Influence of Labor Support on Reducing Cesarean Sections

A cesarean section is major abdominal surgery. In comparison to vaginal births, cesarean births have a higher association with healthcare costs, as well as maternal and newborn morbidity. In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) produced the Obstetric Care Consensus Statement on “Safe Prevention of the Primary Cesarean Delivery”. Several elements related to the care of women in labor were highlighted, as well as the need to balance birth related risks and benefits. The major themes included: 1) the active phase of labor may not start until 6 centimeters dilated, as opposed to the historical number of 4 centimeters; 2) active phase arrest of labor should not be an indication for cesarean delivery until no cervical change has occurred for at least 4-hours or more with adequate contractions or 6-hours or more with inadequate contractions and cervical change; and 3) a cesarean birth should not be considered until the nullipara has pushed for at least 3-hours and a multipara has pushed for at least 2-hours, and longer durations may be appropriate on an individual basis if progress is being documented. (Obstetric Care Concensus No. 1, 2014).

Cesarean delivery is abdominal surgery with risks and benefits, yet it is established as the safest route of delivery for certain complex conditions, such as placenta previa and uterine rupture. However, potential consequences include surgical complications, admission to neonatal intensive care, and higher costs compared to vaginal birth. (CDC, National Vital Statistics Reports, 63, Number 1, 1/23/2014).

In the hospital setting, the average length of stay is 24-48 hours for a vaginal birth, and 36-96 hours for a cesarean birth. The cost associated with each is not only reflected in the length of stay, yet also in the associated elements from the route of birth (i.e., daily room charges, medications, supplies, clinical staff, etc.). Many insurance companies utilize a global billing system that pays the hospital one set amount to cover birth expenses (vaginal or cesarean). Cost savings occur when appropriate care is provided, and the total amount of individually allocated patient global billing funds were not all utilized. More cost is associated with cesarean birth by the nature of the clinical procedure, thus cost savings occur with vaginal births. The opportunity for clinicians to impact birth outcomes have both patient (mom/baby dyad) and financial implications.

Cesarean sections are the most common surgical procedure in the United States, accounting for approximately 33% of births in 2013 (1 in every 3 women) (Bell, Joy, Gullo, Higgins, and Stevenson, 2017). Although there is not an “ideal rate”, the organizational and regulatory suggestions range from a cesarean section target of 10% (Healthy People 2020), to 15% (World Health Organization), and up to 26.2 % (California Maternal Quality Care Collaborative). One of the approaches to reduce cesarean birth rates is to increase the woman’s access to nonmedical interventions during labor, such as continuous labor and delivery support. (Obstetric Care Concensus No. 1, 2014). Clinical team use of continuous labor support techniques is associated with slight reduction in the length of labor and improved maternal satisfaction (coping during labor and level of personal control during childbirth) and has medical benefits for both mom and baby. (Obstetric Care Consensus No. 1, 2014).

In 2017, there were 2667 babies born at the birthing hospital study site. The total cesarean section rate was 29%, and the rate for nulliparous, term, singleton, vertex (NTSV) births was 22%. Implementation of a project to increase the skill set and use of labor support techniques by nurses, certified nurse midwives, and OB residents, presents an opportunity to reduce the cesarean section rate, improve the maternal birth experience, reduce costs (vaginal births have a lower cost), and impact medical benefits for the maternal-newborn dyad (improve birth outcomes and patient experience).

A review of the literature was conducted and consisted of material including quantitative and qualitative studies, labor and delivery units in hospital settings, labor nurses included in the discussion, and women having a cesarean birth. The literature suggests that the use of labor support techniques can influence vaginal and cesarean birth. (Aschenbrenner, et. al. (2016), Simpson and Lyndon, (2017); Gams, et. al. (2018). The anticipated benefits for the patient include: enhanced birth experience using labor support techniques and having a vaginal birth in the presence of non-clinical factors (Consensus, 2016; Bell, Joy, Gullo, Higgins, and Stevenson, 2017).

The study approach is a descriptive mixed-method design. Quantitative outcomes will include monthly total cesarean section rates and the monthly nulliparous, term, singleton, vertex rate (NTSV), as well as knowledge and culture assessments. Qualitative measures will include demographic information and comparisons of a vaginal birth to a cesarean birth. The intervention will bridge contextual and kinesthetic learning as a hands-on labor support class for nurses, midwives, and OB residents. Class content includes maternal positioning, breathing techniques, use of peanut balls/birthing balls, aromatherapy, music therapy, massage, ambulation, showering or bathing, and delayed pushing in the second stage of labor. Outcome measures assess the impact of the labor support class intervention on the prevalence of cesarean sections.