Mercy Health - Cincinnati Nurses Reduce Laboring Moms' Vaginal Tears by More than Half

It's something many moms-to-be fear - vaginal tears that occur during labor. Ranked by severity on a scale of one to four, the worst vaginal tears cause pain as well as discomfort during sex and bowel movements for weeks. They can also lead to more serious concerns, including:
• pelvic organ prolapse, a condition in which the uterus, bladder and bowel fall into the vagina and may require pelvic floor surgery to repair
• lifelong lack of bladder control
• lifelong lack of bowel control

A talented team of Family Birthing Center nurses at Mercy Health - Cincinnati, which provides advanced, quality, compassionate care in your neighborhood through its care network, wanted to spare their patients these issues and researched techniques they could employ to reduce the incidence of vaginal tears during childbirth. They succeeded in reducing the most serious third- and fourth-degree tears by more than half and also reduced pushing time by half.

"“Having a baby should be a happy experience and we wanted to do everything possible to ensure our patients didn’t experience unnecessary pain or lifelong health issues after welcoming their children," said Marie Leist-Smith, MSN, RNC-OB, Mercy Health Director of Nursing Practice and Research. “We found published protocols from Canada that are not currently in widespread use in the United States and conducted an Institutional Review Board-approved research study to see if we could improve our patients’ outcomes.”

From August 2014 through August 2015, the nursing team set out to reduce specifically third- and fourth-degree vaginal lacerations, the most serious tears. The team evaluated 1275 patients who had vaginal births with epidurals who met the study criteria.

“Many women begin pushing once they are completely dilated, even if they do not feel the urge to push. As a result, they push for too long and get exhausted. This can impact the baby negatively, increasing the chance for a C-section or vacuum or forceps delivery. Using an instrument during delivery greatly increases the risk of serious third- and fourth-degree perineal lacerations,” says Donna Green, PhD(c), MSN, RN C-EFM, Mercy Health – Fairfield Hospital Family Birthing Center.

“These protocols noted that in most cases, women with epidurals do feel increasing perineal pressure and the urge to push and we tested that. So long as mom and baby were doing well, we used the protocols. They told us that even when mom was fully dilated, we delay pushing until the baby sat upright in the body and descended into the ideal location in the vagina where he or she triggered the Ferguson reflex – or the urge to push,” says Leist-Smith. “We know that pushing is most productive when the Ferguson reflex kicks in.”

Implementing the protocols at Fairfield Hospital led a decrease in instrument-assisted birth and a 55% reduction in the most severe vaginal tears. When using the protocol, pushing time went down to 50% of moms’ total second stage of labor time (time from complete dilation to delivery of baby). Mercy Health has since launched the patient-centered approach, which, at its heart is about listening to moms’ bodies, at its Family Birthing Centers at Mercy Health – Anderson and West Hospitals, with similarly good results.

The results are significant and put Mercy Health well ahead of the curve. The Health Research and Educational Trust (HRET) of the American Hospital Association (AHA) worked in conjunction with the U.S. Department of Health and Human Services on the Partnership for Patients initiative to recommend a reduction in obstetrical harm by 40 percent, utilizing evidenced-based practice bundles and recommendations. This includes achieving an overall 40 percent reduction in the infant perinatal birth trauma rate and a 40 percent reduction in obstetric (OB) trauma rates for all vaginal deliveries, with or without instrument-assisted delivery.

In addition, the Institute for Healthcare Improvement has set a national goal of reducing severe lacerations by 40% and will, in the next few years, classify severe lacerations as a patient harm that not only causes pain, but also increases patients’ length of stay in hospitals and increases the cost of care.

Marie Leist-Smith MSN, RNC-OB; Donna Green, PhD(c), MSN, RN C-EFM; Jennifer Lipke MSN, RNC-OB, c-EFM, & Lori Trammel MSN, RNC-OB, c-EFM, are sharing their findings with nurses throughout Ohio and nation. They will give a podium presentation titled Decreasing Obstetric Harm with a Patient Driven Protocol at the June 2016 National Association of Women's Health, Obstetrics, and Neonatal Nurses (AWHONN) conference in Grapevine, TX. They presented their findings in a September 2015 podium presentation at the Ohio State AWHONN conference in Cleveland.

Mercy Health - Cincinnati makes advanced, compassionate, quality healthcare easy to help you be well in mind, body and spirit. Mercy Health – Cincinnati has been serving Greater Cincinnati for more than 160 years and provides an integrated network of leading physicians, compassionate caregivers, comprehensive services and exceptional care at more than 140 locations across the region. The Mercy Health – Cincinnati network of care includes five award-winning hospitals, senior living communities, primary care and specialty physician practices, outpatient centers, social service agencies, fitness centers and a variety of outreach programs. Mercy Health - Cincinnati hospitals have earned national Truven Health Analytics’ 100 Top Hospitals honors more times than all other Cincinnati hospitals combined, placing them among the best hospitals in the nation. Truven has also named Mercy Health - Cincinnati as one of the nation’s Top 15 health systems three years in a row and is the only health system in Cincinnati to earn this honor. Mercy Health – Cincinnati is part of Mercy Health, the largest health system in Ohio and fourth largest employer. To learn more visit, and engage in the conversation via Mercy Health - Cincinnati’s social media channels (@mercy_health on Twitter and Mercy Health on Facebook).