Simple visual tool helps safeguard mothers after caesarean section

Five Guide, developed by a Queen's Nurse, uses the hand as a guide to enhance recovery and safeguard women from infection

Five Guide, developed by a Queen's Nurse, uses the hand as a guide to enhance recovery and safeguard women from infection after a caesarean

  • Five Guide uses hand to represent the five layers that need time to heal after a caesarean
  • The 5 layers – skin, fat, muscle, peritoneum, womb – need 5-6 weeks to heal
  • Aim is to develop Five Guide for use in training of all health visitors
Janine McKnight-Cowan explains her Five Guide tool. Picture: Tim George

A simple tool developed by a Queen’s Nurse to help health visitors explain to new mothers who have had a caesarean section why it’s important to take things easy has won the Community and General Practice Nursing category of the 2019 RCNi Nurse Awards, the profession’s top accolade.

The clinically effective Five Guide health promotion tool gives health visitors (HVs) the knowledge and confidence to support new mothers through their recovery from surgery.

It has proved such a success that it has been rolled out as mandatory training throughout Derbyshire Community Health Services NHS Foundation Trust.

Underlining the message

Queen's Nurse Janine McKnight-Cowan spent two years developing the explanation she used in her own practice into a simple visual tool to underline the message that five layers have been cut through and need time to heal.

What the judges said

Judge Ruth Oshikanlu, a Queen’s Nurse and a fellow of both the Institute of Health Visiting and Royal College of Nursing, says the judges were impressed by the project’s ‘demonstrable impact’.

‘The Five-Guide enhances C-section recovery as a simple, safe and effective tool that enables midwives and health visitors to provide consistent advice and promote healing, preventing complications from C-section wounds,’ says Ms Oshikanlu.

‘Janine is a passionate and dynamic health visitor who continues to spread good practice through videos and speaking opportunities.’

The Community and General Practice Nursing category of the 2019 RCNi Nurse Awards is sponsored by NHS England

NHE England

‘Caesarean sections account for approximately 27% of all deliveries in England and their care and the advice given to them should be consistent and appropriate for their needs,’ says Ms McKnight-Cowan.

‘Using a Facebook poll, we asked 140 HVs how they communicated with women after a c-section. The answers showed that communication was neither consistent, sustainable nor evidence-based.’

What happens in theatre

‘With my previous scrub midwife knowledge I knew what had happened to these women in theatre, and now I knew what was happening to them in the community.

‘Of course there was no money to make a difference, but my hand was my asset.’

Ms McKnight-Cowan successfully applied for an RCN Foundation Celebrating Nursing Practice grant, which helped her to make a training video on how to enhance recovery and test the new tool in her team using PDSA – Plan Do Study Act – methodology.

‘It became obvious Five Guide was revealing a clinical risk, so it took on a new agenda,’ she says. ‘HVs were not even looking at the new mum’s wound.

‘HVs enter the profession from different clinical backgrounds, and there is no specialist community public health nursing (SCPHN) module on post-operative risks. I developed training that would enhance HVs’ skills and knowledge to deliver effective post C-section care to women.’

The training has so far been delivered to 200 HVs. ‘It engages participants to do what they are trained to do – making that contact count,’ says Ms McKnight-Cowan.

Watch: Enhancing caesarean section recovery

Mother first

She is proud of the effect the project is having on women and their families.

‘These women are high risk but they are getting better, personalised care,’ she says. ‘They are being asked to show the HV their wound so it can be assessed for infection.

‘It is important that the mother is treated first – mothers need to be looked after so they can look after their baby. Infection could be the underlying cause for low mood, tiredness and difficulty establishing breastfeeding, for example.’

Right language and articulating risk

Partners are also encouraged to listen to Five Guide. ‘They are more responsive when they realise there are other internal healing processes going on,’ says Ms McKnight-Cowan. ‘They realise it is more than just a skin scar.’

There have been challenges, including convincing management to adopt the initiative. ‘Learning the right language to use and clearly articulating risk was the key to getting it adopted,’ she says.

‘There were other challenges such as travelling around the country – and internationally – to share Five Guide and training all the trust’s staff myself but crucially my line manager believed in me and the innovation.’

How the Five Guide works

The Five Guide is a visual tool with a thumb to little finger message. The clinician’s own hand, held with fingers spread, represents the five layers that need time to heal as a result of a c-section:

  1. The thumb is layer one and is the skin wound
  2. The index finger is layer two, the fat layer
  3. The middle finger is layer three, the separation of the abdominal muscles
  4. The ring finger is layer four, the separation of the peritoneum
  5. The little finger and fifth layer is the womb

The representation of each layer as a visual window on recovery helps women understand why they need to take things easy and give themselves time to recover.

From the HVs there have been positive comments like ‘why didn’t we think of this earlier’, ‘so easy to remember’ and ‘so easy as you have it with you all the time’.

As well as winning the Community and General Practice Nursing category of the 2019 RCNi Nurse Awards, Ms McKnight-Cowan was awarded a British Empire Medal in the New Year Honours list for services to nursing over her 40-year career, including work to prevent babies being shaken.

Champion role

Semi-retirement is not stopping her. She is speaking at a wide range of conferences to share her work, including the International Maternity EXPO 2019 in London in mid-November.

She plans to develop a champion role to ensure Five Guide is sustained – a train the trainer programme – and is working to develop links with the trust’s feeder SCPHN universities.

Her dream is for use of the tool to become national practice.

Two years work

‘This is the culmination of two years work and I’m just absolutely blown away with the success of it. It has completely transformed my career almost to a legacy.

‘To go from an idea that “went under the radar” to see it in practice, in a training programme, in women’s care plans and HV narratives, has been amazing. Leading this change has put into reality all the skills I have acquired over 40 years as a nurse. I can now say I led change, looked at care and quality and challenged it, and made a difference.’

‘We need to safeguard new mothers vulnerable to infection’

While developing and delivering her Five Guide training, Janine McKnight-Cowan became aware that health visitors (HVs) were unaware of the community sepsis screening tool.

‘It had never been seen by any HV I interviewed, trained or lectured to,’ she says.

‘In our recent mandatory training we discovered not one HV has had any training on c-section management and post-operative risks either during or since qualifying as a specialist community public health nurse. Yet one quarter of the women on an HV’s caseload will have had a c-section.

‘HVs can have a range of clinical backgrounds, such as midwifery, mental health or children’s nursing, but there is currently no specific competency in managing the risks associated with c-sections.’

Sepsis is the leading cause of maternal deaths, with 55% of surgical site infections detected within ten days of a cesarean section and 75% identified by 14 days. The HV's birth visit takes place between ten and 14 days.

‘But none are looking at the mother’s wound,’ she says. ‘Without the tool, women will slip through the net postnatally’.

Watch: Enhancing awareness of post-partum sepsis


Need to safeguard new mothers

She has recently completed an RCN Foundation funded educational video with Sepsis UK to highlight the risks.

The video features the story of Claire Scothern, who had an emergency caesarean for the birth of her son. She began developing flu-like symptoms around two weeks after the birth and was later diagnosed with sepsis.

‘Claire lost both her legs to sepsis,’ says Ms McKnight-Cowan. ‘She had been treated for mastitis. I hope that this video raises awareness about the need to safeguard new mothers when they are vulnerable to infection because they had a c-section.’

Janine McKnight-Cowan with health visitors and students at Derbyshire Community
Health Services NHS Foundation Trust. Picture: Tim George

‘The guide is now part of my daily practice’

Health visitor and practice teacher Ruth Crawford talks about the Five Guide training:

‘Before qualifying as a health visitor (HV) 18 years ago I worked in the operating department as a theatre nurse, so I have seen many C-sections but I have never had any official training in the recovery process.

‘The Five Guide training was useful and thorough. It made me reflect on my role with mothers who have had a caesarean section. I became more aware of the risks associated with this procedure and the need for HVs to have a good understanding for a mother post-operatively.

‘The tool is simple but effective. I liked the training package and session. I have been able to reread the information to ensure I embed the knowledge into my practice.’

Conversation with husband

‘I went straight from the morning training to visit a mother who had had her fourth baby delivered by emergency section. She was happy for me to view her scar – not something I previously would have offered. She thought the Five Guide hand model was easy to understand.

‘I left her a summary of what needs to heal and she was going to use it in conversation with her husband. She felt her husband expected her to carry on as usual in her role as mother to the older children. She had been finding this tiring and wished he would understand her need to recover and not put her recovery at risk.

‘She also had signs of local infection and made an urgent GP appointment on my recommendation.

‘I will continue to use the Five Guide. It is now part of my daily practice and it should be rolled out nationally.’

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