This collaborative project was developed by CMQCC with funding from California Health Care Foundation. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans A Quality Improvement Toolkit Toolkit to Support Vaginal Birth and Reduce Primary Cesareans Holly Smith, MPH, MSN, CNM; Nancy Peterson, MSN, PNNP, RNC-OB; David Lagrew, MD; Elliott Main, MD, Editors Suggested citation: Smith H, Peterson N, Lagrew D, Main E. 2016. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative. Funding for the development of this toolkit was provided by: California Health Care Foundation Copyright information: © 2016 California Maternal Quality Care Collaborative. The material in this toolkit may be freely reproduced and disseminated for informational, educational and non-commercial purposes only. For correspondence: Nancy Peterson, MSN, PNNP, RNC-OB, Director of Perinatal Outreach, Clinical Program Manager, CMQCC Medical School Office Building, Stanford University 1265 Welch Road MS#5415 Stanford, CA 93405 Phone: (650) 723-4849 FAX: (650) 721-5751 Email: [email protected] Website: http://www.cmqcc.org CMQCC Toolkit to Support Vaginal Birth 2 and Reduce Primary Cesareans Table of Contents ACKNOWLEDGEMENTS 7-9 pItaL LeadershIp and harness the •IMpLeMent current PreventIon power of cLInIcaL chaMpIons and treatMent guIdeLInes for EXECUTIVE SUMMARY 10-17 • transItIon froM payIng for voL- potentIaLLy ModIfIaBLe condItIons (hsv, Breech) HOW TO USE THIS TOOLKIT 18 uMe to payIng for vaLue Part II. Recognition AND Part III. RESPONSE: Manage- THE CASE FOR IMProvement ment OF LABOR Abnormalities 50-55 IN CESAREAN Birth Rates 19-24 Prevention: SUPPorting Intended Vaginal Birth 38-41 • standardIzatIon Matters • IntroductIon • the new norMaL: redesIgnIng Ma- • poor professIonaL coMMunIca- • current Landscape of cesarean ternIty care for Low-rIsk woMen tIon and Lack of teaMwork BIrth In caLIfornIa and the unIted • Lack of InstItutIonaL support for states • Lack of standard dIagnostIc the safe reductIon of routIne crIterIa/standard responses to • QuaLIty MaternIty care Is at stake InterventIon LaBor chaLLenges and fetaL heart • reducIng the cost of care • adMIssIon In Latent (earLy) LaBor rate aBnorMaLItIes • defInIng the optIMaL rate and wIthout a MedIcaL IndIcatIon • faILure to IdentIfy and Intervene reversIng the trend In cesarean • InadeQuate LaBor support for the persIstentLy op/OT Fetus BIrths •LIMIted choIces to Manage paIn • professIonaL chaLLenges In work- LIfe BaLance Part I. READINESS: IMProv- and IMprove copIng durIng LaBor ING THE Culture OF CARE, • overuse of contInuous fetaL •LIaBILIty-drIven decIsIon MakIng Awareness, AND Education 25-27 MonItorIng In Low-rIsk patIents KEY Strategies to Manage • recognIzIng the vaLue of vagInaL • underutILIzatIon of current LABOR Abnormalities AND BIrth treatMent and preventIon guIde- SAFELY REDUCE CESAREAN BIRTHS 56-67 LInes for potentIaLLy ModIfIaBLe • casuaL acceptance of cesarean • create hIghLy reLIaBLe teaMs and condItIons BIrth IMprove InterdIscIpLInary coMMu- • knowLedge defIcIt regardIng the KEY STRATEGIES FOR nIcatIon BenefIts of vagInaL BIrth SUPPORTING INTENDED •IMpLeMent standard dIagnostIc • a MaternIty cuLture that under- VaginAL BIRTH 42-49 crIterIa and standard responses apprecIates woMen’s InforMed •IMpLeMent InstItutIonaL poLIcIes to LaBor chaLLenges and fetaL choIces and preferences that safeLy reduce routIne oB- heart rate aBnorMaLItIes • payMent/reIMBurseMent ModeLs STETRIc INTERVENTIons • utILIze operatIve vagInaL deLIvery that confLIct wIth hIgh-vaLue, • IMpLeMent earLy LaBor supportIve for eLIgIBLe cases hIgh-QuaLIty MaternIty care care poLIcIes and actIve LaBor • IdentIfy MaLposItIon and IMpLe- crIterIa for adMIssIon Ment approprIate InterventIons KEY Strategies FOR IMProv- ING THE Culture OF CARE, •IMprove the support Infrastruc- • consIder aLternatIve coverage Awareness, AND EducatioN 28-35 ture and supportIve care durIng prograMs (LaBorIst ModeLs and LaBor coLLaBoratIve practIce ModeLs) •IMprove QuaLIty of and access to chILdBIrth educatIon • encourage use of douLas and • deveLop systeMs that facILItate work coLLaBoratIveLy to provIde transfer of care froM the out- •IMprove coMMunIcatIon through LaBor support of-hospItaL BIrth envIronMent to shared decIsIon MakIng at crItI- the hospItaL caL poInts In care • utILIze Best practIce recoMMen- datIons for LaBorIng woMen wIth • AVOId defensIve MedIcIne: focus • BrIdge the provIder knowLedge regIonaL anesthesIa on QUALITY AND SAFETY and skILLs gap •IMpLeMent InterMIttent MonItor- •IMprove support froM senIor hos- Ing poLIcIes for Low-rIsk woMen CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans 3 Table of Contents (continued) Part IV. REPorting AND Systems LEARNING: USING APPENDIX I – InforMed consent for eLectIve Data to DRIVE IMProvement 68-69 (non-MedIcaLLy IndIcated) cesarean BIrth 109 • underLyIng prIncIpLes for reportIng and systeMs APPendix J – pre-cesarean checkLIst for LaBor LearnIng dystocIa or faILed InductIon 110 •IMpLeMentatIon BarrIers for data-drIven QI APPendix K – LaBor dystocIa checkLIst 111 KEY Strategies FOR USING Data to DRIVE REDUC- TION IN CESAREANS 70-75 APPendix L – LaBor duratIon guIdeLInes 112 • create awareness APPendix M – spontaneous LaBor aLgorIthM 113 • proMote transparency APPendix N – aLgorIthM for the ManageMent •IMprove data QuaLIty of the second stage of LaBor 114 • create actIonaBLe data APPendix O – actIve LaBor partograM 115 • reduce data Burden • desIgn new Measures to drIve QI APPendix P – aLgorIthM for the ManageMent of category II fetaL heart tracIngs (dr. steven Part V. SUCCESS Stories:LESSONS LEARNED FROM cLark and coLLeagues) 116 CALIFornia HOSPitals 76-79 APPendix Q – aLgorIthM for the ManageMent • the pacIfIc BusIness group on heaLth / cMQcc pILot of IntrapartuM fetaL heart rate tracIngs 117-118 project for cesarean reductIon • john MuIr MedIcaL center, waLnut creek, ca APPendix R – InductIon of LaBor aLgorIthM 119 • kaIser perManente rosevILLe MedIcaL center, ros- APPendix S – acog key LaBor defInItIons 120 evILLe, ca APPendix T – ModeL poLIcIes 121-146 APPENDICES 80-146 • fetaL surveILLance APPendix A – suMMary of the oBstetrIc care • freedoM of MoveMent consensus on safe preventIon of the prIMary cesarean deLIvery (acog/sMfM 2014) 80 • InductIon of LaBor • paIn assessMent and ManageMent APPENDIX B–safe reductFon of prIMary cesarean BIrths BundLe (aIM, 2015) 81-82 REFERENCES 147-159 APPendix C – tooLs arranged By sectIon 83-87 APPendix D – tooLs arranged By topIc 88-94 APPendix E – cMQcc BIrth preferences guIde 95-97 APPendix F – copIng wIth LaBor aLgorIthM 98 APPendix G – guIde to second stage Manage- Ment of MaLposItIon 99-102 APPendix H – cesarean BIrth perforMance Mea- sures 103-108 CMQCC Toolkit to Support Vaginal Birth 4 and Reduce Primary Cesareans Tables Table 1. SUMMARY OF NEOnatAL Table 14. BARRIERS TO APPROPRiatELY Table 26. KEY COMPONEnts FOR RisKS AssOciaTED WitH SCHEDULED ManAGinG LaBOR AbnORMALitiES 51 SUccEssFULLY DECREasinG NON-MEDicaLLY CEsaREan BIRTH 23 INDicaTED (ELEctiVE) INDUctiON OF LaBOR 62 TablE 15. FEatURES OF EFFEctiVE TEAMWORK TablE 2. FactORS INFLUEnciNG THE CULTURE anD SKILLED COMMUnicatiON 52 TablE 27. SUMMARY OF RECOMMENDatiOns OF CARE anD THE VALUE OF VAGinaL BIRTH 25 FOR INDUctiON OF LaBOR (ACOG/SMFM ObsTETRic CARE COnsEnsUS, 2014) 62 TablE 16. GLOssaRY OF TERMS FOR TablE 3. KEY STRatEGIES FOR IMPROvinG INDUctiON OF LaBOR 53 THE CULTURE OF CARE, AWARENEss, anD TablE 28. COMMONLY CitED REASOns FOR EDUcatION FOR CEsaREan REDUctiON 28 INDUctiON OF LaBOR THat DO NOT MEET CRitERia as “MEDicaL INDicatiOns” 63 TablE 17. MaTERnaL anD INFant TablE 4. PatiEnt DEcisiON POints THat OUtcOMES AFTER CHanGES in ELEctiVE IMPact RiSK OF CEsaREan 31 INDUctiON OF LaBOR POLiciES 54 TablE 29. IDEntiFicatiON, PREVEntiON, anD TREatMEnt OF THE MaLPOsitIONED FETUS 65 TablE 18. KEY STRatEGIES TO ManaGE TablE 5. LEADERSHIP ROLES anD ActivitiES LabOR AbnORMALitiES anD SAFELY REDUCE FOR StaKEHOLDERS in PERinataL CARE 34 CEsaREan BIRTH 56 TablE 30. PUBLic BENEFit OF TRansPAREncY anD PUBLic REPORtinG 69 TablE 6. EXAMPLES OF ALTERnativE PaYMEnt TablE 19. SUMMARY OF RECOMMENDatiOns MODELS anD THE POTEntiAL IMPact ON FOR THE FiRst StaGE OF LaBOR (ACOG/SMFM TablE 31. BARRIERS TO UsinG Data TO DRivE CEsaREan BIRTH 35 ObsTETRic CARE COnsEnsUS, 2014) 58 REDUctiON in CEsaREans 69 TablE 7. BARRIERS TO SUPPORtinG IntENDED TablE 20. SUMMARY OF RECOMMEN- VAGinaL BIRTH 39 DatiOns FOR THE SECOND StaGE OF TablE 32. KEY STRatEGIES FOR UsinG Data LabOR (ACOG/SMFM ObstETRic CARE TO DRivE REDUctiON in CEsaREans 70 COnsEnsUS, 2014) 58 TablE 8. BENEFitS OF COntiNUOUS LaBOR SUPPORT 39 TablE 33. LaCK OF AWARENEss 71 TablE 21. EsSEntiAL COMPONEnts OF SAFELY ADMinisTERING OXYTOcin 59 TablE 34. LaCK OF TRansPAREncY 71 TablE 9. KEY STRatEGIES FOR SUPPORtinG IntENDED VAGinaL BIRTH 42 TablE 22. NICHD FEtaL HEART RaTE CLassiFicatiOn 60 TablE 35. POOR Data QUALitY 72 TablE 10. SUPPORT OF COPinG anD LaBOR PROGREss 44 TablE 36. LaCK OF ActiOnabLE Data 73 TablE 23. COnsERvativE CORREctiVE MEasURES FOR CatEGORY II FEtaL HEART RatE TRaciNGS 60 TablE 11. KEY COMPONEnts OF A SUPPORtiVE Table 37. Data BURDEN 74 Unit INFRastRUctURE 45 TablE 24. GEstatiOnaL AGE TERMinOLOGY anD ACOG CRitERia FOR CONFIRMatiON OF TablE 38. NEED FOR NEW CESAREAN QI TablE 12. BEst PRacticE RECOMMENDatiOns TERM GEstatiON 61 MEASURES 75 FOR REGIOnaL ANEstHEsia 47 TablE 25. EXAMPLES OF AccEPTED MEDicaL TablE 39. SUMMARY OF