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Implementing a Systematic Approach to Reduce Cesarean Birth Rates in Nulliparous Women

Bell, Amy D. DNP, RNC-OB; Joy, Saju MD, MBA; Gullo, Susan RN, MS; Higgins, Robert MD; Stevenson, Eleanor PhD, RN

doi: 10.1097/AOG.0000000000002263
Contents: Clinical Practice and Quality

OBJECTIVE: To implement a systematic approach to safely reduce nulliparous cesarean birth rates.

METHODS: This is a quality improvement project at two rural community hospitals and one urban community hospital in North Carolina. These facilities implemented a systematic approach to reduce nulliparous cesarean birth rates, aligning with recommendations developed by the Council on Patient Safety in Women's Health Care: Patient Safety Bundle on the Safe Reduction of Primary Cesarean Births. Health care providers and nurses received education on contemporary labor management guidelines developed by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine Obstetric Care Consensus regarding safe prevention of primary cesarean deliveries and nurses were instructed on labor support techniques. The preguideline implementation period was January 1, 2015, to June 30, 2015. The postguideline implementation period was July 1, 2016, to December 31, 2016. The primary outcome measured was the nulliparous, term, singleton, vertex cesarean birth rate. Secondary outcomes included maternal and neonatal outcomes. Standard statistical analysis was used and a P value of <.05 was considered significant.

RESULTS: There were 434 women identified in the preguideline period and 401 women in the postguideline period. The nulliparous, term, singleton, vertex cesarean birth rate decreased from 27.9% to 19.7% [odds ratio (OR) 0.63, CI 0.46–0.88]. There were improvements in health care provider compliance with following the labor management guidelines from 86.2% to 91.5% (OR 1.73, 95% CI 1.11–2.70), the use of maternal position changes from 78.7% to 87.5% (OR 1.86, 95% CI 1.29–2.68), and use of the peanut birthing ball from 16.8% to 45.2% (OR 3.83, 95% CI 2.84–5.16) as provisions for labor support.

DISCUSSION: Implementing a systematic approach for care of nulliparous women is associated with a decrease in term, singleton, vertex cesarean birth rates.

Implementing a systematic approach for care of nulliparous women is associated with a reduction in cesarean birth rates.

Carolinas HealthCare System, Charlotte, North Carolina; the Institute for Healthcare Improvement, Cambridge, Massachusetts; and Duke University School of Nursing, Durham, North Carolina.

Corresponding author: Amy D. Bell, DNP, RNC-OB, 2709 Water Ridge Parkway, Charlotte, NC 28211; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

The authors thank Susan Silva and Julie Thompson for assistance with statistical analyses; Candy Adkins, Rebekah Overcash, Lynda Sanders, Jamie Drew, Chiquena Moody, and Catherine Morrison for assistance with data collection; and Sara D. Hauber for editorial assistance.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.