were not consistently doing 1 hour of uninterrupted skin-to-skin immediately following birth or until completion of the first feeding which is the minimum standard recognized worldwide. This was a clear indication that this work was needed and so I was able to engage with all members of the team to create a policy that addressed the barriers and concerns identified. I received a lot of feedback and with the identification of staffing and unit culture and was able to start brainstorming. Staffing as we know is an extreme issue in this current climate of nursing so by getting creative, I was able to utilize staff in a new way to allow skin-to-skin to take place in the operating room. Unit culture has been an interesting barrier to face. The dominating culture at this organization has been workflow oriented and practices were oftentimes based on what is convenient as opposed to what is best practice. Nevertheless, with time, this culture will change as we see a dramatic difference in our patient satisfaction and continue to be an organization that is recognized for its innovation in the community.
For this project, I set out to further develop as a leader in my workplace, to gain experience with incorporating best practice standards for obstetrical patients, to gain experience with project management and policy writing, and to gain experience working with the inter-professional team as stakeholders to engage in this project. I would say that I have been able to gain more knowledge and experience in each of these categories and beyond. My learning has far exceeded what I set out to do originally and I gained a completely new perspective on my role as a nurse. Not only was I able to develop skill and expertise in project management by creating and initiating a project and seeing it through, I was also able to learn the beginnings of navigating a very complex and diverse process for making change in healthcare. I have experienced how a project can grow from such a small idea into such a multi-faceted and complex task. I have experienced the challenges of getting key stakeholders involved and engaged in a project that might be seemingly low on their list of priorities but is important for the change it brings to the patient’s experience. I learned what a Gantt chart was and I learned the basics of how to use it. I interacted with departments that I never knew the organization had and was able to add many goals to my learning plan as new things became a reality along the way. I got to experience educating staff in new ways as the project became a reality and proceeded with roll-out. Because of the work I have been able to do, I am hoping that skin-to-skin rates will improve organization-wide. We will also be able to measure this simple yet effective task in relation to the outcomes with ongoing evaluation and audits.
Outcomes
Previously, patients or partners did not get to experience skin-to-skin at all in the operating room. They were required to wait until their procedure was finished to have skin-to-skin with their baby and even then, it was not consistently being done for 1 hour uninterrupted. The work that this project has done has identified and eliminated barriers to this practice and given patients who are having operative births the opportunity to do skin-to-skin during their C-section procedure. From the few patients who have had the opportunity so far, they have expressed extreme satisfaction with their birth experience. For some patients, this is their second or third C-section so by having had both skin-to-skin right away and waiting for skin-to-skin they have reported that right away was much more desirable. In instances where staffing wouldn’t allow, partners have been able to do skin-to-skin with their baby directly in the operating room beside the patient which was also reported with high satisfaction. With this intervention, mother’s will experience increased inherent hormone production and thus a reduction in post-partum hemorrhage and depression, increased bonding with their infant, increased satisfaction with their birth experience, and increased success and longer duration of breastfeeding. Infants will benefit from regulation of vital signs, blood glucose and temperature, and increased bonding with parents. Partners benefit by having increased bonding with their baby. Patients will also be educated prior to their hospital admission through an organizational birth plan document and welcome package with information about the importance and benefits of skin-to-skin in order to maintain high rates of skin-to-skin throughout the duration of their hospital stay. There has also been a project at this organization in the NICU for improved early skin-to-skin rates for infants who have had NICU admissions. This fellowship project and the education that patients are receiving has complimented and supplemented the work being done in the NICU as patients are receiving plenty of education prior to their hospital stay and should their baby require a NICU admission, they will be informed about the importance of early skin-to-skin as soon as the infant has stabilized.
By making this practice change, my colleagues along with key stakeholders have been able to maintain best practice standards for our program. Skin-to-skin during operative births is quickly becoming more widespread among hospitals and it is the future of C-section birth. By making this a standard of care at our organization, we will ensure that our staff are meeting best practices and are continuing to deliver high quality care. We will also continue to maintain a great reputation in the community and further be known as an excellent place to have any kind of delivery. There has also been re-education around the importance of immediate and early skin-to-skin throughout this process and we will eventually be auditing our skin-to-skin rates as a result of this project and improving these rates for our vaginal birth patients as well. This project also aligned with some of the strategic pillars of our organization so the opportunity has been created for staff to easily align with strategic pillars while doing important work with patients and help to meet the goals of the organization. Since the approach of this project was collaborative, my colleagues were able to have a say in how the procedure worked and could offer feedback as the project continued to develop. Each stakeholder was a valuable member of this initiative and opinions were heard from all members to ensure that a consensus was reached. I will also be continuing to work with the group as this practice is solidified as part of our unit culture and able to assist with ongoing education needs.
Overall experience
I would say my fellowship was a mix of challenging and enjoyable. I got off to a bit of a slower start due to some scheduling issues so it seemed to take a while for me to feel like I was in the rhythm of things. Once I started to make headway it felt great. I felt that the work that was done in preparation moved slow but as we got into the implementation phase things moved a lot faster and new little projects developed along the way. It was a very challenging process to get certain key stakeholders engaged in the conversations that needed to happen in order to implement this project but thankfully I was able to advocate for our patients and get everyone on the same page. I loved the extra elements that were added to my project such as updating our organizational birth plan document and creating a poster to put up on our unit to educate patients about the importance of skin-to-skin. I was also able to create a new intervention in our electronic documentation system for ongoing auditing and documentation purposes which is something I never thought I would have the opportunity to do. I have two favourite moments from when I started implementing my project. The first was the first patient who got to hold her baby skin-to-skin. Her first child had been a C-section delivery where she was unable to hold her baby so this time, she reported a great improvement in satisfaction since she could hold her baby right away. The second moment is when we were able to facilitate skin-to-skin with twins. Both the mom and dad had an opportunity to hold each of their babies after their births. The mom was very anxious during the surgery and once her baby was placed on her chest, the difference was noticeable in her anxiety. These are some of the sweetest moments to witness on a regular basis and I am so privileged that I was able to implement the practice change that allowed this.
