Courtesy of Rush-Presbyterian, St. Luke's Medical Center

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Nurses from Rush-Presbyterian-St. Luke's Medical Center such as Noelle Shallcross (left) and Jill Riewe aim to reverse the upward trend in cesareans. The nurses use the natural technique of a birthing ball to help Levita Jones during labor. Among the various tools 50 nurses in Rush's labor and delivery unit learned about during a course was the birthing ball, which encourages women to squat and take advantage of gravity during labor.

The tension in the labor and delivery unit at Rush-Presbyterian-St. Luke's Medical Center in Chicago escalated when a patient delivering a 10-pound baby halted at 8 cm for several hours. A cesarean seemed inevitable.

But Noelle Shallcross, RN, was far from giving up. For her, the dilemma was a cue to take advantage of an alternative technique to facilitate vaginal childbirth. Shallcross and a fellow nurse leapt into action and eased the patient onto a birthing ball, a 2½-foot diameter rubber ball used to expand a patient's pelvis and coax the baby to move through the birth canal.

Before long, the two nurses heard the long-awaited words from the patient: "I feel the baby coming." Shallcross was thrilled when the woman delivered her baby vaginally within 15 minutes.

For nurses at Rush, cases like this are a victory.

When the hospital was baffled about how to lower its cesarean rates, nurses approached administrators with a plan, and their overwhelming success has caught national attention. Cesarean rates have been creeping up in the United States for the last several years, with a 10 percent increase since 1996, according to the National Center for Health Statistics. In 2000, about 23 out of 100 births were cesarean deliveries.

"We felt the rate was higher than we wanted it to be," said Jane Llewellyn, DNSc, RN, vice president of nursing at Rush. "Frankly, we weren't making a lot of progress at lowering it."

Linda Koehl MS, RN, education quality coordinator at Rush, was one of the nurses who was confident that it was possible to reverse this upward trend in cesareans. But before the Rush nurses could tackle the problem, Koehl knew they needed a firm grip on the causes of the increased rates.

"We knew that labor support was an art that in the '60s and '70s was passed on orally," Koehl said. "Mentors would take you aside and tell you, 'In this situation, turn the patient to the left, or in this situation, put her on her hands and knees.' "

But throughout the years, Koehl watched this oral tradition fade away as high-tech advancements took over labor and delivery units. Older nurses essentially stopped passing on these natural techniques as more modern pain medications and fetal monitoring devices moved to the fore.

"We wanted to change that," Koehl said. "We wanted them to see birth not as a disease process, but that nature had intended for women to give birth. We had lost our soul a little in OB nursing."

Heart and soul

To execute the needed changes, nurses like Koehl formed a team of 10 people in 1999 called the Nurses' Initiative to Lower Cesareans. The team, composed of nurse practitioners, staff nurses and an employee from the

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