Date of Award

Fall 2023

Project Type




Program or Major


Degree Name

Master of Science

First Advisor

Pamela Kallmerten

Second Advisor

Kaitlynn Liset



BACKGROUND: Cesarean sections (c-sections), while life-saving in some circumstances, carry a significantly higher risk of morbidity and mortality than vaginal birth for birthing patients and neonates alike. Despite this, rates of c-section have continued to rise in the US and around the world. As primary cesarean births are highly likely to lead to repeat cesarean births, concerted efforts are being made to reduce them both broadly and within the setting of this quality improvement (QI) project: a labor and delivery unit located within a Level II trauma center in New Hampshire. A literature review provided evidence supporting the use of non-pharmacological labor coping (NPLC) methods as a means of promoting c-section reduction among low-risk nulliparous, term, singleton, and vertex (NTSV) pregnancies and revealed a gap in this knowledge and practice among labor and delivery professionals. This project focused primarily on increasing the incorporation of NPLC techniques into nursing care.

METHODS: The Plan, Do, Study, Act (PDSA) framework was used to guide the quality improvement process and increase the utilization of NPLC methods on the unit. Pre and post-intervention surveys of labor and delivery nurses were conducted in order to measure the project’s efficacy and to generate feedback that would inform future PDSA cycles. The unit’s NTSV c-section rate was also calculated and compared with pre-intervention rates to generate preliminary observations about the effect of the initiative.

INTERVENTION: In an attempt to remove the barrier of insufficient access to NPLC tools on the unit and to increase the use of non-pharmacological techniques, a “Labor Lending Library” of supplies to support NPLC alongside the information nurses need to facilitate their use was introduced. Details about the library and the tools it contains were distributed via the weekly email newsletter, via posters hung in key locations on the unit, and via a laminated set of infographics attached to the cart for educational reinforcement. Use of the cart was encouraged during the study period by the project lead with periodic informal presentations during change-of-shift huddles and an appearance at an Obstetric unit practice committee meeting.

RESULTS: The Labor Lending Library project aimed for 75% of surveyed nurses to report that they had sufficient tools to support NPLC nursing care on the unit, with sufficiency being defined as a rating of 8.5 out of 10 or better. It ultimately yielded this rating from 94.44% of post-intervention survey respondents, representing a 35% increase in average rating of the sufficiency of available tools to support NPLC from pre to post-intervention. The project’s additional goal of increasing NPLC support by 25% overall was not entirely met, though reported use of all studied NPLC methods among nurses increased by 16.3% on average during the study period. The NTSV c-section rate on the unit was 24.48% during data collection, representing a 6.2% reduction in rate from the same time frame the previous year and 7.2% reduction from the overall rate of NTSV c-sections on the unit in 2022.

CONCLUSIONS: Actively promoting use of and access to NPLC methods via the Labor Lending Library intervention increased the use of these methods within the setting where it was initiated. Consolidating resources and creating complementary nurse education also led to a significant increase in nurses reporting that they had sufficient tools to facilitate use of NPLC techniques with their laboring patients. Continued use of NPLC supported by the Labor Lending Library may, over time, see a long-term overall decrease in NTSV c-section rates.

Keywords: labor and delivery, primary cesarean, NTSV cesarean, NTSV c-section reduction, primary c-section reduction, non-pharmacological labor coping methods, non-pharmacological pain management, labor and delivery nurses, labor and delivery nursing care, nursing education