By Christine H. Morton, PhD

'Experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.'

Today, on Science & Sensibility, Christine Morton, PhD takes a look at a study examining the role of nurses in helping to achieve a vaginal birth for patients under their care. No surprise from my point of view, my professional experience as a doula has demonstrated that L&D nurses play a critical role in the birth, and can really help a mother to achieve the outcome she desires. Please enjoy Christine's synopsis and interview with one of the study authors.- Sharon Muza, Community Manager

Readers of this blog are well aware of the 50% increase in cesarean delivery rates over the past decade, and are likely aware that the high US cesarean delivery rate is on the maternal quality and patient safety agendas for many organizations. More attention will soon be focused on hospital rates (the Joint Commission recently expanded its performance measurement requirements such that as of January 1, 2014, all hospitals with more than 1100 annual births will be REQUIRED to report on the Perinatal Care Measure Set, which was the subject of a past blog post). The Perinatal Care Measure Set includes a measure on the first birth cesarean among low risk women (nulliparous women who have cesareans at term, with singleton, vertex babies). Furthermore, Centers for Medicare and Medicaid Services (CMS) is requiring that all states report rates of Elective Deliveries <39 Weeks as of 1/1/13 and it is likely that a similar requirement for the NTSV (Nulliparous Term Singleton Vertex) Cesarean measure is not far behind.

One indicator of this trend was the February 2012 symposium on preventing the first cesarean held jointly by National Institute of Child Health and Human Development (NICHD), the Society for Maternal Fetal Medicine (SMFM) and American Congress of Obstetricians and Gynecologists (ACOG.) A comprehensive summary of the proceedings of that symposium was published in the November 2012 issue of Obstetrics and Gynecology, which is well worth reading but is available only with a subscription. That same issue had a commentary on how to create a public agenda for reducing cesarean delivery, written by me and my California Maternal Quality Care Collaborative colleagues, which is free to all, thanks to our funder.

The attention to the detrimental health impact of our country's cesarean rate for women and their babies is a good sign, coming as it does from powerful organizations with interests in providing care and paying for it. Most of the focus on quality measurement reporting on cesarean delivery has been directed at hospital level (i.e., Leapfrog and The Joint Commission), though there is interest among payers and consumers for public reporting of provider-specific rates. Virginia is one example where obstetric outcomes (cesarean, episiotomy) are publicly reported at the hospital and provider levels. However, it is complicated to attribute outcome rates in obstetrics, which is increasingly a 'team sport' with multiple clinicians (physicians, midwives and nurses) involved in the care of a woman throughout her pregnancy and birth.

Yet, in all these domains (institutional, measurement, quality improvement), the role of nurses on cesarean delivery decisions and outcomes has been barely mentioned. Neglecting the labor & delivery nurse's role is unfortunately all too typical in public discourse around quality reporting, shared decision-making and improving outcomes in birth. I have become very interested in the nursing perspective as the more I learn about hospital birth, the more I realize that nurses are central to the management of labor & delivery units, and in measuring and reporting outcomes. Thus, it was with great delight that I saw a new study, Intrapartum Nurses' Perceived Influence on Delivery Mode Decisions and Outcomes in the January 2013 issue of JOGNN

Nurse-researchers Joyce K. Edmonds and Emily J. Jones conducted a semi-structured interview study with 13 nurses who were employed at a hospital with about 2000 births a year and overall cesarean rate of 36%. These nurses work within a 'nurse-managed labor model' which is characterized by a relatively autonomous nursing role, with intermittent communication with an off-site obstetrician. Most nurses in the US practice within this type of model. Nationally less than 10% of hospitals that do births are teaching hospitals, which have 24/7 access to physician consultation. Other hospitals with 24/7 physicians on staff include HMOs like Kaiser Permanente, or those who have hospitalists. In California, about half of all birthing facilities do not have an OB available onsite 24/7.

Shockingly few studies have looked at nurses' role on the mode of delivery. This is more striking when one considers the many specific nursing clinical practice responsibilities that may affect cesarean rates. Nurses are largely responsible for assessing women during triage for admission, monitoring and assessing the health of mother/baby after hospital admission. Nurses manage and administer oxytocin, assess and assist with labor pain, and are primary managers of second stage labor. These practices occur within the administrative context of each hospital's policies on admission in early labor, rates of interventions such as inductions (especially those for no medical indication), cesarean (especially those among the low risk population) and availability and rates of Vaginal Birth After Cesarean (VBAC).

Data for this study were drawn from semi-structured interviews with nurses who had a range of 10-40 years clinical experience in L&D. Questions were specifically designed to elicit active practice and interaction with physicians (interactions with women were not addressed). An example of a question asked of respondents, 'Can you tell me about a time when you intervened to promote vaginal delivery or avoid a cesarean?'

The overarching theme in this study was how nurses described their efforts to 'negotiate for more time' during labor, to positively impact the likelihood of a vaginal delivery. Negotiating for more time was defined in this study as 'a form of nurse-physician interaction and an action taken to create the temporal space in which nursing interventions thought to affect delivery mode decisions operate'. The authors found that nurses' ability to negotiate for more time was based on their knowledge of labor and birth over their many years of experience, as well as their knowledge of individual physician practice patterns. Furthermore, nurses' awareness of physician and institutional-imposed time constraints was a key factor in negotiating for more time.

The important conclusion reached by the authors was that 'experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.' Despite the known limitations of this study - small sample of highly experienced nurses working at a single institution - I was intrigued and excited by the practice implications and the potential to develop quality improvement strategies for reducing cesarean deliveries that are specific to nurses. So often, the labor & delivery nurses' role is overlooked in this area and this study is an important contribution to our understanding of nurses' influence in cesarean outcomes. There is clearly more research and work to be done, and one of the authors, Joyce K. Edmonds, graciously responded to questions I had about the study and future directions for this research and quality improvement initiatives:

CHM: It was interesting that the range of experience represented in your study was 10-40 years - do you think your sample was more weighted toward the more experienced nurses? Do you have any theories for why the lower end of the range was so high? Were there nurses in that hospital with 2-3 years of experience? Any thoughts about why they did or did not participate?

JKE: Our sample was without doubt weighted to the experienced nurse, and we used the term experienced as a qualifier throughout the paper. This particular hospital staff was highly experienced, although, there were nurses with less than < 5 years experience. We think the sample was a self-selecting group of nurses who felt strongly about birth mode and the influence they had on birth mode decisions. Perhaps, less experienced nurses' perspectives on birth mode were not as clearly developed as those who participated. It could also be that those who volunteered to participate were more supportive of promoting vaginal deliveries than those who did not participate. It could also be that scheduling conflicts with less experienced nurses prohibited them from participating.

Joyce Edmonds

CHM: I think the fluid nature of 'time' and the constraints on physician time bear further exploration. In this regard, it would have been helpful have analyses of accounts where nurses felt they were 'unsuccessful' in buying more time for labor. The counter-factual example can sometimes shed light on the dynamics - what didn't work in this case? Do you have any unsuccessful stories in your data and/or did you analyze those? It seemed as though all the nurses in your study DID negotiate for time, or at least provided you with accounts of when they did. Were there any nurses who did NOT have a story to share about negotiating for more time?

JKE: All the nurses did talk about negotiating for time, which is the reason it emerged as the overarching theme. Nurses did talk about not being able to negotiate for more time when cesareans were scheduled because the course of labor management was already established. They also seemed to have less influence when inductions were scheduled because again the labor management plan was established prior to their involvement in the care. I'd have to look back at the interviews with an eye toward specific counter-factual examples.

CHM: I also found it fascinating to read the quote that begins, 'It almost feels like you're working against the machine.' I was curious to know more about the justifications for that taboo of not being able to talk or confront the physician with the 'agenda.' In my interviews with OB nurses, I also came across this and think it is an important factor to explore further. I imagine that nurses with less clinical experience are even less able to identify or recognize this 'agenda' and that comes with its own set of practice and policy issues for nursing training.

JKE: I think the nurse physician relationship shapes the day-to-day work environment of the nurse. It is a long-term relationship relative to the nurse-patient relationship. It is likely that talking about or confronting a particular physician about the potential of an agenda could negatively disrupt the work environment, which is significantly related to nurses' job satisfaction. Nurses want to be seen as team players and discussing the potential of physician 'hidden agendas' is like being a whistle blower. In addition to not wanting to disrupt the power balance, they may not want to invite scrutiny into their own practice patterns.

CHM: I was struck in particular by the account on page 5 of your paper that ends with the quote, 'There are certainly situations where the baby needs to come out via C-section, but it is not as many as we do by any stretch.' What situations? What factors influence those decisions? Where do nurses feel they lost power to bargain /buy more time?

JKE: In this quote, the nurse is referring to medically indicated versus potentially unnecessary cesareans. I believe when nurses speak about cesareans they are not only focused on unplanned, intrapartum cesareans but also scheduled cesareans or scheduled inductions, which can result in a cesarean. It was clear from the interviews that nurses felt less invested in the decision-making process when women came in for scheduled cesareans or planned inductions. Nurses also spoke of how women are set up for failure during pregnancy - by way of unfavorable media messages, lack of unbiased childbirth education, and lack of risk reduction information from prenatal care providers.

CHM: I was intrigued that in this study you did not appear to ask about nurses' views toward physiological birth (vaginal) and cesarean, or other indicators of their philosophy of birth. The comment from the nurses who viewed themselves as a 'dying breed' begin to capture some sense of that - whether it is experience, knowledge, or philosophy of birth that unites them against this perceived different group of newer nurses.

JKE: Great question, although it assumes that nurses' personal philosophy of birth impacts their practice, which it likely does according to Reagan et al. In an attempt to keep the data focused on our main aim we did not ask nurses directly about their personal philosophy of birth. I believe the nurses in the study were united in their knowledge of childbirth - without the now pervasive assessment and intervention technology - knowledge borne out of experience.

CHM: How do you plan to follow up with this research and what are your future projects?

JKE: Locally, we want to continue the discussion about the influence of nursing care and knowledge on cesarean rates that started with our interviews. Due to the sensitive nature of the topic and hospital policies, we have not had much success with direct follow-up where the study was conducted. However, we are very interested in presenting and discussing the results with other interested audiences. With regard to future projects, we are currently initiating a study to document the degree of nursing influence on cesarean rates at the level of the individual nurse, at an academic medical center and at a community hospital, building on the sentinel, yet dated, work of Radin et. al. If the results are significant, we foresee the development of a quality improvement strategy directed at providing individual nurses routine (e.g., bi-monthly or quarterly) feedback on standard measures, such as risk adjusted primary cesarean section rates, cervical dilation at cesarean, and cesarean indication, based on the cohort of women in their care. Clearly, although not without great effort, such a strategy would need to be interdisciplinary and have adequate IT infrastructure and support. I also think nurses, as part of a team, should be involved in giving feedback about physician practice patterns in accordance with obstetric standards.

Are you an L&D nurse? Can you comment on your experiences and how you feel your actions can influence the mode of birth. If you are a doula, what has been your observation. Doctor or midwife? How do you view the role of the L&D nurse? I look forward to a robust discussion. - SM

References

Edmonds, J. K. and Jones, E. J. (2013), Intrapartum Nurses' Perceived Influence on Delivery Mode Decisions and Outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 3'11. doi: 10.1111/j.1552-6909.2012.01422.x

Main, E.K., Morton, C.H, Hopkins, D., Giuliani, G., Melsop, K., and Gould, J.B (2012), Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery, Obstetrics and Gynecology, November 2012; 120 (5):1194-1198.

Radin TG, Harmon JS, Hanson DA. Nurses' Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses' Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

Spong, C. Y. MD; Berghella, V. MD; Wenstrom, K. D. MD; Mercer, B. M. MD; Saade, G. R. MD (2012), Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop, Obstetrics & Gynecology, Volume 120(5), November 2012, p 1181-1193

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