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hospital's quality department, asked the hospital for $15,000 to fund classes to teach nurses the natural techniques of childbirth. The hospital approved the funding, and the team announced the plan to the hospital staff. Its goals were threefold: to lower cesarean rates, increase patient satisfaction and bring the heart and soul back into OB nursing.

During a 2½-day course, 50 nurses in the labor and delivery unit learned about tools such as massage therapy and aromatherapy, as well as methods to assess fetal position and rotate patients to move the baby. If, for example, the baby is posterior-the baby's head is facing the mother's spine-and angled too far to the right, nurses can turn the patient to her left side to shift the baby.

The nurses also learned the importance of birthing balls, which encourage women to squat and take advantage of gravity during labor. Women confined to lying flat in bed lose the benefits of gravity, and inactivity also can slow labor, Koehl said.

The hospital also reconstructed showers in the labor and delivery unit to allow women to take birthing balls into the showers. "The use of water is so soothing to a woman, and it helps her to relax and ease the pain," Koehl said. They also started using waterproof Dopplers to continue monitoring fetal heart rates in the shower.

Although these techniques had tremendous potential to lower cesarean rates, the nursing committee predicted that these methods could meet resistance from some doctors. In response, part of the two-day course included sessions about how to interact with physicians.

If, for example, a doctor wanted the patient to move to a bed rather than use the shower, nurses learned to succinctly communicate their opinions. A nurse could say, "I feel comfortable monitoring her in the shower, so I'd like you to consider letting us do that," Koehl said. In the past, nurses might have agreed with the doctor, or if they had a different opinion, hesitated to speak up.

Long-term change

The nursing committee also knew they had to conquer one other significant hurdle: sustaining the use of the techniques over time.

"The biggest mistake leadership teams make is that they think if you just give people education, that will change their behavior," Koehl said. "We knew we needed strong structures in place to make sure it was sustained in the units."

To that end, the committee wrote a standard of care for labor support, which includes guidelines about when to use certain techniques. Koehl believes Rush is the first hospital in the country to create a standard of care for labor support.

The hospital also started monitoring nurses to see if they were using the techniques, and the results were discussed during quarterly reviews. Although this tracking system could seem oppressive, the team pitched it as a way to keep tabs on the excellent work the nurses were doing. In fact, they give out awards to the top 25 percent of nurses who use the natural methods most frequently.

"The message they sent with this initiative was key," Llewellyn said. "Just the fact that the hospital would spend this much money showed that we valued what the nurses were doing."

Once the program was in place, the team eagerly awaited the statistics on the hospital's cesarean rates.

During the first two years of the new system, the rates dropped by 6 percent. The satisfaction rates from patients also rose. In previous years, roughly 40 percent of patients said the hospital exceeded their expectations. Once nurses started using the new techniques, that number jumped to 60 percent.

For Shallcross, the changes have dramatically improved her day-to-day experience as a labor and delivery nurse. Before the initiative, she was one of the few nurses who advocated techniques like the birthing ball, and her excitement about these methods sometimes drew flak from other nurses. Now, her victories with the natural techniques are celebrated with co-workers.

For Koehl, witnessing this camaraderie is one of the most rewarding perks of pioneering this initiative.

"To see nurses blossoming and high-fiving each other can bring tears to my eyes," she said.
"The doctor will say 'We are going to C-section her,' and a nurse will say, 'Give me an hour,' and she'll come out with a big grin. For me, it's been the single most professionally rewarding adventure that I've had, and I've been in nursing for 23 years."

Contact Heather Stringer at heathers@nurseweek.com