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Safe Reduction of Primary Cesarean

Birth (AIM-RPC) : The Next North
Carolina Statewide Maternal Project

Arthur Ollendorff, MD

January 24, 2019
The Golden Circle: AIM-RPC Edition
• Why
• There are risks to Cesarean birth beyond the surgical risks of the initial surgery
• There is unexplained variation in primary cesarean rates across the state and within
communities indicating an opportunity for improvement
• How
• AIM partners across the state will work together to assure that any women who has
a primary Cesarean for arrest of dilation, arrest of descent or failed induction met
the ACOG/SMFM criteria for those diagnoses
• What
• Teams at each hospital in the state will identify ways to support labor and allow a
safe vaginal birth using resources such as the AIM bundle or the CMQCC toolkit
Cesarean Delivery Metrics
• Total Cesarean delivery rate
• Total number of Cesarean deliveries/Total number of mothers who deliver
• This includes repeat Cesarean deliveries
• Primary Cesarean delivery rate
• Total number of first-time mothers who delivery by Cesarean/total number of
first-time mothers who deliver
• This unadjusted rate makes it hard to compare low-risk centers from high-risk
centers given case complexity particularly in preterm birth
Cesarean Delivery Metrics
• The AIM metric for tracking Cesarean section rates is Nulliparous
Term Singleton Vertex (NTSV) Cesarean Section rate and is also called
PC-02
• Number of NTSV women who have a Cesarean Delivery / Number of NTSV
women who deliver
• Better adjusts risk to allow comparison across hospitals
• Health People 2020 set a NTSV C/S rate of 23.9% as a target
• North Carolina’s NTSV Cesarean rate was 23.6% in 2016
15
20
25
30
35
40
45

GRAHAM
ORANGE
NEW HANOVER
HOKE
PAMLICO
MACON
JACKSON
STOKES
FORSYTH
CRAVEN
DAVIE
PITT
MADISON
DURHAM
PERSON
CASWELL
ALAMANCE
GATES
WAKE
GUILFORD
YADKIN
SURRY
MECKLENBURG
UNION
PASQUOTANK
MARTIN
WASHINGTON
CAMDEN
CALDWELL
ALEXANDER
NC - 2016

TRANSYLVANIA
YANCEY
HAYWOOD
BURKE
EDGECOMBE
AVERY
JONES
RUTHERFORD
IREDELL
LENOIR
ASHE
Total Cesarean Rate by County

DAVIDSON
SAMPSON
BEAUFORT
HERTFORD
PERQUIMANS
HYDE
WILKES
TYRRELL
SCOTLAND
Primary Cesarean Rate – NC Hospitals 2017
Unadjusted Primary C/S Rate
40

35

30

25

20

15

10

5

0
Variation in NTSV Rates Among Provider Groups
at a NC Hospital
NTSV by Practice (Q1-Q3 2017)
40

35

30

25

Health People 2020 Goal
20

15

10

5

0
Safe Reduction of Primary Cesarean Birth
(RPC) Initiative
• Statewide QI project to work with all birthing units in NC to decrease
unnecessary Cesarean Sections and maintain or improve the health of the
mother and newborn
• Expert team has developed specific goals for the project
• Demonstrate 100% compliance with all AIM RPC structure metrics
• Ensure that all NTSV women having a Cesarean Section have met the ACOG/SMFM
Cesarean Criteria for abnormal labor
• Achieve a statewide NTSV Cesarean rate at or below 20.0% and have each hospital
with an NTSV Cesarean rate at or below the Healthy People 2020 goal of 23.9%
• Demonstrate no change in newborn outcome by route of delivery measured by 5-
minute Apgar score < 7 and admission to the NICU stratified by reason for admission
Structure Measures – AIM RPC
S1: Patient, Family & Staff Support S1a: Has your hospital developed OB specific resources and protocols to
support patients, and family through an unexpected/ traumatic Cesarean?
S1b: Has your hospital introduced Principles of shared decision making?

S2: Unit Policy and Procedure Does your hospital have an up-to-date new labor guidelines policy and
procedure (reviewed and updated in the last 2-3 years) that provides a unit-
standard approach for providing labor support, freedom of movement, and
management protocols for labor challenges?
S3: EHR Integration Were some of the recommended tools for the Safe Reduction of Primary C/S
bundle (i.e. order sets, tracking tools) integrated into your hospital’s Electronic
Health Record system?
S4: Multidisciplinary Case Reviews for C/S Bundle Has your hospital established a process to perform multidisciplinary bundle
Alternate Measure for P3: C/S Bundle Compliance Rate reviews on a random sample of 10-20 charts/monthly (depending on hospital
size) for NTSV CS?
Indication for C-Section Algorithm Diagnose
YES
Failed Induction
Proceed with Cesarean
Section

Cervix < 6 cm and Oxytocin used for >= 12
Membranes Ruptured? YES
Bishop > 6 hours after ROM?

Continue Titrating
NO
NO Pitocin
Induced Labor
or
Spontaneous Labor AROM

No change x 4hr Diagnose
Cervix >= 6 cm Membranes Ruptured? YES
with adequate uterine
YES
Arrest of Dilation
activity (or 6hr on Oxytocin with Proceed with Cesarean
inadequate uterine Section
activity)?
NO

NO
AROM
Continue Augmentation

NO

Diagnose
Rest and Descend x1hr
Consider Augmentation: Arrest of Descent
Cervix Completely Urge to Push or Oxytocin, Assisted Delivery, if no Birth within 3hr for
Occiput Anterior? YES NO with descent noted,
Dilated +2 Station Position Change, Manual Natural or 4hr for Epidural,
Q30 min
Rotation Proceed with Cesarean
Section

YES

Push

Adapted from ACOG/SMFM Cesarean Criteria for abnormal labor
Top 10
tasks
identified
as having
the most
value to
the
initiative
No. 1
Create a team of providers
(obstetricians, midwives,
anesthesiologists), staff, quality
department, administrators to lead
the effort and cultivate unit buy in
No. 2

Develop a program for ongoing
staff training for labor support
techniques including caring for
women with regional anesthesia
No. 3

Develop a program with positive
messaging to women and their
families about intended vaginal
birth strategies for use throughout
pregnancy and birth
No. 4

Implement standard criteria for
diagnosis and treatment of labor
dystocia, arrest of disorders and
failed induction
ACOG/SMFM
Labor Dystocia
and Failed
Induction Pre-
Cesarean
Checklist
No. 5

Implement training/procedures
for identification and appropriate
interventions for malposition
No. 6

Implement policy and protocols
for encouraging movement in
labor and intermittent monitoring
for low risk women
No. 7

Perform monthly case reviews to
identify consistency with dystocia
and induction ACOG/SMFM
checklists
No. 8

Implement protocols and support
tools for women who present in
latent (early) labor to safely
encourage early labor at home
No. 9

Share provider level measures
with department (may start with
blind data but quickly move to
open release)
No. 10

Establish a project communication
plan (at least monthly education
and progress updates)
Baseline Average NTSV CS rates
50%

45%
Facility goal: 23.9%
40%

35%
Statewide goal: 20%

30%

25%

20%

15%

10%

5%

0%

June 2018 July 2018 August 2018
Intervention
Tracker
Facility
Planning
Sheet
High Value Interventions

Create a team of providers (obstetricians, midwives, anesthesiologists), staff, quality department,
administrators to lead the effort and cultivate unit buy in
Develop a program for ongoing staff training for labor support techniques including caring for women with
regional anesthesia
Develop a program with positive messaging to women and their families about intended vaginal birth
strategies for use throughout pregnancy and birth
Implement standard criteria for diagnosis and treatment of labor dystocia, arrest of disorders and failed
induction
Implement training/procedures for identification and appropriate interventions for malposition

Implement policy and protocols for encouraging movement in labor and intermittent monitoring for low
risk women
Perform monthly case reviews to identify consistency with dystocia and induction ACOG/SMFM checklists

Implement protocols and support tools for women who present in latent (early) labor to safely encourage
early labor at home
Share provider level measures with department (may start with blind data but quickly move to open
release)
Establish a project communication plan (at least monthly education and progress updates)
PLEASE PUT YOUR FACILITY
NAME ON TOP OF THE
INTERVENTION TRACKER AND
PLANNING SHEET