Best practices from successful hospitals

Guidelines, nursing, and Jacuzzis

Several of the most successful hospitals in the Institute for Healthcare Improvement collaborative group share some of their best ideas for reducing cesarean rates:

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. (See triage order, inserted in this issue.) 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 cesarean 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 rooms 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 intravenous 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 inducing 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.