Vaginal Delivery Optimization Team: An Optimistic Collaborative Practice Initiative To Decrease The Cesarean Section Rate One Vaginal Delivery At a Time

Purpose for the program: Preventing cesarean sections is important for many reasons, largely because they are associated with many adverse outcomes such as infection, increased length of stay and increased maternal morbidity. In an attempt to promote change and lower the cesarean section rate, The Joint Commission has adopted a new perinatal core measure set. This initiative will require the submission of cesarean section rates beginning in 2014. 

Proposed change: As a Magnet facility, we are always striving to improve quality outcomes, improve safety, and provide the newest evidenced-based practice to our patients. The vaginal delivery optimization team was formed to focus on lowering the cesarean section rate. This collaborative practice group, which consists of registered nurses, obstetricians, clinical educators and nursing administration, decided to take on this initiative by optimizing the opportunity for every woman to have the best chance of a vaginal delivery.

Implementation, outcomes and evaluation: There are many reasons why cesarean sections are performed; therefore we chose to focus on factors that we could modify thru collaborative practice changes. After careful data collection and review of clinical practice, we identified two factors that increased the likelihood of cesarean section: elective induction and a lack of labor support. After a yearlong participation with the IHI Perinatal Improvement Community, we successfully implemented no elective inductions prior to 39 weeks. To improve support for our laboring patients, nursing administration supported the implementation of AWHONN perinatal staffing guidelines, and hired more nursing and support staff.   A survey was conducted to determine the comfort level of the nursing staff with low intervention nursing support.  With the assistance of a respected childbirth educator and doula, mandatory education sessions were provided to staff. These educational sessions provided the most up to date evidenced based practice strategies for the management of latent, active, and second stage of labor. 

Implications for nursing practice: As a result, our nurses now enthusiastically embrace and are consistently implementing current evidenced based practices such as active position changes, which encourage fetal rotation and decent; as well as an increased use of passive descent and open glottis pushing, which are shown to decrease maternal exhaustion and improve fetal outcomes. With the incorporation of these measures, we have seen our primary cesarean section rate for term low risk nulliparous women with a singleton vertex fetus decline from a rate of 25.1% in January 2012 to a rate of 18.3% in December 2012.

Keywords: collaboration, evidenced-based practice, low-intervention, optimize outcomes