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Uploaded by Katherine Covey on 2019-04-29.

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Curricular Concepts:
1. ANA Code of Ethics
- Provision 3 states "the nurse promotes, advocates for, and protects the rights, health, and safety of the patient"; if the nurse is not doing something to prevent unnecessary c-sections in otherwise healthy patients, then he/she is not upholding this provision of the Code of Ethics. We must protect both the short and long term health of our patients.
(American Nurses Association, 2015).

2. Shared governance:
- Sullivan (2013) describes shared governance as empowering nurses through participative decision making that keeps nurses accountable for their own practice. In the context of reducing cesarean rates, nursing practice councils would keep labor and delivery nurses in control of the evidence-based practice they utilize on their own units, and perhaps empower them to advocate more and have more confidence when speaking to physicians.

Leadership:

Remembering the basis of our profession is the first step in taking a leadership role on the clinical floor. Our standards of practice and code of ethics guide us to make the safest and healthiest decisions WITH our patients.
Practicing shared governance or advocating for it in its absence is also essential to taking on a leadership role-- if nurses feel they have no say in clinical practice or their workplace environment, how can they be the best patient advocates?

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1. Nurse Education!
Understanding of the issue is crucial for the nurse to do anything to solve it. Labor and Delivery nurses need to be up-to-date on institutional guidelines for labor, AWHONN and ACOG recommendations for labor interventions and be tracking their own unit's progress on reducing cesarean rates.
2. Continue the use of positive interventions like peanut balls and position changes, revisit potentially negative interventions like continuous EFM on low-risk moms.
3. Patient Education!
Since many patients may not be aware of their delivery options or all of the interventions available during labor it is crucial that the nurse prioritize assessing patient knowledge and teaching to any deficits-- and then advocating for those choices (as long as they permit the safety of mom and baby).
4. Interdisciplinary Teamwork
The issue of high cesarean rates in the US, and how to reduce them, is not the responsibility of one profession. Nurses, physicians, midwives, etc. should be working together to understand the challenges of this issue and what everyone can do to solve it. Perhaps nurses can propose/develop interdisciplinary quality improvement teams on their units (or join one if it already exists).

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The attitudes of other providers can have an impact on the nurse's ability to advocate-- especially when it comes to unnecessary cesareans. As previously mentioned, VanGompel et al. (2018) found that physicians attitudes can correlate to higher c-section rates. Nurses may feel that they don't want to "step on any toes" or cross boundaries if they disagree with the decision to perform a c-section on a low-risk patient. During a personal interview with Kendall Gaertner, RN (personal communication, April 21, 2019) other barriers including the litigious nature of labor and delivery, the current culture of some units (physician schedule, it's "what they've always done...") and patient understanding were cited.

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ANALYSIS 2: Importance of Nurse Involvement 

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ANALYSIS 2: Importance of Nurse Involvement 

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As nurses it is our duty to advocate for our patients and ensure that they have all of the information they need to make informed healthcare decisions. Labor and Delivery nurses are in a unique position to work very closely with women and their families during a huge life transition. The responsibility of the nurse is to ensure the safety of two patients-- mom and baby. A focus on non-invasive labor interventions and greater emphasis on patient education should be the goal.

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Currently, nurses on labor and delivery units utilize a few interventions that may have an impact on lowering the cesarean section rates in this country.
- Peanut Balls: these peanut-shaped exercise balls are typically used after a woman receives an epidural; the purpose is to continue the desecent of the fetus and dilation/effacement by keeping the mother's hips open. After epidural placement, the mother typically becomes mostly sedentary, leading to a risk for slowed labor progression and c-section (Tussey, Botsios, Gerkin, Kelly, Gamez, & Mensik 2015).
- Electronic Fetal Monitoring (EFM): most of not all most are placed on external fetal monitors during labor; on the LDRP unit at Sentara Leigh Hospital, all moms are placed on these monitors and watched continuously. - Patient advocate and support: along with physical interventions, nurses also provide emotional support and encouragement to laboring moms. Nurses are the ones obtaining patient consent for intrapartum procedures and assessing patient knowledge. The labor and delivery nurse is the provider most at the bedside-- and is typically the one who first notices any issue with mom or baby.
Is this improving the issue?
Yes and no. Some nursing interventions such as peanut balls have been shown to improve the rates of spontaneous vaginal births (Tussey et al., 2015). However, others, such as continuous EFM on low-risk populations have been found to have a negative impact on cesarean rates (Montoy-Williams et al., 2017). There are also certain barriers and challenges experience by nursing when it comes to advocating for patients.

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Why are the rates so high?
According to Montoya-Williams et al. (2017), there are many contributing factors to such high c-section rates in the United States. Data has shown that cesarean rates tend to be higher in private hospitals rather than public, and that physician scheduling can play a role as well-- more cesarean tend to happen on Fridays as opposed to the weekend. Higher rates have also been linked to an increase in cases of obstetrical malpractice, where perhaps physicians are "better safe than sorry" (Montoya-Williams et al., 2017).
VanGompel, Main, Tancredi, and Melkinow (2018) found a significant positive correlation between a provider's training and attitude/beliefs and the amount of cesarean deliveries they perform.

Patients, especially those of lower socioeconomic class and less access to resources, may not be "well-informed enough to know about their delivery options or have the confidence to assert their preferences" to the provider (Huesch & Doctor, 2015).

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What is the problem?
C-section rates in the United States continue to hover around 33% of all deliveries according to the CDC (2017). Even the rate of Low-Risk Cesareans-- full-term, one baby, head down in the pelvis (vertex)-- has only slightly decreased and Healthy People 2020 goals are not being met (Osterman & Martin, 2014).

Who is affected?
Any mom from any age group, race and ethnicity has a high risk of morbidity from a cesarean delivery. However, non-hispanic black and Asian women, and those aged 35-54 were found to have a greater risk for morbidity (blood transfusion, ruptured uterus, and ICU admission) (Curtin, Gregory, Korst, & Uddin, 2015).

How are they affected?
Having a c-section brings higher risk of maternal morbidity and mortality both from post-surgical complications and the potential for complications with subsequent deliveries (CDC, 2017).

Where?
There seems to be wide variation in c-section rates around the United States, some states, such as Virginia, have greatly improved the overall c-section rate, while some, like Georgia have seen an increase (Curtin et al., 2015).

When?
A low-risk cesarean delivery is defined as one that happens after 37 weeks gestation (fetus needs to be in the head-down position and to a mom giving birth for the first time (Curtin et al., 2015). The majority of c-sections tend to occur at 40 weeks gestation and beyond, although there is significantly higher percentage done at 37 weeks specifically (Curtin et al., 2015).

Why?
Current data supports the increase in elective, planned cesarean sections and non-medically indicated cesareans as the major causes of the increase in rates (Montoya-Williams, Lemas, Spiryda, Patel, Neu, & Carson, 2017).

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According to the Centers for Disease Control (CDC) (2017), the percentage of cesarean deliveries in the United States is a staggering 32%, way above the Healthy People 2020 goal of 23.9%.
This presentation will look at ways nurses can help decrease these numbers and keep moms and babies safe.

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Uploaded by Katherine Covey on 2019-04-28.