Nurses Can Help Reduce Cesareans

Until about a century ago, most mothers in the U.S. delivered their babies at home, surrounded by friends and family and usually assisted by a nurse or midwife. Today the vast majority of babies enter the world in a hospital, many via surgical birth. Cesarean delivery, when a surgeon removes the baby through incisions in the mother’s abdominal skin, muscle and uterus, can be lifesaving, not to mention convenient. But it also carries significant risks. And the proportion of cesarean deliveries is increasing, raising concerns that the procedure is being overused.

How the health care industry arrived at the widespread use of cesarean deliveries is a complex story with many players. But one group — nurses — has been intimately involved in the birth process for more than a century. Once relegated to being passive assistants to doctors, they’re reexamining their roles at the laboring mother’s bedside. Some, including Melissa McIntire Sherrod, professor of nursing, are asking how they can assume more power to influence birth modes.

Melissa Sherrod, professor of nursing, traces a dramatic shift in nurses’ roles during childbirth. Photo by Rodger Mallison

In her research on the history of cesarean delivery, Sherrod traces a dramatic shift in nurses’ roles during childbirth. The profession that once cared for laboring mothers at home may now, she suspects, be enabling the overuse of surgical birth by not fully using communication skills. If older nurses can teach younger ones ways to help mothers through vaginal childbirth and slow down the birth process, then nurses might help safely reduce medically unnecessary cesareans.

“Nursing has been complicit, in my view and in the view of a lot of other people,” Sherrod said, “with allowing the medical community and hospitals to medicalize birth to such a degree that women are lost in this.”

Acknowledging the Problem

In 2018, about 1 in 3 North American babies were born through a uterine incision, up from about 1 in 5 in 1990. The procedure is sometimes necessary, such as when the child’s head is too large to fit through the birth canal. But with risks that include surgical injury, blood clots and complications for future pregnancies, a C-section is not trivial. Children born this way are more likely to have allergies and asthma, and the bacteria in their intestines are less diverse, according to a 2018 study published in the journal Lancet. The World Health Organization recommends a cesarean birth rate of fewer than 1 in 6.

“Not that C-sections are bad. They have their place,” said Lisette Saleh ’02 (BSN ’08), assistant professor of nursing, who is working to create a women’s health track for TCU nursing students. The track will address women’s health across their lifespans, not just their reproductive health, and is intended to empower new nurses to use their bedside judgment and speak out more often.

To counteract her students’ perception that cesareans are routine, Saleh ensures they witness the cold, bright, sterile surgical environment, how bloody the operation is, the way a mother’s belly may be curtained from her view behind a blue drape, even the irrelevant banter of the surgical staff.

“Is the mom an active participant in the birth of her child?  She is not,” Saleh said of surgical delivery.

Some reasons for the rising rates of the procedure, such as an increase in older mothers, are independent of obstetric practices. Others, including physicians’ desire for predictability and fear of malpractice, are entwined in the health care system. Hospital and insurer policies also play a role.

Electronic fetal monitoring may be a factor, too, Saleh said. “When we see things that we don’t like on the monitor, we feel that we need to do a C-section or intervene.”

The popularity of inducing labor is also part of the equation. Induction can reduce the C-section rate for some mothers, but medical professionals should perform inductions for the right reasons and under the right circumstances, Saleh said.

Efforts are underway to reduce cesareans. In 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine released a consensus document on how to safely prevent them. The U.S. Department of Health and Human Services has issued requirements intended to cut back on convenience C-sections.

Bearing Responsibility

But Sherrod argues that nurses’ roles need to be examined, too. That would be novel. The Joint Commission, a not-for-profit organization that accredits hospitals and sets many U.S. health care standards, doesn’t recommend checking nurses’ cesarean rates, despite previous research showing nurses can affect these rates and influence physicians’ judgment.

Melissa Sherrod, professor of nursing, briefs a student on her simulated patients in a nursing simulation lab in the Annie Richardson Bass Building. Photo by Rodger Mallison

“If we’re going to look at the physicians, and we’re going to look at the hospital, and we’re going to look at patients, we better look at the nurses and find out what they’re doing, too,” Sherrod said. “We need to hold them as accountable as we’re holding everybody else.”

In most hospitals, nurses manage the patients’ labor. They admit and assess laboring mothers, begin intravenous lines, administer medications and check vital signs. Doctors often remain voices on the phone, making only intermittent appearances at the bedside and occasionally arriving only minutes before delivery.

“With this model, the nurse develops a very large role in the birth story,” Saleh said.

The decision to proceed to cesarean delivery can be influenced by nurses’ judgment, Sherrod said. A nurse decides when to call the doctor, and what happens next can vary depending on how the nurse frames the situation. If the nurse is able to convey that the mother and unborn baby just need more time, Sherrod said, that calming message may affect the rapidity of medical intervention.

A birthing unit’s culture is probably also a factor, Saleh said. “I think sadly at some facilities they’re just moving towards a ‘Hey, this is the way it is — we put a patient in the bed, we give ’em a gown, we start their Pitocin, we rupture their membranes. If they’re not delivered by this time, we have a C-section.’ ”

Nurses with lower rates, she suspects, have certain practices in common.

“Chances are they’re in the rooms a lot more, they’re doing more interventions, they’re communicating a lot with the patient,” Saleh said.

A Medical Model of Childbirth

Sherrod, the daughter of an obstetrician, grew up in Odessa, Texas. After nursing school, then a master’s in maternal-child care, she started a prenatal clinic at the community hospital in her hometown that served low-income women during the ’80s oil boom. Later, she earned her PhD in nursing. She joined TCU’s faculty 15 years ago.

The World Health Organization recommends a cesarean birth rate of fewer than 1 in 6. The current rate in the United States is 1 in 3. Photo by Getty Images | Julen Garces Carro

An interest in history led her to join the American Association for the History of Nursing. When Mary Gibson, then an associate professor of nursing at the University of Virginia, asked Sherrod to write an article on the history of cesarean sections for the Journal of Obstetric, Gynecological & Neonatal Nursing, she agreed.

“In nursing, we have the opportunity to influence practice by some of the historical work that we do,” Gibson said.

Sherrod’s article traces the emergence of obstetrics as a legitimate specialty, shifting childbirth away from female midwives in the home and toward doctors in the hospital and a concurrent rise in cesarean deliveries.

Early in the last century, Sherrod said, mothers usually labored with friends and family in the room in what was a “community event.”

During that time, cesareans were beginning to overcome their grim reputation as a postmortem procedure or as a last resort during childbirth catastrophes. Doctors were increasingly using anesthesia and antisepsis. As more mothers began to survive childbirth, the life of the fetus began to take on new value, in part because saving them no longer seemed quite so futile.

With a growing faith in technology, a new understanding of germ theory and the belief that giving birth at home was riskier, the 1910s and 1920s saw more upper- and middle-class women opting for hospital births. Mothers began to embrace options such as anesthesia.

Until the 1930s, doctors still made house calls to perform techniques such as a forceps delivery or the extrication of a nonviable fetus. But families often second-guessed the doctor’s wishes to, say, use sterile techniques.

“They were washing the mother’s body using antiseptic and draping her all over in white sheets, showing only perineum,” Sherrod said. “They were doing everything they could to kill germs, but it was just over the top. A lot of families wanted a family-centered, cozy situation in their home, and they ended up with this woman looking like a mummy and smelling like Listerine.”

Obstetricians preferred to convince laboring mothers that hospitals were a better birthing environment. This was part of a movement to wrest control of childbirth from midwives as the obstetric specialty came into its own in the 1920s, as well as an attempt to ensure cleanliness and access to a surgical theater and anesthetics, Sherrod said. “That’s when nursing made its Faustian bargain with medicine.”

“Nursing has been complicit, in my view and in the view of a lot of other people, with allowing the medical community and hospitals to medicalize birth to such a degree that women are lost in this.”
Melissa Sherrod

The early 20th century was an uncertain time for the then-young nursing profession. Nurses had begun to value scientific knowledge and technical skill, and they sought to gain acceptance from doctors and establish a role within the medical model of childbirth. They earned a place on the team by encouraging mothers to deliver in the hospital but paid for it by relinquishing much of their power, Sherrod said. Especially in the hospital setting, “physicians really saw them as handmaidens.”

Since the 1920s, nurses have dealt with a tension between two roles: that of patient advocate and that of someone who must do as doctors direct, which is sometimes at odds with what patients prefer.

After the 1930s, hospital births became the norm, even as many mothers and nurses felt uneasy with how mechanized and impersonal the process could be.

Electronic fetal monitoring debuted in the 1960s, and the cesarean rate rose along with its use, as nurses and obstetricians were inclined to act on readings that looked concerning. Mothers tethered to monitors had less freedom of movement, a restriction that can stall labor. Nurses wheeled patients from labor room to delivery room to recovery room, then to a postpartum room, Gibson recalled from her early days on the labor and delivery unit in the 1980s.

“I think we did things at the convenience of the doctors for a very long time,” Gibson said, “which didn’t necessarily reflect a good experience for the mom.”

“I think we did things at the convenience of the doctors for a very long time, which didn’t necessarily reflect a good experience for the mom.”
Mary Gibson

Leading the Way to Change

To begin reducing unnecessary cesareans, Sherrod said, hospitals and nurses can take several key steps.

For one, nurses need to learn about racism in health care and how it affects outcomes, she said. Stark race-based disparities haunt obstetrics, including those relating to maternal mortality and cesareans, which affect a disproportionate number of African American mothers. Sherrod is studying the history of those disparities, too. In addition, Black mothers, on average, receive less prenatal care than white mothers.

Sherrod also pointed out that many health care providers continue to hold false and harmful beliefs about racial and ethnic minorities — such as that Black women are hypersexual or that they have a higher pain tolerance than white women.

To tackle such attitudes, she formed a multiracial faculty discussion group at the Harris College of Nursing & Health Sciences in fall 2019 to devise a plan to educate faculty and students about race-based inequities in health care. The committee began to meet in January to discuss readings, raise faculty awareness and plan workshops.

Sherrod has also called for increasing nurses’ autonomy and giving them more say in forming institutional policies, some of which she said incentivize higher-paid cesareans over vaginal births. It’s crucial, she said, to ensure that nurses are represented in hospital decision-making bodies and to examine physician resistance to nurses’ autonomy. Nurses can prevent the need for many cesareans if doctors listen to and respect their judgment, Sherrod said, adding that at the same time, nurses will need the support of hospital administrators to feel safe when asserting their authority.

“Nurses’ intuition, guidance and opinion based on what they’re actually seeing and doing [at the bedside] needs to take precedence,” Sherrod said. “Why not allow them more freedom in decision-making?”

Finally, Sherrod would like to see more research on labor and delivery nurses’ role in cesarean birth rates. Those with lower cesarean rates should be rewarded and put in a position to teach their techniques, Sherrod said.

Melissa Sherrod, professor of nursing, said increasing nurses’ autonomy and giving them more say in forming institutional policies can reduce the number of unnecessary C-sections. Photo by Rodger Mallison

These nurses know a variety of methods to help laboring mothers along. They can suggest pain-control options that don’t immobilize a mother the way an epidural does. Encouraging the mother to walk, change position or put a ball between her knees can all help open the pelvis for easier vaginal childbirth, Saleh said. Breech fetuses can be rotated to the proper position while still in the womb, and twins can often be safely delivered vaginally if the first one’s head is properly aligned. And a nonreassuring fetal monitor tracing can often be converted to normal by gently stimulating the fetal scalp.

These nurses may also be better communicators. One of the few studies done on this topic, Sherrod said, cited nurses who describe “negotiating for more time” for the mother to give birth and resisting doctors inclined to speed the process along.

To provide TCU nursing students with an understanding of the politics of women’s health and to empower them to hold difficult conversations, Saleh and fellow TCU nursing professors Lynnette Howington ’94 (DNP ’11) and Susan Fife ’91 are creating a pair of electives tentatively planned for a rollout in Fall 2020. One will focus on women’s health and care of the female patient, while the other will address high-risk pregnancies. Added to Maternal, Child and Family Nursing Concepts, the traditional maternity course required of all seniors, the new courses will create a women’s health track within the standard nursing program, Saleh said.

But above all, Saleh said, students must learn not only to advocate for patients, but also to ask providers “why” questions. The need to be inquisitive about medical decisions made by others certainly goes for improving C-section rates, she said: “If nothing else, ask the question. Then at least we know why we’re doing what we’re doing. We’re not just doing it because someone said to.”