Does the Assigned Nurse Impact a Low-Risk Patient's Chance of Having a Cesarean?

No one can disagree that cesarean rates are too high

In the United States, the most recent yearly cesarean rate is 32.0 percent.  It is clear that while almost one in three people give birth by cesarean, our high maternal and infant morbidity and mortality demonstrates that current obstetrical practices do not provide for better outcomes.

Does the nurse you have predict your cesarean chance-1.jpgThe reasons for our current national cesarean rate are many, and the pressure is certainly on to reverse this trend and get this number down to an acceptable and appropriate level if researchers can agree on what that might be.  According to obstetrician Neel Shah, one of the researchers on this paper, both the hospital a person chooses to birth at and the provider that a person chooses to birth with may be the biggest predictors of the likelihood of giving birth by cesarean.  What role does the labor and delivery nurse assigned to that laboring person play in that outcome?  

Are labor and delivery nurses affecting outcomes?

This study just published in the Journal of Obstetric, Gynecologic, and Neonatal Nursing (JOGNN); Variation in Cesarean Birth Rates by Labor and Delivery Nurses examines how individual nurses can influence the mode of birth (cesarean or vaginal) of patients in their care.  The study also examines how individual nurses affect the care and outcomes of women and newborns during childbirth.  Examining the role of the nurse is a new area of study, but cesarean rate variations amongst physicians have been well-studied both within the same facility and across different hospital locations.

Some background

Labor and delivery nurses attend almost all of the 4,000,000 births that occur in the hospital setting in the USA (Bingham and Ruhl, 2015).  Previous research has shown that nurses affect the clinical behaviors and labor management decisions of physicians. Some ways that labor and delivery nurses can have influence is in their communications and ability to negotiate with physicians to provide additional time for labor.  The nurses also are able to discuss and share their clinical opinions on the current health of the fetus and the management of oxytocin administration.  Other factors regarding the role of the nurse in birth outcomes include how many nurses are caring for the patient through the course of the labor, a nurse's beliefs about birth, and how much time a nurse spends providing labor support versus other clinical duties.  It is possible that an increased number of nurses managing a woman in labor, nurse beliefs that birth is a risky process, and less time spent providing direct nursing care and support at the bedside might increase the risk for cesarean.

It is no surprise that some nurses seem to consistently have low intervention rates, low cesarean rate and good maternal and neonatal outcomes versus other nurses, regardless of the level of risk their patients have. Every unit can identify the particular staff that fits that category.

How was the study done?

Screenshot 2017-06-07 23.42.55.pngThe researchers chose to examine retrospectively the cesarean rates at a single, large, tertiary care hospital.  This facility is an academic hospital and sees approximately 3500 births each year.  There are 12 private LDR rooms, two operating rooms, and a triage area where patients go prior to being admitted.  All the nurses are RNs and are able to circulate into the ORs as needed. This facility has received the designation of a Magnet facility by the American Nursing Credentialing Center, which is means that the facility has been recognized for the high-quality nursing services available there. 

Nurses are assigned to patients in this facility independently of a person's risk for cesarean birth and all of the patients included in this study were nulliparous women presenting with a term, singleton fetus in the vertex position (NTSV) which is considered the standard low-risk patient.  

There are 36 obstetricians and 22 midwives on staff in one practice. There were no new nurse hires or float or temporary nurses during the study period and almost all the nurses work a twelve-hour shift, 7AM-7PM or 7Pm-7AM.  The cesarean rate amongst women with NTSV pregnancies (the population included in this study) at this hospital in 2015 was 24.3%.  To be included in the study, a nurse had to have attended a minimum of 15 NTSV births during the study period, which 72 nurses met. Nurses were assigned numbers and individual nurses were not identifiable in the study. The data was conducted from births that occurred between January 1, 2013, through June 30, 2015, and information was collected on all the NTSV patients by pulling from the electronic health records system used at the hospital.   All schedule cesareans were excluded.  Each eligible birth was attributed to the primary nurse present at the time of birth.  After all the data was pulled, each nurse's cesarean rates were calculated from the total NTSV births they attended in the study period. The nurses were grouped into four quadrants based on their calculated cesarean rates. To determine if significant differences existed in the population of NTSV women included in the study, characteristics (maternal age, gestational age, birth weight, Apgar scores, and time of birth) of the women and neonates they attended were compared using one-way analysis of variance. Gestational age was based on best dates for estimated date of birth as evaluated by the clinician. Birth weight in grams and Apgar scores at 1 and 5 minutes were extracted from the electronic health record. Times of birth were categorized into day and night based on when they occurred relative to day and night nursing shifts.

What were the findings?

Our findings provide current evidence of a nearly threefold variation in the cesarean birth rates across labor and delivery nurses at the same institution.

3,031 NTSV births and 72 RNs were included in the study. The distribution of the individual nurse NTSV cesarean rates ranged from 8.3% to 48.0%, with a mean of 26.0% (95% confidence interval [CI] [23.9, 28.1]). The distribution of nurse case counts and NTSV cesarean rates are summarized by quartiles and were 15.7% for Quartile 1 to 37.6% for Quartile 4, and nurse case counts ranged from 15 to 90 (mean 1⁄4 42.1 ` 16.7). For births that occurred during day shifts (1535 births) the mean nurse NTSV cesarean rate was 27.8% and for births that occurred during night shifts the mean nurse NTSV cesarean rate was 23.8% (1496 births). 

Screenshot 2017-06-07 23.41.01.png

There were no significant differences in the distribution of gestational age, birth weight, or Apgar scores by nurse quartile. There were, however, significant differences in maternal age and time of birth by nurse quartiles. Statistical tests indicated an approximate 1-year (0.92) difference in maternal age between Quartiles 2 and 4. Nurses with lesser cesarean rates (Quartiles 1 and 2) attended a greater proportion of night births than nurses with greater cesarean rates (Quartiles 3 and 4).  136.57. After adjusting for maternal age, gestational age, birth weight, and time of birth, the effect of nurse quartiles on the likelihood of cesarean remained significant. The adjusted odds for cesarean among births attended by nurses in the highest quartile were nearly three times greater than births attended by nurses in the lowest quartile.

What do we know from this study?

This study showed significant variations in the NTSV cesarean birth rates for labor and delivery nurses at a single tertiary hospital. This variation in NTSV cesarean rates was not associated with the number of NTSV eligible births attended by each nurse during the study period.  If eligible for the study, (attending a minimum of 15 NTSV births) it did not seem to matter if they attended many births or few.  All of the patients included in the study were from a population considered to be at low risk for cesarean. There were no differences in the gestational age, birth weight, or Apgar scores of the births amongst the four quartiles of nurses. Nurses who attended births at night had a lower NTSV cesarean rate.  When all other factors are accounted for and adjusted, the nurses' general likelihood to attend a cesarean birth remained a significant predictor of cesarean for individual women.  

These findings suggest that the nurse assigned to a birthing patient may influence the likelihood of cesarean birth for that patient. This finding is in line with previous research that found that which physician attended a labor and birth influenced a person's likelihood to have a cesarean birth as well.  This is called the "physician factor".  There appears to be a "nursing factor" at play as well.  Although most nurses had rates similar to the hospital’s overall rate, a 40% difference was observed between the nurse with the highest rate and the nurse with the lowest rate.

 Nurse-level NTSV cesarean rates may need to be adjusted based on additional patient characteristics to be meaningful.  While published risk adjustment models have identified factors important for calculation and comparison of hospital and physician level primary cesarean rates, the same models for labor and delivery nurses have not yet been developed. 

Discussion and Conclusion

What could be the differences amongst various nurses?  Differences in birth beliefs, skills, education levels, and experience levels could all contribute to the observed differences. Maybe those nurses who understand and consider physiologic birth to be the norm have different behaviors that contribute to the difference. When nurses see labor and birth as an activity fraught with risk and danger, they may practice differently than those who see birth as normal (until it is not).  As nurses were not identified in this study, each being assigned a number only, it is not possible to evaluate the above variables.  Nurses assigned to the birth may not have been the nurse that provided the bulk of the patient care.  This could also impact the results.  Just as was seen with physicians, measuring the cesarean rates of individual labor and delivery nurses may inform a more effective audit and feedback intervention to help reduce rates and improve outcomes.   The authors agree that more research is needed that takes a deeper dive into examining how various factors of individual nurses are examined to study the impact on cesarean rates of the patients they serve.  A question I have is how would you tease that out from the impact that the physician has on the birth outcome.

The authors conclude "examination of the relative effects of clinicians on the prevention of primary cesarean birth is a current focus of hospital-based performance improvement strategies in the United States. Our findings provide current evidence of a nearly threefold variation in the NTSV cesarean birth rates across labor and delivery nurses at the same institution. These findings highlight the potential influence of the individual nurse practice on mode of birth outcomes. Further refinement of this nurse-level outcome measure and examination of how individual nursing practice might be modified to improve birth outcomes are needed."

I was able to connect with Neel Shah,MD, MPP one of the study investigators and asked his thoughts around what birth professionals can learn from this study and be sharing with families about this study and what happens next.  He responded:

"neel shah head shot 2017.jpegWe completely agree that this raises many questions and we are submitting an NIH grant next week to address some of them. The biggest question is how much influence does the nurse actually have on a person's chances of getting a c-section? Does one nurse at the hospital make their risk six times higher compared to another?

Last year we published this paper that makes the case for why your nurse matters. Nurses spend more time at the bedside than any other clinician and represent the largest clinical workforce. Everyone who works on a labor and delivery unit knows that some nurses are better than others. When it comes to c-sections, our goal is to try to understand what it is that makes the best nurses so good and how we can extract lessons for everyone else."

Joyce K. Edmonds, PhD, MPH, RN, and the lead investigator added:

"Joyce K Edmonds headshot 2017.jpgSuccessful quality improvement efforts to reduce cesareans have made extensive use of provider performance data to improve quality of care. Including data on nurse performance could potentially accelerate and improve the effectiveness of this strategy."

I have many questions and look forward to further studies that examine the impact that labor and delivery nurses have on cesarean rates.  When we know better, we do better.  Our families deserve that.


 Bingham, D., & Ruhl, C. (2015). Planning and evaluating evidence- based perinatal nurse staffing. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(2), 290–308. 1111/1552-6909.12544

Edmonds, J. K., O'Hara, M., Clarke, S. P., & Shah, N. (2017). Variation in Cesarean Birth Rates by Labor and Delivery Nurses. Journal of Obstetric, Gynecologic & Neonatal Nursing. 



June 13, 2017 04:30 PM by Jordan

This paper is intriguing because it suggests that something other care providers such as doulas or family members know anecdotally about the influence of medical staff on a person's health outcomes. I also wonder about how nurse rotation affect this outcome and also whether this was affected by how long that person stayed in labor and delivery (e.g. is there a breakdown for those who labored at home and came to the hospital closer to when they were completely dilated v. folks who spent most of their labor in the hospital?).

An underlying cause may be day vs. night shifts

July 13, 2017 01:23 PM by Henci Goer

Some of the variance in cesarean rates may lie not in individual practice style but in whether the nurse works the day or the night shift. As noted, cesarean rates were higher during the day. This is probably because during the day more women are being induced, and induced or not, doctors may want to get women delivered by evening so they can enjoy their evening in peace, whereas at night, nurses are less likely to have impatient doctors breathing down their necks. 

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