The Natural Way
Rise in Cesareans gives birth to nurses' initiative to reverse the trend and boost surgery-free delivery rates

By Heather Stringer
January 16, 2003

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 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