Reducing Primary Cesareans: An Innovative Multipronged Approach to Supporting Physiologic Labor and Vaginal Birth

Becky Gams, Carrie E Neerland, Sheila Kennedy

Research output: Contribution to journalArticlepeer-review

10 Scopus citations


Primary cesarean birth increases a woman's risk for hemorrhage, infection, pain, and cesarean births with subsequent pregnancies. A woman may experience difficulties with breastfeeding, bonding, and incorporating the newborn into the family structure. One urban, academic hospital in the Midwest participated in the American College of Nurse-Midwives Healthy Birth Initiative: Reducing Primary Cesarean Births Project. The project purpose was to reduce the rate of cesarean births in nulliparous, term, singleton, and vertex pregnancies. Strategies employed included use of intermittent auscultation, upright labor positioning, early labor lounge, one-to-one labor support, and team huddles. The baseline nulliparous, term, singleton, vertex cesarean rate in 2015 was 29.3%. In 2016, after 1 year of implementation of the project, the hospital decreased nulliparous, term, singleton, vertex cesarean rate to 26.1% - a reduction of 10%. In 2017, the rate was decreased to 25.3% - a reduction by 3.7%.

Original languageEnglish (US)
Pages (from-to)52-60
Number of pages9
JournalJournal of Perinatal and Neonatal Nursing
Issue number1
StatePublished - Jan 25 2019

Bibliographical note

Funding Information:
The final student project was implemented near the end of the second year of the RPC project, during the academic fall semester of 2017. The overall aim of this project was to increase the rates of one-to-one labor support, noted in the literature as critical for reducing cesarean rates.22,23 The project started after a survey to determine the level of interest of current junior and senior nursing students in the baccalaureate program and in the postbaccalaureate master’s degree in nursing program regarding a desire for Doula training. The results showed an overwhelming interest with approximately 100 students responding. Supported by the high-interest level, the students, faculty, and a Doula trainer developed a 4-day, 2-hour didactic curriculum and 16-hour Doula training workshop. Known as Partners in Birth, this project included the development of an elective nursing 2-course credit Doula training course offered by the University of Minnesota School of Nursing. The Doula training course content consisted of didactic and hands-on practice of labor support comfort strategies, basic breastfeeding techniques, a panel of local leaders who described the community resources available to childbearing families, and a tour of the labor and delivery unit where the Doulas would provide labor and birth support. Students involved in the pilot project then provided four 8-hour shifts of labor support at no cost to women in labor at the hospital. The students set up the student nurse Doula calendar and designed a T-shirt designating the student as part of the Partners in Birth program. The RPC project leaders provided a tour to the students, ensured that students’ calendars were available to the unit charge nurses, collaborated on the data collection items, and developed and covered the cost of a brochure to promote the Partners in Birth program in the associated prenatal clinics. To keep the course sustainable for the fall 2018 and spring 2019 semesters, a hospital staff nurse participated as a faculty member. The course allowed 20 students to enroll and the number of Doula support hours increased from 32 per student to 40 per student. The same nurse who was responsible for assisting with data collection fulfilled the faculty for the student Doula program.

Publisher Copyright:
© 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Copyright 2019 Elsevier B.V., All rights reserved.


  • nulliparous
  • physiologic birth
  • primary cesarean
  • quality improvement


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