In the summer of 2021, the Perinatal Clinical Practice Multidisciplinary Committee (PCPMC) for Salinas Valley Health’s Women’s and Children’s Department found that despite numerous interventions, it was still underperforming on a key measure of perinatal care quality. The nulliparous term singleton vertex (NTSV) cesarean birth rate indicates the proportion of live babies born via cesarean section at or beyond 37 weeks gestation to women in their first pregnancy, which are singleton (no twins or beyond) and in the vertex presentation (no breech or transverse positions).

Seeking to support vaginal births whenever medically appropriate, the California Maternal Quality Care Collaborative set a 23.6% target for the NTSV cesarean birth rate in 2021. When, in August 2021, PCPMC saw the medical center’s NTSV cesarean birth rate soar to a high of 45.2%, members, Julie Vasher, DNP, RNC-OB, APRN-CNS, C-EFM, C-ONQS, and physician leaders set out to reduce the rate. “Within six months, our team forged a multipronged intervention that has the department consistently meeting the CMQCC target – and usually exceeding it,” Vasher says.

Checklists, Focused Education and Accountability

Vasher; Erica Chan, MD; Kelsey Gray, MD; Gregory Kanter, MD; and Scarlett Karakash, MD, gathered recommendations from the literature for the safe prevention of primary cesarean birth. Ultimately, they collaborated with the Perinatal Unit Practice Council; Labor and Delivery (L&D) Manager Daniela Jago, MSN, RNC-OB; and Director of Quality and Patient Safety Aniko Kukla, DNP, RN, CPNP, to create recommendations for actions that physicians and nurses could take to address the challenge.

One key recommendation was the use of a checklist created by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to accurately diagnose labor dystocia, a frequent reason for recommending cesarean section. Another recommendation was to implement best practices for L&D nurses to support the prevention of cesarean section, including active labor support and ensuring that documentation captured data needed for physicians to complete the labor dystocia check­list. The PCPMC approved the recommendations in November 2021.

Subsequently, Vasher and the physician leads:

• Worked with Salinas Valley Health obstetricians to garner support and approval for implementing the checklist and educating providers, with Vasher supporting the provider education piece.
• Established a new threshold for triggering physician peer review for provider-specific cesarean birth rates.
• Coordinated with the medical center’s informatics team to include the checklist process in physician workflows and added this required element to the cesarean operative note template.
• Vasher and L&D clinical nurse Norma Coyazo, BSN, RNC-OB, C-EFM, developed an education plan for nurses that addressed the required documentation, collaborated with physicians on checklist completion and included a labor support refresher aimed at supporting vaginal birth. The refresher education included content about hands-on and physiologic labor support and appropriate management of oxytocin for labor induction and augmentation.
• Disseminated NTSV cesarean birth rates to all staff via the Perinatal Magnet^® Data Displays, and unblinded provider-specific rates were shared quarterly with physicians.

“We also ensured implementation success through regular communications with physicians and nurses by email, discussions in daily shift huddles and just-in-time education during rounding,” Vasher says.

The numbers in the chart below demonstrate just how successful the initiative has been. “It demonstrates what a focused, interdisciplinary approach can accomplish,” Vasher says.