Meeting the special needs of first time mothers is a top priority at Sutter Health. Nearly 40 percent of the 40,000+ babies born every year at Sutter Health hospitals are delivered by first time mothers.

First Pregnancy and Delivery Initiative

What is our "First Baby" initiative? Our physicians and other mother and baby experts joined forces to create a task force to address the difficulties and special needs of first time mothers. After carefully studying the literature and reviewing clinical data from Sutter Health hospitals and doctor groups, the task force created a system-wide First Pregnancy and Delivery (FPAD) Clinical Initiative. The initiative is unique in that it examines the entire birth process rather than focusing on just one issue, such as reducing cesarean section rates.

First Time Mothers Face Special Risks

Delivering a baby can be complicated, even more so when it is a woman’s first baby. First time mothers have three to four times more labor complications than women who’ve given birth before. Compared to veteran mothers, women delivering their first baby experience have:

• Five times the cesarean section rate
• Two and a half times longer labor
• Twice the rate of epidural use
• Almost twice as many babies admitted to the neonatal intensive care unit (NICU)
• Nearly three times the cost

Research shows that proper timing of admissions, the appropriate use of induction and episiotomies, and consistent labor support play a major role in reducing these risks and improving outcomes for first time mothers and their babies. Given current labor and delivery trends, however, achieving such outcomes requires changes in behaviors and attitudes on the part of physicians, nurses, and pregnant women.

Project Goals

• Improve quality of care and outcomes for first time mothers and their babies
• Reduce the need for cesarean sections
• Shorten the amount of time first time mothers spend in labor
• Reduce the need to induce labor
• Decrease the use of episiotomies
• Improve the birth experience

Care Guidelines

1. Admit women to labor unit when cervical dilation is >= 3 cm.
Research shows that first time mothers admitted to the hospital in early labor and confined to a labor bed experience longer labor and a greater risk of cesarean birth than women admitted in active labor (cervical dilation >=3 cm). Similarly, a study involving thousands of Sutter Health patients found significantly shorter labors, half as many cesarean births, better APGAR scores (used to measure the baby’s health), and lower costs when first time mothers were admitted in active labor.

2. Induce labor only when medically necessary.
Inducing labor in first pregnancies is very serious and risky with very different outcomes than induction in women who’ve given birth before. Induction in first time mothers in their 37th to 41st week of pregnancy can lead to long and difficult labors, two to three times the cesarean birth risk, third and fourth degree lacerations of the rectum, more operative vaginal births, low APGAR scores, and increased costs. Multiple studies show that the increase in the cesarean birth rate occurs regardless of the reason for the induction.

3. Perform episiotomies selectively.
Formerly routine practice during deliveries, recent studies show that episiotomies have no medical benefit. To the contrary, studies done by Sutter Health, Harvard, and others show that mid-line episiotomies increase the likelihood of third and fourth degree lacerations of the rectum by two to three fold, most especially in first time mothers. Such tears can lead to temporary or permanent bowel incontinence.

4. Provide continuous labor support.
Numerous clinical trials conducted over the past few years show those women who receive continuous labor support experience better outcomes, including shorter labors, less use of analgesia/anesthesia, fewer cesarean births, fewer episiotomies, and greater satisfaction with the birthing process. They also have fewer babies with five-minute Apgar scores less than seven. Proven labor support techniques include work with birthing balls, positioning, emotional support, and other practices.

5. Educate women throughout the prenatal process.
Involvement and education of patients is critical to improving mother and baby outcomes. The lay literature is full of articles about scheduling childbirth, and today’s busy mothers often find that opportunity attractive. Nowhere in the lay literature, however, is there a distinction between first births and subsequent deliveries. Neither is there any discussion of the risks of inducing first time deliveries. Women must be told about these risks and about new research discouraging the use of episiotomies. They must also be taught to recognize when they are in active labor and need to go to the hospital. These messages need to be consistent between physician offices, prenatal education classes, and patient education materials and communications.

On the Right Track

Since the start of the First Pregnancy and Delivery project, we have collected data on the seven FPAD measures on over 40,000 women experiencing their first birth. We are encouraged by the steady progress and positive changes we have seen in patient outcomes to date, especially regarding the decrease in episiotomies and inductions.

Labor Support Makes a Comeback

Over the past few decades, the centuries-old concept of labor support has been downplayed in favor of fetal monitoring and other high tech, medical interventions. The pendulum is swinging back, however, now that scientific evidence has validated the benefits of labor support for mothers and babies. FPAD combines the best elements of high and low tech and encourages affiliates to integrate labor support into their labor and delivery practices.

Sutter Medical Center Sacramento recently developed a labor support training curriculum for their labor and delivery nurses. Based on the teachings of Polly Perez, a renowned leader in the field of labor support, the four-hour course includes hands-on experience in proven labor support techniques, including work with birthing balls, positioning, emotional support, and other practices. Plans are underway to share the curriculum and provide labor support training for other Sutter family hospitals.

Labor Support Components

• Advocacy
• Comfort Measures
• Education/Information
• Emotional Support
• Environmental and Sensory Stimuli
• Family Centered Care

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Updated January, 2008