The Influence of Nursing Labor Support on the Reduction of Cesarean Sections

Abstract

Background: In the United States, childbirth is the leading reason for hospitalization, with approximately 4 million women giving birth annually, the majority of whom will receive care and support from a nurse. A cesarean section is a major abdominal surgery and accounted for approximately 33% of births in 2013. In comparison to vaginal births, cesarean births have a higher association with healthcare costs, as well as maternal and newborn morbidity. One of the approaches to reduce cesarean birth rates is to increase the woman’s access to nonmedical interventions during labor, such as continuous labor and delivery support. Research suggests that nurses are likely influential in the birth outcome of a woman, and personal beliefs can impact how a nurse supports vaginal birth during labor. Consequently, increasing nursing knowledge of labor support techniques can improve overall birth experiences and outcomes.

Design: This study is a descriptive mixed-method design, conducted at a large urban hospital. The study participants included a convenience sample of 75 eligible Labor and Delivery staff nurses.

Methods: Quantitative measures analyzed data for the total cesarean section rates, and the nulliparous, term, singleton, vertex (NTSV) cesarean birth rates, collected in April and May 2019 (pre-intervention), and January and February 2020 (post-intervention). Additional quantitative measures included use of the survey tool “Intrapartum Nurse’s Beliefs Relate to Birth Practice” (IPNBBP), to analyze nurse beliefs related to normal birth in comparison to medicalized birth. Qualitative measures of the IPNBBP tool included thematic analysis of two-open ended questions about the individual nurses’ beliefs related birth practice.

Intervention: The project intervention is an 8-hour interactive hands-on labor support class aimed at merging contextual (mind) learning focusing on “why” and “when”, and kinesthetic (hand/body) learning focusing on “what” and “how”.

Results: The pre- and post- total cesarean section rates respectively were 28.55% to 32.45 %, a 3.9% increase. The NTSV cesarean birth rates pre- and post- intervention averaged 21.5% and 20.5% respectively, a 1.0% decrease. There were N=69 nurses who completed the pre-intervention IPNBBP survey, and N=34 nurses who completed the post-intervention survey. No significant differences are observed between the pre-post scores for medicalized birth (0.0510) or normal birth (0.5439). However, the difference between the pre and post intervention is marginally significant in medicalized birth. The IPNBBP survey also included 30 elements related to intrapartum nurse experience. Seven elements (unmedicated vaginal birth, ambulation in labor, intermittent fetal monitoring, laboring down, use of breathing and relaxation techniques, hydrotherapy, and encouraging upright positioning during labor & birth) were incorporated into the labor support class. Upon comparison of pre- and post- intervention data, experience using the 7-elements, except for laboring down which stayed the same at 100%, increased by 2.73%-5.8%. Qualitative thematic analysis of the pre- and post- intervention survey responses for the two-open ended questions about the individual nurses’ beliefs related birth practice, identified 18-common themes. In further analysis, the top-5 most common themes, collectively, include support, safety, natural/normal birth, teach/educate, and helping.

Conclusions: Labor support education and training can increase nurse beliefs related to normal birth in comparison to medicalized birth, and can enhance the skills of labor and delivery nurses, and improve the overall maternal, newborn, family, and clinician birth experience and outcomes.

The impact on the cesarean birth rate takes time and continued evaluation to see changes. The outcome of reducing cesarean birth must include ongoing education of entire clinical team.