Cesarean Sections

Help Lower Unnecessary Primary Cesarean Section Rates

Research shows that reducing the rate of cesarean deliveries does not lead to worsened birth outcome for mothers or newborns¹. In addition, cesarean sections pose greater maternal risks in low-risk pregnancies compared to a vaginal delivery.

In 2023, Florida’s overall cesarean section (CS) rates were among the second highest in the nation²:

•  36.2% of live births were cesarean deliveries.
• The rate of primary cesarean deliveries was 27.3 per 100 live births.
• The rate of vaginal births after a cesarean (VBAC) was 11.6 per 100 live births.

Healthy People 2030 aims to reduce cesarean births among low-risk women with no prior birth experience to 23.6% of all births³. In an effort to promote healthy vaginal deliveries among low-risk women, this email provides strategies and additional resources to help lower CS rates.

Suggested Strategies

• Identify malposition ideally by the early second stage of labor. Use an ultrasound if unable to clearly define the position of the vertex with digital exam and Leopold’s maneuvers⁴.
• Encourage vertex rotation from an OP position with maternal positioning, and manual or instrumental rotation by a well-trained provider⁴.
• Help patients change position at least every 20 minutes for necessary fetal rotation⁴.
• Encourage teamwork and good communication between nurses, providers and doulas⁴.
  
• Patients who undergo cesarean birth for active phase arrest in the first stage of labor should be at or beyond 6 cm dilation with ruptured membranes and:
  • 4 hours of adequate contractions without cervical change, OR
  • At least 6 hours of oxytocin with inadequate contractions and no cervical change⁴
• Use other methods to help progress labor:
• Pushing should begin when complete cervical dilation occurs⁶.
•  
  • Tools to help with labor positions include a peanut ball, birthing ball, squat bar or hand grips. Studies show that a peanut ball shortens the length of labor and decreases the CS rate in patients with epidurals⁵.
• ACOG recommends either low-dose or high-dose oxytocin strategies as reasonable approaches to the active management of labor to reduce operative deliveries⁶.
• The second stage of labor should be defined as 2 hours of pushing for multiparous patients, and more than 3 hours of pushing in nulliparous patients.  Each patient’s unique circumstances should be carefully evaluated before extending the duration of the second stage of labor⁶.
• Evidence suggests that regular nursing care plus continuous one-to-one emotional support (provided by support personnel, such as a doula) is associated with improved outcomes for women in labor⁷.

Additional Resources

• Florida Perinatal Quality Collaborative’s (FPQC) PROVIDE Initiative: The goal of the PROVIDE Initiative is to improve maternal and newborn outcomes by applying evidence-based interventions to promote primary vaginal deliveries at Florida delivery hospitals and ultimately reduce NTSV cesareans.
  • What Can Florida Do to Have California’s Results in Reducing Low Risk (NTSV) Cesarean Births? (PDF) California has reduced their low-risk cesarean births quickly, and they are a great example for Florida hospitals.
  • Vaginal and Cesarean Birth Pro/Con Rack Cards: These cards explain the differences between vaginal and cesarean deliveries and what advantages each have.
  • Labor Support Skills to Promote Vaginal Birth: FPQC provides an outline of a course that can be utilized in workshops. Providers can learn how to be more supportive and caring towards patients.
• Quality-Improvement Strategies for Safe Reduction of Primary Cesarean Birth: from the American College of Obstetricians and Gynecologists (ACOG)
• First and Second Stage Labor Management: ACOG
•  Agency for Healthcare Research and Quality (AHRQ): A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries
• California Maternal Quality Care Collaborative (CMQCC) : This organization wrote the downloadable Toolkit to Support Vaginal Birth and Reduce Primary Cesareans⁴ that was used for majority of the strategies above.
• March of Dimes Perinatal Data Center: This resource has maternal and infant data from all counties in the United States
• Spinning Babies: Provides workshops that train providers, nurses and other professionals on how to support patients during labor process and how to assist during fetal malposition

We encourage you to develop a plan to decrease CS rates by implementing and utilizing these strategies and resources. We also encourage you to learn more about Sunshine Health’s C-Section Birth Incentive for Obstetricians (OBs).  OB providers can earn an additional $500 per quarter — for a total of up to $2,000 for the year — if they meet the C-section birth target set in their ACHA region. 

Thank you for your assistance with improving the maternal health and birth outcomes of our members. If you have questions, please call Provider Services at 1-844-477-8313 from Monday–Friday, 8 a.m. to 8 p.m. Eastern.

*This guidance applies to Sunshine Health Medicaid and Medicaid specialty plans, Children's Medical Services (CMS) Health Plan, and Ambetter Health.

Sources

¹ USF

² March of Dimes

³ Office of Disease Prevention and Health Population

⁴ California Maternal Quality Care Collaborative

⁵ Florida Perinatal Quality Collaborative

⁶ ACOG: First and Second Stage Labor Management

⁷ ACOG: Approaches to Limit Intervention During Labor and Birth