PQCNC 2010-2011 Maternal Initiative Recommendation

Increase the rate of vaginal delivery among low-risk, nulliparous women with a term,
singleton, vertex baby utilizing a quality improvement approach with a focus on
standardizing the management of term labor, including but not limited to induction and
augmentation of labor, among participating North Carolina hospitals.

Process:
An email was sent to teams involved in the current PQCNC project, heads of OB
departments throughout the state, statewide leaders in OB-GYN, pediatrics, family
medicine, midwifery, and nursing to elicit ideas for the next obstetric project.

The PQCNC administrative team determined that the project for next year should be
hospital-based, evidence-based, fundable, applicable to most North Carolina obstetrical
services, and that there should be existing best practice models. Most important, the
project needs to move us closer to the PQCNC mission of “making North Carolina the
best place to be born”. Ten to twelve ideas were generated, and the PQCNC staff
eliminated some as they did not meet the above criteria, primarily because they were
focused on the outpatient setting.

The remaining nine projects were then sent to a broader group of obstetric and pediatric
care providers, hospital administrators, family support specialists and other relevant
stakeholders, with a request that they rank the results. Approximately 200 individuals,
who were asked to identify their primary professional affiliation, responded. The results
of that survey are attached.

On the basis of these results, it is clear that addressing the rate of primary cesarean
section is the leading issue for our surveyed constituents. All of the other projects are
important as well, and each would be a reasonable selection for next year’s project. The
selection of CS as the first choice may be related to the fact that this topic is one element
of The Joint Commission’s new perinatal core measure set. (PC-02)

From Joint Commission National Quality Core Measures Manual for Perinatal Core-02:

“Rationale: The removal of any pressure to not perform a cesarean birth has
led to a skyrocketing of hospital, state and national cesarean section (CS) rates.
Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20%
have infant outcomes that are just as good and better maternal outcomes (Gould
et al., 2004). There are no data that higher rates improve any outcomes, yet the
CS rates continue to rise. This measure seeks to focus attention on the most
variable portion of the CS epidemic, the term labor CS in nulliparous women.
This population segment accounts for the large majority of the variable portion of
the CS rate, and is the area most affected by subjectivity.

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 As compared to other CS measures, what is different about NTSV CS rate (Low-
risk Primary CS in first births) is that there are clear cut quality improvement
activities that can be done to address the differences. Main et al. (2006) found
that over 60% of the variation among hospitals can be attributed to first birth
labor induction rates and first birth early labor admission rates. The results
showed if labor was forced when the cervix was not ready the outcomes were
poorer. Alfirevic et al. (2004) also showed that labor and delivery guidelines can
make a difference in labor outcomes. Many authors have shown that physician
factors, rather than patient characteristics or obstetric diagnoses are the major
driver for the difference in rates within a hospital (Berkowitz, et al., 1989; Goyert
et al., 1989; Luthy et al., 2003). The dramatic variation in NTSV rates seen in all
populations studied is striking according to Menacker (2006). Hospitals within a
state (Coonrod et al., 2008; California Office of Statewide Hospital Planning and
Development [OSHPD], 2007) and physicians within a hospital (Main, 1999)
have rates with a 3-5 fold variation.

Type of Measure: Outcome

Improvement Noted As: Decrease in the rate

It is our recommendation that we embrace this topic for PQCNC for 2010-2011. By
framing the goal in a positive statement—increasing the rate of nulliparous women
achieving a vaginal birth—the project extends beyond simply addressing what some
consider a runaway cesarean section rate to promoting normal, safe vaginal birth at
term. Reasons to select this project include:

1. The project will build on successes gained with the “elimination of under 39 week
gestational age elective delivery” project for 2009-2010 and may contribute to
sustainability of the 39 Weeks Project at participating hospitals.
2. By “piggy-backing” onto JCAHO core measure data collection, we are likely to be
able to engage a significantly greater number of obstetric hospitals throughout the
state. It is vital that any project we undertake in this area be focused on improving
the actual quality of care rather than simply facilitating the collection of data for the
JCAHO core measure. Selection of this topic runs this risk, and PQCNC will work to
ensure that participating sites engage in processes to promote successful term
vaginal birth, in addition to the required JCAHO data collection. However, hospital
teams in the current initiative have suggested that a future initiative would
correspond to the JCAHO core measures in order to minimize additional data
collection burdens to participate in a PQCNC initiative.
3. The key drivers of cesarean section rates among nulliparous, term patients relate to
protocols for induction of labor and augmentation of labor. Feedback from our
participating hospitals in the current project suggests that processes related to
augmentation of labor are particularly vexing, lack standardization and are ripe for
quality improvement processes and measurement.
4. There are various procedural components of term labor that may be particularly
amenable to quality improvement strategies. PQCNC expert panel and leadership
teams could develop a robust tool kit for participating sites to choose from (in

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 addition to those developed locally) to assist with their local interventions. Such
procedures might include:

A. Selection of patients for augmentation

B. Selection of patients for cervical ripening prior to induction
C. Use of cervical ripening agents
D. Pitocin protocols
E. Standardization of “soft call” indications for induction, such as
oligohydramnios, macrosomia, pregnancy induced hypertension to facilitate
peer review committees at the local level.
F. Use of NICHD definitions for fetal monitoring terminology to address the
issue of the abnormal fetal monitoring.
G. Standardize antenatal testing protocols for selected term patients
H. Standardized protocols for patients who present at term for evaluation of
labor.

Expert team

The expert team will be developed to do the following:

1. Define the endpoints to be studied

2. Develop a “tool kit” to address selected topics and others from “4”, above
3. Be a resource to participating hospitals in developing their interventions and data
collection processes, and implementing their interventions.

Hospital teams

Each participating hospital will be asked to have a physician champion, nursing

champion and administrative champion who will be charged with leading their hospital
teams. Teams will also be asked to consider including a patient representative, and
PQCNC will work with teams to support this effort. Each hospital will be required to
collect their historical data for a set period of time and provide some data to identify the
drivers of their CS rates in low-risk, nulliparous patients with term, vertex fetuses. Each
hospital will then be asked to identify practice changes to test and implement (from the
tool box or elsewhere) to address their individual hospital’s issues. Each hospital will
then provide monthly data for 9 months after initiation of the process changes to track
the rates of CS.

Data collection

The project will need to include the data needed for the JCAHO core measure and will
also include other measures related to induction and augmentation, such as cervical
exam at admission or specific maternal and neonatal complications. Specific measures
and a data collection tool will be developed by the expert committee for this project.

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 Appendix A

2010 New Initiative Member Preferences

Overall

1 Breastfeeding
2 Resuscitation checklist
3 Hospital readmission
4 Neonatal abstinence

1 Primary c-section
2 Antenatal steroids
3 Breastfeeding
4 Substance abuse
5 Prenatal records transfer
6 Augmentation of labor
7 Obesity
8 Hemorrhage
9 Wound infection

Clinical - Pediatrics

1 Breastfeeding
2 Hospital readmission
3 Neonatal abstinence syndrome
4 Resuscitation checklist

1 Primary c-section
2 Antenatal steroids
3 Breastfeeding
4 Prenatal records transfer
5 Substance abuse
6 Augmentation of labor
7 Wound infection
8 Obesity
9 Hemorrhage

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 Clinical - Maternal

1 Breastfeeding
2 Resuscitation checklist
3 Hospital readmission
4 Neonatal abstinence

1 Primary c-section
2 Augmentation of labor
3 Substance abuse
4 Breastfeeding/Antenatal steroids
6 Prenatal records transfer
7 Obesity
8 Hemorrhage
9 Wound infection

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