Techniques That Keep Labor Going Reduce Cesarean Section Rate
Noa Gleaner didn’t think twice when a nurse in the labor room at Einstein Medical Center Philadelphia asked her if she wanted to move around on the “peanut ball” to help her labor progress.
Gleaner, who is from Lower Merion, had arrived at Einstein early in the morning to be induced. She had been tethered to a Pitocin drip for hours, which meant she couldn’t stray far from her bed.
“I’d never heard of a peanut ball, but I was so bored, anything that got me out of bed was fine by me,” says Gleaner. “They said it was a good way to deal with early labor and I said I would try anything that would make it easier and faster.”
She was able to get out of bed and straddle the bright orange, peanut-shaped fitness ball at her bedside. At that point, says Gleaner, “It just felt good to be out of bed and to get to stretch.”
Gleaner’s first child — daughter Maya, now a year old — was born vaginally at 2 the next morning.
C-section Rates Reduced
Use of the peanut-shaped ball was one of the first new measures implemented last year at Einstein’s Philadelphia campus to help reduce the number of cesarean sections among first-time mothers like Gleaner who are at low risk for needing a surgical birth. Other approaches have contributed to the initiative, as well.
The efforts have already lowered C-section rates, especially in the target group. Obstetrics staff are continuing to refine the program for a greater impact.
Peanut balls and the large, round “birth balls” that are part of Einstein’s maternity armament look like they were appropriated from a local gym. In fact, the birth balls aren’t any different from the inflated balls you might use to build up your core muscles or to sub as a desk chair to help strengthen your back.
In labor, straddling and balancing on the ball can help balance your pelvic muscles and loosen your ligaments so the baby can more easily move into the optimal position for birth. It also takes advantage of gravity, which can help move the baby into the birth canal.
While Gleaner opted to get out of bed, the peanut can also be used directly on the bed. That’s a boon to women who have had an epidural and are anesthetized from the waist down.
Keeping Labor Going
Studies suggest that the use of peanut balls helps to keep labor moving forward naturally and reduce the need for C-sections.
“Laboring women can place the peanut ball between their legs and move around in various positions, which opens up the pelvis and encourages the baby to descend and turn to maneuver through the birth canal,” explains Melissa Rosenberg, CNM, CRNP, MSN. Rosenberg is a midwife and nurse practitioner at Einstein Philadelphia.
One 2015 study looked at laboring women who were not able to get out of bed after an epidural. Those who straddled and moved around on a peanut ball on their beds had shorter average labor times and higher rates of spontaneous vaginal birth than similar women who didn’t use the ball.
Anything that encourages labor to move forward naturally can help reduce the need for surgical intervention, says Rosenberg. “Failure to progress” — when labor is slow or stalls out altogether – is one of the leading causes of C-sections in the United States.
Advantages of Vaginal Birth
About one-third of all U.S. babies are now born via cesarean section. That’s seven times the rate in 1965, when it was first measured. C-section is now the most common U.S. operating room procedure, according to the National Partnership for Women and Families. The World Health Organization has established 10% to 15% as the target goal for C-sections.
Many U.S. medical centers, like Einstein, are trying to reach that lower number. While a cesarean can often be a life-saving procedure, it’s also major abdominal surgery. Largely safe, cesareans have the same risks as other pelvic surgeries.
When Rosenberg and Paige Rowland, her fellow certified nurse-midwife, arrived in 2017, they immediately started preparing the hospital to join the Reducing Primary Cesareans Project. Einstein Philadelphia officially signed on to the project in January 2018.
The national program was launched in 2015 by the American College of Nurse-Midwives to give women and their health care providers evidence-based tools to curb unnecessary C-sections.
Program Pioneered at Montgomery
Einstein Medical Center Montgomery, where the C-section rate was lower than average to begin with, was already participating. Nationwide, 26 individual hospitals, as well as a statewide program in Michigan, have taken part in the project since 2015.
“Before we started our interventions in 2015, our rate was 19.6%,” says Michelle Djevharian, CNM, the lead nurse-midwife at Einstein Medical Center Montgomery. Djevharian first brought the Reducing Primary Cesareans Project to Einstein administration after seeing an ad for it in a midwife journal.
Once the program started, Montgomery’s C-section rate dropped to 16.1% the following year. It’s currently 18.6% — evidence that “we always have to stay on top of it,” she says.
The Einstein Philadelphia team, which includes nurses, residents, attending physicians, and other labor and delivery room personnel, has seen impressive results since joining the Reducing Primary Cesareans Project.
Quick Drop in C-sections
Before, Rosenberg says, the C-section rate was “slightly better than average—around 31%.” Since then, it has dropped 5.5 percentage points for all maternity patients.
The rate has fallen 6.5 points among women in the project’s target demographic: first-time mothers at low risk for C-section, carrying one baby who is in the head-down position. The goal is to keep reducing C-sections, she says. “We want to be the safest.”
David Jaspan, DO, chair of the Department of Obstetrics and Gynecology at Einstein Healthcare Network, agrees.
“We are so proud of the work and innovation that this initiative has brought to Einstein,” he says. “The initiative has expanded how our team approaches labor, and through this process enabled us to offer properly selected patients safe labor options such as the peanut ball, ambulation and various other options.”
Peanut balls and birth balls were just the first and most visible of the new approaches the Einstein team rolled out in 2017.
Behind the scenes, Rosenberg and her project colleagues have worked on educating the staff on the evidence-based strategies for promoting spontaneous labor progress and natural birth.
Admitting Women Later
For example, she says, the standard for admitting a woman in labor to the hospital has been to wait until the opening in her cervix is dilated (widened) to at least 4 centimeters (cm).
The new guideline is to wait for a woman to be in the active stage of labor before admitting her. That means she should be at least 6 cm dilated. “Six is the new four,” Rosenberg says.
Studies have shown that women who are further along in labor when they are admitted to labor and delivery are less likely to need Pitocin to help them progress in labor.
“The transition from 4 to 6 cm is often very long — hours,” says Rosenberg. What is actually normal progress may look prolonged to patients. Psychologically, “it sort of follows that old saying, that a watched pot never boils,” she says.
“In the hospital,” Rosenberg says, “we now urge moms who are able to safely get up and walk around. And for those who can’t — because they’ve had an epidural or are hooked to a fetal monitor or Pitocin drip — we encourage them to change positions in bed or to use the peanut or birth balls to move around.
“The mom’s moving can actually change the dimension of the pelvis, which helps the baby descend.”
Doulas and Fetal Monitoring
Another science-based effort Einstein Philadelphia has initiated is to connect pregnant women with a birth doula. This person, usually a woman, is trained to offer physical and emotional support during childbirth.
“It’s documented that having a person constantly with you lowers your risk of C-section, shortens labor and lowers the desire for pain medication and increases satisfaction with the birth experience,” says Rosenberg.
There are more than a dozen doula agencies in the Philadelphia area. Einstein works with the Maternity Care Coalition, a Philadelphia-based nonprofit focusing on pregnant women and families, to help provide free and low-cost doulas to lower income expectant families.
Currently, Einstein Philadelphia uses continuous fetal monitoring during labor and childbirth. On the horizon, Rosenberg expects that the hospital will adopt an option that would enable eligible patients to have fetal monitoring at intervals.
Fetal monitors don’t move, so a woman in labor who is connected to a monitor can’t venture far from her bed. “We’ve applied for a grant to buy some portable monitors so women who need them can still move around,” Rosenberg says.
Safe for Mothers and Babies
To confirm that the measures taken to avoid C-sections don’t result in harm to mothers or babies, Rosenberg says, Einstein is also tracking other data, including Apgar scores, an instant assessment of newborn health.
“The lower C-section rate has been accomplished without compromising the safety of the babies that we deliver,” Dr. Jaspan says.
The changes at Einstein Philadelphia have been well received by patients. For example, in late February a first-time mom who had some pregnancy complications came to the hospital with a birth plan that included vaginal childbirth with no epidural.
“She used a birth ball and position changes, and had a doula. Her labor progressed spontaneously and she had a vaginal delivery, and is very happy with how things went,” Rosenberg says.
The labor and delivery staff have become true believers, too. “Staff were initially apprehensive and skeptical,” admits Rosenberg. “We won over the labor and delivery nurses once they saw these balls in action.”
It’s common during an induction, like Noa Gleaner’s, for a woman’s cervix to hover at 4 or 5 cm for a long time. “But when a nurse or provider has the opportunity to utilize the peanut, this may enhance progression towards delivery,” Dr. Jaspan says.
Once the nurses were won over, the residents and other doctors followed. Says Rosenberg, “Now, if there’s a mom who has been laboring and her cervix has been unchanged for a while, one of the first things I hear the residents say is, ‘Have we tried a peanut ball?’ It’s been amazing to see this transformation.”
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Top photo: Michelle Barcus, MSN, an Einstein nurse practitioner and midwife, demonstrates how the birthing ball allows women to move during labor.