Why It Matters
The intent of “Keeping Normal Normal” is to mitigate the emerging data that tells us cesarean sections are associated with greater immediate and delayed maternal morbidity and mortality.
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Improving Perinatal Care: “Keeping Normal Normal”

By Sue Leavitt Gullo | Thursday, June 12, 2014

Sue Gullo, RN, BSN, MS, a Director at the Institute for Healthcare Improvement, has more than 33 years of health care experience, with expertise in maternal-child health and patient safety. She has led the IHI Perinatal Improvement Community since 2004, the longest-running continuous perinatal safety collaborative in the US and internationally. Ms. Gullo is also a member of the AWHONN (Association of Women’s Health, Obstetrical and Neonatal Nursing) Board of Directors and of several national maternal-child health advisory committees. Learn more in the IHI Virtual Expedition: Triple Aim Approaches to Maternal and Infant Health.

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Sue Gullo (on right), working in Denmark


In recent months, the IHI Perinatal Improvement Community espoused a new galvanizing focus for our work — “Keeping Normal Normal” — that is, care is focused on the right things to do for every mother and every baby, no matter where physiology may take a woman during the pregnancy, delivery, and postpartum experience. This new lens for our work is intended to help us design and learn our way forward, to maximize the “normal human components” and minimize interventions which have been “normalized” in current times. This includes:

  • Learning how to apply the emerging evidence to correctly identify when labor begins;
  • No routine, non-medically indicated inductions;
  • No routine separation of mother and baby, regardless if the birth occurs vaginally or by cesarean; and
  • Providing support to women and their family members through the postpartum and discharge period.

The intent of “Keeping Normal Normal” is to mitigate the emerging data that tells us cesarean sections are associated with greater immediate and delayed maternal morbidity and mortality. Cesarean section rates in the US climbed between 1996-2011, and maternal mortality substantially increased during approximately the same period. We have the power to greatly impact the care that mothers and babies are receiving by “Keeping Normal Normal” and only applying the life-saving intervention of a C-section when it is needed, not as part of routine care.

Recently, I was privileged to apply my own perspective on perinatal care as I supported my niece and her family through the labor and birth of her baby girl, a late preterm infant at 36 weeks. I was excited by the evidence-based administration of tocolytics to get her to “steroid complete” for the baby’s 34-week lungs. She made it to 36 weeks before her membranes ruptured and labor ensued, but I was saddened by the lack of evidence-based practice her nurse provided during second stage management and the last-minute negotiation by her young female obstetrician for an episiotomy. I was excited by the support of the nursing and neonatology staff and their focus on “Keeping Normal Normal” in a few key ways: 1) encouraging “skin to skin” (or heart to heart, as Baptist Women’s Hospital in Memphis has called it) to support breastfeeding by keeping mother and baby together as much as possible; 2) engaging my niece in all of her baby’s care, whether at the bedside or in the Special Care Nursery; and 3) discharging my niece and her baby to home as soon as safely possible.

Let’s start a revolution in perinatal care that engages all stakeholders — pregnant women, families, obstetrical care providers, nurses, educators, doulas, health care insurers, policy makers — in doing the right thing, every time, for every woman and baby by “Keeping Normal Normal.”

Learn more in the IHI Virtual Expedition: Triple Aim Approaches to Maternal and Infant HealthThis program is one of the benefits included in the Passport to IHI Training membership.

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