Nurses ramp up efforts to lower U.S. cesarean rates

In the United States, cesarean births have increased from 20% to 32% over the past 22 years.

The Centers for Disease Control and Prevention reports cesarean rates as high as 37% in states such as Florida and Louisiana. Studies also have shown rates vary widely from hospital to hospital.

While C-sections are medically necessary in some cases, researchers estimate that almost half of these procedures performed in the U.S. are not necessary.

Cesarean sections are not only more costly than vaginal births, but also increase the risk of obstetrical hemorrhage, anesthesia complications, injuries to the bladder, bowel and vascular system, postpartum pain and other problems.

The procedure also can cause placenta accreta — a serious condition in which the placenta grows too deeply into the uterine wall — in future pregnancies.

Pam Lesser, MSN, RNC-AWH

An increase in complications caught the attention of Pam Lesser, MSN, RNC-AWH, director of perinatal services at SSM Health St. Mary’s Hospital-St. Louis.

Several years ago, Lesser noticed more women were being referred to her hospital for abnormal placental attachments, and the perinatal team knew that avoiding the first C-section was one way to decrease the risk of these complications.

To tackle the problem, the team decided to steer away from elective inductions before 39 weeks gestation. Even for patients who reached this milestone, “we started asking ourselves and mothers whether we could wait a little longer for labor to start naturally,” she said.

They also stopped putting time limits on deliveries. Rather than giving mothers 12 or 24 hours to deliver a baby after their water membranes had ruptured, mothers could wait for labor to begin naturally while nurses regularly checked for signs of infection.

Lesser’s team also ramped up interdisciplinary communication between patients, nurses, neonatologists, anesthesiologists and physicians to ensure everyone was more aware of the mother’s progress throughout labor.

“Now we meet as a team twice a day to talk about what we see that is reassuring versus concerning with the patients,” Lesser said. “This helps us decide whether to continue or change the plan of care.”

After implementing the new strategies, the overall C-section rate at the hospital dropped from 30% to an average of 25%. For first-time C-sections, that rate dropped to 13.5%.

The power of whiteboards

Improved communication between physicians, nurses and patients helped South Shore Hospital in Massachusetts reduce C-section rates. In 2018, the labor-and-delivery unit started placing a whiteboard in each room listing the mother’s birth plan, medical history and names of care team members.


Heather Powderly, RNC, BSN

“It’s been interesting to see how much more everyone communicates when we write things down,” said Heather Powderly, RNC, BSN, a staff nurse at South Shore. “If the patient’s preferences have changed or she doesn’t understand something on the board, we talk about it.”

This strategy is part of a new initiative known as Team Birth Project, …read more

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