Collaborative to Reduce Nulliparous Term Singleton Vertex (NTSV) Cesarean Deliveries

Why NTSV?

The NJPQC is working with the New Jersey Department of Health to reduce Nulliparous Term Singleton Vertex (NTSV) C-sections – these occur when a first-time mother with a normal, uncomplicated, low-risk pregnancy ends up having a C-section.

C-sections have long been controversial and various groups nationally have sought to reduce the incidence to minimize post-partum complications for both mother and baby. Primary cesarean deliveries are a major contributor to the large increase in total cesarean delivery rates in the United States over the past two decades. Moreover, approximately 90 percent of women who have a primary cesarean delivery are likely to deliver by cesarean again in subsequent pregnancies, which incurs higher costs and progressively higher morbidity risks with each additional cesarean delivery.

For most low-risk NTSV women, cesarean birth increases risk of hemorrhage, infection, uterine rupture, abnormal placentation and cardiac events. Psychological stress, anxiety and post-traumatic stress disorder have also been identified as potential risks. Other less acute, but nonetheless significant, consequences may include longer hospital stays, increased pain and fatigue, slower return to normal activities and productivity, and delayed and difficult breastfeeding.

Risks of cesarean birth for neonates are also of concern. Increases in the rate of cesarean births only appear to be beneficial to fetuses in breech presentation, and cerebral palsy and neonatal seizure rates have remained unchanged since 1980. Cesareans have been shown to be associated with impaired neonatal respiratory function, neonatal intensive care unit admission, difficulty breastfeeding and lifelong health issues.

Still, the procedure accounts for more than 30 percent of births nationally and in New Jersey, with some hospitals in the state reporting rates of over 40 percent. The cesarean rate among low-risk NTSV births in New Jersey has seen an increase from 23.5 percent in 1990 to 36.3 percent in 2009. The provisional rate for 2016 is 30.3 percent.

Although there has been a modest decrease in NTSV cesarean rates, current data shows that the state is still far from meeting the Healthy People 2020 target of 23.9 percent.

The NTSV Collaborative Initiative

As an NTSV participant, NJPQC will provide education on the latest and best subject matter application and research, as well as tools and interventions for process improvement. This initiative will also provide coaching to teams and organizations.

The overall goals of the NJPQC NTSV Collaborative are:

  • To achieve a 10 percent reduction in NTSV cesareans within 18 months
  • To improve safety culture in all participating organizations, and
  • To improve teamwork and communication between stakeholders.

Participating in the NTSV Collaborative is voluntary. Participating hospitals will be asked to:

  • Connect the goals of the collaborative work to a strategic initiative in their organization
  • Provide a senior leader to actively support the team and champion the spread of improvements within the facility
  • Provide expert staff from key support units in the organization to support the team as needed
  • Perform tests of change leading to process improvements within the organization, and
  • Communicate regularly with their partners in other healthcare settings.

About Communication and Teamwork

The importance of culture, teamwork, communication and a focus on patient-centric care has been demonstrated in improving patient safety. Like in intensive care units, things can go wrong in seconds in pregnancy-related care, and the ability to communicate effectively and work in well-coordinated teams is critical to achieving a positive outcome for mother and baby.

In 2004 The Joint Commission (TJC) issued a sentinel alert advisory on preventing infant death and injury during delivery. While the absence of early and regular prenatal care is a leading contributor to the risk of infant death or morbidity, review of TJC’s sentinel alert cases reveals that in all sentinel alert cases, communication issues topped the list of identified root causes (72 percent), with more than one half of the organizations citing organization culture as a barrier to effective communication and teamwork, i.e. hierarchy and intimidation, failure to function as a team and failure to follow the chain of communication.

Other identified root causes include: staff competency (47 percent), orientation and training process (40 percent), inadequate fetal monitoring (34 percent), unavailable monitoring equipment and/or drugs (30 percent), credentialing/privileging/suspension issues for physicians and nurse midwives, staffing, lack of prenatal information and other issues.

NTSV Collaborative Approach and Structure

Because reduction of NTSV cesareans is so multi-faceted, and efforts need to span the entire pregnancy (not just the hospital stay), in this collaborative two areas of focus will be developed:

  • The perinatal phase, which includes appropriate care for mom and baby; childbirth; and breastfeeding education to optimize patient and family engagement in education, informed consent and shared decision-making about normal healthy labor and birth throughout the maternity care cycle.
  • The hospital stay, which includes policies promoting best practices to support vaginal birth, education for nursing staff on labor support skills, pain management, etc.

Similar to the key strategies identified by the Florida PROVIDE Initiative , the collaborative will recommend the adoption of the following key practices to promote primary vaginal deliveries:

  1. Improve access to and promote quality childbirth education, informed consent and shared decision making
  2. Implement institutional policies that uphold best practices in obstetrics, safely reduce routine interventions in low-risk women and consistently support vaginal birth
  3. Educate nurses and providers on intermittent auscultation/Electronic Fetal Monitoring and implement intermittent monitoring for low-risk women
  4. Educate nurses on labor support skills that promote labor progress, labor support and pain management
  5. Educate and encourage providers on external version, operative vaginal delivery and breech delivery
  6. Establish standard criteria for induction, active labor admission and assess all women on admission
  7. Encourage use of doulas and create doula-friendly policies
  8. Increase access to non-pharmacological pain management/labor progression tools
  9. Implement standard diagnostic criteria and responses to labor challenges and heart rate abnormalities, and
  10. Track provider-level cesarean section rates and conduct case reviews to drive improvement.

This Collaborative will be a virtual collaborative, with webinars and monthly coaching conference calls.

NTSV Contacts:

Suzanne Spernal, DNP, RNC-OB, APN-C, CBC suzanne.spernal@rwjbh.org

Andrew F. Rubenstein, MD Andrew.Rubenstein@hackensackmeridian.org

Angela Centellas, MPH acentellas@njha.com