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Menomonee Falls, WI, boasts a community hospital that started with a low cesarean section rate of 14.8% lower than the 15% goal set by the U.S. Public Health Service in Rockville, MD and made it lower. Much lower.
Between 1994 and 1995, Community Memorial Hospital dropped to a cesarean rate of l0.5%, with no adverse fetal or maternal outcomes. At the end of this period, this hospital also had a low epidural rate (15%) and neonatal intensive care unit (NICU) transfer rate (2%).
The director of Community’s birthing center, Alice Maki, RN, and other nurses started the campaign to lower Community’s cesarean rate by asking each physician and nurse involved in the OB/GYN unit to sign a philosophical statement that they supported the goal of lowering the hospital’s cesarean rate by 2%.
This statement contained no specifics about how the reduction would be accomplished, says Maki. It was simply a way of making sure that everyone had the same intention.
Maki says that key components in the Community Memorial program were:
• Meetings to share information, such as articles and books on ways other hospitals had cut their cesarean rates, on low-intervention childbirth techniques used in Europe, and the benefits of doula’s minimally trained labor assistants who offer support during chidbirth. These meetings were held with both nursing and medical staff.
Organizers made a point of seeing that nurses and physicians received and discussed the same information in meetings held at least once a month.
• A labor support nurse for each laboring woman.
• Training for labor support nurses in simple interventions to ease labor pain, such as hydrotherapy (a warm shower with a spray nozzle), massage, encouraging the mother to walk, use of birthing balls, oral rehydration, and different positions for labor and delivery. These comforts enabled women to hold off their need for anesthesia longer, says Maki.
• A protocol for admitting women that distinguished between patients in the early stages of labor and those in true labor. "Now women are usually 4 cm to 5 cm dilated before admission. This new protocol helps short-circuit the tendency to do something once a woman is in the hospital, whether they need an intervention or not. We found that previously some women had received C-sections even before they were dilated 4 to 5 cm," says Maki.
• A change in the protocol for using an electronic fetal monitor, which previously was routinely attached to a woman for the duration of her labor. Most women are monitored intermittently, which allows them more opportunity to get up and walk. "Moving around seems to be a key factor in getting labor going," says Maki.
• Encouragement for women who have had cesareans to attempt a vaginal birth for subsequent babies. They are asked to attend vaginal birth after cesarean (VBAC) classes, where they learn that VBACs are safe and that vaginal births have certain advantages, such as fewer complications for mothers and less time in the hospital. (For a recent report on VBAC, see The Last Word, at the end of the newsletter.)
"Our physicians will not do C-sections on demand," says Maki. "If a woman is making progress with her labor, she is expected to deliver vaginally."
Maki says that her staff regularly communicate with other birthing centers, read new literature on birthing techniques, and otherwise actively stay abreast of any means of making deliveries easier, safer, and less invasive for women.
In 1970, cesareans accounted for 5% of all deliveries in the United States. By 1987, this figure had risen to 24.4%. Yet experts say there was no medical reason for the increase. In the 1990s, with the federal government and leading health organizations calling for a lower rate, cesareans declined somewhat. The rate was 21.4% in 1994, the most recent year reported by the National Center for Health Statistics in Atlanta.
Instead, the goal of the World Health Organization in Geneva, Switzerland, as well as the U.S. Public Health Service, is no more than 15% of births by cesarean.
In Mothering the Mother, How a Doula Can Help You Have a Shorter, Easier, Healthier Birth (Addison-Wesley, New York City), Marshall H. Klaus, MD, John H. Kennell, MD, and Phyllis H. Klaus, CSW, MFCC, cite seven randomized, controlled trials that have demonstrated that doula-assisted women experience an average of 50% fewer cesareans, 25% shorter time in labor, and 40% less need for oxytocin, forceps, and pre-medication. (For more information on doulas, see Women’s Health Center Management, January 1997, p. 11.)
The September 1996 issue of Birth magazine contains a randomized, controlled study from a Canadian tertiary care center in which low-risk births attended by nurse-midwives resulted in a cesarean rate of 4%, compared to a cesarean rate of 15.1% for low-risk births attended by physicians.
The episiotomy rate for the nurse-midwife group was 15.5% compared with 32.9% in the physician group. The rates of epidural anesthesia were 12.9% and 23.7%, respectively. The authors of the study concluded: "Comparison [of nurse-midwife care] with standard physician care demonstrated a lower application of technologic assessment, fewer interven- tions, shorter hospital stays, fewer neonatal intensive care unit admissions, and less maternal morbidity."