1. Tillett, Jackie ND, CNM, FACNM
  2. Clinical Professor

Article Content

The cesarean delivery rate in the United States in 2012 was 32.8%.1 There is no reason to believe that this rate will decrease without increased knowledge, intervention, and publicity from both healthcare providers and women. Many registered nurses practicing in labor and delivery units would like to see this rate decrease but are often constrained by the atmosphere and hierarchy on the unit. Registered nurses may feel that they do not have the knowledge or evidence base to challenge established routines. Nurses are busy and may have difficulty staying current with obstetrical literature from multiple sources.


Cesarean delivery is not without consequences for women and infants. These consequences for the mother may include infection, chronic pain, future placental complications, and cesarean delivery for subsequent births.2 Infants born by cesarean delivery are more likely to experience respiratory tract distress.


A recently published consensus statement from the American College of Nurse-Midwives (ACNM), the Midwives Association of North America, and the National Association of Certified Professional Midwives defines physiologic labor and birth as a labor and birth process that is powered by the innate human capacity of the woman and the fetus.3 Physiologic birth has no unnecessary intervention that interferes with normal physiologic processes but allows for intervention in the presence of complications.


The characteristics of normal physiologic birth are listed in Table 1.3 The factors that have the potential to disrupt physiologic birth are listed in Table 2.3

Table 1 - Click to enlarge in new windowTable 1. Characteristics of normal physiologic birth
Table 2 - Click to enlarge in new windowTable 2. Barriers to normal physiologic birth

After the consensus statement was developed, the ACNM formed a Task Force on Normal Physiologic Birth. This task force was charged with developing resources to expand the understanding of the value of physiologic birth among consumers, healthcare providers (including nurses), and the healthcare system. One of the resources developed and recently released is the online Web site BirthTOOLS is the acronym for Birth Tools to Optimize Outcomes of Labor Safely. The goal of the site is to present evidence and to offer targeted resources, protocols, and success stories for clinicians, families, and administrators.


The resources in the toolkit Web site are simply accessed and provide information on the evidence supporting physiologic birth and the care that promotes physiologic birth; quality improvement practices including the FOCUS-PDCA model; and a "Menu of Change." The Menu of Change is the largest section and includes evidence, a review of key outcomes from changes made to existing policy, and resources for all groups including model policies, staff education materials, references for further studies and changes, and national guidelines, among other information. The information is in several formats to meet the needs of varying types of learners, including written information, algorithms, and templates.


There are several ways to use can be accessed for a larger focus. For example, one of the pathways includes a tab for learning about nurse-sensitive perinatal quality measures. Using this tab leads to the Framework for Quality Improvement, which, in turn, leads to definitions and characteristics of High Quality Maternity Care as woman-centered, safe, effective, timely, efficient, and equitable. Included in this section are resources for obstetrical nurses such as the Association of Women's Health, Obstetrical, and Neonatal Nurses Perinatal Quality Measures Process as well as "Quality Patient Care in Labor and Delivery: A Call to Action," a white paper developed by a partnership of professional organizations, among others. There is also a search function so that new information can be constantly added and accessed.


A narrower focus can help nurses research and implement change in one particular area. If a nurse, working group, or unit is interested in looking at the first stage of labor from a physiologic birth standpoint, there is a Toolbox for Promoting Progress in First Stage Labor. The resources and tools in this toolbox include improvement stories such as a description of a project at the Oregon Health and Science University introducing manual rotation of the occiput posterior fetus, an audit tool for tracking the use of evidence-based process, clinical education and staff training resources, and access to related guidelines such as the ACNM Intermittent Auscultation for Intrapartum Fetal Heart Rate Clinical Bulletin. New resources are being added to each section.


There are toolboxes for the assessment of fetal well-being, for the provision of comfort and coping during labor and birth, and for the promotion of physiologic pushing in labor, among others. The Web site is well-designed and easily accessed. Much of the information is in PDF format and simple to download. is current and kept current, minimizing the need for more cumbersome search tools and eliminating the numerous irrelevant search hits that often result from Web searches. The information presented on the site is vetted by the ACNM and thus is woman-focused and dedicated to the promotion of physiologic birth and evidence-based care. This author encourages all nurses who work with pregnant, laboring, and postpartum women to visit the site, test drive the resources, and share the evidence with colleagues, including physicians and administrators.


-Jackie Tillett, ND, CNM, FACNM


Clinical Professor


Department of Obstetrics and Gynecology


University of Wisconsin School of Medicine and Public Health


Madison, Wisconsin




1. Centers for Disease Control and Prevention. FastStats. Accessed May 17, 2014. [Context Link]


2. Guise JM, Eden K, Emeis C, et al. Vaginal Birth After Cesarean: New Insights. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Evidence Report(Technical Assessment No. 191. [Context Link]


3. American College of Nuse-Midwives. Supporting healthy and normal physiologic childbirth: a consensus statement by the American College of Nurse-Midwives, Midwives Alliance of North America, and the National Association of Certified Professional Midwives. Journal of Midwifery and Women's Health. 2012;57(5):529-532. [Context Link]


4. American College of Nurse-Midwives. Accessed May 15, 2014. [Context Link]