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PROJECT SUMMARY

ADMISSION PROCESS TASK FORCE

FETAL HEALTH ASSESSMENT TASK FORCE

PAIN MANAGEMENT TASK FORCE

INDUCTION TASK FORCE

ORDERING YOUR COPY OF THE FIRST BIRTHS MANUAL

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The First Births Project evolved as the first phase of a Continuous Quality Improvement project aimed at "Lowering the Cesarean Section Rate at BC
Women's," which began in January of 1996. Rather than focusing on poor performers or attributing blame, Continuous Quality Improvement is a
process-oriented approach to improve quality of care. Using the Continuous Quality Improvement framework, the First Births team viewed all work as a process that leads to an output. A true understanding of a work process required data to identify significant sources of variation and to define and
analyze all improvement opportunities. Careful measurement of the process of care, combined with a team approach involving people from all disciplines relevant to the process, led to identifying opportunities for improvement in several processes of care. The Continuous Quality Improvement approach has also required the support of both upper management and clinical leaders with a willingness to introduce change into the clinical arena.

A multi-disciplinary group including representatives from Nursing, Midwifery, Family Practice, Obstetrics, Perinatology, and Anesthesia met and
decided to focus the first part of the initiative on nulliparous women with term, singleton, cephalic presentations. This group developed the following
target objective:

TARGET OBJECTIVE

The target objective was to lower the Cesarean section rate by 25% for comparable nulliparous low-risk women, while maintaining maternal and infant
outcomes at BC Women's.
 
 

PROJECT SUMMARY

A Continuous Quality Improvement process was undertaken for the project. The focus was on the process of care and began with generating hypotheses from the time of conception to delivery, which might be contributing to the
problem. Flowcharting the process of care led to a detailed examination of the patterns of practice which contributed to hypothesis generation. The
team chose four areas of focus that they agreed had the most significant impact on the outcome of high Cesarean section rates. Their choices were
verified with data collected through a chart audit. The four areas of focus and potential opportunities for improvement are listed below:

á For nulliparous women with singleton, cephalic, term pregnancies:

1. Forty-nine percent (49%) of women are admitted in the latent phase of labour and this is associated with a two fold increase in Cesarean section
rate [Admission];

2. Electronic fetal monitoring is being used > 80% of the time in a low risk population [Fetal Health Assessment];

3. Epidurals are being initiated at ó 3 cm cervical dilation in sixteen percent (16%) of patients [Pain Management];

á For all births:

4. Unnecessary inductions are being done and the booking process is inconsistent [Induction].

RESULTS

After six periods, BC Women's had admitted and delivered 1369 nulliparous women with singleton, cephalic, term presentations. The Cesarean section
rate was reduced by 21% compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 3 cms was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22% and admission at 3 3 cms cervical dilation had dropped 21%. All changes were statistically significant. Newborn outcomes were unchanged post implementation.

First Births is the first phase of the Lowering the Cesarean Section Rate Project at BC Women's. While nulliparous patients are the primary focus of
the First Births initiative, all strategies presented in this document are expected to have a broader impact on all patients, although some may require
modification for certain patient populations. A second phase of the Lowering the Cesarean Section Rate Project is planned. This second phase will focus on Vaginal Births After Cesarean Section (VBAC's).

The spirit of this initiative is Continuous Quality Improvement. It is about making gains in the quality of care and then holding them. The teams are
continuing to meet and deal with other issues identified as potential opportunities for improvement. We expect that the First Births strategy will
serve as an ongoing vehicle for introducing change concepts into the process of care at BC Women's.

Further information on specific strategies is available in the First Births Manual [Ordering Your Copy of the First Births Manual].
 
 

ADMISSION PROCESS TASK FORCE

PROBLEM STATEMENT:

Are women admitted too early in labour? There is evidence in the literature that admission before the active phase of labour (> 3 cm dilation to
complete delivery) is associated with a higher Cesarean section rate.

SUPPORTIVE DATA:

A random audit of charts showed that 49% of nulliparous women with term, singleton, cephalic, presentations were admitted to the Labour and Delivery
Room (LDR) in the latent phase of labour (Cervix £ 3 cms dilation).

OBJECTIVES:

1. To establish criteria for admission in active labour.

2. To establish recommendations for those not in active labour.

The aim of this change is to provide assessment and care for low risk patients, such that they can safely be admitted only when in active labour.
Our initial goal was to reduce the numbers admitted, who are not in active labour, by 50% within six months of implementation.
 
 

FETAL HEALTH ASSESSMENT TASK FORCE

PROBLEM STATEMENT:

Electronic fetal monitoring is overused in 'low risk' delivery. This is not consistent with best evidence (SOGC Guidelines, September 1995).

SUPPORTIVE DATA:

Greater than 80% of nulliparous women with singleton, term, cephalic, presentations delivered at BC Women's have electronic fetal monitoring
(EFM). EFM was defined as monitoring which occurred either intermittently or continuously, usually after a 20 minute assessment room strip was done.

Further data was collected to determine the reasons for the high number of low risk patients with electronic fetal monitoring (EFM). 220 charts were
surveyed of low risk patients. EFM was done in 79.1% of the cases.

OBJECTIVES:

To evaluate fetal well-being in all low-risk women by intermittent auscultation, only reserving electronic fetal monitoring for those
situations where the criteria for intermittent auscultation were not met.
 
 

PAIN MANAGEMENT TASK FORCE

PREAMBLE:

Epidurals provide effective pain relief for labour with minimal effects on the fetus. Labour progress and outcome is influenced by a wide variety of coexisting anesthetic, obstetric and patient variables. Good clinical research encompassing randomization, blinding and absence of selection bias
is a major challenge in the obstetric setting. There is ongoing debate about whether the association between epidurals and CS rate in nulliparous
patients is causal or merely reflective of a need for increased pain relief due to underlying obstetric factors or complications. Questions about the
timing of epidural initiation during labour have also been raised.

PROBLEM STATEMENT:

The range of comfort measures and pain relief options being offered at BC Women's is less than desirable (some may be underutilized) and may be
resulting in more epidurals than necessary being initiated at £ 3 cm dilation.

Are there effective labour support measures or alternative pain management strategies that could be introduced to increase the range of options
available to women delivering at BC Women's?

SUPPORTIVE DATA:

A random sample of 300 charts out of a total 3100 term ( < 37 weeks gestation), singleton, cephalic, nulliparous deliveries at BC Women's
between the six month period of 1 April - 30 September 1995 revealed an epidural rate of 50.6% (152/300 epidurals). 33% (50/152) of the epidurals
were initiated at £ 3 cm cervical dilation (latent phase). Also observed was a difference in the number and timing of epidurals in induced compared to
non-induced labours.

PRINCIPLES:

1. Stepped and complementary approach to managing labour pain

2. Appropriate & effective pain management

3. Individualized care

4. Evidence-based care

5. Woman-centered focus

6. Family-centered approach
 
 

OBJECTIVES:

* To provide appropriately-timed, effective pain management strategies (stepped, complementary care approach) individualized to support women's
    preferences and needs.
* To expand the range of comfort measures and pain management options available to caregivers and patients at BC Women's.
* To evaluate the range and effectiveness of the non-pharmacologic and pharmacologic pain relief options and the labour support measures being
    offered at BC Women's.
* To provide consistent pain management information to patients from prenatal to post-partum.
* To safeguard the physical and emotional health of the mother and fetus/newborn.
* To maximize support for women - informational, physical, emotional and advocacy.
* To decrease any inappropriate interventions during the latent phase of labour (lower patient risk by reducing early high tech intervention if other
    alternatives are effective).
 
 

INDUCTION TASK FORCE

PROBLEM STATEMENT:

Are unnecessary inductions being done and is the booking procedure being bypassed?

SUPPORTIVE DATA:

A chart audit done on a sample of deliveries in 1995-96 of singleton term cephalic presentations of nulliparous women found that thirty percent (30%)
of the time, women induced for post dates were not yet 413 weeks.

OBJECTIVES:

1. To reduce the overall induction rate for all births.

2. To reduce the induction rate within six months of implementation by 20% for post dates for singleton term cephalic presentations of nulliparous
    women.

EVALUATION:

Key indications and criteria will be tracked from the new Induction Booking Form. These forms will be audited on a monthly basis post-implementation.
 
 

ORDERING A COPY OF THE FIRST BIRTHS MANUAL
 
 

The First Births project team has published a Project Manual detailing the change concepts, strategies, and clinical practice guidelines which were
implemented as part of this initiative; as well the resulting changes in practice and key indicator tracking are included. The input of over 80
clinicians (including nursing staff, midwifery, anaesthetists, general practitioners, obstetrician's, and childbirth educators, etc.) has gone into
the writing of this manual. Copies of the First Births Project Manual are for sale at BC Women's and can be obtained by contacting the project leader,
Dr. Stefan Grzybowski at (604) 875-3281 or by writing:

Quality Improvement & Utilization Management

Room F406

Children's & Women's Health Centre of British Columbia

4500 Oak Street

Vancouver, BC V6H 3N1

Fax: (604) 875-3186

Cost: $40.00 (plus GST, PST and $4.00 postage & handling)
 
 

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