Quality Improvement Initiative to Support Vaginal Birth and Reduce Primary Cesarean Delivery

In 2019 a multidisciplinary group was formed with the purpose of evaluating opportunities for improvement and implementing targeted strategies to reduce nulliparous, term, singleton, vertex (NTSV) cesarean deliveries. Key stakeholders were engaged from the beginning and included private and hospital-employed physicians, midwives, residents, nurses, and leadership.

Following basic principles of quality improvement, a fishbone diagram was used to identify variation and problem areas. These were then prioritized according to the level of value and complexity. Based on this information, work was divided into several different areas: labor support education, implementation of tools to promote standardization, guideline development that included intermittent auscultation and supported freedom of movement for laboring patients, and regular review of data.

The following interventions were implemented:

• Multidisciplinary labor support workshops that provided a basic overview of the problem and call to action,skills stations including review of maternal positioning strategies to promote labor progress, nonpharmacologic labor support (i.e. aromatherapy), intermittent auscultation, and cervical exam with identification of fetal malposition
• Multidisciplinary labor support education modules via HealthStream TM
• Grand Rounds on the topic of labor support and normal physiologic birth
• Spinning Babies workshop was hosted at the hospital
• A standardized approach to cervical ripening
• Use of a labor dystocia checklist (American College of Obstetrics & Gynecology and Society for Maternal-Fetal Medicine)
•  Regular review of data

Using data to drive change has been a key strategy. This includes a regular review of both outcomes (NTSV cesarean rate) and balancing measures (postpartum hemorrhage, shoulder dystocia linked with birth trauma, and unexpected term newborn complication rates). NSTV cesarean rates are monitored on a monthly basis and shared regularly with staff. Individual provider and group rates are also shared on a quarterly basis. This has been helpful in raising overall awareness and allowing providers to evaluate how their rate contributes to both their group and the overall department rate. In assessing our data one-year pre and post-implementation, we found an overall 14% decrease in our NTSV cesarean rate.A review of balancing measures obtained from the National Perinatal Information Center (NPIC) has helped to evaluate if we are causing unintended harm in other areas as a result of this quality improvement initiative. Case lists are obtained on a quarterly basis and reviewed in detail. Trends and areas of opportunity are then incorporated into ongoing quality work. Another data tool supplied by NPIC that has been particularly helpful is the Quality Improvement Dashboard. This allows for the evaluation of metrics over a period of several years. As we continue working to reduce our NTSV cesarean rate, this dashboard will be helpful in reviewing postpartum hemorrhage, inductions resulting in cesarean delivery, shoulder dystocia cases linked with birth trauma, and unexpected term newborn complication rates over time.Special thanks to the staff at NPIC for your support in our ongoing efforts to improve quality and safety for our moms and babies!

Jeanette Zocco MSN, RNC-OB, C-EFM

Written for and previously published by; National Perinatal Information Center Member Newsletter