Safely Reducing C-section Rates for Failure to Progress/Dystocia

The following recommendations are from a collaborative of the Institute for Healthcare Improvement in Boston:

1. Better practice

o Avoid unnecessary inductions:

— Inductions are done only for clear medical indications, such as post 42 weeks.

— Criteria for inductions are agreed upon and used by OB medical and nursing staff.

— Patients who do not enter labor after induction attempt are allowed to go home, unless some other reason forces more intervention.

o Sample targets:

— Primary C-section rate decreases by 30%.

— C-sections for FTP/Dystocia decrease by 50%.

— Decrease in C-sections following failed inductions by 75%.

2. Better practice

o No C-sections for FTP in latent phase of labor:

— Patients are not admitted for false labor, or before 3-4 cm dilation, unless they have a risk factor that necessitates admission.

— A triage capacity is available to assess and monitor patients prior to admission.

— OB staff use active labor management, including careful assessment of labor progress, use of oxytocin to augment labor, and guidelines to manage slow progress in the latent phase.

o Sample targets:

— C-sections for FTP in the latent phase decrease by 100%.

— Admission with cervical dilation less than 4 cm decrease by 75% in low-risk, nulliparous patients.

— Median cervical dilation on placement of epidural anesthesia to at least 4 cm.

3. Better practice

o Alleviate pain:

— Physicians offer adequate pain relief to patients.

— Nursing staff assess pain and provide a variety of pain relieving techniques (hydrotherapy, positioning).

— Epidurals are used judiciously, and placement is often delayed until 4 cm dilation. A walking epidural is available.

o Sample targets:

— Patients stating that their pain was the key factor in wanting a C-section decrease by 50%.

4. Better practice

o Support every patient in labor:

— Patients receive 1:1 labor support from nursing staff, doulas, or midwives.

— Patients are encouraged to ambulate and are given oral fluids during labor.

o Use patience:

— Allow patients in second stage of labor to "rest in descent," delaying pushing until the patient feels the urge to push.

— Eliminate arbitrary time deadlines for second stage of labor.