Improving Nurse Management of the Second Stage of Labor

OBJECTIVE

To develop, implement, and evaluate an educational program to improve nurses' management of the second stage of labor.

DESIGN

Evidence-based practice project guided by the Iowa Model-Revised.

SETTING

Acute care teaching hospital in central California averaging 2,100 births/year with 12 labor, delivery, and recovery rooms and a Level III nursery.

PARTICIPANTS

Eighteen registered nurses participated in the educational intervention.

INTERVENTION

An instructional course addressed contemporary labor management guidelines and delayed and open/closed glottis pushing. Assessment/documentation of maternal-fetal status, progress/fetal descent, and nurse/provider communication were discussed. Participants engaged in an interactive experience regarding maternal positions.

MEASUREMENTS

Data collected from the electronic health record included the number of position changes, nurse/provider communication interactions, and minutes from 10 cm to birth and minutes in delayed pushing.

RESULTS

Second-stage labor outcomes for nulliparous patients at term with a singleton in vertex presentation improved with more position changes and percentage of spontaneous vaginal births. Patients of nurses who participated in the educational intervention (n = 18) had a vaginal birth rate of 87.5% and a surgical birth rate of 6.2%. Patients of nurses who did not participate in the educational intervention (n = 31) had a vaginal birth rate of 81.8% and a surgical birth rate of 9.1%.

CONCLUSION

Based on the positive response to the intervention and improved clinical outcomes, regularly scheduled interactive nursing education focused on strategies to improve the second stage of labor may be beneficial.

Examining Outcomes for Nulliparous, at Term, Singleton and Vertex Deliveries During the First Wave of the COVID-19 Pandemic in Rhode Island

BACKGROUND

During the initial wave of the COVID-19, there was uncertainty related to whether the pandemic would affect pregnancy delivery outcomes. We sought to identify whether changes in hospital policies and provider practices, driven by COVID-19, would influence delivery outcomes in nulliparous, term, singleton, vertex (NTSV) pregnancies in Rhode Island.

OBJECTIVE

We compare the delivery outcomes and associated factors for NTSV deliveries during the first wave of the COVID-19 pandemic in Rhode Island compared to patients who delivered the year prior.

STUDY DESIGN

This is a retrospective cohort study of patients who presented to Women & Infants Hospital for NTSV deliveries during April 2019, pre-COVID-19, and April 2020, during COVID-19.

RESULTS

During COVID-19, patients were more likely to have abnormal electronic fetal monitoring (AEFM) as an indication for cesarean section (p<.02) and less likely to have an elective cesarean delivery (p<.01). Patients during COVID-19 were more likely to have a midwife involved in their care compared to pre-COVID-19 (p<.001). The cesarean section rate was not statistically different between the two time periods.

CONCLUSION

Those delivering during the pandemic were more likely to have AEFM as an indication for cesarean delivery and less likely to have elective cesareans. They were more likely to have a midwife involved in their care. Further investigation into factors associated with changes in NTSV cesarean rates is warranted.

Chorioamnionitis after premature rupture of membranes in nulliparas undergoing labor induction: prostaglandin E2 vs. oxytocin

OBJECTIVES

To assess the risk of chorioamnionitis in nulliparous, term, singleton, vertex (NTSV) pregnancies with premature rupture of membranes (PROM) and an unfavorable cervix undergoing labor induction with either prostaglandin E2 (PGE2) or oxytocin only.

METHODS

Retrospective cohort of NTSV pregnancies presenting with PROM who underwent labor induction with either PGE2 (n=94) or oxytocin (n=181) between October 2015 and March 2019. The primary outcome of chorioamnionitis was compared between the two groups. Statistical analysis included Chi-squared and Wilcoxon rank-sum tests, as well as logistic regression. For time to delivery, a Cox proportional hazard regression was used to determine the hazard ratio (HR) and adjusted HR (aHR).

RESULTS

Baseline characteristics were similar between the two groups. Cervical ripening with PGE2 was associated with an increased rate of chorioamnionitis (18.1 vs. 6.1%; aOR 4.14, p=0.001), increased neonatal intensive care unit admissions (20.2 vs. 9.9%; aOR 2.4, p=0.02), longer time interval from PROM to delivery (24.4 vs. 17.9 h; aHR 0.56, p=<0.0001), and lower incidence of meconium (7.4 vs. 14.4%; aOR 0.26, p=0.01), compared to the oxytocin group.

CONCLUSIONS

Based on our data, the use of oxytocin appears both superior and safer compared to PGE2 in NTSV pregnancies with PROM undergoing labor induction.

Implementing an Evidence-Based Bundle to Reduce Early Labor Admissions and Increase Adherence to Labor Arrest Guidelines: A Quality Improvement Initiative

BACKGROUND

At many hospitals, the cesarean birth rate among nulliparous term singleton vertex (NTSV) pregnancies is higher than World Health Organization benchmarks. Reducing NTSV cesarean birth is a national quality imperative. The aim of this initiative was to implement an evidence-based bundle at an urban community teaching hospital in at least 50% of labors in 60 days in order to reduce early labor admissions and increase adherence to evidence-based labor management guidelines shown to decrease cesarean birth.

METHODS

Chart audits, root-cause analysis, and staff engagement informed bundle development. An early labor triage guide, labor walking path, partograph, and pre-cesarean checklist were implemented to drive change. Four Rapid Cycle Plan Do Study Act cycles were conducted over 8 weeks.

RESULTS

The bundle was implemented in 58% of births. The bundle reduced early labor admissions labor from 41% to 25%. Team knowledge reflecting current guidelines in labor management increased 35% and 100% of cesareans for labor arrest met criteria. Patient satisfaction scores exceeded 98%.

CONCLUSIONS

Implementing an evidenced-based bundle was effective in reducing early labor admissions and increasing utilization of and adherence to labor management guidelines.

IMPLICATIONS FOR NURSING

Implementation of evidence-based bundles has the potential to achieve meaningful quality improvements in maternity care.

Literature Review of the Association Between Prenatal Education and Rates of Cesarean Birth Among Women at Low Risk

A review of the literature was performed to explore the association between prenatal education and rates of primary cesarean birth for women at low risk for cesarean birth. Most women who are nulliparous with a singleton fetus of term gestational age and in the vertex position are considered to be at low risk and favorable for a vaginal birth, yet the cesarean birth rate for women at low risk was 25.6% in 2019. It has been suggested that the rise in the cesarean birth rate among low-risk women may not be due to medical indications but, rather, to nonmedical factors, such as a provider's or woman's preference or lack of prenatal education. Evidence from this literature review supports the premise that prenatal education classes should be routinely incorporated into maternity care in an effort to reduce cesarean birth rates for the low-risk population.

Population risk factors for nulliparous, term, singleton, vertex caesarean birth: a national cross-sectional study

OBJECTIVE

To characterise medical, obstetric and demographic risk factors associated with nulliparous, term, singleton, vertex (NTSV) caesarean birth.

STUDY DESIGN

Cross-sectional study.

SETTING

United States delivery hospitalisations.

POPULATION

NTSV births in 2016-18 US natality data.

METHODS

This study analysed a national sample of natality data generated by the United States National Vital Statistics System. NTSV deliveries were identified. The primary outcome was caesarean birth. Risk factors including maternal age, body mass index (BMI) and pregestational diabetes were analysed. Multivariable log-linear regression models analysed factors associated with NTSV caesarean with adjusted risk ratios (aRR) as measures of effect.

RESULTS

Of 11 622 400 deliveries, 3 764 707 met NTSV criteria, and their caesarean section rate was 25.9%. Maternal age 35-39 years (aRR 1.51, 95% CI 1.50-1.52) and 40-54 years (aRR 2.03, 95% 2.00-2.05) compared with age 19-34 years; BMI 25 to <30 kg/m2 (aRR 1.32, 95% CI 1.31-1.33), 30 to <35 kg/m2 (aRR 1.57 95% CI 1.56-1.58), 35 to <40 kg/m2 (aRR 1.82, 95% CI 1.80-1.83) and ≥40 kg/m2 (aRR 2.17, 95% CI 2.15-2.19) compared with BMI 18.5-24.9 kg/m2; and pregestational diabetes (aRR 1.54, 95% CI 1.51-1.57) were all associated with increased risk. Risk factors allowed stratification of patients into high-risk versus low-risk groups. The NTSV caesarean rate was 37.9% in women who had one or more of the following characteristics: age ≥35 years, BMI ≥30 kg/m2 or pregestational diabetes. In comparison, the NTSV caesarean rate was 20.8% among women without any of these three risk factors (P < 0.01).

CONCLUSION

Among NTSV births, BMI, maternal age and medical conditions are important risk factors for caesarean delivery.

Implementing Interventions Aimed at Reducing Rates of Cesarean Birth

Increased incidence of both nulliparous, term, singleton, vertex and overall cesarean birth rates has warranted close monitoring and scrutiny by various health care associations and by individual obstetric facilities and providers of obstetric care. Concerted efforts to reduce rates of nonmedically indicated cesarean birth have resulted in the development and implementation of comprehensive action plans aimed at effecting reductions and enhancing overall obstetric quality care. Here we describe how a multidisciplinary team at our hospital developed and implemented interventions aimed at reducing rates of cesarean birth.