Reducing NTSV cesarean rates is one of the most common goals on labor and delivery units right now. But knowing the goal and knowing how to move the number are two different things.
In 2024, a labor and delivery unit at Bon Secours Mercy Health in Cincinnati, Ohio had a 25% NTSV cesarean rate. Their goal for 2025 was to bring it below 24% through nurse-driven, hands-on peanut ball training and a trauma-informed care framework.
They finished 2025 at 23%.
Here is what happened.
Why This L&D Unit Needed More Than a Skills Checklist
Bon Secours Mercy Health was not struggling because their nurses were not trying. They were dealing with something most L&D units know well: significant provider turnover, a growing population of newer nurses still building confidence in the basics, and a gap between what nurses knew and what they felt ready to do at the bedside.
Fetal monitoring, charting, and documentation were getting the attention. Hands-on labor support skills were getting pushed aside. Peanut ball use was inconsistent. Repositioning was not happening as often as it could. And the framework that connects all of it, the understanding of how nurse presence and behavior directly shape a patient’s birth experience, was not yet embedded in daily practice.
The unit needed more than a skills checklist. They needed a shift in how nurses understood their role.
Peanut Ball Training With a Trauma-Informed Care Framework
Bon Secours Mercy Health brought in The Birth Nurse for a two-day Peanut Ball Learning Day. The workshop was hands-on from the start. Nurses practiced placing each other in positions. They worked through a clinical positioning Labor + Birth Flipbook for Nurses designed for quick bedside reference. They built muscle memory around techniques that can change the course of a labor.
They also spent time on something most peanut ball trainings skip entirely: the trauma-informed care framework. Nurses learned how life experience shapes the way patients perceive and move through birth. They talked about consent, about the intimacy of the birth space, about how a nurse’s presence can protect or cause harm. The AIM Safe Reduction of Primary Cesarean Birth Change Package, published by the Institute for Healthcare Improvement, cites The Birth Nurse as a trauma-informed care resource for perinatal teams implementing cesarean reduction work.
The goal was not just to teach nurses what to do with a peanut ball. It was to help them understand why it matters, grounded in the trauma-informed care education research that shows how nurse psychological safety directly affects patient outcomes
What L&D Nurses Said After the Workshop
Weeks after the workshop, Emily Shroyer, an L&D nurse who attended, sent this reflection:
"I am huge in moving and repositioning patients and using peanut balls. I really believe it helps our patients with malpositioned babies, pain, stalled labors. The class also made me think about being more aware that people have all different life experiences. That those experiences can shape and affect how one can experience and perceive birth. We could be inflicting trauma on a patient, even in a 'good birth,' without even realizing it."
She also started doing something that was not asked of her. She gave copies of the positioning flip book to unit educators. She loaned her copy to new hires. She began showing newer colleagues how to use peanut balls and talking through the reasoning behind each position.
That is peer-to-peer culture change. That is a nurse who left a workshop and went back to her unit and started leading. I did not create that. The framework gave her something worth sharing, and she ran with it.
The NTSV Reduction Results: What the Data Showed
By the end of 2025, the unit’s NTSV rate had dropped to 23 percent, a full point below their goal and two points below where they started.
Erica Edell, the nurse leader who coordinated the program, put it plainly:
"I have no doubt that the skills, ideas, and new energy that came from our workshop will help us continue this trend into 2026."
The unit is now using ongoing provider turnover as an opportunity to build culture intentionally, bringing new practitioners into a space where patient-centered care is already the standard, not something being retrofitted after the fact.
How Peanut Ball Training Reduces NTSV Rates
Failure to progress is the most common reason for an unplanned primary cesarean. It is also one of the most preventable.
Peanut balls work because they give nurses a nurse-driven, no-order-required tool to support labor progress. Strategic positioning encourages fetal rotation, reduces the length of labor, and gives patients a sense of agency in their own birth. When nurses understand the physiology behind each position, they reach for the peanut ball earlier, more consistently, and with more confidence.
But the training is not just about the tool. It is about what the tool opens up.
When nurses learn positioning in the context of trauma-informed care, they start thinking differently about how they enter a room, how they offer options, how they slow down and ask. That shift in approach changes the patient’s experience of labor. And it changes outcomes.
What This Means for Your Unit
NTSV rates do not move because of one training. They move because nurses change their practice, sustain it, and start expecting it of each other. That kind of change requires nurses who understand the connection between their clinical decisions, their presence, and their patients’ progress.
Peanut balls are one of the most accessible, nurse-driven tools available on any L&D unit. They require no physician order, no new protocol, and no additional equipment budget. What they require is nurses who know how to use them, feel confident enough to reach for them, and understand the physiologic reasoning behind positioning.
Add a trauma-informed lens to that skill set, and you are not just teaching nurses a technique. You are building a team that approaches birth differently.
L&D Team Training That Moves Outcomes
The Birth Nurse offers Peanut Ball Learning Days for hospital teams of all sizes. Programs are hands-on, nurse-led, and grounded in the trauma-informed care framework. They are designed for units that want to move outcomes, not just check a training box.
If you are a nurse leader, educator, or CNO thinking about what your team needs in 2026, let’s talk. You can learn more about corporate training programs here.
Your nurses are the most direct line to your patients. Invest in them like it.
Sources
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- Runyon, M. C., Irby, M. N., & Rojas Landivar, P. (2024). Trauma-Informed Care Education Initiative Explores Impact on Perinatal Nurse Secondary Traumatic Stress and Workforce Challenges. The Journal of perinatal & neonatal nursing, 38(2), 167–177. https://doi.org/10.1097/JPN.0000000000000822
2. Alliance for Innovation on Maternal Health. (2024). Safe reduction of primary cesarean birth patient safety bundle change package. Institute for Healthcare Improvement. https://saferbirth.org/wp-content/uploads/Safe-Reduction-of-Primary-C-section-Change-Package_Updated-May-2024.pdf
3. Alliance for Innovation on Maternal Health. (n.d.). Safe reduction of cesarean birth. https://saferbirth.org/psbs/safe-reduction-of-cesarean-birth/
- Runyon, M. C., Irby, M. N., & Rojas Landivar, P. (2024). Trauma-Informed Care Education Initiative Explores Impact on Perinatal Nurse Secondary Traumatic Stress and Workforce Challenges. The Journal of perinatal & neonatal nursing, 38(2), 167–177. https://doi.org/10.1097/JPN.0000000000000822
