Running head: DECREASING PRIMARY CESAREANS

Nursings Contribution to Decreasing Primary Cesarean Rates:

Research Proposal Idea Paper
Katherine deS
SUNY Institute of Technology

DECREASING PRIMARY CESAREANS

Nursings Contribution to Decreasing Primary Cesarean Rates:

Research Proposal Idea Paper

Background
The primary cesarean section rate for obstetrical delivery, along with its associated
complications and expense, has been on the rise at an astronomical rate (Caughey, 2009). Citing
MacDorman, Menacker, & Declercq (2008), Caughey (2009) states although we have seen the
cesarean rate rise 50% since 1995, there has been no concomitant reduction in neonatal
morbidity and mortality (p. 717). More and more women are choosing, or steered, toward
primary cesareans for delivery for a myriad of reasons, but newborns are not ending up healthier
for it. In fact, as the rate of cesarean deliveries increases, so does the rate of maternal mortality
(Caughey, 2009). In the US healthcare culture, free will and medical technology are highly
valued, leading to increased numbers of c-sections on demand (Alnaif & Beydon, 2012) as well
as paternalistic practices on the part of healthcare providers (Deline et al., 2012). When
combined with the highly litigious environment that medicine is practiced in, it has been difficult
to reverse this trend because attempts to deter c-sections are often viewed as an attack on
personal choice or the primacy of the doctor/patient relationship (Deline et al., 2012). However,
when nurses act as patient advocates, positive patient outcomes can be seen (Lyndon et al.,
2011).
Problem statement
The increasing rate of cesarean sections, coupled with the declining rate of attempted
vaginal births after cesarean (VBAC), is leading to higher rates of complications for mothers
(Caughey, 2009), inflated costs for healthcare (DSouza & Arulkumaran, 2013), and delayed
breastfeeding (Zanardo et al., 2010) without any measurable decrease in infant morbidity and
mortality (Caughey, 2009).

DECREASING PRIMARY CESAREANS

Purpose of the Research

In order to decrease the rate of primary cesareans, we need to address the problem from a
number of angles. For this research, the impact that nursing can have on the cesarean rate is
explored. Lyndon et al. (2011) established that nurses can affect positive change in patient
outcomes by acting as vocal patient advocates. Berard (2008) and Goldberg (2009) discuss how
educating patients can lead to more informed choices. The purpose of this research is to answer
the question, What self-described personality characteristics, if any, of labor & delivery nurses
lead to lower rates of primary non-scheduled cesarean sections? I specify non-scheduled at this
time because nurses have very little opportunity to effect change on patients who come to the
hospital on the day of a scheduled surgery.
Applicable Theories
Gadows Existential Advocacy
This theory espouses the idea that the freedom of self-determination is a primary
fundamental right (Bishop & Scudder, 2003). It is, therefore, the distinct role of nurses to
advocate for those choices the patient would make for herself (Bishop & Scudder, 2003).
Existential advocacy focuses on treating the body objectively without reducing the patient to an
object (Bishop & Scudder, 2003, p. 108). For my research, nurses personality characteristics
that encourage patient advocacy might have some bearing on the cesarean rate. Bu & Wu (2008)
designed a tool for measuring nurses likelihood for engaging in patient advocacy activities
which could be useful for my research.
Game Theory
According to Tarrant, Dixon-Woods, Colman, & Stokes (2010), game theory suggests
that social norms, awareness of others reputations, and signals of trustworthiness from verbal
and nonverbal communication influence decisions about trust and cooperation, alongside the
structural and dynamic aspects of the situations within which individuals interact (p. 441). I am

DECREASING PRIMARY CESAREANS

exploring how this theory could relate to my question on a number of levels, particularly in
patient interpretations of nonverbal cues of trustworthiness both from the nurse and the
obstetrician. I would hypothesize that maternity nurses who give verbal and nonverbal cues of
trustworthiness would be able to elicit more cooperation with techniques and interventions
designed to reduce the odds of cesarean rate, such as anesthesia free delivery and mobility during
labor.
Orems Self Care Deficit Theory
In Orems theory, patients seek nursing care when they have a need that they are
incapable of addressing on their own and require teaching and guidance to do so (Orem, 2001).
Orem (1991) believes that within the theory of self-care, person and environment are identified
as a unity characterized by human-environmental interchanges and by the impact of one on the
other (p. 143). It is nursings responsibility to teach patients coping skills in order to fill the
self-care void (Orem, 2001). Orems theory is applicable to my research study because it forms
part of the basis for my hypothesis that nurses who educate, advocate, and coach women
adequately through childbirth can remove the fear and stress responses that contribute to
increased cesarean deliveries.
Conclusion
The steady increase in cesarean sections for obstetrical delivery is leading to undue
increases in healthcare costs and rising complication rates for mothers with little to no benefit for
newborns. To address this problem, it needs to be combatted from multiple angles. Due to the
intimate, personal relationship between the labor & delivery nurse and the mother, the nurse may
have an impact on her ultimate mode of delivery. This research study, therefore, would address
the following research question: What characteristics, if any, of labor & delivery nurses lead to
lower rates of primary non-scheduled cesarean sections? Utilizing existential advocacy, self-care
deficit, and game theory to form a hypothesis, I would predict that nurses who highly identified

DECREASING PRIMARY CESAREANS

themselves as trustworthy and outspoken would have a lower primary cesarean rate than those
who identified themselves and inexperienced, softspoken, or patriarchal.

DECREASING PRIMARY CESAREANS

References
Alnaif, B. & Beydon, H. (2012). Practice of primary elective cesarean upon maternal request in
the commonwealth of Virginia. JOGNN: Journal of Obstetric, Gynecologic & Neonatal
Nursing, 41(6), 738-746. doi: 10.1111/j.1552-6909.2012.01387.x
Berard, V. (2008). Restoring balance in maternity care... "Combating coercion: breech birth,
parturient choice, and the evolution of evidence-based maternity care" (Birth
2007;34(2):176-180). Birth: Issues In Perinatal Care, 35(1), 86-87.
Bishop, A., & Scudder, J. R. (2003). Gadow's contribution to our philosophical interpretation of
nursing. Nursing Philosophy, 4(2), 104-110. doi: 10.1046/j.1466-769X.2003.00125.x
Bu, X., & Wu, Y. (2008). Development and psychometric evaluation of the instrument: attitude
toward patient advocacy. Research in Nursing & Health, 31(1), 63-75. doi:
10.1002/nur.20233
Caughey, A. (2009). Reducing primary cesarean delivery: can we prevent current and future
morbidity and mortality? Journal of Perinatology, 29(11), 717-718.
doi: 10.1038/jp.2009.132
Deline, J., Varnes-Epstein, L., Dresang, L.T., Gideonsen, M., Lynch, L., & Frey, J.F. (2012).
Low primary cesarean rate and high VBAC rate with good outcomes in an Amish
birthing center. Annals of Family Medicine, 10(6), 530-537. doi:10.1370/afm.1403
D'souza, R., & Arulkumaran, S. (2013). To 'C' or not to 'C'?/Caesarean delivery upon maternal
request: a review of facts, figures and guidelines. Journal Of Perinatal Medicine, 41(1),
5-15. doi: 10.1515/jpm-2012-0049
Goldberg, H. (2009). Informed decision making in maternity care. Journal of Perinatal
Education, 18(1), 32-40.
Gould, D. (2008). Professional dominance and subversion in maternity services. British Journal
of Midwifery, 16(4), 210.

DECREASING PRIMARY CESAREANS

Lothian, J. (2009). Ethics and maternity care: from principles to practice. Journal of Perinatal
Education, 18(1), 1-3.
Lyndon, A., Sexton, J., Simpson, K., Rosenstein, A. H., Lee, K., & Wachter, R. M. (2011).
Predicting likelihood of speaking up in labor & delivery. JOGNN: Journal of Obstetric,
Gynecologic & Neonatal Nursing, 40(S), 117-8. doi: 10.1111/j.1552-6909.2011.01243
MacDorman, M., Menacker, F., & Declercq, E. (2008). Cesarean birth in the United States:
epidemiology, trends, and outcomes. Clinical Perinatology, 35(2): 293307.
doi: 10.1016/j.clp.2008.03.007
Orem, D. E. (1991). Nursing: Concepts of Practice (4th ed.). St Louis: Mosby.
Orem, D. E. (2001). Nursing: Concepts of practice (6th ed.). St. Louis: Mosby.
Schmidt, N. (2008). Guided imagery as internally oriented self-care: a nursing case. Self-Care,
Dependent-Care & Nursing, 16(1), 41-48.
Tarrant, C., Dixon-Woods, M., Colman, A., & Stokes, T. (2010). Continuity and trust in primary
care: a qualitative study informed by game theory. Annals of Family Medicine, 8(5), 440446. doi: 10.1370/afm.1160
Walker, H. (2008). The balance of power. Nursing Standard, 22(27), 64.
Wood, M.J. & RossKerr, J.C. (2011). Basic steps in planning nursing research: From question
to proposal (7th ed.). Sudbury, MA: Jones & Bartlett. ISBN: 9780763771799
Zanardo, V., Svegliado, G., Cavallin, F., Giustardi, A., Cosmi, E., Litta, P., & Trevisanuto, D.
(2010). Elective cesarean delivery: does it have a negative effect on breastfeeding? Birth:
Issues In Perinatal Care, 37(4), 275-279. doi: 10.1111/j.1523-536X.2010.00421.x