Enhanced Recovery Versus Conventional Care After Cesarean Section
Condition: Cesarean Section; Enhanced Recovery
Study type: Observational

Summary: 
      A protocol of ERACS is introduced to our hospital aiming at saving a lot of time and money
      for the patients and the population at large .By this way ,free beds for more cases can be
      available for others patients, so the researcher is welling to study this research on women
      undergoing CS at Woman's Health University Hospital.
    

Detailed description: 
      This study aims to assess the level of satisfaction of the women undergoing Enhanced Recovery
      Program (ERP) versus conventional care after cesarean section..

      The study will be conducted at the woman's Health University Hospital at obstetrics ward and
      postpartum ward of that hospital,at the Assuit

      The sample size for this study will be 300 randomized -controlled trails women and divided
      into two groups :

      The first 150 of women will be enrolled to the control group, receiving conventional care and
      the second 150 of women will be recruited to the study group , receiving enhanced recovery
      program based care .

        -  Randomization will done by using computer -generated random table.

        -  After acceptance of eligible women to participate in the study ,they will assigned
           randomly to either one of the above groups.

      Two tools will be used to collect data of this study:

      Tool I: perioperative cesarean Section assessment tool:

      This tool will be developed by the researcher based on reviewing available related literature
      and will be used to collect data regarding outcomes .

      This tool will include the following parts:

      Part 1:women's personal data: Consisted of 6 questions such as age, level of education ,
      occupation, weight, height, indication for CS ,date ,time of admission and discharge .

      Part 2: preoperative Data: Consisted of 13 questions such as present medical ,past and
      surgical histories, obstetric history ,smoking history , vital signs, investigations, patient
      advice and information ,breast feeding education ,discuss NPO status (reduced fasting times
      ),hemoglobin optimization ,contact women the day before delivery to review ERAS goals , bowel
      preparation, ,medications, time of transfer to theatre.

      Part 3:Intraopreative Data: Consisted of 10 questions such as duration of operation , total
      fluid replacement ( including blood transfusion), vital signs ,urine output ,active warming,
      delayed cord clamping , skin to skin contact on operation table , minimally invasive surgical
      technique, anesthetic and analgesia medication .

      Part 4:Post-operative Data: Consisted of 16 questions such as time of admission to ward, time
      of starting oral fluid, time of mobilization , time of remove urinary catheter ,duration of
      IV fluid ,use of chewing gum in early postoperative period ,pain intensity , use of analgesia
      drug and anibiotics,postoperative complication, pain intensity on discharge ,postoperative
      length of stay and reason of delayed postoperative length of stay.

      Tool II: Patient's satisfaction tool:

      This tool will be developed by researcher based on reviewing related literature including
      existing satisfaction tools, tested of validity ,piloted for internal consistency reliability
      ,scored and will utilize to assess patient's satisfaction about quality of perioperative care
      services. It is six domains and 40 items. Hospital admission procedure domain ( has 4
      domains) such as women satisfied about ease of overall ,health care domain (has 10 domains)
      such as women satisfied about number of around made of doctor, physician services
      ,information provision domain (has 13 domains) such as women satisfied about information of
      breast feeding and pain management , ,the personal treatment domain (has 5 domains) such as
      women satisfied about kindness of staff , food domain (has 3 domains) such as women satisfied
      about served food quality (has 5 domains) such as women satisfied about cleanliness in the
      room and hospital facilities .

      - Patient's satisfaction will measures by using four points Likert's scale ; Four point
      Likert's format that goes from strongly satisfied (4) to strongly dissatisfied (1), which
      helps in obtaining an ordinal measure of the strength of the satisfaction with each item. The
      tool score range from 40 to 160 .The score of ≤ 80 = dissatisfied, the range score > 80- 120
      = satisfied , and the range score of > 120 - 160 = very satisfied (Ahmed et.al,2017).

      Validity of data collection tools Content validity of the data collection tools will be
      established by 5 experts in the field of the study .The necessary modifications will be done
      accordingly.

      Pilot study:

      A pilot study will be carried out on the first 10 % of the total sample to test the content
      validity, feasibility, clarity and objectively of the tool as well as estimate the time
      needed for data collection. Data will analyzed manually following pilot study. According to
      the result of pilot study the necessary modifications will be done accordingly.

      procedure: An written official approval letter from Faculty of Nursing at the University of
      Assuit to the director of Women Health Hospital; this letter will include a brief explanation
      of the objective and permission to carry out the study .

      Data will be collected from control group first and then from study group to prevent sample
      contamination. The control group will receive the conventional care while study group will
      receive developed enhanced recovery program care .

      Phase 1: Conventional Care Assessment Perioperative data will be collected from this group by
      tool I .Every patient will be assessed at a day before operation to gather all preoperative
      data .the women's operative report is reviewed by researcher and required information will be
      recorded on data collection tool .After that women will be followed up till she is
      transferred to postpartum ward where patient will daily be reassessed during morning shift
      till patient discharge. The patient's satisfaction will be assessed at discharge using tool
      II .

      Phase 2: Designing enhanced recovery program:

      Based on reviewing related to literature; enhanced recovery program after cesarean section
      will be formulated by a designer team, which will consist of a supervisor and head nurse of
      ward, and researcher.

      The established enhanced recovery pogram will consist of four parts:

      Part I: Preoperative evaluation and preparation:

      This part will include health history, physical examination, and diagnostic investigation, as
      well as pre-operative patient preparation.

      Part II: Postoperative daily intervention:

      This part will include the daily nursing and collaborative interventions such as assessment,
      nutrition, activities, medications, patient and family education, and discharge planning and
      instructions.

      Part III: Expected daily outcome :

      This part will include the patient's daily outcomes such as vital signs stability , pain
      control ,activities of daily living and mobility improvement; return bowel function, and
      meeting discharge criteria .

      Phase three: Implementing enhanced recovery program:

      The established pathway will implement on the study group by researcher from admission till
      discharge as conventional care group assessment in phase one.

      Phase four: Evaluating enhanced recovery program outcomes:

      The efficacy of enhanced recovery program will be determined by comparing outcomes for
      patients of both control and study groups
    

Intervention name(s): ERACS; Regular care
Intervention type(s): Other; Other
Intervention description(s): Pregnant women scheduled for cesarean section will be subjected to preoperative, intra-operative and postoperative nurse care aiming at early recovery.; Usual care for all cases subjected to cesarean section at our hospital.
Observational model: Case-Control
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        Elective cesarean section for a pregnany woman.
      
Keywords: cesarean section; Nursing; Enhanced recovery