Saturday, March 17, 2007

More Nursing Hand-Offs May Be Associated Greater Risk of C-Sections

A study published in the current issue of the journal Birth examined the number of nursing hand-offs (switches in the nurse responsible for a patient's care) for women giving birth to determine whether this was associated with a greater risk of having a c-section.

Who Was Included
Researchers looked at the medical records at a university teaching hospital in Quebec, Canada 9with a c-section rate of 24%). They examined records for women who were admitted to the intrapartum (labor & delivery) unit, were having a 1st birth of a single baby, had a vertex presentation (baby coming out head first), and were at 37 weeks or more gestational age from March 1997-March 1998. Records for 467 women were included in the study that met the inclusion criteria and had complete data.

What Was Done
Medical records included the recording of the nurse (with date and time) responsible for each woman; the researchers examined the number of nurses caring for each woman during labor, the number of times care responsibility switched (patient taken care of by a different nurse), and length of time each nurse was responsible for the laboring woman. Data also included predictors of cesarean birth, such a length of labor, infant birthweight, day of week, maternal age, gestational age, method of delivery, physician attendant during pregnancy and birth, maternal height, type of rupture of membranes, epidural anesthesia, stimulation, and induction. This data was used to control for factors that might also influence c-section rate.

What They Found
After controlling for other factors that may lead to c-section, the researchers found that the number of nurses caring for a laboring woman was associated with number of c-sections. The authors state that "each additional nurse caring for the same laboring woman was associated with a 17% greater risk of cesarean section, with a range of risk 4-32% greater." Other factors ("switches" ≥1 per 2 hours, same nurse responsible for ≥33% of labor) were not statistically associated with a greater risk of c-section.

Comments
The authors note that it might seem strange that only one of the three nursing factors was associated with greater risk of c-section, stating: "Given that the 3 indicators are very closely related, someone might have thought that if one showed an effect, so too would the others. The lack of effect of the "number of switches," however, might be explained by the fact that several switches could have occurred among few nurses (e.g., nurses who are paired) such that a relatively high level of continuity of responsibility remained. Having the "same nurse responsible for ≥33 percent of the labor" likely provided some of the information already included in the "number of nurses," whereas the latter included additional information." They essentially found that while the total number of nurses and greater length of time (>1/3 of time) was not associated with increased c-section risk, the total number of switches is what mattered.

One of the findings that might be somewhat surprising is that the number of nurses per woman ranged from 1-17 (mean, or average, of 5.4), the number of hand-offs or switches per woman ranged from 1-31 (mean 4.5), and the range of length of labor that a single nurse stayed with a woman was 10-1,045 minutes, or from 1/6 of an hour to 17.4 hours (mean 126 minutes, or 2.1 hours). Mean length of labor was 14 hours, with 26% laboring less than 9 hours. Although more individualized data on length of labor and duration of care is not provided, it is clear from the 1-17 range of switches that none of the 467 women were cared for continuously by a single nurse throughout their labor.

Citation
Gagnon AJ, Meier KM, Waghorn K. Continuity of nursing care and its link to cesarean birth rate. Birth. 2007 Mar;34(1):26-31. Free Full Text

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