Can Your Nurse Increase Your Chance of Having a C-section?

It's well known that the rate of c-section in the United States is higher than it should be at 32 percent. It's also clear that the United States' high rate of death for moms and babies is not being helped by the amount of c-sections performed and that current maternal medical practices are not yielding better outcomes.

A study just published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing(JOGNN) called "Variation in Cesarean Birth Rates by Labor and Delivery Nurses" examines how individual nurses can influence the mode of birth (cesarean or vaginal) of patients in their care. The study also examines how individual nurses affect the care and outcomes of women and newborns during childbirth. This is the first time that researchers have examined the nurse's role for cesarean outcomes, but cesarean rate variations among physicians have been well-studied.

According to obstetrician Neel Shah, one of the researchers on this paper, both the hospital a person chooses to birth at and the provider that a person chooses to birth with may be the biggest predictors of the likelihood of giving birth by cesarean. What role does the labor and delivery nurse assigned to that laboring person play in that outcome?

Some background

Labor and delivery nurses attend almost all of the 4,000,000 births that occur in the hospital setting in the USA (Bingham and Ruhl, 2015). Previous research has shown that nurses affect a physician's clinical behaviors and decisions in labor. Labor and delivery nurses can have influence in their communication and ability to negotiate with physicians to provide additional time for labor. Nurses also are able to discuss and share their clinical opinions on baby's health and management of pitocin. Other factors regarding the role of the nurse in birth outcomes include how many nurses are caring for the patient through the course of the labor, a nurse's beliefs about birth, and how much time a nurse spends providing labor support versus other clinical duties. It is possible that an increased number of nurses managing a woman in labor, a nurse's belief that birth is a risky process, and less time spent providing direct nursing care and support at the bedside might increase the risk for cesarean.

How was the study done?

The researchers examined the cesarean rates in retrospect (after they happened) at a single, large, tertiary care (ie, "major") hospital. The facility sees approximately 3,500 births each year. Nurses are assigned to patients regardless of a person's risk for cesarean birth. All of the patients included in this study were nulliparous women (first-time pregnancy and birth), presenting with a term (at least 39 weeks), singleton fetus (only one baby) in the vertex position (head down) -- also known as "NTSV," which is considered the standard low-risk patient.

A total of 72 nurses fit the requirements for the study and were evaluated over a period of two and a half years, which totaled a review of 3,031 births. All schedule cesareans were excluded. After all the data was pulled, each nurse's cesarean rates were calculated from the total NTSV births they attended in the study period. The nurses were put into four groups based on their calculated cesarean rates. To determine if significant differences existed in the women included in the study, characteristics like maternal age, gestational age, birth weight, Apgar scores, and time of birth were compared.

What were the findings?