IMPLEMENTING INTERVENTIONSAimed at Reducing Rates of Cesarean Birth

LUCIE J. AGOSTA

CHERI JOHNSON

High rates of cesarean birth in the United States have remained a topic of principal concern among health care professionals, institutions, and consumers. A variety of interventions have been proposed and implemented to address this troubling trend. In addition to the close scrutiny of overall rates of cesarean birth, the rate of nulliparous, term, singleton, vertex (NTSV) cesarean birth has been specifically adopted by a variety of nationally recognized entities as a significant obstetric quality indicator.

Abstract: Increased incidence of both nulliparous, term, singleton, vertex and overall cesarean birth rates has warranted close monitoring and scrutiny by various health care associations and by individual obstetric facilities and providers of obstetric care. Concerted efforts to reduce rates of nonmedically indicated cesarean birth have resulted in the devel-opment and implementation of comprehensive action plans aimed at effecting reductions and enhancing overall obstetric quality care. Here we describe how a multidisciplinary team at our hospital developed and implemented interventions aimed at reducing rates of cesarean birth. http://dx.doi.org/10.1016/j.nwh.2017.06.006

Keywords: cesarean | childbirth | labor induction | NTSV | oxytocin administration

IMPLEMENTING INTERVENTIONSAimed at Reducing Rates of Cesarean Birth

262 © 2017, AWHONN nwhjournal.org

The U.S. Department of Health and Human Services Healthy People 2020 goals (n.d.), the American College of Obstetri-cians and Gynecologists (ACOG; 2010), and the Joint Com-mission (2009) all consider overall and NTSV cesarean birth rates to be significant indicators of the overall obstetric perfor-mance of providers and facilities, as well as a key variable on which individual performance data are benchmarked. Efforts aimed at reducing NTSV and overall cesarean birth rates are considered critical objectives of all facilities and practitioners providing obstetric care (ACOG, 2010; the Joint Commission, 2009; U.S. Department of Health and Human Services, 2011). Potential adverse outcomes associated with cesarean birth include higher rates of hysterectomy, postpartum hemorrhage, venous thromboembolism, wound complications, and hospital readmissions (Ehrenthal, Jiang, & Strombino, 2010). Increased risk for future uterine rupture, placental abnormalities, and bowel and bladder injuries are also associated with cesarean birth (ACOG, 2013a).

Factors That Influence Mode of BirthMultiple variables influence whether a woman will give birth vaginally or via cesarean. Preexisting maternal factors and medical conditions, including diabetes, hypertension, and advanced maternal age, have been associated with higher overall and NTSV cesarean birth rates (Brennan, Murphy, Robson, & O’Herlily, 2011; Coonrod, Drachman, Hobson, & Manriquez, 2008). Additional factors shown to be associated

with higher rates include African American race, increased birth weight, and the practice of labor induction (Edmonds, Hawkins, & Cohen, 2014; Edmonds, Yehezkel, Liao, & Moore Simas, 2013). Multivariable analysis of institutional, individual, clinical, and nonclinical factors showed that variables such as the presence of a high-level nursery and higher prevalence of Medicaid reimbursement for birth-associated health care costs have been associated with lower overall rates, whereas the presence of lower-level nurseries and obstetric and gynecology

residency programs have been associated with higher cesar-ean birth rates (Coonrod et al., 2008). Conversely, significant variations in current cesarean birth rates appear to be possibly related to nonclinical factors, such as obstetric provider prac-tice patterns, malpractice history, and personal dynamics such as competing pressures of practice and lifestyle (Coonrod et al., 2008). Additionally, overweight and obesity in nulliparous women undergoing elective labor induction has been shown to be associated with higher rates of cesarean birth and a higher incidence of NICU admission (Wolfe, Timofeev, Tefera, Desale, & Driggers, 2014).

The continuous presence and support during labor by trained doulas have also been shown to decrease time in labor among a population of low-income laboring women (Camp-bell, Lake, Falk, & Backstrand, 2006). Attendance and participa-tion in childbirth education classes during the prenatal period, before labor onset, have also been associated with higher rates of vaginal birth (Stoll & Hall, 2012). More recent studies have suggested that appropriate methods of childbirth education and preparation serve to actually facilitate and promote vaginal birth (Kennedy et al., 2016).

Interventions That May Influence Rates of Cesarean BirthAs shown by a Cochrane Review by Khunpradit et al. (2011), a number of nonclinical interventions have been determined to effectively reduce cesarean birth incidence. Interventions

aimed at women included relaxation education, birth prepara-tion classes, and group therapy sessions. Interventions focused on health care professionals include the use of peer review examination of the labor and birth records, the use of evidence-based guidelines, fee equalization for vaginal and cesarean births, 24-hour in-house physician coverage, implementation of systems of performance audits and feedback, and the dis-semination of nationally accepted practice guidelines and rec-ommendations (Khunpradit et al., 2011).

Education of nursing staff regarding appropriate first- and second-stage labor management has been associated with low-ered cesarean birth rates (Lennon & Seaver, 2014). Targeted educational sessions aimed at facilitating adoption and routine use of therapeutic measures such as frequent maternal position changes to facilitate fetal rotation and descent, as well as the use

Lucie J. Agosta, PhD, RNC-OB, ANP-BC, FNP-BC, is a nurse practi-tioner; Cheri Johnson, BSN, RNC-OB, is Vice President of Perinatal Services; both authors are at Woman’s Hospital in Baton Rouge, LA. The authors report no conflicts of interest or relevant financial relation-ships. Address correspondence to: lucie.agosta@womans.org.

Efforts aimed at reducing NTSV and overall cesarean birth rates are considered critical objectives of all facilities and practitioners providing obstetric care

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of open glottis pushing maneuvers to reduce maternal exhaus-tion and fatigue, have all been shown to facilitate an overall significant reduction in cesarean birth rates (Bloomberg, 2016; Hamilton, 2016).

Additional factors that might influence NTSV cesarean birth rates include the use of positioning and assistive devices during labor (Tussey & Botsios, 2011). The intrapartal use by labor and birth nurses of maternal positioning devices such as peanut-shaped exercise balls has been shown to decrease overall length of labor and increase overall vaginal birth rates among laboring women undergoing epidural anesthesia through the facilitation of fetal descent and rotation (Tussey et al., 2015).

Influence of Trial of Labor After Cesarean Birth and Vaginal Birth After Cesarean Birth Controversy exists regarding the practice of vaginal birth after cesarean birth (VBAC), with many obstetric services elect-ing to discontinue the practice of trial of labor after cesarean birth (TOLAC). Although ACOG (2010) recommendations suggest that most women with a history of one operative birth should be counseled regarding VBAC and be considered for TOLAC, many facilities and obstetric providers fail to offer this option to laboring women, citing patient safety and medical/legal concerns. The increase in the overall incidence of cesar-ean birth in the United States has been postulated in some instances to be related to the failure of women being offered the

option to undergo TOLAC. Furthermore, an inverse relation-ship has been shown between overall VBAC rates and NTSV cesarean birth rates, with those obstetric services with higher VBAC rates having lower cesarean birth rates (Rosenstein et al., 2013). Because of the perceived reluctance of some providers to offer VBAC opportunities, some women are actually electing home birth after a cesarean birth (Keedle, Schmied, Burns, & Dahlen, 2015). A qualitative study by Keedle et al. emphasizes the importance of considering a woman’s request for a VBAC and possibly relaxing institutional policies and practice prohi-bitions, which serve to inhibit acceptance of such home birth requests. Organizational culture and philosophy, where an

overriding heightened emphasis on vaginal birth by all care providers is exhibited and supported, are hypoth-esized to be possible and plausible variables effecting lower cesarean birth rates (Snowden, Darney, Cheng, McConnell, & Caughey, 2013).

For those providers who remain receptive to offering TOLAC oppor-tunities, ACOG recommends the use of Patient Safety Checklists for assessments of the appropriateness of TOLAC for women in the antepar-tum and intrapartum periods. These checklists attempt to standardize and minimize variations in care among providers caring for women undergoing TOLAC (ACOG, 2012a; ACOG, 2012b). Recommendations by ACOG (2010) further stress the importance of determining appro-priate candidates for TOLAC. Factors shown to increase the prob-ability of successful VBAC include previous vaginal birth and the onset

of spontaneous labor. Those factors shown to decrease the likelihood of successful VBAC include advanced maternal age, non-White ethnicity, maternal obesity, preeclampsia, labor dystocia, shortened interpregnancy time frame, and increased fetal weight at birth (ACOG, 2010).

Antepartum and Intrapartum Labor Management StrategiesSeveral antepartum and intrapartum labor management strate-gies have been found to exert tremendous influence on cesar-ean birth rates. These include the appropriate recognition and diagnosis of prolonged labor, arrest of labor, and dystocia; the appropriate and judicious use of analgesia in labor; the proper use of forceps and vacuum-assisted vaginal births; and the use

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The use of partographs for the graphic assessment of labor progression further aids in the diagnosis of true dystocia, the decreased use of oxytocin, and overall cesarean birth reduc-tion. In addition to partographs, further recommendations include a reexamination of the traditional definition of latent labor (Neal & Lowe, 2012). In a 2014 joint publication, ACOG and the Society for Maternal–Fetal Medicine state that latent labor periods in excess of 20 hours for nulliparous women and 14 hours for multiparous women should not be indications for cesarean birth (ACOG et al., 2014). They advocate cervical dila-tation of 6 cm as the threshold for the diagnosis of active labor for most women and further state that cesarean birth for arrest of labor in the first stage should be indicated only for women who have dilated to at least 6 cm. They further advocate no set definition for the maximum time spent in second-stage labor, recommending a minimum of 2 hours of pushing for mul-tiparous women and at least 3 hours for nulliparous women.

of scalp stimulation as a means of fetal assessment in cases of suspected fetal compromise in labor (Spong, Berghella, Wen-strom, Mercer, & Saade, 2012).

Defining Labor ProgressionIntrapartum labor management has historically been guided by the standard definition of normal labor progression as 1.2-cm/hour cervical dilatation for nulliparous women and 1.3-cm/hour dilatation for multiparous women, with arrest of labor progression being defined as no change in cervical dila-tation in 2 hours (Friedman, 1978; Neal & Lowe, 2012). The finding that cervical dilatation from 4 cm to 5 cm may take in excess of 6 hours and that progression from 5 cm to 6 cm may take in excess of 3 hours provides the basis for recommending a concerted national reexamination of the traditionally estab-lished and accepted definitions of normal labor progression, labor curves, and arrest of labor (Zhang et al., 2010). Ph

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Education of nursing staff regarding appropriate first- and second-stage labor management has been

associated with lowered cesarean birth rates

August September 2017 Nursing for Women’s Health 265

documentation of Bishop scores, requiring a minimum score of 8 before scheduling a woman for an elective induction. Addi-tionally, adherence to the ACOG recommendation of requir-ing a gestational age of at least 39 weeks for elective induction scheduling and hiring a dedicated induction scheduler charged with the sole responsibility of overseeing and policing the scheduling of all elective inductions have collectively served to effect an overall decreased incidence of inappropriate induc-tions and a subsequent decrease in NTSV and overall cesarean birth rates (Ehrenthal et al., 2010; Fisch et al., 2009).

Our Team’s Efforts to Reduce Cesarean Births Obstetric data and indicators, including cesarean birth rates at our facility, have historically been monitored and bench-marked through the National Perinatal Information Center. As a result of an increased emphasis and attention to rising rates of cesarean birth, nurses, physicians, administrators, and all staff in the perinatal services division of our facility have been actively involved in a number of interdisciplinary interventions developed and used during the time period from 2010 through 2015. Composite statistical information for this time period is presented, along with a discussion of interventions used in an attempt to illustrate our many successes with this impressive and extensive endeavor.

Data regarding overall and primary cesarean birth rates at our facility from 2010 through the first two quarters of 2015 are given in Table 1, illustrating statistically significant

Additional interventions shown to prevent primary cesarean births include the use of amnioinfusion for variable decelera-tions of the fetal heart rate and scalp stimulation for ongo-ing assessment of fetal well-being in periods of abnormal fetal heart rate patterns (ACOG et al., 2014).

Standardized Admission CriteriaThe implementation of standardized admission criteria aimed at reducing admission before the onset of active labor has been shown to significantly reduce the overall incidence of cesarean birth rates (Neal, Lamp, Buck, Lowe, Gillespie, & Ryan, 2014). By allowing and encouraging an observational period before the onset of active labor, establishing realistic expectations for cervical dilatation, and admitting and committing to birth only after achievement of the diagnosis of active labor, a reduction in cesarean birth rates has been shown (Neal et al., 2014).

There is evidence that the incidence of operative cesarean birth may be as much as twice as high in women who undergo elective labor induction compared with those who experience spontaneous labor onset, and the implementation of induc-tion guidelines aimed at reducing inappropriate elective labor inductions has been shown to significantly reduce the inci-dence of cesarean birth (Fisch, English, Pedaline, Brooks, & Simhan, 2009). The implementation of standardized induc-tion guidelines in conjunction with programs of nursing staff education and enhanced medical staff awareness have all been shown to positively affect cesarean birth incidence (Ehrenthal, Jiang, & Strobino, 2010). Recommendations regarding stand-ardized induction guidelines include accurate assessment and

TABLE 1 Overall and Primary Cesarean Birth Rates From 2010 Through Second Quarter 2015

Year

Overall Cesarean

Birth Rate, % n

Confidence Interval

66-Month % Decrease

and p

Primary Cesarean

Birth Rate, % n

Confidence Interval

66-Month % Decrease

and p

2010 39.7 3,083 [38.6, 40.8] — 26.5 1,654 [25.4, 27.6] —

2011 38.4 3,065 [37.3, 39.5] — 24.3 1,537 [23.2, 25.3] —

2012 39.1 3,298 [38.0, 40.1] — 25.5 1,723 [24.5, 26.6] —

2013 37.1 3,118 [36.1, 38.1] — 23.1 1,541 [22.1, 24.1] —

2014 36.7 3,118 [35.6, 37.7] — 22.4 1,541 [21.4, 23.4] —

2015 Q2

35 1,443 [33.5, 36.5]–7.7%

p < .00121.4 705 [20.0, 22.8]

–15.4% p < .001

Note. Source: National Perinatal Information Center, 2015. Q = quarter.

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downward trends realized at our facility since the implementation of our cesarean birth reduction interventions. Statisti-cal analysis of our repeat cesarean birth rates exhibited similar decreases, shown in Table 2. Data illustrating an increased incidence of vaginal births for the same time period are given in Table 3.

About Our FacilityOur facility, founded in 1968, is one of the largest obstetric hospitals in the Southern United States and has a colorful and illus-trious history as a nationally renowned center of obstetric excellence. A private, nonprofit organization, our facility is one of the largest women’s specialty hospitals in the United States and has maintained status as an American Nurses Credential-ing Center Magnet Hospital since 2003. According to national ShareCor Data, our facility is where 80.6% of all newborns in our geographic area are born and is ranked 17th in the country in total births, with more than 8,500 each year.

Adhering to its mission to improve the health of women and infants, the nurses and staff of our hos-pital are dedicated to providing comprehensive and innovative programs of obstetric and perinatal care to women and families within our metropolitan area. As a Magnet facility, we consist-ently strive for excellence in delivery of nursing care, quality improvement efforts, and implementation of evidence-based practices. Nurses in the obstetric service actively participate in, measure, and benchmark data with many of the highest-performing health care networks in the world, including The Council of Women and Infants’ Specialty Hospitals, National Perinatal Information Center, and the Institute for Healthcare Improvement Collaborative on Perinatal Improvement. Our facility has been actively involved in collaborative endeavors to reduce overall and NTSV cesarean birth rates over the 5-year time period from 2010 to 2015.

Project Leadership and StakeholdersThe project, consisting of several individual endeavors, was co-managed by a nurse–physician dyad. Both members of the dyad held Vice President– and Chief of Staff–level leadership positions at the facility. Physician leadership was primarily responsible for directing physician practice changes, develop-ing policies and procedures, and identifying and delineating areas in which changes in physician behaviors were warranted. Nursing leadership led the direct implementation and opera-tionalization of practice changes among the perinatal nursing

TABLE 2 Incidence of Cesarean Births in Women With a Previous Uterine Scar From 2010 Through Second Quarter 2015

Year

Cesarean Birth Rate in Women With a Previous Uterine Scar, % n

Confidence Interval

2010 94.0 1,429 [92.6, 95.1]

2011 93.2 1,528 [91.9, 94.4]

2012 92.0 1,575 [90.6, 93.2]

2013 91.4 1,577 [90.0, 92.7]

2014 90.7 1,639 [89.3, 92.0]

2015 Q2 89.7 738 [87.4, 91.7]

66-month change –3.5

Note. Q = quarter.

TABLE 3 Vaginal Birth Rates From 2010 Through Second Quarter 2015

YearVaginal

Birth Rate, % n

2010 60.3 4,679

2011 61.6 4,913

2012 61.0 5,148

2013 62.9 5,288

2014 63.4 5,497

2015 Q2 65 2,681

66-month change 5.1

Note. Q = quarter.

August September 2017 Nursing for Women’s Health 267

staff. As part of the nursing initiative, a committee of 12 staff registered nurses and one medical librarian formed the Peri-natal Improvement Collaborative Committee and Alliance in Maternal Health. This committee researched and shared evi-dence, assisted with protocol development, attended provider meetings, provided ongoing communication and education to the entire perinatal nursing staff, and assumed the role of unit champion during this endeavor.

InterventionsSome of the initial consciousness-raising efforts used by our facility included monitoring, benchmarking, and dissemina-tion of data related to NTSV cesarean birth rates, overall cesar-ean birth rates, VBAC rates, and TOLAC rates (ACOG, 2012a, 2012b). Further interventions included the development of clinical pathways and standardized order sets for oxytocin administration for all women undergoing labor induction and augmentation. An array of protocols guiding the administra-tion of intrapartum oxytocin had previously been in place at our facility. Efforts aimed at standardization were postulated to provide consistency and further help reduce cesarean birth rates (ACOG, 2009). In an attempt to electively induce labor in

women with cervixes conducive to labor readiness and effect optimal and effective contractions, a Bishop’s score assess-ment was included in the revised pathway order sets, as was a recommendation to electively schedule only those women at 39⁰⁄7 weeks gestation (ACOG, 2013a). New protocols and intra-partum interventions related to use of alternative positioning devices, the process of laboring down, and closed glottis push-ing attempts in second-stage labor were developed and imple-mented (ACOG, 2017; Hamilton, 2016).

Oxytocin Order RevisionsIn an early effort to address cesarean birth incidence, obstet-ric nursing staff were actively involved in comprehensive mea-sures to revise the clinical pathway standardized order set for oxytocin administration for all women undergoing labor induction and augmentation, with a concentration on women being induced. Nursing input was instrumental in revising the pathway order set to ensure inclusion of electronic health record fields indicating estimated fetal weight, clinical pelvim-etry, and Bishop’s scores more than or less than 8, indicating cervical readiness for successful labor induction. The primary focus of this intervention was women scheduled for elective

As first-line providers and active participants in the concerted approach to reduce rates of cesarean birth, nursing staff began to

investigate interventions within their scope of practice and expertise that could be successfully and autonomously implemented

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The cesarean birth rate in August 2012, before the recom-mendation to include a Bishop’s score when scheduling women for elective induction, was calculated to be 39.02%. Dur-ing the 1-month period after implementation of the Bishop score assessment recommendation, the rate was noted to have decreased considerably to 30.95%.

Month-to-month variations continued to exist. In June 2013, the rate was noted to be 35.5%; in July 2013, it had risen slightly to 36.84%. Noting the apparent and consistent posi-tive effect of requiring Bishop score documentation before scheduling an elective induction, medical staff leadership was successful in effecting a hospital policy change in July 2013 to require assessment and documentation of a Bishop score of 8 or greater to schedule an elective induction. Additionally, upon recommendation of the nursing staff, the electronic scheduling system was modified to include a pop-up window for entering and electronically calculating the Bishop’s score by the induc-tion scheduler. In October 2013, the issue of Bishop score doc-umentation before scheduling an elective induction became a recurring agenda item subject to review by the hospital’s medi-cal review committee. During this same month, October 2013, the rate had significantly decreased to an all-time low of 14.8%. Although changes and variation in month-to-month sample size and confidence interval calculations accounted for some degree of fluctuation, the overall trend in the data indicated an overall reduction in operative births.

In March 2014, in an attempt to further enhance commu-nication and awareness, individual cesarean birth rates were

labor induction; however, the protocols were globally adopted and used for all women undergoing labor induction or intra-partum augmentation.

Separate protocols were delineated for oxytocin administra-tion rates, beginning at one milliunit with increases by 1 milli-unit, beginning at 2 milliunits with increases by 2 milliunits, and beginning at 4 milliunits with increases by 4 milliunits. Each of the three administration protocols was modified to address uterine response and tachysystole and hyperstimula-tion. Each protocol directed that increases in the administra-tion rate were to occur every 30 minutes according to uterine response and that uterine activity should not exceed five con-tractions within a 10-minute tracing interval, averaged over a 30-minute period. Oxytocin also was not to exceed 20 mil-liunits/minute without further assessment and direction from the obstetrician (Woman’s Hospital, 2016), with a maximum administration rate of 35 milliunits/minute.

Elective Induction Scheduling Practices and Bishop’s ScoresProcesses associated with elective induction scheduling were also examined. In September 2012, a change in procedure in which physicians were requested to optionally document a Bishop’s score assessment at the time of induction scheduling was implemented (Woman’s Hospital, 2014.) In an effort to ensure consistency and continuity, the obstetric unit also hired dedicated personnel to function in the position of induction scheduler during this time.

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scoring requirements in May 2015, a cesarean rate decrease from 36.59% to 22.22% in June 2015 was noted.

Laboring Down in the Second Stage of LaborIn October 2013 we implemented a procedure for laboring down in the second stage of labor, along with ongoing adher-ence to guidance in AWHONN’s Nursing Care and Manage-ment of the Second Stage of Labor (AWHONN, 2008). Amid

recent conflicting evidence regarding its use (ACOG, 2017), the laboring down procedure advocates that laboring women who do not feel the urge to push when completely dilated because of regional anesthesia and those who are ineffective pushers upon becoming completely dilated should delay active pushing attempts for selected time intervals and allow the fetus to descend passively. The avoidance of closed glottis pushing attempts in an effort to avoid perineal lacerations and injuries is also advocated. Laboring down avoids maternal fatigue and exhaustion and decreases the incidence of abnormalities of the fetal heart rate associated with sustained, coached, closed glot-tis pushing (AWHONN, 2008).

Defining Term GestationDuring this same time period, one of the larger obstetric groups affiliated with our facility became the first in the area to institute a policy congruent with the ACOG (2013b, 2017) recommen-dation of scheduling no elective inductions before full-term gestation at 39⁰⁄7 weeks, thus deviating from the traditional practice of convenience scheduling of inductions between 37 and 40 weeks gestation. In addition to concerns regarding com-plications of fetal prematurity, this endeavor attempted to limit elective inductions to those term pregnancies with cervixes that were potentially more inducible.

Results and Implications for CliniciansCollectively, these interdisciplinary interventions have resulted in significant decreases in overall cesarean birth rates and com-parable significant reductions in the NTSV cesarean rates. Fig-ure 1 depicts overall cesarean birth rates and NTSV cesarean birth rates from 2010 through the second quarter of 2015.

As a center of excellence in obstetric care, our facility has been instrumental in implementing a number of successful interventions to directly address and positively influence the increased incidence of cesarean birth in our community. Amid our successes we acutely recognize the need to thoroughly

directly communicated to providers and also posted anony-mously for review in conspicuous areas of the hospital fre-quented by obstetric nursing staff and physicians. These data were inaccessible to patients. These blinded graphs were com-municated without prior knowledge and notice to the medical and nursing staffs by the project leaders, the nurse–physician dyad. The initial reaction of many of the providers was to chal-lenge the data; however, as the month-to-month composites

were communicated, an informal sense of competition seemed to develop. After these initiatives, rates were noted to decrease from 37.14% in February 2014 to 22.22% in March 2014. Dur-ing the remainder of the 2014 calendar year, rates fluctuated between 18.18% and 36.84%. In January 2015 the rate was noted to remain less than many national averages at 16.22%.

Intrapartum Management and Assistive DevicesAs first-line providers and active participants in the con-certed approach to reduce rates of cesarean birth, nursing staff began to investigate interventions within their scope of practice and expertise that could be successfully and autono-mously implemented. One such intervention was the use of the peanut ball to assist with labor positioning during the intrapartum period. Although positioning devices such as rolled blankets and foam wedges had been used in the past, these had become very unpopular with laboring women and nursing personnel.

Several members of the obstetric nursing staff in early 2015 became interested in the use of assistive devices in labor and decided to pursue implementation of their use at our facil-ity. Their literature search showed evidence-based findings suggesting the effectiveness of peanut ball assistive devices in reducing second-stage labor pushing time and risk for cesarean birth (Tussey & Botsios, 2011; Tussey et al., 2015).

Approximately 89% of all laboring women at our facility request and receive epidural anesthesia during the intrapar-tum period. Although ambulation is common during latent labor, few women ambulate in active labor after receiving epidural anesthesia. Hydrotherapy during labor is an offered option; however, few women elect to use this alternative. Sev-eral devices were purchased, and protocols were developed for their use. The assistance of two doulas functioning in the com-munity was elicited to participate in training staff and trialing the new apparatuses. After full implementation of the assistive devices and in conjunction with implementation of Bishop

A vital contributor to our project’s success was ongoing open communication and dissemination of information provided by our physician–nurse dyad leadership team

270 Nursing for Women’s Health Volume 21 Issue 4

of excellence, we embrace opportunities to evolve and build upon our successes while still remaining committed to our mis-sion of improving the health care of the women and children whom we have the privilege of serving. For those facilities con-sidering the implementation of interventions to reduce cesar-ean birth rates, we propose the action steps in Box 1.

ConclusionAdhering to our hospital’s mission to improve the health of women and children, our multidisciplinary approach to reduc-ing rates of NTSV and overall cesarean birth has yielded many successes. A vital contributor to our project’s success was ongo-ing open communication and dissemination of information provided by our physician–nurse dyad leadership team. Several key interventions were included in the implementation of our program. Among these was the development of clinical path-ways and standardized order sets for oxytocin administration.

investigate additional evidence-based interventions and mea-sures that might be effectively used in the future.

Women whose labor was traditionally and solely managed by private physicians have been found to undergo cesarean birth more frequently than their counterparts who were managed by a midwife/physician laborist model (Nijagal, Kuppermann, Nakagawa, & Cheng, 2015; Rosenstein, Nijagal, Nakagawa, Gregorich, & Kuppermann, 2015). Because our hospital does not currently use laborists or certified nurse-midwives, we recognize the need to further investigate the potential benefits of these roles and expand the current roles of our doulas and childbirth educators.

Improvements in our current VBAC, TOLAC, and repeat cesarean birth rates present yet other opportunities along with the potential successes that could subsequently result from revisiting our use of the historically standard definitions of labor progression and dystocia. Recognized as a national center

FIGURE 1 Cesarean Birth Rate and NTSV Rate From 2010 Through Q2 2015

Note. Source: Woman’s Hospital (2015). CY = calendar year; NTSV = nulliparous, term, singleton, vertex; Q = quarter; WH = Women’s Hospital.

37.83%

33.23% 34.60%

31.60% 31.94%

27.33%

40.47% 37.68% 37.94%

35.91% 35.71% 34.04%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

2010 2011 2012 2013 2014 2015

Cesarean Section Rate and NTSV Rate

WH CY NTSV Rate WH CY Section Rate

August September 2017 Nursing for Women’s Health 271

American College of Obstetricians and Gynecologists. (2010). ACOG practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstetrics & Gynecology, 116(2 Pt. 1), 450–463. doi:10.1097/AOG.0b013e3181eeb251

American College of Obstetricians and Gynecologists. (2012a). ACOG patient safety checklist no. 8: Appropriateness of trial of labor after previous cesarean delivery (antepartum period). Obstetrics & Gynecology, 120(5), 1254–1255. doi:10.1097/01.AOG.0000422588.22542.e0

American College of Obstetricians and Gynecologists. (2012b). ACOG patient safety checklist no. 9: Trial of labor after pre-vious cesarean delivery (intrapartum admission). Obstet-rics & Gynecology, 120(5), 1256–1257. doi:10.1097/01.AOG.0000422539.04754.27

American College of Obstetricians and Gynecologists. (2013a). ACOG Committee opinion no. 559: Cesarean delivery on maternal request. Obstetrics & Gynecology, 121(4), 904–907. doi:10.1097/01.AOG.0000428647.67925.d3

We also established definitions for term gestation at 39⁰⁄7 weeks and required the assessment and documentation of a Bishop’s score for all elective inductions. Establishing laboring down procedures and closed glottis pushing, as well as implementing the use of alternative positioning devices in labor, additionally contributed to our accomplishments. NWH

ReferencesAmerican College of Obstetricians and Gynecologists. (2009).

ACOG practice bulletin no. 107: Induction of labor. Obstet-rics & Gynecology, 114(2 Pt. 1), 386–397. doi:10.1097/AOG.0b013e3181b48ef5

BOX 1 Action Steps in Our Project to Reduce Cesarean Birth

1. Identified a group of 12 dedicated and passionate registered nurse champions and one medical librarian, who formed the Perinatal Improvement Collaborative Committee/Alliance in Maternal Health who worked in conjunction with senior leadership nurse-physician dyad project managers.

Responsibilities of Perinatal Improvement Collaborative Committee/Alliance in Maternal Health team included

• Discussing and demonstrating strategies to effectively manage reductions in operative births

• Exploring evidence-based approaches to reduce cesarean births

• Reviewing current tools and feasibility of intervention implementation

• Exploring national projects and research

• Reviewing ongoing outcome data

• Serving in active role as unit champions

• Facilitating ongoing communication with nursing staff

2. Revised clinical pathway standardized order set for oxytocin administration for labor induction and labor augmentation.

3. Revised Elective Delivery Protocol to include Bishop’s score assessment as criteria for induction. Added field for Bishop’s score assessment as a pop-up window in electronic health record. Added Bishop’s score documentation as an item subject to monthly review by the hospital’s medical review committee. Hired dedicated personnel to manage scheduling of all elective inductions.

4. Ensured that individual cesarean birth rates were directly communicated to providers and posted anonymously for review by nursing and medical staffs.

5. Implemented use of intrapartum assistive devices, including peanut ball, along with extensive education to nursing staff members by trained doulas.

6. Implemented procedures for laboring down in the second stage of labor and closed glottis pushing attempts.

7. One of the larger obstetric groups implemented scheduling of no elective inductions before 39 weeks.

8. Communicated all successes realized to all stakeholders.

272 Nursing for Women’s Health Volume 21 Issue 4

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