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Cesarean birth has been identified as an international public health issue placing both the mother and infant at increased risk for severe morbidity and mortality. Preventing the first cesarean section is recognized as a primary strategy in reducing the overall cesarean birth rate. Nurses play a key role in the management of labor and the birth outcome of cesarean or vaginal birth may be strongly influenced by the nurse’s role in the scrutiny of fetal heart monitoring and interventions in response to his/her interpretation. This study proposes the detection and treatment of category II patterns may be an effective strategy in reducing the incidence of primary cesarean births. Notably, examination of components of the nursing surveillance process (assessment, assimilation, action, alert, advise/advocate) and resulting interventions (oxygen supplementation, maternal reposition, intravenous (IV) fluid bolus, and decreasing or discontinuing Pitocin) during the management of labor may help identify effective nursing strategies to reduce cesarean birth. A nursing surveillance conceptual model was used as a framework for identifying evidence-based solutions for improving maternal and neonatal outcomes. The purpose of this study was to identify whether frequency of category II patterns and nursing surveillance interventions increase the risk of cesarean birth in women who are nulliparous, term with single infant in vertex position.
Methods:
A descriptive, cross-sectional, correlational design. Data were collected through a retrospective audit of electronic medical records of patients admitted and delivered between May and June 2013 at a large urban southern California women’s hospital. Inclusion criteria: nulliparous, single fetus in vertex position, and ≥37 weeks’ gestation. Category II fetal heart rate (FHR) tracings were defined by characteristics of fetal heart rate, baseline variability, decelerations, and presence or absence of accelerations. Nursing interventions were defined as oxygen supplementation, maternal reposition, IV fluid bolus, and Pitocin adjustment.
Results:
Statistically significance differences were found between women who delivered vaginally and those who delivered by cesarean when examining nursing documentation of frequency of category II FHR tracing F (1) 6.3, p < .05 and nursing interventions F (1) 13.6, p < .05. Logistic regression (1) estimated the relations of frequency of category II FHR tracings and frequency of nursing interventions (oxygen supplementation, maternal reposition, IV fluid bolus, and Pitocin adjustment) recommended for category II FHR pattern, to the risk of cesarean birth. The overall model was statistically reliable with a good fit in distinguishing between mothers who delivered by cesarean section and those who did not (- 2Log Likelihood = 540.401; χ2 (2) = 14.32, p = .001). The odds of having a cesarean delivery was 12% (OR = 1.12) higher among women who had an increased number of nursing interventions within four hours prior to delivery; (2) estimated the strength of association of frequency of documentation of characteristics consistent with category II FHR tracings and type of nursing intervention (oxygen supplementation, maternal reposition, intravenous (IV) fluid bolus, and Pitocin adjustment) with mode of birth. The overall model was statistically reliable with a good fit in distinguishing between mothers who delivered by cesarean section and those who did not (- 2Log Likelihood = 15370.415; χ2 (5) = 17.14, p = .01). Maternal reposition trended toward statistical signficance; overall type of nursing intervention was not significant as a predictor of cesarean delivery.
Conclusion:
Nurses play a key role in the evaluation of maternal and fetal status during labor, continued surveillance, initiation of corrective measures when indicated, and reevaluation. A key attribute of nursing surveillance is that it is a systematic process for assessment, intervention, and evaluation. In this study a category II FHR pattern and specific type of nursing intervention was not associated with an increased risk of cesarean delivery supporting prior studies, in contrast increased nursing interventions was a predictor of cesarean birth. Nursing practice may benefit from a more well-defined process in the evaluation of FHR tracing; current guidelines for nursing intervention may need to be more clearly defined and associated with occurrence, as well as type of category II FHR pattern.