FPQC Safe Reduction of Primary Cesarean Birth Key Resources

• Safe Reduction of Primary Cesarean Birth Toolkit Document

• Safe Reduction of Primary Cesarean Birth Key Driver Diagram

• Safe Reduction of Primary Cesarean Birth Quick Start Guide

FPQC Safe Reduction of Primary Cesarean Birth Data Resources

• Patient-Level Data Collection Form - Coming Soon

• Hospital-Level Data Collection Form - Coming Soon

• Safe Reduction of Primary Cesarean Birth Baseline Data Form - Coming Soon

• Measurement Grid - Coming Soon

• Safe Reduction of Primary Cesarean Birth Data Collection Instructions and Tools - Coming Soon

1a. Mobilize a QI Team of administrators, nurses, physicians, nurse midwives to lead efforts to promote vaginal birth

Evidence and Rationale

Quality-Improvement Strategies for Safe Reduction of Primary Cesarean Birth (ACOG Committee Statement 17, 2025). ACOG recommendations for reducing cesarean births including respectful care in labor and birth, shared decision making, and clinician training on labor support methods.

National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births- Supporting Intended Vaginal Births (Lagrew et al. 2018). The National Partnership for Maternal Safety recommends reducing cesarean births through multiple quality initiatives including improving unit culture, optimizing patient and family engagement, and provider training on labor support and supporting vaginal birth.

Safe Reduction of Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rates Using Multidisciplinary Quality Improvement Efforts (McGee et al., 2026). A quality improvement project at a tertiary care hospital reduced cesarean births without increasing neonatal complications through data sharing, standardizing oxytocin administration, chart audits, patient centered decision aids and labor support protocols, and standardized algorithms for determining need for primary cesarean section.

Project Planning and Hospital Charter Examples

• IHI Project Planning Form

• Charter Template: Baptist Health

• Lee Health Project Format Example

• Birth Project Charter Baylor

NTSV Patient Identification

• NTSV Magnet Example Lee Health - Magnet for patient door

• Stork Door Banner – NTSV signage for patient door

1b. Promote patient and family engagement through accessible, evidence-based birth education with an emphasis on informed consent & shared decision making

Evidence and Rationale

Partnering with Doulas in Clinical Settings (ACOG Committee Statement 31, 2026). ACOG supports creating respectful labor support teams with doulas and using strategies to foster open and positive communication.

Effective Patient-Physician Communication (ACOG Committee Statement 23, 2025). ACOG recommends using relationship centered communications skills and interpreters when needed to support effective patient-physician communication and shared decision making.

Continuous Labor Support Position Statement (AWHONN, 2026). AWHONN supports the impact nurses make through labor support. Incorporates Respectful Maternity Care and doula integration during labor and birthing.

Intrapartum doula support and cesarean delivery rates: A systematic review and meta-analysis (Dias et al., 2025). Article demonstrates the impact doula support can make, lowering cesarean birth rates.

A meta-analysis on the impact of doula care on Cesarean section rates (Achebe et al., 2024). Analysis of randomized controlled trials demonstrate a decrease in rates of Cesareans.

Birth Preferences

• ACOG 2026 Birth Preferences Example

• Doula Initiative Birth Preferences Template

• AdventHealth Birth Wishes

• Partner to Decide Birth Preferences

• Partner to Decide Vaginal or Cesarean

• Partner to Decide for Routine Labor Induction

• CMQCC My Birth Matters

• APQC The Right Birth For Me

1c. Provide interdisciplinary perinatal team education on strategies that maximize the likelihood of a safe vaginal birth

Evidence and Rationale

Safe Reduction of Nulliparous, Term, Singleton, Vertex Cesarean Delivery Rates Using Multidisciplinary Quality Improvement Efforts (McGee et al., 2026)

Continuous Labor Support Position Statement (AWHONN, 2026)

Intrapartum Fetal Heart Rate Monitoring: Interpretation and Management (ACOG Clinical Practice Guideline 10, 2025). Overview of Fetal heart rate monitoring nomenclature and recommended interventions by fetal heart rate category.

Fetal Heart Monitoring (AWHONN Position Statement, 2024). AWHONN National Standards for EFM. Includes intermittent Auscultation.

Nonpharmacologic Labor Support

• FPQC Labor Support Training Modules

• Colorado PQC Hands on Labor Support Module – 6 hour Labor Support PPT

• Labor Support Cart – Labor Supplies/Patient support tools organized for hospital consideration

• Labor Skills Workshop – FPQC PPT & recordings featuring Jessica Brumley, CNM

• UF Doula Friendly Guidelines – Example policy from UF for Doula Integration into OB services including cesarean birth. Doulas are part of team and not a visitor.

Fetal Monitoring Assessment Education

• Intermittent Auscultation ACNM reference

• AWHONN Fetal Monitoring training programs – National Course developed in 1992 to training RNs, CNMs, MDs on Fetal Heart Rate Monitoring skills. Cost involved for both Intermediate in person training along with the Advanced Virtual course

• ACOG Fetal Monitoring Training - ACOG online training webinar for fetal heart rate interpretation. 4 hours of CME credits. Cost involved.

• PQI Intermittent Auscultation (IA)Training Course. Developed by Perinatal Quality Improvement (PQI) in partnership with AWHONN & ACNM experts, this 45 min simulation-based course provides training on how to appropriately perform and interpret Intermittent Auscultation (IA) for low-risk laboring patients. Cost involved.

2a. Implement policies, protocols, and support tools for women who present in latent (early) labor to safely encourage early labor at home or in hospital

Evidence and Rationale

First and Second Stage Labor Management (ACOG Clinical Practice Guideline No. 8)

Use of an early labor lounge to promote admission in active labor (Paul et al. 2017)

Latent Labor

• Latent Labor Slides from PROVIDE

Walking Path Examples

• Labor Walking Path example from Kaiser Permanente

• South Miami Baptist Walking Path Example

• Sarasota Memorial Hospital Walking Path

Cervical Ripening Patient Education

• Cervical Ripening Patient Education - BayCare (Includes page in Spanish)

Hospital Triage Protocol Examples

• UF Health Triage Protocol

2b. Implement standardized policies and protocols to support physiologic labor

Evidence and Rationale

Approaches to Limit Intervention During Labor and Birth (ACOG Committee Opinion No 766)

Fetal Heart Monitoring (AWHONN Position Statement, 2024)

Intrapartum Anesthesia and Analgesia (AWHONN Clinical Practice Guideline, 2020)

Continuous Labor Support (AWHONN Position Statement, 2018)

Implementing Labor Induction with a Commitment to Physiologic Birth (ACNM Position Statement, 2025)

Evaluating the Impact of the Second Stage and Pushing Duration on Maternal and Neonatal Outcomes: a systematic review and meta-analysis (Aboukhater et al. 2025)

Intermittent Auscultation for Intrapartum Fetal Heart Rate Surveillance (Ostrem‐Niemcewicz et al. 2026)

CMQCC Key Strategies – Supporting vaginal birth, using data to drive reduction in Cesareans, Midwifery Integration, improved safety across birth settings, doula integration.

Hospital Protocols on Fetal Monitoring and Intermittent Auscultation

• TGH Intermittent Auscultation Protocol

• TGH Intermittent Auscultation Badge Cards / Badge Buddy

• Sarasota Memorial Hospital Fetal Monitoring Protocol

• UF Health Intermittent Auscultation Protocol

Labor Support Resources

• FPQC Labor Support Training Modules

• Labor Support Cart and Courses

• Positioning Infographic Lamaze

• 8 Key Labor Positions Proven to Help Labor Progress Lamaze

• SOAR Labor Position Bingo Card

2c. Implement policies and protocols for induction of labor

Evidence and Rationale

AWHOHN Cervical Ripening and Labor Induction and Augmentation 6th Edition

Cervical Ripening in Pregnancy (ACOG Clinical Practice Guideline 9, 2025)

Methods for the induction of labor: efficacy and safety (Sanchez-Ramos et al. 2024)

Prevention of Group B Streptococcal Early-Onset Disease in Newborns (ACOG Committee Opinion No. 797, 2019) There are no data to suggest that artificial rupture of membranes increases the risk of neonatal disease when appropriate intrapartum antibiotic prophylaxis is given and, therefore, amniotomy is reasonable to perform if clinically indicated.

Early amniotomy after cervical ripening for induction of labor: a systematic review and meta-analysis of randomized controlled trials (De Vivo et al. 2020)

Bishop Scores (Wormer et al., 2024)

Hospital Examples of Cervical Ripening Policies

• UF Outpatient Balloon Foley Protocol

• USF Cervical Ripening Document

• Labor Induction Scheduling Form from HCA FL NW

• UF Health Scheduling Induction of Labor Guideline

Patient Facing Documents on Induction of Labor

• Evidence-Based Induction of Labor Unit Flyer

• Patient Flyer on Induction of Labor: Obstetric Initiative

3a: Implement standards and checklists for prevention, diagnosis, and management of failed induction, arrest of labor, and malposition

Evidence and Rationale

First and Second Stage Labor Management (ACOG Clinical Practice Guideline No. 8, 2024)

Quality Improvement Strategies for Safe Reduction of Primary Cesarean Birth (ACOG Committee Statement No. 17, 2025)

Pre-Cesarean Checklists

• ARPQC Pre-Cesarean Communication Tool

• CMQCC Appendix J – Pre-Cesarean Checklist

• CMQCC Appendix K – Labor Dystocia Checklist

• TGH Pro-SVD Huddle Form

Labor Management Tools

• CMQCC Appendix L – Labor Duration Guidelines

• CMQCC Appendix N – Algorithm for Management of Second Stage of Labor

  Note: Immediate pushing may be indicated even without an urge to push. An individualized approach to the start of pushing is recommended.

• CMQCC Appendix O – Active Labor Partogram

• Operative vaginal delivery: checklists for performance and documentation (SMFM Special Statement, 2020)

Management of Malposition

• CMQCC Appendix G – Guide to Second Stage Management of Malposition

• Manual Positioning Videos

  • Manual Rotation – ROTATE Trial

  • Occiput Posterior Position in Labor

3b: Implement standardized assessment and response to indeterminate and abnormal fetal heart rate patterns

Evidence and Rationale

Intrapartum Fetal Heart Rate Monitoring: Interpretation and Management (ACOG Clinical Practice Guideline No. 10, 2025)

Fetal Heart Monitoring (AWHONN Position Statement, 2024)

A Standardized Approach for Category II Fetal Heart Rate with Significant Decelerations: Maternal and Neonatal Outcomes (Shields et al., 2018)

Intrapartum management of category II fetal heart rate tracings: towards standardization of care (Clark et al., 2013)

When Evidence Fails to Change Practice: Examining the Persistence of Continuous Fetal Monitoring (De Vries et al., 2025)

Category II Algorithm Examples

• FPQC Cat II Algorithm Guidelines

• Obstetrics Initiative Category II Fetal Heart Rate Tracing Management Algorithm

• Obstetrics Initiative Cat II Smartphrase Examples

• CMQCC Appendix Q – Algorithm for the Management of Intrapartum Fetal Heart Rate Tracings

• UF Cat II Algorithm

3c: Implement a workflow process for shared decision-making during labor

Evidence and Rationale

Informed Consent and Shared Decision-Making in Obstetrics and Gynecology (ACOG Committee Opinion No. 819, 2021)

Shared Decision-Making in Midwifery Care (ACNM Position Statement, 2022)

Shared Decision-Making in Perinatal Care (Breman et al., 2024)

Effect of TeamBirth on Patient Trust and Autonomy During Childbirth in Oklahoma (Griffith et al., 2025)

TeamBirth

• Ariadne Labs TeamBirth Labor and Delivery Planning Board

• Ariadne Labs TeamBirth Website

• OPQIC TeamBirth Resources

SHARE Approach

• AHRQ The SHARE Approach

• FPQC SHARE Approach Badge Buddy

CHOICEs Tool

• Reliability and Validity of a Perinatal Shared Decision-Making Measure: The Childbirth Options, Information, and Person-Centered Explanation (Breman et al., 2022)