Nurses ramp up efforts to lower U.S. cesarean rates

By | 2022-10-07T12:14:58-04:00 June 6th, 2019|3 Comments

In the United States, cesarean births have increased from 20% to 32% over the past 22 years.

The Centers for Disease Control and Prevention reports cesarean rates as high as 37% in states such as Florida and Louisiana. Studies also have shown rates vary widely from hospital to hospital.

While C-sections are medically necessary in some cases, researchers estimate that almost half of these procedures performed in the U.S. are not necessary.

Cesarean sections are not only more costly than vaginal births, but also increase the risk of obstetrical hemorrhage, anesthesia complications, injuries to the bladder, bowel and vascular system, postpartum pain and other problems.

The procedure also can cause placenta accreta — a serious condition in which the placenta grows too deeply into the uterine wall — in future pregnancies.


Pam Lesser, MSN, RNC-AWH

An increase in complications caught the attention of Pam Lesser, MSN, RNC-AWH, director of perinatal services at SSM Health St. Mary’s Hospital-St. Louis.

Several years ago, Lesser noticed more women were being referred to her hospital for abnormal placental attachments, and the perinatal team knew that avoiding the first C-section was one way to decrease the risk of these complications.

To tackle the problem, the team decided to steer away from elective inductions before 39 weeks gestation. Even for patients who reached this milestone, “we started asking ourselves and mothers whether we could wait a little longer for labor to start naturally,” she said.

They also stopped putting time limits on deliveries. Rather than giving mothers 12 or 24 hours to deliver a baby after their water membranes had ruptured, mothers could wait for labor to begin naturally while nurses regularly checked for signs of infection.

Lesser’s team also ramped up interdisciplinary communication between patients, nurses, neonatologists, anesthesiologists and physicians to ensure everyone was more aware of the mother’s progress throughout labor.

“Now we meet as a team twice a day to talk about what we see that is reassuring versus concerning with the patients,” Lesser said. “This helps us decide whether to continue or change the plan of care.”

After implementing the new strategies, the overall C-section rate at the hospital dropped from 30% to an average of 25%. For first-time C-sections, that rate dropped to 13.5%.

The power of whiteboards

Improved communication between physicians, nurses and patients helped South Shore Hospital in Massachusetts reduce C-section rates. In 2018, the labor-and-delivery unit started placing a whiteboard in each room listing the mother’s birth plan, medical history and names of care team members.


Heather Powderly, BSN, RNC

“It’s been interesting to see how much more everyone communicates when we write things down,” said Heather Powderly, BSN, RNC, a staff nurse at South Shore. “If the patient’s preferences have changed or she doesn’t understand something on the board, we talk about it.”

This strategy is part of a new initiative known as Team Birth Project, a program that aims to improve the patient experience and provide a safe and dignified birth for all women.

The program was developed by Ariadne Labs, a joint center between Boston’s Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, to reduce the number of unnecessary C-sections.

The hospital also has started using an admission decision aid in labor and delivery, which helps providers decide whether to admit a laboring mother, send her home or move her to the early labor lounge. The lounge includes dim lighting, soothing music, birthing balls and other items that support the labor process.

Since the program began, Nulliparous, Term, Singleton, Vertex (NTSV) cesarean rates dropped from 30% to 26%.

Patients also are pleased with the changes, Powderly said. “In the surveys, patients are more specific than in previous years about what they appreciated, and people who have had multiple children here say the most recent birth experience was different,” she said.

New approach to labor pains


Elisabeth Howard, PhD, CNM, FACNM

Elisabeth Howard, PhD, CNM, FACNM, is an associate professor of obstetrics and gynecology (clinical) at Warren Alpert Medical School and midwifery director at Women and Infants Hospital in Providence, RI.

She was bothered by the high C-section rates in the U.S. and advocated for her hospital to address the problem by joining a national initiative known as the Reducing Primary Cesareans Project.

As part of the program, which was developed by the American College of Nurse-Midwives, the hospital started applying a new evidence-based strategy to pain assessment.

Rather than using the traditional scale of one to 10 — a tool originally created for post-surgical patients — they switched to a coping versus not coping model.

Cues for coping included rhythmic breathing, relaxation between contractions and vocalizations such as counting or chanting. Signs that a woman was not coping included crying, writhing, lack of concentration and loud vocalizations.

If a patient is not coping, the care team can suggest non-pharmaceutical options such as yoga balls, an upright birthing chair or nitrous oxide.

Howard also started teaching a 10-hour workshop to train nurses how to promote relaxation, comfort and confidence in laboring women. Nurses learned how to use guided meditation, essential oils and acupressure.

“Helping nurses understand the importance of normal labor physiology has been critical,” Howard said. “Women need to be upright and mobile as much as they can.”

The program, which launched two years ago, helped the hospital decrease the epidural rate in first-time, low-risk mothers by 20%, and the C-section rate 5%.

Aware that labor-and-delivery nursing can be emotionally and physically exhausting, Howard incorporated lessons on self-care and self-compassion into the training.

The nurses learned about deep breathing, guided meditation and how to be present themselves. So far, she’s trained 200 nurses, and participants describe the workshop as incredibly helpful.

“It’s been rewarding to see that nurses feel empowered because they have more techniques at their fingertips to create a comfortable space for patients,” she said. “It’s helping them reconnect to why they became nurses.”

For more resources related to cesarean sections:

About the Author:

Heather Stringer is a health and science freelance writer based in San Jose, Calif. She has 20 years of writing experience and her work has appeared in publications such as Scientific American, Discover, Proto, Cure, Women and the Monitor on Psychology.


  1. Jun April 2, 2020 at 3:15 am - Reply

    The increase in epidural and c-section is very alarming. These procedures should be done in emergency cases only. There are many birth classes out there, like Bradley Method, BirthForMen, Lamaze, etc can educate expectant couples more regarding natural and/or unmedicated birth . The most important thing is to care for the mother and the baby, getting them healthier and have higher chances of survival.

  2. Danielle M Arnold March 10, 2022 at 3:03 am - Reply

    I think maybe people should mind there own damn business if someone wants a c section. They dont argue when someone wants a abortion or try talking there way out of that. I’ve known plenty to have c sections and I was a c section baby I have had NO ISSUES growing up or anyone I know. If they want to preach pros and cons ok but they def shouldn’t be forceful and they def should have no right to push encouraging something someone does not want. I’m pregnant at 33 weeks and would prefer a c section. If these celebrities are allowed to get them with no arguments then so should average people.

  3. Danielle M Arnold March 10, 2022 at 3:10 am - Reply

    They need to mind their own. They don’t make someone feel uncomfortable about getting an abortion even though that rips a child apart and has safety issues for a mother. If they want to preach pros and cons ok, but they shouldn’t be forceful or discouraging when it’s their body and with how painful labor is. Yes, afterwards the healing from the wound takes longer, but I’m sure altogether way less painful. What’s wrong with a woman wanting less pain and not wanting to be torn up if there is an easier option that doesn’t pose HUGE risks. I was a C-section baby and so was my brother. I didn’t have any issues physically or mentally or him. Most C-section babies might seem to have a higher percentage of issues but because a lot of these C-sections are necessary due to complications to begin with in pregnancy, I don’t see how they can even bring up that meaning it was due to a c section or maybe being due to one. Going through a birth canal poses risks as well. Babies being stuck in too long and lack of oxygen.

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