The Promotion of Continuous Labor Support to Reduce Primary Cesarean Birth

Abstract

There is a 15-fold variation in the cesarean birth rate across the US, yet only 25% can be explained by health risks or objective diagnoses. This suggests that care practices may influence cesarean birth rate. Implementation of bundles of care is intended to reduce practice variations. The Promoting Continuous Labor Support ( CLS ) bundle from the American College of Nurse-Midwives’ (ACNM) Reducing Primary Cesarean (RPC) Collaborative was adopted by our hospital in southcentral Virginia. Items include promoting comfort measures in labor, use of nonpharmacologic tools, promoting spontaneous progress in labor, and initial and ongoing education for nurses on nonpharmacologic comfort methods. Access to CLS is one specific bundle implementation item that addresses each of these aims. In efforts to increase the use of CLS, an interdisciplinary team consisting of nurses, midwives, doulas, and physicians was created. A SurveyMonkey survey was administered to nurses in 2016, 2017, and 2019. Workshops, grand rounds presentations, e-learning, and monthly on-unit meetings with community doulas were used to educate nursing staff and clinicians. Policies for fetal monitoring and documentation frequency were updated. Documentation fields in the health record were updated. Rates of patients receiving CLS were tracked monthly. The work was Institutional Review Board (IRB)–exempt as part of the quality improvement work related to participation in RPC Collaborative. From 2016 to 2019, nursing knowledge of the benefits of CLS and confidence in their ability to use techniques increased (p = 1.81E-09 and p = .00000, respectively). The rate of patients receiving CLS increased to 9.91% in 2019 compared with 5.12% in 2016–2018 (p = .0007). For those same date ranges, the rate of nulliparous, term, singleton, vertex (NTSV) cesarean birth was significantly lower among women who received CLS. The overall cesarean birth rate for NTSV birth was also reduced, although it was not statistically significant. Survey-guided education resulted in increased knowledge of outcomes associated with CLS and self-efficacy for skill and comfort-providing techniques. More women received CLS. Areas to improve included clinician education, collaboration with doulas, and creation of annual competency for nurses, currently in development. Additional changes to documentation fields are needed to consistently document CLS for improved outcome tracking.