November 12, 2015

Welcome to the Reducing Primary Cesarean Sections (RPC) Learning Collaborative! We are looking forward to working together over the next year to increase vaginal deliveries and reduce NTSV cesareans. Twenty-one hospital teams were selected to participate in the learning collaborative. You will work with our multi-disciplinary RPC Quality Improvement (QI) expert panel (composed of physicians, hospital administrators, nurses, and ACNM staff) over the next year to identify areas of improvement, and track process and outcome measures to demonstrate improvement. Each hospital team will be supported to select one of 3 “Bundles” for implementation in their Ob Department, based upon the hospital specific most common reason (driver) for cesarean section in NTSV women at term.The bundles, along with lots of supporting materials for change, can be reviewed at our website, encourage you to explore this website, especially the resources found here

  • Toolbox: Promoting Progress in Labor
  • Toolbox: Promoting Comfort in Labor
  • Toolbox: Assessing Fetal Well-Being

This memo provides an overview of the work ahead, and contains the initial work for your team to prepare for our first webinar session on Dec 4, 2015.

Data driven quality improvement

The approach ACNM is using for the RPC Collaborative is a nationally recognized one in perinatal quality improvement.The unique focus of our proposed collaborative is a focus on normal healthy birth, which can and should be a reality for the majority of the 4 million women who give birth annually.

A review of the data supporting this project leads us directly to our methodology:

  • There is a 15-fold variation in NTSV cesareans (2.4% to 36.5%) in the USA. (Kozhimannil et al 2013)
  • Labor abnormalities and “non-reassuring” fetal heart rate tracings account for 60% of NTSV cesareans. (Barber 2011)

Data from a national survey of women contribute to this picture (Listening to Mothers I, II,III)

  • 53% experienced attempted labor induction, and
  • 30% had a medically induced labor.
  • 89% (of women who labored) experienced electronic fetal monitoring, 83% used pain medications
  • 50% experienced synthetic oxytocin,
  • 11% had assisted vaginal delivery with vacuum extraction or forceps
  • 31% had a cesarean section.

Your important role

As we know, unwarranted variation in care (that which cannot be attributed to a medical indication) indicates an opportunity for quality improvement. Analysis of the data that each participating hospital provided in the baseline survey demonstrates this.

The 21 hospitals participating in the RPC Collaborative care for a total of 54, 561 women giving birth each year. The total number of primary cesareans is 10,974 equivalent to an average primary cesarean rate of 20%. However, the variance in this rate is from 9% to 38%. This means that most hospitals have room for improvement. Even a modest goal of a 15 % reduction for each institution would prevent 1,600 women in 21 institutions from experiencing a cesarean.

To that end, we will be asking you to choose the Bundle you wish to implement based upon the underlying causes of the rate of NTSV cesareans in your institution.

Pre-Collaborative Data Needed

The first step will be ensuring that you can measure the primary outcome variable of NTSV cesareans. Below is the definition of this measure, and details of the measure are attached at the end of this document.

Nulliparous Term Singleton Vertex Cesarean SectionRate (NTSV) / All cesarean deliveries among the denominator / Nulliparous (first birth) women 37 weeks.
Exclusions: breech or transverse presentation, preterm / Joint Commission PC-02
currentfor the time period

We will be asking you to upload your numerator and denominator of the measure BY MONTH for 2015.

Additionally, it would be very useful for your group to examine the reasons for NTSV cesareans for 2014. We will discuss this further in the January Webinar.

The second step is to have the data for our balancing measure: Apgars <7 at 5 minutes.

We would also like you to be prepared to have this data available for up load. During 2016 this will be reported as 0-3, 4-6, and 7-10. It would be very helpful if you are able to provide Apgar rates in this same manner for 2015.

What You Can Expect

Our RPC process will be tailored to the specific goals of our collaborative. A snapshot of the process appears below.

Based on your responses, we have developed the following schedule for our meetings. All members of your team need to participate in each webinar, and we would like each team to send at least two members to the in-person meeting.Please make sure that everyone on your team has these calendared.

Monthly webinars, on the first Friday of each month, beginning December 4, from 1-3 p.m. Eastern (12 Central, 11 Mountain, 10 Pacific). In January, since the first Friday is January 1, we will switch to January 8, only for January. Please register for the webinars at:

After registering, you will receive a confirmation email containing information about joining the webinar.

In person meeting, all day, January 28, 2016. We will be meeting at the Baltimore Washington Westin Hotel at Baltimore Washington International airport. Participants will be responsible for booking and paying for their own travel and hotel costs; a discounted hotel rate will be available. Do not register at the Hotel at this time, a link to the conference rate will provided in the near future. Coffee breaks and lunch will be provided.

Opportunity for you to communicate publicly about your RPC participation.

This is a groundbreaking project, and we are glad that you will join us. Attached is a template for a press release with sections that you can customize for your hospital. We encourage you to use this in communicating with local media this important work.

Thank you again for your enthusiasm about participating in this important work. We look forward to partnering with you!

Best,

Leslie Cragin, CNM, PhD

Project Director