Unit Culture

Fostering a Unit Culture that
Promotes Care Approaches
to Support Physiologic Birth

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What’s the best mix of maternity care professionals to provide high quality maternity care? How can the unit culture and the administrators of that unit best support implementation of care practices that encourage physiologic birth? It starts with maternity care teams and administrators who value physiologic birth and are motivated to provide evidence-based, family-centered care.1 When midwives, physicians and nurses work together on such a team, the quality of care is improved, clinical errors are reduced, women are more satisfied with their care and overall safety is enhanced.2 Features of a birth environment that promote this model of care include:

For the birth setting and environment:

  • Access to midwifery care for each woman;3

  • Adequate time for shared decision making with freedom from coercion;

  • No inductions or augmentations of labor without an evidence-based clinical indication;4

  • Encouragement of nourishment (food and drink) during labor as the woman desires;5

  • An environment that promotes freedom of movement in labor and the woman’s choice of birth position;

  • Intermittent auscultation of fetal heart tones during labor unless continuous electronic monitoring is clinically indicated;6

  • Maternity care providers skilled in supporting women during labor including the use of non-pharmacologic methods for coping with labor pain;7

  • Access to non-pharmacologic resources such as the use of tubs for water immersion, birth balls, doulas;

  • Availability of anesthesia alternatives such as availability of nitrous oxide;

  • Care that supports each woman’s comfort, dignity, and privacy; and

  • Respect for each woman’s cultural needs.2


Creating and fostering a unit culture that promotes care practices that support physiologic birth, requires that all members of the maternity care team ideally share a mutual vision of “normality” and the evidence base to support the selection of approaches to care.1 The benefits of physiologic birth for women have been presented under “A Focus on Physiologic Birth” and include satisfaction with the birth experience and the potential for less separation from the newborn and increased breastfeeding success, among other advantages. In addition all members of the maternity care team then benefit from this model of care.

Physiologic birth has the following expected benefits for nurses:

  • Potential for increased engagement and support of women in labor leading to increased professional satisfaction;

  • Improved performance on measures likely to be linked to payment, including patient experience measures (eg, Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] Survey); and

  • Possible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims.8

  • More efficient use of nursing and lactation consultant staff due to: Fewer scheduled inductions, shorter labors with more spontaneous labor, fewer cesareans and newborn complications, improved breastfeeding success, shorter second stage due to less epidural use.

Physiologic birth has the following expected benefits for physicians/midwives:

  • Increased professional satisfaction;

  • Improved performance on measures likely to be linked to payment as payment reforms are implemented; and

  • Possible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims.8

Physiologic birth has the following expected benefits for administrators:

  • Improved performance on measures likely to be linked to payment and accreditation as reforms are implemented, including
    • nulliparous, term, singleton, vertex cesarean rate
    • elective delivery before 39 weeks gestation
    • episiotomy
    • exclusive breast milk feeding during the hospital stay
    • experience of care measures (eg, HCAHPS survey)9;

  • Possible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims;8and

  • Possible reduction in staff turnover as physiologic care may be more rewarding for physicians, midwives, and nurses.

Hospital Accreditation

Hospital accreditation will be tied to reporting of maternity care performance; physiologic birth practices can be effective inimproving performance. Beginning in January 2014, accredited hospitals with at least 1100 births per year will be required to report to the Joint Commission on perinatal core measures.10 Measures that are amenable to improvement by implementing physiologic care in labor and birth include

  • nulliparous, term, singleton, vertex cesarean rate

  • elective delivery before 39 weeks gestation

  • episiotomy

  • exclusive breast milk feeding during the hospital stay


In summary, unit management that includes a focus on promotion of physiologic approaches to care of the women during childbirth have the potential to increase safety, improve quality and promote optimal health outcomes for childbearing women and their families. An atmosphere that promotes optimal care for women and newborns includes collaboration, mutual respect and a mutual understanding of the value of physiologic birth.


Click to view additional resources available in the Unit Culture Resource Toolbox, or search our resource library by clicking here.


References

  1. Kennedy, H.P., Grant, J., Walton, C., Shaw-Battista, J., Sandall, J. Normalizing birth in England: A qualitative study. J Midwifery Womens Health.2010; 55(3):262-9.

  2. Quality Patient Care in Labor and Delivery: A Call to Action 7. November 2011 http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000267/Call%20to%20Action%20FINAL%20Nov%202011.pdf accessed April 14, 2014.

  3. Hatem M, Sandall J, Devane D, et al. Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev. 2008; Oct 8(4):CD004667.

  4. Mozurkewich E, Chilimigras JL, Berman DR, et al. Methods of induction of labour: a systematic review. BMC Pregnancy Childbirth. 2011; 11(84):1-19.

  5. American College of Nurse-Midwives. Providing oral nutrition to women in labor. Clinical bulletin. http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000000064/ACNM_Clinical_Guidelines_on_Nutrition_in_Labor.pdf. Published March, 2008. Accessed May 4, 2012.

  6. American College of Nurse-Midwives. Intermittent auscultation for intrapartum fetal heart rate surveillance. Clinical bulletin. http://onlinelibrary.wiley.com/doi/10.1016/j.jmwh.2007.03.021/abstract?userIsAuthenticated=true&deniedAccessCustomisedMessage= . Pulished March, 2007. Accessed May 4, 2012.

  7. Simkin PP, O’Hara M. Nonpharmacologic relief of pain during labor: systematic reviews of five methods. Am J Obstet Gynecol. 2002;186(5 Suppl Nature):S131-S159.

  8. Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol. 2009;200:35.e1-35.e6.

  9. National Quality Forum. Patient safety collaboration. http://www.qualityforum.org/Setting_Priorities/NPP/NPP_Action_Teams.aspx. Accessed March 2, 2014.

  10. Zhani EE. The Joint Commission expands performance measurement requirements. http://www.jointcommission.org/the_joint_commission_expands_performance_measurement_requirements/. Published November 30, 2012. Accessed March 2, 2014.


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