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9-month study provides some answers
About 22% of all babies are delivered by cesarean in the United States, making cesarean the most common major surgery in the country. The cesarean rate, while down from a peak of 25% of births 10 years ago, remains four times higher than it was in 1970. The U.S. Public Health Service and the World Health Organization say that rate should be reduced to 15%.
Twenty-eight hospitals and nine physicians and nurses who participated in The Institute for Healthcare Improvement's (IHI) Break through Series on reducing cesarean rates agreed that the rates can be reduced without harming fetal and maternal outcomes. For nine months, they attended meetings and swapped ideas to help them meet a goal of reducing rates by 25%.
In the end, they delivered: Half of the hospitals met their goals, and the other half made significant strides, says Andrea Kabcenell, RN, MPH, director of the collaborative series for the Boston-based IHI. The hospital addressed several key issues, many of which became measurements for assessing cesarean rates. They included:
· preventing admission for false labor;
· avoiding unnecessary induction of labor, especially for social reasons such as the arrival date of the new grandparents;
· educating women more extensively during their pregnancy to expect a trial of labor if they've had a prior cesarean and to be sent home if they're in false labor;
· changing the physiologic model for labor to include walking, changing positions, and drinking;
· managing pain well, including using walking epidurals so women aren't confined to bed.
"Most of the things we looked at were not rocket science. They have been in the medical literature for many, many years," says Bruce Flamm, MD, chairman of the collaborative group and area research chairman in obstetrics and gynecology for Kaiser Permanente in Riverside, CA. "It's putting them into action that's difficult." (The table on p. 32 shows the types of data and measurements the collaborative collected.)
To help with implementation, the hospitals were advised to work on creating a will for change in their organization. "It's a prerequisite that you have to get buy-in from at least a certain segment of nurses and physicians," Flamm says. Suggestions include identifying external pressures for safely reducing cesarean rates, bringing in experts in the field, and identifying best practices. Some hospitals post individual cesarean rates with the physician identities blinded and give physicians monthly reports on their rates compared to the rest of the staff.
Another idea involves tracking the key measures of dilatation and effacement of women when they are admitted and their subsequent outcomes. As a general guideline, a woman having her first baby should not be admitted until she's 100% effaced and at least 2 cm dilated, Flamm says.
A look at several of the best performing hospitals shows that several important factors contributed to lowering their cesarean rates. Here are tips from managers of four successful programs:
1. Indianapolis Community Hospital East reduced its total cesarean rate from 16.3% to 13.5% and its primary cesarean rate from 11.8% to 9.8%, says Laurie Husted, RN, clinical facilitator of education. Successful efforts included setting guidelines to reduce the number of admissions prior to 4 cm of dilatation and to defer epidurals until 5 cm. Nurses attended an on-site workshop on alternative comfort measures including massage, warm showers, and walking. The hospital also developed a triage form to assess patients for admission. Women who aren't ready for admission but need some relief are given therapeutic rest in a quiet area with drugs to help them sleep and then sent home if they still aren't in labor.
2. Houston Northwest Medical Center reduced its overall cesarean rate from 25% to 17% and its primary rate from about 16% to 10%, says Vicki Thomas, RNC, director of maternal/child nursing. The hospital implemented one-on-one nursing: during an eight-hour shift, each patient has one nurse and each nurse has one patient. They also increased the number of times physicians attempt to turn breach babies manually instead of automatically going to a cesarean. Patients are encouraged to walk and sit in chairs instead of lying in bed.
3. Mercy General Health Partners Special Delivery Birth Center in Muskegon, MI, reduced its overall rate from 21.2% to 14.5% and wants to cut it to 10% by next June, says Jan Kolkema, RN, childbirth education coordinator. Patients are encouraged to sit in the Jacuzzi in their room and to use physical therapy birthing balls that allow them to lean into a wall to get relief for back pain or sit and rock side-to-side to help the baby descend. Women are allowed to drink instead of getting IV fluids, and fetal monitoring is done intermittently so the women are free to move around. Nurses also use a maneuver for patients having difficulty pushing in which they tie knots in a towel or sheet, hold on to one end, and have the patient hold on to the other while she pushes.
4. The Mayo Medical Center in Rochester, MN, reduced its primary cesarean rate from about 11.5% to 8%, says Jeri Sehl, RN, MS, perinatal clinical nurse specialist. Guidelines for elective inductions were set to wait until 41 weeks before induc - ing for nonmedical reasons. Nurses put patients in a triage space before admitting them to a birthing room. If a patient is in false labor, the nurse sends her home with coping skills she can use to relieve her discomfort. Nurses attend hands-on classes during which they practice such comfort measures as using birthing balls and giving massages. The team met weekly with physicians.
[For more information, contact:
· Laurie Husted, RN, clinical facilitator of education, Indianapolis Community Hospital East, 1500 N. Ritter Ave., Indianapolis, IN 46219. Telephone: (317) 355-5073.
· Vicki Thomas, RNC, director, maternal/child nursing, Houston Northwest Medical Center, 710 FM 1960 W, Houston, TX 77090. Telephone: (281) 440-2520.
· Jan Kolkema, RN, childbirth education coordinator, Mercy General Health Partners Special Delivery Birth Center, 1700 Oak Ave., Muskegon, MI 49442. Telephone: (616) 777-6291.
· Jeri Sehl, RN, MS, perinatal clinical nurse specialist, Mayo Medical Center, 200 First St. SW, EI 1-9, Rochester, MN 55905. Telephone: (507) 284-5744.]