Embedding evidence of early postoperative off-bed activities and rehabilitation in a real clinical setting in China: an interrupted time-series study

A caesarean section (C-section) is the only safe option to deliver the baby of a woman experiencing serious complications such as dystocia [1]. C-section is a widely used practice in clinical gynaecology and obstetrics [2, 3].

The rate of C-sections in developed countries remains high and continues to show an upwards trend [4]. The C-section is also quite common in China [5]. After the implementation of the two-child policy in this country, the incidence of placenta accreta has increased dramatically in recent years [6]. At present, caesarean section is the main option for the termination of pregnancy in a case of abnormally implanted placenta, which is invasive and traumatic, making postoperative recovery slow and difficult [6]. Consequently, post caesarean care is becoming increasingly significant and challenging for obstetrics care centres in China [7].

Due to the invasive nature of C-section deliveries, postoperative recovery is slow and usually requires 3–4 days in the hospital [6]. Evidence suggests that early mobilization can reduce the risk of complications during puerperium and enhance the safety and health of mothers and babies [7]. However, there is a knowledge gap among institutions, and adherence to the evidence supporting early mobilization remains highly variable [8‐10]. The acceptance of Enhanced Recovery After Surgery (ERAS) has been slow in the field of emergency medicine, but recent research has found that ERAS utilization in the emergency setting is possible and effective, but certain changes to the protocol may need to be adapted [8, 9]. To implement evidence-based practices successfully, health care providers should tackle existing barriers [9]. Since facilitators and barriers are dependent on context, it is important to examine them in the clinical setting for which the protocol is intended and to supply the protocol of structured postoperative mobilization [10].

This study aims to develop tailored implementation strategies that optimise and standardise preoperative care of the early mobilization of patients after C-section and embed them in the clinical setting. Five guidelines [11‐15] were retrieved via systematic review, and eight recommendations were developed based on the Grades of Recommendation, Assessment, Development, and Evaluation framework. We embedded this evidence into a clinical setting in China and evaluated the effectiveness of the length of postoperative hospitalization stay and the incidence rates of postoperative ileus (POI) and infection.

We conducted an interrupted time-series study of early mobilization after C-section based on a literature review in the Guangzhou Obstetrics Critical Care Center from February 1st, 2019, to January 31st, 2020. This study was approved by the clinical scientific research section of the Ethics Committee of Guangzhou Medical University. Informed consent was obtained from every participant in this study.

Our study showed that early mobilization after C-section conducted by a multidisciplinary health care team could singly shorten the time until the patient’s first ambulation, shorten the length of hospital stay and reduce complications after C-section. This result is consistent with those of many previous studies [18, 19], and early mobilization after C-section can improve patient recovery. In the study, all of the clinical practices included in the intervention were successfully implemented except abdominal drainage tube removal within 24 h and activity recording by patients, and the onset time of off-bed activities decreased from 31.89 ± 9.50 h to 20.01 ± 4.65 h.

Although the incidence of POI was reduced from 5.38% before to 1.67% after the intervention, as shown in the tables, both incidence rates were much higher for POI than in other research [20‐23], which always had strict exclusion criteria, such as emergency operation, scarred uterus and other conditions that might influence gastrointestinal motility. In this study, the percentage of emergency operations was 47.35%, the scarred uterus complication was 45.85%, the duration of operation was 1.31 ± 0.63 h, and the blood loss was 382–714 ml (exceeding 500 ml was 74.78%) before the intervention, as shown in Table 2. According to previous study results, patients who had previous abdominal surgery, long duration of surgery, emergency surgery, blood loss exceeding 500 ml, extensive adhesiolysis, acute gestational complications such as preeclampsia and received magnesium sulfate, which may affect intestinal peristalsis, are at higher risk of developing POI [21, 22]. This is the reason why there is a high incidence of this serious complication both before and after the intervention in the clinical setting of the Guangzhou Obstetrics Critical Care Center in China.

Preoperative education and preoperative behavioural interventions have a direct impact on patients’ postoperative rehabilitation and were well documented in this study. According to previous study results, postoperative patients may suffer postoperative problems such as incision pain [19], intestinal distension [18], and incision site or urinary tract infections [19, 20], and they would refuse mobilization. Therefore, preoperative education of patients is an important part of postoperative care in C-sections [21]. In this study, preoperative maternal education was dominated by traditional oral education, and there was no implementation of a postoperative activity plan or daily activity goals. After the intervention, standardized preoperative health education was carried out in various forms, such as an activity manual with pictures and text, a propaganda column on the wall, and videos on TV in the ward. There was a significant increase in the rate of implementation of postoperative activities plans and daily activity goals that were communicated in writing by the nurse prior to the operation. It also relieved the worries of parturient women and their families so leaving bed for the first time after surgery occurred earlier, and the rate of leaving bed after 24 h was obviously improved. But the low compliance rate with activities recorded by patients and nurses with a ground scale was just 59.83%. The reasons were likely that it can not be recorded in real time and need to be manually added by the nurses, which increases the workload of the nurses.

In the present study, a shortened duration of indwelling drainage tube/catheter placement shortened the time to the patient's first ambulation and the hospital stay. After surgery, early mobilization and early ambulation are facilitated in most patients after the drainage tube is removed [22, 23]. Another study also found that complications of postoperative infection and POI tended to be higher in the drainage group than in the no-drainage group [23]. Abdominal drainage was first performed in abdominal surgery by Chassaignac in 1859 [24]. One of the main goals of prophylactic abdominal drainage placement at the end of the procedure was to shorten the time to diagnosis of haemorrhage [25]. Abdominal drain placement was generally considered a harmless preventive measure and still performed routinely [26] before the evidence-based intervention, so 15.49% of C-section patients received drainage before intervention. In an era where promotion and application of ERAS practices are gaining increasing acceptance, abdominal drainage is no longer undertaken routinely [10‐14] and has decreased from 15.49% before to 7.11% (Table 3) after the intervention. However, this result is still slightly higher than findings in other research [4, 7]. There are two main reasons for this outcome: (1) Whether to perform abdominal cavity drainage after surgery because of the large wound, long operation time and extensive intraoperative bleeding in repeat caesareans is controversial [25]. (2) After a high risk of bleeding after surgery was established, such as intraoperative blood loss over 1000 ml, abdominal drainage is performed in China [26]. The removal of the drainage within 24 h remained quite low (41.17%), possibly because many patients who used a tube had severe pelvic adhesions and continuous build-up of fluid in the abdomen.

Previous studies[27] have shown that 71% of parturients are most worried about pain during early ambulation. The combination of local anaesthetics and opioids reduces the dose of opioids and has the benefit of achieving postoperative analgesia after C-section [28, 29]. This study showed that the localization analgesia programme standardized the postoperative analgesia administration procedure in the department and kept the postoperative pain score below 3, which also reduced the risk of POI due to improper use of opioids.

This study had several limitations. First, the clinical practices of this intervention were limited by the resources/technologies available in our Obstetrics Care Center. Second, this was a single-centre investigation. With the advance of modern information technology, application programs such as bracelets can be used to record patients’ activities in real time. Future multicentre trials employing more advanced technologies are required to further validate and improve the intervention.

In conclusion, we established an evidence-based nursing intervention that can effectively promote early postoperative off-bed activities and rehabilitation among C-section patients in China. Multidisciplinary collaboration and multiple forms of preoperative health education for family members and patients could help promote evidence-based postoperative management, alleviate postoperative pain, shorten hospital stays, and decrease the incidence of POI and infection. Our study shows that evidence-based nursing intervention in C-section patients can significantly improve patient outcomes, and evaluation of the effect of evidence-based practices should be considered in the clinical setting.