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Preventing Cesarean Delivery – What is the Nurses’ Role?

By Christine H. Morton, PhD

 ”Experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.” 

Today, on Science & Sensibility, Christine Morton, PhD takes a look at a study examining the role of nurses in helping to achieve a vaginal birth for patients under their care.  No surprise from my point of view, my professional experience as a doula has demonstrated that L&D nurses play a critical role in the birth, and can really help a mother to achieve the outcome she desires.  Please enjoy Christine’s synopsis and interview with one of the study authors.- Sharon Muza, Community Manager

© 2013 Patti Ramos Photography

Readers of this blog are well aware of the 50% increase in cesarean delivery rates over the past decade, and are likely aware that the high US cesarean delivery rate is on the maternal quality and patient safety agendas for many organizations.  More attention will soon be focused on hospital rates (the Joint Commission recently expanded its performance measurement requirements such that as of January 1, 2014, all hospitals with more than 1100 annual births will be REQUIRED to report on the Perinatal Care Measure Set, which was the subject of a past blog post).  The Perinatal Care Measure Set includes a measure on the first birth cesarean among low risk women (nulliparous women who have cesareans at term, with singleton, vertex babies).  Furthermore, Centers for Medicare and Medicaid Services (CMS) is requiring that all states report rates of Elective Deliveries <39 Weeks as of 1/1/13 and it is likely that a similar requirement for the NTSV (Nulliparous Term Singleton Vertex) Cesarean measure is not far behind.

One indicator of this trend was the February 2012 symposium on preventing the first cesarean held jointly by National Institute of Child Health and Human Development (NICHD), the Society for Maternal Fetal Medicine (SMFM) and American Congress of Obstetricians and Gynecologists (ACOG.)  A comprehensive summary of the proceedings of that symposium was published in the November 2012 issue of Obstetrics and Gynecology, which is well worth reading but is available only with a subscription.  That same issue had a commentary on how to create a public agenda for reducing cesarean delivery, written by me and my California Maternal Quality Care Collaborative colleagues, which is free to all, thanks to our funder.

The attention to the detrimental health impact of our country’s cesarean rate for women and their babies is a good sign, coming as it does from powerful organizations with interests in providing care and paying for it.  Most of the focus on quality measurement reporting on cesarean delivery has been directed at hospital level (i.e., Leapfrog and The Joint Commission), though there is interest among payers and consumers for public reporting of provider-specific rates.  Virginia is one example where obstetric outcomes (cesarean, episiotomy) are publicly reported at the hospital and provider levels.  However, it is complicated to attribute outcome rates in obstetrics, which is increasingly a ‘team sport’ with multiple clinicians (physicians, midwives and nurses) involved in the care of a woman throughout her pregnancy and birth.

Yet, in all these domains (institutional, measurement, quality improvement), the role of nurses on cesarean delivery decisions and outcomes has been barely mentioned.  Neglecting the labor & delivery nurse’s role is unfortunately all too typical in public discourse around quality reporting, shared decision-making and improving outcomes in birth. I have become very interested in the nursing perspective as the more I learn about hospital birth, the more I realize that nurses are central to the management of labor & delivery units, and in measuring and reporting outcomes.  Thus, it was with great delight that I saw a new study, Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes in the January 2013 issue of JOGNN

Nurse-researchers Joyce K. Edmonds and Emily J. Jones conducted a semi-structured interview study with 13 nurses who were employed at a hospital with about 2000 births a year and overall cesarean rate of 36%.  These nurses work within a “nurse-managed labor model” which is characterized by a relatively autonomous nursing role, with intermittent communication with an off-site obstetrician.  Most nurses in the US practice within this type of model.  Nationally less than 10% of hospitals that do births are teaching hospitals, which have 24/7 access to physician consultation.  Other hospitals with 24/7 physicians on staff include HMOs like Kaiser Permanente, or those who have hospitalists.  In California, about half of all birthing facilities do not have an OB available onsite 24/7.

Shockingly few studies have looked at nurses’ role on the mode of delivery.   This is more striking when one considers the many specific nursing clinical practice responsibilities that may affect cesarean rates.  Nurses are largely responsible for assessing women during triage for admission, monitoring and assessing the health of mother/baby after hospital admission.  Nurses manage and administer oxytocin, assess and assist with labor pain, and are primary managers of second stage labor.  These practices occur within the administrative context of each hospital’s policies on admission in early labor, rates of interventions such as inductions (especially those for no medical indication), cesarean (especially those among the low risk population) and availability and rates of Vaginal Birth After Cesarean (VBAC).

Data for this study were drawn from semi-structured interviews with nurses who had a range of 10-40 years clinical experience in L&D.  Questions were specifically designed to elicit active practice and interaction with physicians (interactions with women were not addressed).  An example of a question asked of respondents, “Can you tell me about a time when you intervened to promote vaginal delivery or avoid a cesarean?”

The overarching theme in this study was how nurses described their efforts to ‘negotiate for more time’ during labor, to positively impact the likelihood of a vaginal delivery.   Negotiating for more time was defined in this study as “a form of nurse-physician interaction and an action taken to create the temporal space in which nursing interventions thought to affect delivery mode decisions operate”.    The authors found that nurses’ ability to negotiate for more time was based on their knowledge of labor and birth over their many years of experience, as well as their knowledge of individual physician practice patterns.  Furthermore, nurses’ awareness of physician and institutional-imposed time constraints was a key factor in negotiating for more time.

The important conclusion reached by the authors was that “experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.”  Despite the known limitations of this study – small sample of highly experienced nurses working at a single institution – I was intrigued and excited by the practice implications and the potential to develop quality improvement strategies for reducing cesarean deliveries that are specific to nurses.  So often, the labor & delivery nurses’ role is overlooked in this area and this study is an important contribution to our understanding of nurses’ influence in cesarean outcomes.   There is clearly more research and work to be done, and one of the authors, Joyce K. Edmonds, graciously responded to questions I had about the study and future directions for this research and quality improvement initiatives:

CHM: It was interesting that the range of experience represented in your study was 10-40 years – do you think your sample was more weighted toward the more experienced nurses?  Do you have any theories for why the lower end of the range was so high?  Were there nurses in that hospital with 2-3 years of experience?  Any thoughts about why they did or did not participate?

JKE:  Our sample was without doubt weighted to the experienced nurse, and we used the term experienced as a qualifier throughout the paper. This particular hospital staff was highly experienced, although, there were nurses with less than < 5 years experience. We think the sample was a self-selecting group of nurses who felt strongly about birth mode and the influence they had on birth mode decisions. Perhaps, less experienced nurses’ perspectives on birth mode were not as clearly developed as those who participated. It could also be that those who volunteered to participate were more supportive of promoting vaginal deliveries than those who did not participate. It could also be that scheduling conflicts with less experienced nurses prohibited them from participating.

Joyce Edmonds

CHM: I think the fluid nature of ‘time’ and the constraints on physician time bear further exploration.  In this regard, it would have been helpful have analyses of accounts where nurses felt they were ‘unsuccessful’ in buying more time for labor.  The counter-factual example can sometimes shed light on the dynamics – what didn’t work in this case? Do you have any unsuccessful stories in your data and/or did you analyze those?   It seemed as though all the nurses in your study DID negotiate for time, or at least provided you with accounts of when they did.  Were there any nurses who did NOT have a story to share about negotiating for more time?

JKE: All the nurses did talk about negotiating for time, which is the reason it emerged as the overarching theme.  Nurses did talk about not being able to negotiate for more time when cesareans were scheduled because the course of labor management was already established. They also seemed to have less influence when inductions were scheduled because again the labor management plan was established prior to their involvement in the care. I’d have to look back at the interviews with an eye toward specific counter-factual examples.

CHM: I also found it fascinating to read the quote that begins, “It almost feels like you’re working against the machine.” I was curious to know more about the justifications for that taboo of not being able to talk or confront the physician with the ‘agenda.’   In my interviews with OB nurses, I also came across this and think it is an important factor to explore further.  I imagine that nurses with less clinical experience are even less able to identify or recognize this ‘agenda’ and that comes with its own set of practice and policy issues for nursing training.  

JKE: I think the nurse physician relationship shapes the day-to-day work environment of the nurse. It is a long-term relationship relative to the nurse-patient relationship. It is likely that talking about or confronting a particular physician about the potential of an agenda could negatively disrupt the work environment, which is significantly related to nurses’ job satisfaction. Nurses want to be seen as team players and discussing the potential of physician ‘hidden agendas’ is like being a whistle blower. In addition to not wanting to disrupt the power balance, they may not want to invite scrutiny into their own practice patterns.

CHM: I was struck in particular by the account on page 5 of your paper that ends with the quote, “There are certainly situations where the baby needs to come out via C-section, but it is not as many as we do by any stretch.”  What situations?  What factors influence those decisions?  Where do nurses feel they lost power to bargain /buy more time?  

JKE: In this quote, the nurse is referring to medically indicated versus potentially unnecessary cesareans. I believe when nurses speak about cesareans they are not only focused on unplanned, intrapartum cesareans but also scheduled cesareans or scheduled inductions, which can result in a cesarean. It was clear from the interviews that nurses felt less invested in the decision-making process when women came in for scheduled cesareans or planned inductions. Nurses also spoke of how women are set up for failure during pregnancy—by way of unfavorable media messages, lack of unbiased childbirth education, and lack of risk reduction information from prenatal care providers.

CHM: I was intrigued that in this study you did not appear to ask about nurses’ views toward physiological birth (vaginal) and cesarean, or other indicators of their philosophy of birth.  The comment from the nurses who viewed themselves as a ‘dying breed’ begin to capture some sense of that – whether it is experience, knowledge, or philosophy of birth that unites them against this perceived different group of newer nurses.

JKE:  Great question, although it assumes that nurses’ personal philosophy of birth impacts their practice, which it likely does according to Reagan et al. In an attempt to keep the data focused on our main aim we did not ask nurses directly about their personal philosophy of birth. I believe the nurses in the study were united in their knowledge of childbirth–without the now pervasive assessment and intervention technology–knowledge borne out of experience.

CHM: How do you plan to follow up with this research and what are your future projects?    

JKE: Locally, we want to continue the discussion about the influence of nursing care and knowledge on cesarean rates that started with our interviews. Due to the sensitive nature of the topic and hospital policies, we have not had much success with direct follow-up where the study was conducted. However, we are very interested in presenting and discussing the results with other interested audiences. With regard to future projects, we are currently initiating a study to document the degree of nursing influence on cesarean rates at the level of the individual nurse, at an academic medical center and at a community hospital, building on the sentinel, yet dated, work of Radin et. al.  If the results are significant, we foresee the development of a quality improvement strategy directed at providing individual nurses routine (e.g., bi-monthly or quarterly) feedback on standard measures, such as risk adjusted primary cesarean section rates, cervical dilation at cesarean, and cesarean indication, based on the cohort of women in their care. Clearly, although not without great effort, such a strategy would need to be interdisciplinary and have adequate IT infrastructure and support. I also think nurses, as part of a team, should be involved in giving feedback about physician practice patterns in accordance with obstetric standards.

Are you an L&D nurse?  Can you comment on your experiences and how you feel your actions can influence the mode of birth.  If you are a doula, what has been your observation.  Doctor or midwife?  How do you view the role of the L&D nurse?  I look forward to a robust discussion. – SM

References

Edmonds, J. K. and Jones, E. J. (2013), Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 3–11. doi: 10.1111/j.1552-6909.2012.01422.x

Main, E.K., Morton, C.H, Hopkins, D., Giuliani, G.,  Melsop, K., and Gould, J.B (2012), Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery, Obstetrics and Gynecology, November 2012; 120 (5):1194-1198.

Radin TG, Harmon JS, Hanson DA. Nurses’ Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses’ Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

Spong, C. Y. MD; Berghella, V. MD; Wenstrom, K. D. MD; Mercer, B. M. MD; Saade, G. R. MD (2012), Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop, Obstetrics & Gynecology, Volume 120(5), November 2012, p 1181–1193

ACOG, Cesarean Birth, Fetal Monitoring, Guest Posts, Maternal Quality Improvement, Maternity Care, Research, Transforming Maternity Care , , , , , , , , , , ,

  1. avatar
    Kallie
    January 8th, 2013 at 04:40 | #1

    Just a quick comment on “how women are set up for failure” – Everyday I feel like this is a very true statement. I’ve been reading baby/birthing books by the dozen lately and even the ones that are overall “good” act as if Cesarian birth is one of many normal and expected outcomes. I am absolutely grateful for 21st century medical advances, when we NEED them. On the same note, I feel like as a society, we have become too sensitive to making everyone feel comfortable with “whatever they decide to do” regardless of if it is best for the health of themselves and their babies.

  2. avatar
    Cileag
    January 8th, 2013 at 08:19 | #2

    I’ve been a labor nurse for 5 years at a moderately busy hospital (3000 births a year). I absolutely think rns have a large role in promoting or influencing the mode of delivery. I think I see it most obviously in a nurse’s ability to help a baby achieve an optimal positioning for birthing. While I find epidurals generally safe and effective, I do think they create more mal positioned babies, which end up as cesarean births more frequently. Helping a mom move after epidural placement, using positioning techniques that help babies descend and rotate, allowing for passive descent or waiting for the urge to push and then ultimately assessing whether or not a mom is pushing effectively, these are all things I do with little or no ob consultation. The cnms at our hospital are much more involved, but our obs rely very much on our judgement.

  3. avatar
    Mom and Midwife
    January 8th, 2013 at 09:10 | #3

    I was an L&D nurse for over 11 years. And as important as an OB’s c/s rate is to the woman’s outcome, I think that her primary nurse’s rate is as well. Good ones will do as Cileag listed: pay attention to positioning and encourage OFP. However, and more importantly, I think, are the ones who see possible fetal distress on every EFM strip. What is it that strikes fear into every OB’s heart? Liability. If the nurse is calling the OB claiming “baby looks bad,” then the OB is required to do SOMETHING. He has no idea what she is charting. So if he has to come DO something because of the RNs assessment and fear of what she is documenting, what choices does he have? Internal monitors? Then what? To the OR…

  4. avatar
    Meghan
    January 8th, 2013 at 13:40 | #4

    I was a labor nurse for a decade, half of which I spent on an amazing birthing unit. We had the highest VBAC success rate in the region. Our patients were often home birth transfers from midwives who had trusted and liked us for years. What made that different was not any one RN, but the structure and the culture that supported physiologic birth.

    We were expected to be in our patient’s room, unless there was a good reason not to be. We were staffed 1:1, except for very early inductions. Those inductions, by the way, were by policy never elective. Our docs and midwives would talk with the nurses about their patients before they went in the room. Our OBs had our backs. They trusted nurses and nursing judgment. We were unionized, with a strong contract. We were valued as members of the patient’s care team.

    Focusing on RN care is important, but it does merit caution. It’s not always about the individual nurse, but it’s almost always about the context — and culture — in which she practices.

  5. avatar
    Christine Morton
    January 8th, 2013 at 14:12 | #5

    Thank you everyone for these thoughtful comments. I particularly want to respond to Meghan and underscore the point she makes about the role of the local birthing unit culture. She is right that such a cultural context is larger, and probably has greater impact than the actions of any individual nurse. I would love to see more research which observes, identifies and measures key features of birthing unit culture and shows the relation of these features to birth outcomes. Too much research on birth outcomes (mode of delivery in particular) relies on very crude measures of ‘context’, such as type or ownership of hospital, annual births, primary cesarean rate or percentage of Medicaid patients. The practices and policies Meghan describes so vividly are clear indicators of a unit culture which supports vaginal birth. But in this age of ‘evidence-based care,’ we unfortunately have little research demonstrating this to help lay the case for promoting these policies and practices. I welcome additional dialogue on how to foster this type of research.

  6. avatar
    Meghan
    January 8th, 2013 at 20:06 | #6

    Research in this is tricky — who will fund it? NIH/NINR have shown little interest in improving outcomes for maternity care, except reducing preterm birth. Funding is at such a low level currently that systems research for “soft” issues like nursing unit culture would be hard to come by. I wish I were not quite so cynical, but I’m halfway through NRSA application revisions, and even the biophysiologic research I’m working on is hard going.

    The ACA may change this, in that there will be a national agenda for cost containment. Collaborating with business researchers in the large health systems may also be helpful — Kaiser has, after all, thousands and thousands of patient charts, and a large system of nurses to study. But definitely, cost of research is a barrier to identifying and improving unit culture and its connections to outcomes.

  7. January 9th, 2013 at 00:33 | #7

    While I applaud the effort these nurses make to prevent preventable cesareans and celebrate their successes, with the hospital’s cesarean rate at 36%, clearly they aren’t having much effect. Nor would one expect them to, seeing as they have no power over decision making other than influencing the decisions made by those who do have the power through negotiation or by spinning the information they provide.

    Christine points to unit culture as the core of the problem, but I would expand that to a dysfunctional system, as evidenced by the rarity of healthy intrapartum unit cultures with less rigidly hierarchical social structures in which optimal care (care that produces the best outcomes with the least use of medical intervention given the individual woman’s case) is practiced. What we need are far more radical reforms than can be accomplished by any strategy implemented by nurses.

  8. avatar
    Meghan
    January 9th, 2013 at 05:16 | #8

    Unit culture is not a nurse-dependent concept. It does encompass the entire structure of the health care system and how that filters through to the clinics, to the protocols, to the kinds of providers who choose to practice at a given site. The unit I spoke of earlier is an HMO with a group practice model and employee-physicians. There’s no reason to do a section for slow progress if you’re in-house all night anyway. In many ways, the providers work like nurses: on shifts, with no clinic post-call. By policy, we did not do elective inductions. Intermittent monitoring was part of the standard orders. The entire system de-emphasized the hierarchy of an individual provider with privileges at a given hospital. Were these culture changes perfect? No. But our cesarean rate was 21% the last year I worked there, and we had been avoiding near-term births for at least a decade before ACOG decided to notice they were problematic. Unit culture isn’t about what nurses do alone; it’s about all the systems that are in place before the patient ever walks in the room.

  9. avatar
    Terrie Watkins
    January 9th, 2013 at 11:21 | #9

    I welcome this discussion as a realization of a frequently ignored fact- L&D nurses have a C/S rate! I would especially like to call attention to a particular omission. AWHONN is the professional organization of OB/Neonatal/ Women’s Health nurses. I have been disappointed in their hesitation to discuss the implications of the rising C/S rate on women and children’s health in their publications and national conferences. I am hopeful that Science & Sensibility can help steer nursing actions to reduce the C/S rate.

  10. avatar
    Sylvia Ross
    January 9th, 2013 at 11:58 | #10

    Great discussion. I am a CNM, working on my PhD and my topic is looking at nurse’s attitudes toward “normal” physiologic birth. Nurse are actively involved at the bedside for the majority of births in this country. This is the professional group to reach out to, try to understand, help create change, as they have the most access to women and babies. Understanding the beliefs and attitudes that drive the care practices that support normal physiologic birth is the place to start. There is not a lot in the literature about the impact nurses have on maternal-newborn outcomes, I totally agree with the other writers. This is perplexing, as nurses are the key group, on the front line, who can systematically begin to make the changes the maternity system so desperately needs.

  11. avatar
    Sylvia Ross
    January 9th, 2013 at 12:04 | #11

    Does anyone the reference information for Radin et al?

  12. avatar
    Christine Morton
    January 9th, 2013 at 12:58 | #12

    Sorry, two references were left off the blog post:

    Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses’ Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

    Radin TG, Harmon JS, Hanson DA. Nurses’ Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

  13. January 9th, 2013 at 14:57 | #13

    We were so happy to see this article – thank you so much for helping to publicize this research! We also firmly believe that nurses are the ones on the front line, by the bedside, who can make such a difference – both to outcomes as well as how women feel about their experiences.
    This past October, the Power to Push Campaign hosted a one-day workshop for nurses called ‘Champions for Change: Nurses Driving Change for Normal Birth’, which invited maternity care nurses to share their insight and expertise on supporting normal birth at the patient level. In case anyone is interested, the summary report, as well as links to videos of all the presentations, are available here:
    http://www.powertopush.ca/info-for-professionals/conferences/championsforchange/

    We also wanted to show nurses how important we think they are, and how grateful *so* many women are for the nursing support they received; our video tribute thanking labour & delivery nurses is here:
    http://www.youtube.com/watch?v=qVEs3b0Xgww

    Thanks again!

  14. January 9th, 2013 at 15:04 | #14

    @Mom and Midwife
    Great article.

    I think nurses have great influence on cesarean rates, both towards and against. An experienced nurse can often counsel a patient convincingly towards the best course. This may mean convincing a woman to go home when she arrives to the hospital in latent labor, even though she is uncomfortable. A less experienced nurse might be more encouraging of admission and placement of an epidural, which when done prior to the onset of active labor increases interventions and likely cesarean rates.

    Conversely, some nurses are so concerned about abnormal tracings that they push physicians into action by documenting things in the chart that demand action. Less experienced nurses look at a tracing like an ornithologist looks at a bird – look at each piece and go down the algorithm until you have identified what one is a looking at. A good physician, and hopefully a more experienced nurse, looks at a tracing as a continuous fetal heartrate, and then interprets what is going on with the infant that would cause the heart rate to do what is being seen. This higher level of interpretation will often prevent rash action and excess cesarean delivery for abnormal tracings without failing to deliver the infants that truly need to be delivered expediently.

  15. January 9th, 2013 at 15:06 | #15

    Meghan is working in an ideal situation that decreases cesarean rates through structural changes in the delivery system.

    Most likely this system makes it less likely that a woman will be attended by a specific doctor when she is in labor. This is still worth it, but some women prefer the method that leads to their physician being available.

  16. avatar
    Meghan
    January 9th, 2013 at 16:19 | #16

    @Nicholas Fogelson

    There is preference, and then there is the body of research that supports limited working hours, including time awake. Shift staffing supports that. Also, how “available” is one’s own physician? In my experience in hospitals without employee-physicians, the docs wanted to be called exactly in time to catch the baby and do the repair. The fetishization of one’s “own physician” perpetuates the physician hierarchy while not necessarily improving care.

    As a CNM, I would not find it acceptable to encourage a patient’s attachment to me as an individual to the detriment of her being able to work well with other providers.

    And to clarify, I was a labor nurse on this unit. I currently do not work there; I’m a doctoral student at a research-intensive university.

  17. January 10th, 2013 at 17:07 | #17

    This is a great point about the level of experience of the RN. If something is documented and created concern in the RN, then from a liability standpoint, how can the provider not at least counterpoint the area of concern with another statement. It takes a team to make this work well, and someone who is very, very cautious and does not evaluate the entire strip, circumstances, observations, etc will force the hand of others to act at times. It begs for liability reforms such as Childbirth Connection discusses in their recent report. http://transform.childbirthconnection.org/reports/liability/ so that skilled providers can do what they do best without this hanging over their head. thanks for your thoughts, Dr. Fogelson.

  18. January 10th, 2013 at 20:26 | #18

    @Sylvia Ross
    Your dissertation work sounds fascinating! I can’t wait to read it some day!! As a nurse educator, I would love it if we could start reaching out to nurses about normal birth while they are still in their educational programs. I have been guest-speaking to the BSN nursing students in my University during their OB rotation for the past 3 semesters, and it seems to have a huge impact on their knowledge and attitudes toward birth. Although many of them will not go on to work in L & D, a large number will have babies of their own someday, and their knowledge and attitudes toward birth (as well as their status as RNs) will influence their peers.

  19. January 11th, 2013 at 10:36 | #19

    Great Discussion! I want to emphasize a couple of points with regard to researching nurses’ influence on obstetrics outcomes. First, it is difficult to isolate the impact of nursing care because it does occur in an interdisciplinary and multidimensional context as Meghan points out. I think it is important to keep in mind that nursing care is just one piece of the puzzle or one variable in a model that seeks the explain variation in a outcome such as mode of delivery. What we need to determine is the relative degree to which nurses impact obstetric outcomes AND the mechanisms or how they impact obstetric outcomes, in a given context. In our article we suggest that experienced nurses in a nurse-managed labor model negotiate for more time in order to implement interventions that may impact outcomes such as positioning, support/coaching, delayed scrutiny by physicians, monitoring, watchful waiting. Negotiating for more time is one of the ways certain nurses counter the time pressured environments of modern obstetrics. Do you think there is value in determining the characteristics of those “certain” nurses that are successful in promoting vaginal delivery given a particular organization context? Do you think nursing practice would improve if nurses received aggregated outcome data about the population of women they served? Do you think there is merit to nurses providing input into physician practice and physicians providing input into nursing practice? I look forward to reading your input.

    Joyce K. Edmonds
    Updated web site information: http://www.bc.edu/content/bc/schools/son/faculty/edmonds.html

  20. January 15th, 2013 at 08:07 | #20

    Great discussion, nurses need recognition and support. I remember my birth of my son. The nursing staff was very nice, but the only thing I was offered were pharmaceuticals, and I never asked for them, they were pushed on me over and over again. I wonder if nurses feel like they are trained to be foot soldiers for the pharmaceutical companies.

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