No one can disagree that cesarean rates are too high

In the United States, the most recent yearly cesarean rate is 32.0 percent. It is clear that while almost one in three people give birth by cesarean, our high maternal and infant morbidity and mortality demonstrates that current obstetrical practices do not provide for better outcomes.

The reasons for our current national cesarean rate are many, and the pressure is certainly on to reverse this trend and get this number down to an acceptable and appropriate level if researchers can agree on what that might be. 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?

Are labor and delivery nurses affecting outcomes?

This study just published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing (JOGNN); 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. Examining the role of the nurse is a new area of study, but cesarean rate variations amongst physicians have been well-studied both within the same facility and across different hospital locations.

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 the clinical behaviors and labor management decisions of physicians. Some ways that labor and delivery nurses can have influence is in their communications and ability to negotiate with physicians to provide additional time for labor. The nurses also are able to discuss and share their clinical opinions on the current health of the fetus and the management of oxytocin administration. 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, nurse beliefs 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.

It is no surprise that some nurses seem to consistently have low intervention rates, low cesarean rate and good maternal and neonatal outcomes versus other nurses, regardless of the level of risk their patients have. Every unit can identify the particular staff that fits that category.

How was the study done?

The researchers chose to examine retrospectively the cesarean rates at a single, large, tertiary care hospital. This facility is an academic hospital and sees approximately 3500 births each year. There are 12 private LDR rooms, two operating rooms, and a triage area where patients go prior to being admitted. All the nurses are RNs and are able to circulate into the ORs as needed. This facility has received the designation of a Magnet facility by the American Nursing Credentialing Center, which is means that the facility has been recognized for the high-quality nursing services available there.

Nurses are assigned to patients in this facility independently of a person's risk for cesarean birth and all of the patients included in this study were nulliparous women presenting with a term, singleton fetus in the vertex position (NTSV) which is considered the standard low-risk patient.

There are 36 obstetricians and 22 midwives on staff in one practice. There were no new nurse hires or float or temporary nurses during the study period and almost all the nurses work a twelve-hour shift, 7AM-7PM or 7Pm-7AM. The cesarean rate amongst women with NTSV pregnancies (the population included in this study) at this hospital in 2015 was 24.3%. To be included in the study, a nurse had to have attended a minimum of 15 NTSV births during the study period, which 72 nurses met. Nurses were assigned numbers and individual nurses were not identifiable in the study. The data was conducted from births that occurred between January 1, 2013, through June 30, 2015, and information was collected on all the NTSV patients by pulling from the electronic health records system used at the hospital. All schedule cesareans were excluded. Each eligible birth was attributed to the primary nurse present at the time of birth. 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 grouped into four quadrants based on their calculated cesarean rates. To determine if significant differences existed in the population of NTSV women included in the study, characteristics (maternal age, gestational age, birth weight, Apgar scores, and time of birth) of the women and neonates they attended were compared using one-way analysis of variance. Gestational age was based on best dates for estimated date of birth as evaluated by the clinician. Birth weight in grams and Apgar scores at 1 and 5 minutes were extracted from the electronic health record. Times of birth were categorized into day and night based on when they occurred relative to day and night nursing shifts.

What were the findings?

What do we know from this study?

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