Learning session 2 - Nineteen of the twenty-four hospitals participating in this initiative came together in Raleigh for a full day to explore factors influencing the c-section rate, strategies to increase the rate of vaginal birth, and other considerations related to mode of delivery in North Carolina hospitals. Speakers included SIVB expert team member John Allbert, MD, a maternal-fetal medicine specialist in Charlotte and the clinical lead of Novant’s Women’s Council, Anne Drapkin Lyerly, MD, MA, an obstetrician-bioethicist at UNC, and Craigan Gray, MD, MBA, JD, the current Director of the NC Division of Medical Assistance. Hospital teams shared their challenges and successes to date, and described their goals for the second half of this initiative.
Updates
PQCNC Support for Intended Vaginal Birth Learning Session 2 Agenda PQCNC SIVB LS2 Novant Perinatal Quality Improvement PQCNC SIVB LS 2 Catawba Valley Nursing Model PQCNC SIVB LS2 Pregnancy Home PQCNC SIVB LS2 Is Cesarean Section Rate a Reasonable Quality Measure? PQCNC SIVB LS2 Ethics and Guideline Development: Implications for the Supporting Intended Vaginal Birth In...
Preparations are underway for the June 7 all-day learning session in Raleigh. We hope all SIVB teams will be able to join us.
The May webinar included a presentation from a member of the SIVB expert team, Leigh Ann Joel, a certified nurse midwife with experience in private practice, hospital-based and birth center settings, who discussed how the midwifery model of care can help increase the rate of vaginal birth. Celeste Milton, RN, BSN, MPH, Associate Project Director at The Joint Commission, who works on the Perinatal Care measure set, gave an update about the first year of Joint Commission data collection using the new perinatal care measures. A review during the webinar of data collected to date suggests that patients who are admitted in labor have less than half the cesarean rate compared to patients who are not in labor at admission (15.42% vs. 33.06%). Furthermore, the more dilated the non-laboring (induction) patient is at admission, the less likely she is to deliver via cesarean, but the cesarean rate is always higher in non-laboring patients at admission than laboring patients at admission. This finding is consistent with several studies in the literature, including those published in 2010 by the Consortium on Safe Labor.
This month’s webinar included a review of the data collected thus far. It appears that women who are already at elevated risk for a cesarean based on risk factors such as diabetes, advanced maternal age or obesity, may be more likely to be induced with an unfavorable cervix, which in turn is a risk factor for cesarean delivery.
Hospital teams also heard from Ann Tumblin, a certified doula and doula trainer who has trained hundreds of birth doulas in the U.S. and abroad, about the role of doula care in avoiding cesarean delivery.
The next learning session has been announced: it will be held in Raleigh at the McKimmon Center at NC State University on June 7. All SIVB teams are encouraged to attend.
A second webinar was held with the focus on induction scheduling practices. A physician and the nurse manager from WakeMed talked about what is in place at that hospital that has led to a relatively low c-section rate (26% overall, 14% primary c-section rate), which led to another good discussion among hospital teams about what approaches are most effective and what challenges they are facing. Several hospitals are reporting challenges with "physician buy-in" or engaging physicians around the validity and importance of improving the vaginal birth rate as a quality improvement focus. Frieda Norris gave an overview of Lamaze International's six healthy birth practices in relation to the role of labor support and other evidence-based practices to increase the rate of vaginal birth. These practices reflect a patient-centered approach to the intrapartum proceses.
Teams are actively working on the action items they identified on their action plans for this initiative. Several are in the process of developing new policies for scheduling inductions, many are working to increase the use of cervical ripening and to test changes to the cervical ripening methods they are using, and some hospitals have eliminated or plan to eliminate elective inductions generally. The Novant hospitals have formed a Women's Council to work jointly across facilities on quality improvement in the maternity setting (there are 4 Novant facilities in Support for Birth: Forsyth, Presbyterian, Presbyterian Huntersville, and Presbyterian Matthews).
Cesarean Births: What Do the National Data Tell Us? - audio presentation
NC Statewide maternal Health Initiatives - audio presentation
"The Bucket List" -or- Induction of labor in the NTSV Patient - audio presentation
Right click to download MP3 file, click on arrow to play...
Where: McKimmon Center, 1101 Gorman St, Raleigh, NC 27606
When: Tuesday, June 7, 2011 9:00 - 3:30
What: All three primary team members (physician champion, nurse champion, senior hospital adminsitrator) are encouraged to attend. CME Category I credit, lunch and materials will be provided at no cost.
How: Email Kate Directly
This is the first month of the active phase of the Support for Birth initiative, which means teams should be working toward the first objective on their action plans. Twenty-four hospitals are working to achieve site-specific goals over the next 5 months. At the February 22 webinar, we will hear from teams about how things are going so far. We have a limited amount of time in this initiative to try to make important and significant changes. Let's make the most of the strong enthusiasm and commitment that were evident in the January learning sessions to get off to a good start.
At this time, teams should have the following items in place in order to concentrate on taking the steps described in their draft action plans to achieve their goals:
1. SIVB Extranet access
2. SIVB Data Site access for those team members who will be entering data
3. Draft action plan - each hospital team should now have a draft action plan in place. This should include a broad goal and SMART objectives - Specific, Measurable, Attainable, Realistic, Time-bound objectives.
The Support for Birth initiative was officially launched this month through two learning sessions for participating hospitals. The first session was held by webinar due to winter weather interfering with plans for hospital teams to travel to Winston Salem. While we regret not having the opportunity for teams in the western part of the state to interact in person, those teams presented key challenges to improving the vaginal birth rate and areas to focus their work over the next several months. At the second session in Raleigh, teams demonstrated strong commitment to implementing changes and making an impact on the rate of c-section among the NTSV (nulliparous, term, singleton, vertex) population.
Baseline data is in, and teams have received individual reports as well as a report of the aggregate data for the entire cohort of hospitals participating in this initiative. The PQCNC team will continue to mine the baseline data for associations that suggest specific courses of action. The baseline data suggests that many women are admitted “in labor” at cervical dilations of 3cm or less, and that many c-sections for failure to progress are performed without having assessed adequacy of contractions using an IUPC or, among those deliveries where an IUPC was used, without having reached 200 Montevideo units for a minimum of 2 hours. Consistent with large studies in the literature, the c-section rate among patients admitted for induction is significantly higher than for those admitted in spontaneous labor.
Baseline data collection is now complete for teams and we are receiving an abundance of data. We have extra hands on staff to help us review and enter all of the data before the January learning sessions. Feedback continues to be directed to all teams regarding collection methods and omissions. The data reporting system is almost ready to begin generating baseline data reports for Learning Session 1.
Almost all SIVB teams have now registered for one of the two January learning sessions. One session will be held in Winston-Salem on 1/11 and the other in Raleigh on 1/25. Teams should bring 4-6 members, including their nurse champion, physician champion, and administrator champion. We are very excited to see such dedication to the Support for Intended Vaginal Birth initiative!