Reducing the NTSV Cesarean Birth Rate by Implementing Intermittent Auscultation
Friday, July 19, 2019
By Siena Davis, MPH, Project Manager, PQI
“You are considered a healthy, low-risk mom. We don’t need to monitor you continuously. Actually, that increases your risk of a C-section.” -Beth Stephens-Hennessy
Beth Stephens-Hennessy, RNC-OB, EFM, MSN, CNS, is the Perinatal Clinical Nurse Specialist at Sutter Medical Center, Sacramento. She is responsible for labor and delivery, triage, and antepartum testing. As part of her position, Beth leads various quality improvement (QI) projects aimed at reducing the NTSV cesarean birth rate.
In January of 2018, Beth was working with hospital management to implement several elements of the California Maternal Quality Care Collaborative Toolkit to Support Vaginal Birth and Reduce Primary Cesareans. Beth explained, “We realized that our staff did not have the competency or the tools that they needed to perform intermittent fetal monitoring or auscultation.” Hospital administrators decided to conduct a QI project to train staff. Sutter Medical Center, Sacramento was selected as the pilot site for the project because it is one of the largest hospitals in the Sutter Health network; a network that includes 18 hospitals with OB units.
After Sutter Medical Center, Sacramento was selected, Beth helped to revise the fetal monitoring policy and update the physician order sets in the electronic medical record (Epic) to match the new policy. Before the project was conducted, the physicians had different order sets. Many of them had prechecked continuous monitoring and they used it for every patient. Now, Beth explained, “Every physician uses the same order set. Every order set says ‘Fetal monitoring per protocol.’” The new fetal monitoring protocol clearly explains whether a patient meets the criteria for fetal monitoring. According to Beth, “We’re definitely seeing an increase in the number of patients who qualify.”
To help staff nurses develop competency in performing intermittent auscultation, administrators and staff leaders developed a skills station, held staff meetings, offered hands-on demonstration, provided staff education, and wrote a script for staff to share with patients. Once trained, staff were instructed to perform intermittent auscultation on a real patient. Beth said, “They were told to perform intermittent auscultation while the fetal monitor strip was running and they were not looking at it. And then, when they were done, to compare the two.” Since the staff had to turn in their assessment, they were motivated to keep practicing until their assessment looked like the fetal monitoring strip. Nearly all of the 150 nurses at Sutter Medical Center, Sacramento have completed the competency.
From the start of the project, some staff nurses have expressed concerns about the possible legal ramifications of not providing continuous monitoring. Hospital administrators have assured the nurses that intermittent monitoring or auscultation is best for women in labor, holds up in court, is standard care according to AWHONN, ACOG, and ACNM, and has been successfully implemented in other facilities. Sutter Davis, a hospital in the Sutter Health network, has the lowest cesarean birth rate in California. At Sutter Davis, Beth explained, “They do nothing but intermittent monitoring unless they hear something abnormal.” The hospital has not had any legal issues as a result of their fetal monitoring policy.
Since nurses have been trained at Sutter Medical Center, Sacramento, hospital data show that both the number of nurses using intermittent fetal monitoring or auscultation of the fetal heart rate and the number of patients ambulating during labor have increased. In addition to conducting this project, Beth has also been involved with implementing other elements of the CMQCC toolkit to reduce cesarean births. For example, Sutter Medical Center, Sacramento has started providing tub labors, a volunteer doula program, peer review audits for every woman who has a nulliparous, term, singleton, vertex (NTSV) cesarean birth, labor support classes for staff, an outpatient cervical ripening program, an external cephalic version clinic, and education for staff so that they do not admit patients who are in early labor. As a result of numerous efforts, the NTSV cesarean birth rate at Sutter Medical Center, Sacramento dropped from 24.5% to 20.0% over three years.
At this stage in the project to increase intermittent auscultation, administrators are starting to audit. Beth explained, “We send notes to the assistant nurse managers and the staff to say ‘This patient met criteria. Please remember to try auscultation. If you need any help, let me know.’” Since the project has been successful at Sutter Medical Center, Sacramento, it is now being rolled out in the other 17 hospitals that are part of the network.
Beth's advice to others thinking about conducting QI projects:
- “Get one-on-one time with staff to find out what they think the barriers are.”
- “Start talking to staff… Say, ‘Okay, this is what the recommendation is. What do you see as positive or negative? How do you feel about it?’”
- “Use early adopters to help pull up the laggards.”
- “To sustain any QI project, you really need to do some auditing. You would hate to put in all this effort, all this work, all this education, and then 6 months later it’s not happening.”
- “Send out kudos to staff to say, ‘Good job!’”