Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Provider, Education; Hospital, Chart audit and feedback, Elective induction policy, Guideline change and implementation, Quality improvement , HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Elective Induction Policy, Guideline Change and Implementation, Quality Improvement

Intervention Description: At a large Southern US women's hospital, new measures were made to reduce the rates of cesarian delivery at the facility. Endeavors were led by nurse / doctor leaders (VP & chief of staff). These included monitoring, benchmarking & disseminating information about CD at the facility; new protocols for oxytocin administration; Bishop's score assessment; elective CD performed only at 39 weeks; new protocols and intrapartum alternative positioning devices, the process of laboring down, and closed glottis pushing attempts in second-stage labor.

Intervention Results: Collectively, these interdisciplinary interventions have resulted in significant decreases in overall cesarean birth rates and comparable significant reductions in the NTSV cesarean rates.

Conclusion: Concerted efforts to reduce rates of nonmedically indicated cesarean birth have resulted in the development and implementation of comprehensive action plans aimed at effecting reductions and enhancing overall obstetric quality care.

Setting: One large obstetric hospital in the Southern USA

Population of Focus: NTSV births

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Organizational Changes, Peer Review, Quality Improvement

Intervention Description: To improve quality and safety of care to our obstetric and neonatal patients (presenting between 34 0/7 and 36 6/7 weeks) by lowering the overall induction rate, lowering the elective induction rate less than 39 weeks, decreasing the unanticipated admissions of late preterm infants to the special care nursery (SCN), decreasing the number of transports out of our level II SCN to a higher level III neonatal intensive care unit, and increasing safety culture scores of the Family Birth Center staff at Mercy Hospital Anderson, Cincinnati, OH.

Intervention Results: Rate of CS among electively induced women at the level II hospital decreased from 37.4% (2005) to 31.5% (2006) to 25% (2007). From 2005 to 2006, one year after hospital review was launched, there was a 5.9% decrease in CS (p<0.05)2. From 2006 to 2007, two years after hospital review was launched and supplemental changes to elective induction policies and practices were made, there was a 6.5% decrease in CS (p<0.05)2.

Conclusion: In 2007, outcomes including total induction rate, elective induction rate for less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and SCN unanticipated admissions of infants 34 0/7 to 36 6/7 weeks' gestation (late preterm infants) were compared with these same measures in 2005.

Study Design: QE: pretest-posttest

Setting: 1 level-II maternity hospital in Ohio

Population of Focus: Nulliparous women who gave birth between January 2005 to December 20072

Data Source: Not specified

Sample Size: n=2,172

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Midwifery, PROVIDER/PRACTICE, HOSPITAL, Chart Audit and Feedback, Organizational Changes, Quality Improvement, POPULATION-BASED SYSTEMS, Community — Outreach, Outreach, COMMUNITY, COMMUNITY

Intervention Description: To improve quality of care by offering more women a safe and attractive normal vaginal delivery. The target group was primarily nulliparous women at term with spontaneous onset of labor and cephalic presentation.

Intervention Results: The CS rate in nulliparous women at term with spontaneous onset of labor decreased from 10% in 2006 to 3% in 2015. During the same period the overall CS rate dropped from 20% to 11%. The prevalence of children born at the unit with umbilical cord pH <7 and Apgar score <4 at 5 min were the same over the years studied. At present, 95.2% of women delivering at our unit are satisfied with their delivery experience.

Conclusion: The CS rates have declined after implementing the nine items of organizational and cultural changes. It seems that a specific and persistent multidisciplinary activity with a focus on the Robson group 1 can reduce CS rates without increased risk of neonatal complications.

Study Design: Time trend analysis

Setting: 1 public, medium-sized tertiary level obstetric unit

Population of Focus: Nulliparous women who gave birth between January 2006 and October 2015

Data Source: Not specified

Sample Size: n=~900 (880-924) per year

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Quality Improvement, Policy/Guideline (State), STATE, Collaboration with Local Agencies (Health Care Provider/Practice), Collaboratives, Policy/Guideline (Hospital)

Intervention Description: Hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. As a requirement of participation, hospital teams sent at least one team member to each collaborative event. Activities included a June 2016 in-person kick off meeting for two to three representatives from each hospital to familiarize them with the cesarean delivery bundle and the requirements of participation, followed by conference calls that occurred every month in the first year and every 2 months in the second year. Additional in-person meetings for all hospital teams took place at 12 months and at the end of the collaborative (November 2018). Nice webinars on related clinical topics were presented throughout the 30-month period. The collaborative director provided facilitation support to site teams through calls and visits when requested by the site team or when site participation lapsed.

Intervention Results: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle.

Conclusion: The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.

Setting: 31 Maryland birthing hospitals

Population of Focus: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0–23) already in place before the collaborative and implementing a median of four (range 0–17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P5.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P,.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the “Response” domain of the bundle.

Intervention Components (click on component to see a list of all articles that use that intervention): Chart Audit and Feedback, Policy/Guideline (Hospital), HOSPITAL

Intervention Description: To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

Intervention Results: A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

Conclusion: A reduction in CB rate may be safely achieved through implementing a multifaceted strategy

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Chart Audit and Feedback, Quality Improvement

Intervention Description: The aim of this study was to evaluate pregnancy outcomes before, during, early post and late post introduction of the nine‐item list. The list included the following: 1) monitoring of obstetric results, 2) a midwife coordinator, 3) risk 4) classification of women according to the Robson Classification, 5) three midwife-competence levels, 6) obstetric morning round, 7) fetal monitoring skills, 8) obstetric skills training, and 9) teamwork with a midwife, obstetrician and nurse working together with the common goal of a normal delivery. The target group for the intervention was nulliparous women at term with spontaneous onset of labor and cephalic presentation (Robson group 1).

Intervention Results: Apgar score <7 at 5 minutes, Apgar score <4 at 5 minutes and umbilical cord arterial pH <7 did not differ significantly between the four time periods. Between before introduction and early post introduction, instrumental vaginal delivery decreased from 19.8% to 12.2% and cesarean section from 9.6% to 4.5%. The late post introduction period showed a maintained effect with 10.7% instrumental deliveries and 3.9% cesarean sections. Obstetric anal sphincter injury grade III decreased instantly during the introduction of the nine-item list from 7.8% to 5.1% and thereafter remained unchanged.

Conclusion: Implementation of the nine-item list increased the proportion of spontaneous vaginal deliveries by reducing the number of instrumental deliveries and cesarean sections without affecting the neonatal outcomes in nulliparous women with spontaneous onset of labor. The nine-item list intervention seems to provide long-term sustainable results.

Setting: Delivery unit in Linköping, Sweden

Population of Focus: Nulliparous women at term with spontaneous onset of labor and cephalic presentation

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback

Intervention Description: The Robson classification was introduced in Lithuanian hospitals, prospectively classifying all the deliveries in 2012 and repeating the analysis in 2014. The overall C-section rate, sizes of the Robson groups of women, and C-section rate in each group was calculated and the results were discussed. In 2013 all the data from hospitals were analyzed and a summit conference was organized specifically for the project. The attendees of the meeting included administrators of the participating hospitals, members of the Lithuanian Society of Ob-Gyns, the Lithuanian Health Ministry, and the Lithuanian Parliament. During the conference the C-section rates among different hospitals and different groups of women were compared and discussed. The general consensus to try and reduce the cesarean section rate was accepted.

Intervention Results: Nineteen Lithuanian hospitals participated in the study. They represented 84.1% of the deliveries (23,742 out of 28,230) in 2012 and 88.5% of the deliveries (24,653 out of 27,872) in 2014. The CS rate decreased from 26.9% (6379/23,742) in 2012 to 22.7% (5605/24,653) in 2014 (p < 0.001). The greatest contributions to the overall CS rate were made by groups 1, 2 and 5. The greatest decrease in the CS rate was detected in group 2. The absolute contribution to the overall CS rate decreased from 4.9% to 3.8%.

Conclusion: The Robson classification can work as an audit tool to identify the groups that have the greatest impact on the CS rate. It also helps to develop a strategy focussing on the reduction of the CS rate.

Setting: 19 Lithuanian hospitals

Population of Focus: All women who gave birth

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Elective Induction Policy, Guideline Change and Implementation

Intervention Description: To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures.

Intervention Results: Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit.

Conclusion: Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.

Study Design: Time trend analysis

Setting: 1 private hospital

Population of Focus: Nulliparous women who gave birth between January 1995 and November 1997 with scheduled induction of labor and for whom completed medical forms were available

Data Source: Not specified

Sample Size: Total (n=531) Pre-intervention (n=168) Post-intervention (n=164)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Labor Support, Midwifery, HOSPITAL, Chart Audit and Feedback, Peer Review, Quality Improvement

Intervention Description: This quality improvement initiative involved multiple interventions that were monitored over time by statistical process control charts. Components included a nested case-control review of local risk factors, provider and patient education, multidisciplinary reviews based on published guidelines with feedback, provider report cards, commitment to labor duration guidelines, and a focus on natural labor. The nursing team received training and certification in holistic nursing, and certified nurse-midwives were employed and given delivery privileges. The six-bed Karmanos Center for Natural Birth (NBC) was opened in November 2014 for low-risk women who were managed without continuous fetal monitoring, epidural analgesia, and obstetrical interventions.

Intervention Results: Control chart analysis demonstrated that the institutional cesarean delivery rate was due to culture and not "outlier" obstetricians. The primary singleton vertex cesarean rate decreased from 23.4% to 14.1% and the NTSV rate decreased from 34.5% to 19.2% (both p < .0001). There was a decrease in NICU admission but no significant changes in postpartum hemorrhage, chorioamnionitis, stillbirth, or neonatal mortality.

Conclusion: Structured quality improvement initiatives may decrease primary cesarean deliveries without increasing maternal or perinatal morbidity.

Setting: Beaumont Hospital, Royal Oak, an academic-community hybrid facility in southeastern Michigan

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation

Intervention Description: An internal clinical audit committee was established at a secondary hospital in Spain, and modifications were made to the clinical management protocol. A clinical audit was conducted and evaluated for two periods: years 2011−2014 (as baseline preaudit data) and the years 2015−2018 (the audit period). All C-sections were retrospectively classified according to the Robson TGCS to allow comparisons between both periods. The audit committee met biweekly with all obstetric staff involved in order to review, discuss, and evaluate individual cases and to determine whether cesarean indication was reasonable and adequate based on standards.

Intervention Results: Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01). No differences in perinatal and maternal results were found between preaudit and audit group.

Conclusion: Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

Setting: Spanish secondary hospital

Population of Focus: All women who gave birth

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Labor Support, Midwifery, Prolonged Second Stage of Labor, HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation

Intervention Description: 419 consecutive patients were divided into two groups, with one group (216 patients) receiving “standard management” (with medical acceleration of labor commencing at the ‘‘action line’’ in the case of arrested or protracted labor) and the other group (203 patients) receiving “comprehensive management” (CM) where arrested or protracted labor was considered a warning sign promoting further diagnostic assessment prior to considering intervention. Comprehensive management included the daily audit and discussion of clinical cases by medical and midwifery staff; the introduction of intrapartum ultrasonography alongside traditional clinical assessment to determine fetal head and trunk position accurately; one-on-one labor support facilitated by midwives and/or labor partners; and attention to the psychological well-being of the patient throughout labor and delivery.

Intervention Results: his study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59-0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31-0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44-1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06-13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66-0.97; P = .02).

Conclusion: The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies.

Setting: Obstetric Unit of Sesto San Giovanni Hospital, Milan, Italy, an urban community hospital

Population of Focus: nulliparous women with a single fetus in cephalic presentation, in spontaneous labor at term or induced labor post term.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Organizational Changes, Quality Improvement

Intervention Description: Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates.

Intervention Results: After management change the overall cesarean section rate was decreased (9.5% vs 12%, p < 0.0001). In our population spontaneously laboring nulliparous women with a singleton, cephalic, term pregnancy contributed a significant number of cesarean sections 1982 to 1988 (19.7% of all cesarean sections). Applying principles of early diagnosis and treatment of dystocia in these women resulted in a decrease in the cesarean section rate (2.4% vs 7.5%, p < 0.0001). This was primarily responsible for the overall decrease in the cesarean section rate.

Conclusion: Effective medical audit of labor management can reduce cesarean section rates.

Study Design: Prospective cohort

Setting: 1 private hospital

Population of Focus: Nulliparous women who gave birth between 1984 and 1988 and between September 1989 and August 1992

Data Source: Not specified

Sample Size: Total (n=9,207) 1984-1988 (n=5,622) 1989-1992 (n=3,585)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Quality Improvement, Policy/Guideline (Hospital), Collaboratives

Intervention Description: This was a multifaceted quality improvement initiative designed to decrease the cesarean delivery rates for NTSV births in California. From 2016 to 2019, the California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Guided by the Consolidated Framework for Implementation Research, efforts were aimed at both the internal (hospital level) and the external (statewide) environment. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019. Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives.

Intervention Results: A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]).

Conclusion: In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.

Setting: 238 nonmilitary hospitals providing maternity services in California

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Continuity of Care (Caseload), HOSPITAL, Chart Audit and Feedback, Quality Improvement

Intervention Description: Using data from Robson classification, a novel labor–ward management protocol termed Comprehensive Management (CM) was carried out at the Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy, from 1 January 2012 to 31 December 2013. CM included regular labor monitoring, documentation of events, audit and feedback, the use of intrapartum ultrasound, mobility in labor and birth posture of choice, a partograph conceived as a screening tool, continuity of care; respectful labor and childbirth care; oral fluid and food intake, and emotional support from a person of choice. The CM “framework” provides tools to make medical interventions performed during childbirth quantitatively measurable and comparable.

Intervention Results: Following CM a substantial reduction was observed in the Overall Treatment Ratio, as well as in the ratios for augmentation (amniotomy and synthetic oxytocin use) and for caesarean section ratio, without any increase in neonatal and maternal adverse outcomes. The key component of this reduction was the dramatic decline in the proportion of women progressing to augmentation, which resulted not only the most practiced intervention, but also the main door towards further treatments.

Conclusion: The proposed framework, once combined with Robson Classification, provides useful tools to make medical interventions performed during childbirth quantitatively measurable and comparable. The framework allowed to identifying the key components of interventions reduction following CM. In its turn, CM proved useful to reduce the number of medical interventions carried out during childbirth, without worsening neonatal and maternal outcomes.

Setting: Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy

Population of Focus: Nulliparous or multiparous women, at term, with single cephalic baby in either spontaneous or induced labor

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Quality Improvement

Intervention Description: The aim of this initiative was to implement an evidence-based bundle at an urban community teaching hospital in at least 50% of labors in 60 days in order to reduce early labor admissions and increase adherence to evidence-based labor management guidelines shown to decrease cesarean birth. Chart audits, root-cause analysis, and staff engagement informed bundle development. An early labor triage guide, labor walking path, partograph, and pre-cesarean checklist were implemented to drive change. Four Rapid Cycle Plan Do Study Act cycles were conducted over 8 weeks

Intervention Results: The bundle was implemented in 58% of births. The bundle reduced early labor admissions labor from 41% to 25%. Team knowledge reflecting current guidelines in labor management increased 35% and 100% of cesareans for labor arrest met criteria. Patient satisfaction scores exceeded 98%.

Conclusion: Implementing an evidenced-based bundle was effective in reducing early labor admissions and increasing utilization of and adherence to labor management guidelines.

Setting: Urban community teaching hospital

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Active Management of Labor, HOSPITAL, Chart Audit and Feedback, Quality Improvement,

Intervention Description: From 2008 through 2015, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the cesarean delivery rate among nulliparous patients with term singleton vertex gestations. This quality improvement initiative included the standardization of fetal heart rate tracing, provider training based on consensus guidelines, and the implementation of audits and provider feedback.

Intervention Results: More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed.

Conclusion: Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery.

Setting: A single tertiary care academic medical center

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Provider Training/Education, HOSPITAL, Quality Improvement, Chart Audit and Feedback, Guideline Change and Implementation,

Intervention Description: This quality improvement project was planned, implemented, and evaluated over an 8‐month time period from July 2018 through March 2019. Within this time frame, 7 weeks from October through December were devoted to four plan‐do‐study‐act (PDSA) cycles. The tests of change implemented during the PDSA cycles included both team engagement (interdisciplinary team huddles) and process changes (pilot of a best practices checklist (based on evidence-based guidelines) and audits of unplanned cesarean births). Interdisciplinary teams met regularly (53 times during the study period) to review individual cases, checklists, and audit data, and contribute to the decision-making process with the aim of reducing C-section rates.

Intervention Results: Over 7 weeks, 13 of 55 NTSV patients gave birth by cesarean, resulting in an NTSV CB rate of 23.6%. Fifty-three huddles were held by 218 staff members for 28 patients. Team engagement scores improved from 85% to 98%. Although the effective care CB scores trended upward, the overall mean was 51%.

Conclusion: Interdisciplinary team huddles, coupled with the use of a best practices checklist and feedback from audits, achieved a more effective use of CB in the NTSV patient population.

Setting: Community hospital in Mid-atlantic state

Population of Focus: Nulliparous patients with term singleton vertex gestations