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

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


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.


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.


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

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