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Running head: RESEARCH PROPOSAL: PART II
Research Proposal: Part II
Liberty University
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RESEARCH PROPOSAL: PART II
Research Proposal: Part II
Background
Delivery by cesarean section has become the most common surgical procedure performed
worldwide and, when done in necessity, can decrease perinatal morbidity and mortality
significantly (Montoya-Williams et al., 2017). However, a cesarean section is considered major
surgery and carries many risks, including surgical site infection, hemorrhage, complications in
future pregnancies, and even maternal and/or neonatal death. The most common reason that a
woman in labor undergoes delivery via cesarean section is due to dysfunctional labor, or
dystocia, in which labor does not progress and the cervix ceases to dilate (Murphy et al., 2015).
This occurs when the uterus no longer functions as it should and fails to create an adequate
contraction pattern in order to create cervical change needed for vaginal delivery.
Due to the unpredictability of labor and potential need for delivery by cesarean section,
women are traditionally barred from eating and instructed that they may consume ice chips only
or sometimes nothing at all. This policy became the practice standard in the 1940s and stems
from the unlikely potential that a woman may end up needing general anesthesia to undergo an
urgent or emergent cesarean section. This practice was said to decrease the risk of aspiration and
its associated pneumonia related to general anesthesia and intubation (Chackowicz, Spence, &
Abenhaim, 2016). However, with new research on this topic, this policy has become outdated
and could actually create adverse effects on the woman during labor and delivery, such as
nausea, vomiting, and operative vaginal delivery due to fatigue (Chackowicz, Spence, &
Abenhaim, 2016).
When these two concepts are married, the question of their correlation arises. With
uterine muscle fatigue, the switch from aerobic to anaerobic metabolism occurs, creating a
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RESEARCH PROPOSAL: PART II
buildup of intramuscular lactic acid, and subsequent decreased muscle activity and/or
effectiveness (Murphy et al., 2015). Furthermore, this could possibly lead to labor dystocia and
the need for delivery by cesarean section.
Significance
While much research has been done on decreasing cesarean section rates in nulliparous
women at term with a singleton pregnancy and vertex presentation (NTSV), very little has
occurred specifically related to decreasing cesarean section rates related to diet during labor. In
2020, The Joint Commission will begin reporting hospitals with cesarean section rates >30%,
forcing hospitals to analyze their labor management practices, which could include implementing
eating throughout labor as a standard practice. This study has the potential to identify a factor
that adds to the problem, which can then create a change in practice to decrease the rate of
cesarean section.
Research Question
“Does implementation of a clear liquid diet decrease the primary cesarean section rate
in nulliparous laboring women?”
Key variables include:
Clear liquid diet (independent).
Primary cesarean section rate (dependent).
The population of interest for this study is nulliparous laboring women.
The purpose of this study is to identify a potential correlation between diet during labor
(NPO versus clear liquid) and primary cesarean section rates.
The hypothesis is that implementation of a clear liquid diet will, in fact, decrease primary
cesarean section rates in nulliparous laboring women.
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RESEARCH PROPOSAL: PART II
Literature Review
Introduction
Delivery of an infant by cesarean section can pose many health risks to the mother as
well as the neonate. Reducing the rate of cesarean sections in the United States has become a
national goal, as these rates will begin to be reported to The Joint Commission beginning July
2020 (Baker, 2019). This literature review explores the reasons behind cesarean sections and
initiatives to reduce the rate. It will also look at dietary intake during labor, which relates to the
research question of “Does implementation of a clear liquid diet decrease the primary cesarean
section rate in nulliparous laboring women?”.
Review
Over the last 20 years, the rate of delivery by cesarean section has steadily increased.
According to preliminary data, one in three women underwent a cesarean section in 2017 (Gams,
Neerland, & Kennedy, 2019). Mothers who undergo this procedure have a higher risk of
hemorrhage, infection, increased pain, and longer hospital stays. It is also likely they will
experience difficulty with bonding and breastfeeding due to the delay of contact with the infant.
Furthermore, the newborn is at an increased risk of being admitted to the neonatal intensive care
unit related to respiratory distress and/or hypoglycemia (Gams, Neerland, & Kennedy, 2019).
The optimal rate of cesarean section is suggested to be between 15% to 19%, a rate which
was determined through global epidemiological studies over the last ten years. The rate in the
United States remains around 32% nationwide (Montoya-Williams et al., 2017). Furthermore, the
World Health Organization, or WHO, reports that one-third of these are deemed unnecessary, or
avoidable. In order to decrease the rate of these avoidable surgeries, it is important to implement
a multifaceted approach. One study found that the use of intermittent auscultation, upright labor
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RESEARCH PROPOSAL: PART II
positioning, an “early labor lounge”, student doulas, one-to-one labor support, and team huddles
including all interdisciplinary team members was integral in decreasing their hospitals cesarean
rate of nulliparous, term, singleton, vertex (NTSV) women from 29.3% to 25.3% in two years
(Gams, Neerland, & Kennedy, 2019). Another study found that there are different clinical and
patient driven interventions that can effectively reduce the cesarean rate. The authors describe
clinical interventions for clinicians that include allowing a woman to attempt a TOLAC (trial of
labor after cesarean), performing external cephalic version for breech fetuses, and decreasing the
use of oxytocin. Furthermore, the study describes the use of auditing and feedback, guidelines
for clinical practice, “hard stop” policies, and financial incentives for clinicians. These practices
decreased the cesarean rate at their hospital by 10.3% in the first nine months! Additionally, this
study claims that patient driven interventions can also aid in decreasing their risk for cesarean
section. These interventions include prenatal social support and education, continuous labor
coaching, and the use of non-pharmacological pain control during labor (such as breathing
techniques, hypnosis, and use of labor/peanut balls). These practices reduced the cesarean rate by
nearly one third overall (Montoya-Williams et al., 2017).
If performed in necessity, cesarean sections can prevent harm to the mother and infant in
the setting of maternal or neonatal distress (Montoya-Williams et al., 2017). However, the most
common reason that a nulliparous woman undergoes the procedure is due to labor dystocia, or
labor that has ceased to produce cervical change (Murphy et al., 2015). The most common cause
of this problem is related to ineffective uterine activity, in which the frequency, duration, and/or
strength of uterine contractions becomes inadequate, which can likely be avoided (Murphy et al.,
2015). A very interesting study performed by Murphy et al. (2015) found an association between
high amniotic fluid lactic acid (AFL) levels in women who were given high doses of oxytocin,
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RESEARCH PROPOSAL: PART II
diagnosed with labor dystocia, and subsequently delivered by cesarean section. Women with a
level of 10mmol/L or greater were three times as likely to require a cesarean section. The data
suggests that increased AFL is the resultant of myometrial fatigue related to the change from
aerobic to anaerobic metabolism. This creates a buildup of lactic acid within the uterine muscle,
resulting in an inadequate uterine contraction pattern (Murphy et al., 2015). The authors also
discussed that women with AFL levels of 5.0mmol/L to 9.9mmol/L who were diagnosed with
inadequate contraction patterns could potentially be corrected using an active labor management
protocol (Murphy et al., 2015).
In discussing myometrial fatigue related to anaerobic metabolism, which should only be
used for a short amount of time, it is important to discuss the fact that women are mostly allowed
only ice chips during labor. Restricting a women’s oral intake during labor has become the
standard practice since the 1940s, when a relationship between aspiration in anesthetized women
and mortality in labor was made (Chackowicz, Spence, & Abenhaim, 2016). However, with
more advanced practices and improved training for anesthesiologists, the practice of not eating in
labor has become archaic (Chackowicz, Spence, & Abenhaim, 2016). The study performed by
Chackowicz, Spence, & Abenhaim (2016) surveyed 118 Canadian hospitals to determine their
dietary protocols during labor. They determined that without the use of epidural anesthesia,
50.9% of hospitals restricted their patient’s to clear liquid/ice chip diets, while 38.1% of hospitals
allowed solid food. With the use of epidural anesthesia, these rates became 82.8% and 7.2%,
respectively. The authors also found that parenteral dextrose was added to the patient’s protocol
in 77.5% of hospitals when an epidural was initiated. They conclude their study by stating that
these restrictive measures do not align with the current literature and that these hospital policies
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RESEARCH PROPOSAL: PART II
should be revised in order to meet the psychological and physiological requirements of a woman
in labor.
Conclusion
With consideration of the following studies, it is clear that there is a strong need to study
and determine the relationship of dietary protocols during labor and the rate of primary cesarean
section. The information throughout these studies points to a connection between oral restriction
and labor dystocia, which can lead to delivery by cesarean section and increase maternal and
neonatal morbidity and mortality. The studies above appear to support the hypothesis that
implementing a clear liquid diet for laboring women can assist in decreasing primary cesarean
section rates in nulliparous laboring women throughout the United States.
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RESEARCH PROPOSAL: PART II
References
Baker, D. (2019). Public reporting of high cesarean rates to begin in July 2020 [Web log post].
Retrieved July 21, 2019, from https://www.jointcommission.org/
the_view_from_the_joint_commission/public_reporting_of_high_cesarean_rates_to_
begin_in_july_2020/
Chackowicz, A., Spence, A. R., & Abenhaim, H. A. (2016). Restrictions on oral and parenteral
intake for low-risk labouring women in hospitals across Canada: A cross-sectional
study. Journal of Obstetrics and Gynaecology Canada,38(11), 1009-1014.
doi:10.1016/j.jogc.2016.08.003
Gams, B., Neerland, C., & Kennedy, S. (2019). Reducing primary cesareans: An innovative
multipronged approach to supporting physiologic labor and vaginal birth. The Journal of
Perinatal & Neonatal Nursing,33(1), 52-60. doi:10.1097/jpn.0000000000000378
Montoya-Williams, D., Lemas, D. J., Spiryda, L., Patel, K., Neu, J., & Carson, T. L. (2017).
What are optimal cesarean section rates in the U.S. and how do we get there? A review of
evidence-based recommendations and interventions. Journal of Womens Health,26(12),
1285-1291. doi:10.1089/jwh.2016.6188
Murphy, M., Butler, M., Coughlan, B., Brennan, D., O’Herlihy, C., & Robson, M. (2015).
Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in
nulliparous women at term. American Journal of Obstetrics and Gynecology,213(5).
doi:10.1016/j.ajog.2015.06.035
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