Cesarean Task Force BC Women’s Hospital

Initiatives & Achievements –The First Two Years:

2010‐2012

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The BC Women’s Hospital Cesarean Task Force (CTF) committee members would like to acknowledge the important financial and practical support the task force has received from the Provincial Health Services Authority (PHSA). Also, the work of the CTF would not have been possible without the support of BC Women’s Hospital care providers and staff, especially in Labour & Delivery, the Ambulatory Program, Ultrasound and the Operating Room Departments. Thank you to the care providers; family doctors, midwives, obstetricians, nurses and others, at BC Women’s Hospital and throughout the province who have supported and assisted the efforts of the CTF in numerous ways. Finally, sincere thanks to all of the women and their families who have been involved with the Best Birth Clinic and Power to Push Campaign for all of their contributions, suggestions, and participation in the CTF initiatives.

Acknowledgments

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BC Women’s Hospital Cesarean Task Force ....................................................................... iv

Partners ............................................................................................................................... vi

Executive Summary ............................................................................................................ vii

Background on Rising Cesarean Rates ................................................................................1

Cesarean Birth in BC ............................................................................................................3

Cesarean Task Force Project Implementation ......................................................................5

Project Direction and Branding ...................................................................................5 The Power to Push Campaign ..............................................................................................7

Website ......................................................................................................................7 Brochures ...................................................................................................................9 Facebook and Twitter ...............................................................................................10 Campaign Effectiveness...........................................................................................11

The Best Birth Clinic............................................................................................................12 Choices in Childbirth Clinic.......................................................................................14 VBAC .......................................................................................................................15 Breech......................................................................................................................21

Labour Management Committee.........................................................................................26 Early Labour Sub-Committee ...................................................................................26 Active Labour Sub-Committee..................................................................................26

Other BC Women’s Hospital Initiatives ...............................................................................27 Department of Obstetrics—Cesarean Audit..............................................................27 Scalp Lactate............................................................................................................27

Overall Cesarean Rate at BC Women’s Hospital ................................................................28

Conferences and Workshops..............................................................................................30 Presentations, Articles and Media Coverage ......................................................................31

Challenges, Successes, and Lessons Learned...................................................................33 Appendix (Resources).........................................................................................................37

Table of Contents

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BC Women’s Hospital (BCWH) Cesarean Task Force Members:

Project Sponsor: Dr. Jan Christilaw, MD, FRCSC, MHSc (President, BCWH) Project Manager: Pam O’Sullivan, RN, BSN, MBA (Vice President, Acute Perinatal Program, BCWH)

Project Lead: Lee Saxell, RM, MA Obstetrician Lead: Dr. Dale Steele, MD, FRCSC Research Manager: Susan Pinkney, MA Project Coordinator: Crystal Bewza, BA, BSc

CTF Committee Members: Andrea Aikens, RN, BSN (Birthing Program Coordinator, BCWH) Dena Bloomenthal, MD, FRCSC (Obstetrician, Best Birth Clinic, BCWH) Karen Buhler, MD, CCFP (Head, Dept. of Family Practice, BCWH) Jan Christilaw, MD, FRCSC, MHSc (President, BCWH) Leanne Dahlgren, MD, FRCSC, MHSc (Perinatologist, MFM, BCWH) Kathryn Dewar, PhD (Research Program Manager, Women's Health Research Institute) Ellen Giesbrecht, MD, FRCSC (Head, Dept. of Obstetrics and Gynecology and Interim Senior Medical Director, Acute Perinatal, BCWH) Liz Grose, RM (Registered Midwife, Dept. of Midwifery, BCWH) Alison Humphrey, RM (Registered Midwife, Dept. of Midwifery, BCWH) Georgia Hunt, MD, CCFP (Assistant Head – Quality, Dept. of Family Practice, BCWH) Patti Janssen, PhD (MPH Director, Co-Lead, Maternal Child Health Theme, UBC School of Population and Public Health) Lily Lee, BN, MSN, MPH (Provincial Leader, Surveillance, Perinatal Services BC) Scott MacRae, MN, RN (Clinical Consultant, Women & Family Health, Performance Measurement & Reporting, PHSA) Horacio Osiovich, MD, FRCP (Acting Division Head of Neonatology, BCWH, Clinical Professor of Pediatrics, University of British Columbia) Pam O’Sullivan, RN, BSN, MBA (Vice President, Acute Perinatal Program, BCWH) Lee Saxell, RM, MA (Program Lead, Cesarean Task Force, BCWH) Dale Steele, MD, FRCSC (Obstetrician Lead, Cesarean Task Force, BCWH) Brenda Wagner, MD, FRCSC (Program Medical Director for Fraser Health Women’s Health and Maternal, Infant, Child and Youth Program)

BC Women’s Hospital Cesarean Task Force

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Past CTF Committee Members: Zoe Hodgson, PhD (Director of Research, Women's Health Research Institute) Emmanuelle Paré, MD, MSCE, FRCSC (Perinatologist, MFM, BCWH) Roanne Preston, MD, FRCPC (Head, Dept. of Anesthesia, BCWH) Lehe Spiegelman, RM (Past Acting Assistant Head, Dept. of Midwifery, BCWH) Helen Ting, MD, CCFP (Family Physician, Dept. of Family Practice, BCWH)

Labour Management Committee Members: Kathryn Dewar, PhD (Research Program Manager, Women's Health Research Institute) Ruth Dueckman, RN, BSN, MSc Public Health (Program Manager, Birthing & Surgical Services, Acute Perinatal Program, BCWH) Georgia Hunt, MD, CCFP (Assistant Head – Quality, Dept. of Family Practice, BCWH) Patti Janssen, PhD (MPH Director, Co-Lead, Maternal Child Health Theme, UBC School of Population and Public Health) Patrycja Niesluchowska, MA, CCC (Counselor, Choices in Childbirth, Best Birth Clinic, BCWH) Pam O'Sullivan, RN, BSN, MBA (Vice President, Acute Perinatal Program, BCWH) Emmanuelle Paré, MD, MSCE, FRCSC (Perinatologist, MFM, BCWH) Roanne Preston, MD, FRCPC (Past Head, Dept. of Anesthesia, BCWH) Elizabeth Ryan, RM, BScN (Registered Midwife, Dept. of Midwifery, BCWH) Lee Saxell, RM, MA (Program Lead, Cesarean Task Force, BCWH) Helen Ting, MD, CCFP (Family Physician, Dept. of Family Practice, BCWH) Janet Walker, RN, MSN (Provincial Lead, Education and Quality, Perinatal Services BC)

Best Birth Clinic - Staff: Dale Steele, MD, FRCSC (Obstetrician) Michelle Belanger, MD, FRCSC (Obstetrician) Dena Bloomenthal, MD, FRCSC (Obstetrician) Mark Rosengarten, MD, FRCSC (Obstetrician) Wally Unger, MD, FRCSC (Obstetrician) Kellie Whitehill, MD, FRCSC (Obstetrician) Courtney Chang, MOA

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A number of organizations have been important partners in supporting these initiatives:

Provincial Health Services Authority PHSA has generously provided the funding and support necessary for the implementation and

operation of CTF initiatives. www.phsa.ca

BC Women’s Hospital and Health Centre BCWH has been an essential supporter in the provision of facilities and personnel for the operation of

the Best Birth Clinic, as well as providing supportive expertise in all aspects of project development and operation.

www.bcwomens.ca

Perinatal Services BC (formerly BCPHP) PSBC’s Cesarean Birth Task Force released a comprehensive report in February 2008 which

examined the trend of rising cesarean rates in BC, and offered specific recommendations which were vital in informing the strategies undertaken.

www.perinatalservicesbc.ca

Partners

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Over the past few decades, the rate of cesarean births in BC has risen steadily, a trend echoed in many developed countries. In Canada in 1997, the national cesarean rate was 18.7%. In 2010, cesarean delivery accounted for 26.9% of all births; in the same year, the rate in BC reached 31.8%, the highest of all provinces and territories in Canada.1 Reasons for this increase are multi-factorial, but this increasing trend has raised concerns and questions in many countries, among obstetrical care providers, government bodies, as well as the public. While cesareans are a necessary and at times a lifesaving procedure for both mother and baby, they are not without risk. In an attempt to understand and address this issue, in 2006 the Ministry of Health requested assistance from the BC Perinatal Health Program (now Perinatal Services BC), which led to the formation of the Cesarean Birth Task Force (CBTF). The mandate of the CBTF was to determine whether the cesarean birth rate was appropriate for the province and if not, to suggest steps that could be taken to address it. In January 2008, just prior to the release of the CBTF recommendations, the UBC Collaboration for Maternal and Newborn Health, with support from BCPHP, BC Women’s Hospital (BCWH), PHSA, and the BC Ministry of Health hosted a consensus conference, Cesarean Birth in BC: Trends, Perspectives and Future Strategies. The recommendations of both groups were released in February 2008. In July 2008, BCWH struck the Cesarean Task Force (CTF), an interprofessional committee of obstetricians, anesthetists, pediatricians, midwives, family physicians, nurses and researchers, as well as representatives from Perinatal Services BC. The CTF was directed to implement the recommendations from the CBTF and the consensus conference, and to research best practices for labour management, identify and prioritize key projects, and develop strategies for optimizing the cesarean rate at BCWH. In June 2009, the CTF successfully applied to the PHSA for funding to implement key projects identified for optimizing the cesarean rate. These projects included safely increasing the rate of vaginal birth after cesarean (VBAC), providing options for women with breech presentation at term, avoiding admission to hospital in early labour, and the appropriate management of active labour. Strategies to achieve these objectives were rolled out through a public awareness campaign called the Power to Push (PTP) campaign, which has proven to be an effective and innovative communications strategy (www.powertopush.ca). The PTP campaign has been received positively by the public, with a large and growing online community generated through the use of social media tools. The PTP campaign provides up-to-date information and resources, encouraging women to ‘know their options, take control, and push for the safest and best birth possible.’ The campaign also offers research-based information and resources to maternity care providers across BC. In September 2010, an in-hospital outpatient clinic, the Best Birth Clinic (BBC), was launched. It is located at BCWH and is staffed by experienced obstetricians who provide information and medical consultations and procedures. Women can consult on their suitability for VBAC, external cephalic version (ECV) of a breech baby, as well as suitability for vaginal breech birth. In addition, they can self-refer to the BBC clinical counselor to discuss non-medically indicated cesarean birth, or their previous difficult birth experiences. Early and Active Labour Management sub-committees were also struck with the goal of improving and standardizing labour management practices and protocols.

Executive Summary

1. Canadian Institute for Health Information (CIHI). Health Indicators Interactive Tool. http://www.cihi.ca/CIHI-ext-portal/internet/en/applicationfull/health+system+performance/indicators/health/cihi011641 (Accessed July 2012).

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While many tertiary care hospitals have continued to see an increase in cesarean section rates, BCWH has begun to see a decline; from an all time high of 34.1% in 2010/11, to 31.1% in the 2012/13 fiscal year to date. In this same period, the rate of women safely planning a VBAC increased from 25% to 29%, with a success rate hovering around 75%. The proportion of successful VBACs among all women with at least one previous cesarean delivery has reached 22.4%, the highest rate seen over the past five years. The rate of planned vaginal breech birth has doubled since 2008, with a success rate from 50% to 67%; the overall rate of successful vaginal breech births out of all singleton breech presentations at 36 weeks and greater has risen to 7%. In the two years since the PTP Campaign and the BBC were launched, the clinic has had more than 600 appointments; women have come for consultations from all over the Lower Mainland, as well as Vancouver Island and Northern BC. The PTP website is currently one of the largest consumer maternity care information sites in Canada. This report outlines the development of these initiatives, the process of their implementation, and the results from the first two years of the project. The CTF will be launching several new projects in 2013. We look forward to continuing the CTF work with the goal of sharing the knowledge and new care practices with our BC perinatal colleagues. We hope that this will continue to further optimize the cesarean rate in BC. Jan Christilaw, OB/GYN Pam O’Sullivan, RN, BSN, MBA President, BC Women’s Hospital Vice President, Acute Perinatal Program CTF Project Sponsor CTF Project Manager BC Women’s Hospital BC Women’s Hospital Lee Saxell, RM, MA Dale Steele, OB/GYN CTF Project Lead CTF Obstetrician Lead BC Women’s Hospital BC Women’s Hospital

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The cesarean delivery rate in Canada has risen steadily for the last three decades in all jurisdictions. While an ideal, specific cesarean rate is neither possible nor easily determined (due to differences in populations and resources), many experts agree that the current high rates of cesarean in many developed countries could be lowered without compromising the safety of the mother or baby. There is no universal agreement as to the appropriate cesarean rate, but several national and international bodies have proposed a benchmark. In 1985, the World Health Organization (WHO) concluded the optimal rate to be no greater than 10 – 15%.2 In the U.S., The Healthy People 2010 initiative set a never-achieved target cesarean delivery rate of 15%,3 while the Healthy People 2020 target cesarean rate for low-risk women with term, singleton and vertex presentations is set at 23.9%.4 However, birth trends in the U.S. run counter to these targets — in 1996 the overall cesarean rate was 20.7%, and by 2007 this rate had risen to 32.8%.5 In addition, more than 90% of U.S. women who underwent a primary cesarean will have a repeat cesarean for their subsequent deliveries; many of these women will not be given the option to plan a vaginal birth after cesarean.6 There are some factors that help explain the rising rates: increasing maternal age, increase in pre-pregnancy overweight and obesity (associated with increased risk of gestational hypertension, diabetes, pre-eclampsia, and higher birth weight babies), and higher rates of multiple gestations.7 However, the increase in the number of cesarean deliveries exceeds actual increases in the prevalence of these conditions among pregnant women. In other words, the cesarean rate is rising faster than medical conditions would justify; the rates have increased in every age and BMI category, as well as in singleton pregnancies.8 A number of studies comparing cesarean and vaginal birth outcomes among low-risk women suggest that vaginal birth is preferable for maternal health. Not only does cesarean surgery increase maternal morbidity in the index pregnancy, studies have shown it has implications for future pregnancies. Adhesions of the uterus, bowel, and bladder can result in trauma at surgery, whereas abnormal placentation (placenta previa, accreta, increta, percreta) and uterine rupture can be catastrophic for both the mother and her baby.9 In addition, large studies have shown a 2 to 3-fold increase in various neonatal respiratory morbidities following elective cesarean compared to vaginal delivery, with resultant increase in need for admission to an NICU.10, 11 In addition to concerns for maternal and neonatal health, economic issues are important to consider. Canadian Institute for Health Information (CIHI) estimates the average cost of cesarean delivery to be significantly higher, and the length of hospital stay longer, than vaginal birth.12 Thus, a rising cesarean birth rate puts increasing economic and human resource demands on our already challenged health care system.

Background on Rising Cesarean Rates

2. World Health Organization. Appropriate technology for birth. Lancet 1985; 2: p. 436-7. 3. Healthy People 2010. Healthy People 2010, Volume II: Objectives for Improving Health (Focus Area 16-9). Available at: http://www.healthypeople.gov/2010/Document/HTML/Volume2/16MICH.htm#_Toc494699664 (Accessed September 2012). 4. Healthy People 2020. Maternal, Infant, and Child Health Objectives. Available at: www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=26. (Accessed April 2012). 5. Guise J-M et al. Vaginal Birth After Cesarean: New Insights. Evidence Report/Technology Assessment No.191. AHRQ Publication No. 10-E001. Rockville, MD: Agency for Healthcare Research and Quality, March 2010. http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf 6. Ibid. 7. Weiss JL, M.F., Emig D, Ball RH, Nyberg DA, Comstock CH, Saade G, Eddleman K, Carter SM, Craigo SD, Carr SR, D'Alton ME. Obestity, obstetric complications and cesarean delivery rate - A population-based screening study. Am J Obstet Gynecol 2004; 190: p. 1091-7. 8. Ehrenberg HM, D.C., Catalano P, Mercer BM. The influences of obesity and diabetes on the risk of caesarean delivery. Am J Obstet Gynecol 2004; 191: p. 969-74. 9. Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol 2011; 205: p. S2-10. 10. Hansen, A.K., et al., Elective caesarean section and respiratory morbidity in the term and near-term neonate. Acta Obstet Gynecol Scand 2007; 86 (4): p. 389-94. 11. Morrison, J.J., J.M. Rennie, and P.J. Milton. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102(2): p. 101-6. 12. CIHI. Giving Birth in Canada: the Costs. 2006. https://secure.cihi.ca/free_products/Costs_Report_06_Eng.pdf (Accessed July 2012).

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13. Spong CY, Berghella V, Wenstrom, KD, et al. Preventing the First Cesarean Delivery. Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists Workshop. Obtset Gynecol 2012; 120 (5): p. 1181-93. 14. Chaillet N, Dumont, A. Evidence based strategies for reducing cesarean section rates: a Meta-analysis. Birth 2007; 34 (1): p. 53-64.

From a population health perspective, the best way to lower the cesarean rate is to avoid the first or primary cesarean delivery. While the dramatic rise of cesarean is largely due to the primary cesarean birth, it is also the result of a decline in planned vaginal birth after cesarean. In order to lower the primary cesarean rate, there must be a focus on the management of early and active labour, the timely diagnosis and management of labour dystocia, and the appropriate management of labour pain. In November 2012, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists convened a workshop to address the concept of preventing the first cesarean delivery. Key points were identified to assist with the reduction in cesarean rates including limiting the induction of labour primarily for medical indications and after 39 weeks of pregnancy, adherence to appropriate definitions of failed induction of labour, and allowing adequate time for normal latent and active phases of labour as long as maternal and fetal conditions permit. In addition they state, “Given the progressively declining use, it is critical that training and experience in operative vaginal delivery are facilitated and encouraged.”13 They also suggest that when discussing the first cesarean delivery, counseling should include its effect on future reproductive health. Evidence suggests that significant reductions in cesarean rates can be achieved through multi-faceted improvement strategies. A meta-analysis of trials conducted between 1990 to 2005 on the effectiveness and barriers to the implementation of strategies designed to lower the cesarean rate (as well as their impact on morbidity and mortality) was published in 2007.14 The authors concluded that cesarean rates could be safely reduced through interventions that involved care providers and enabled them to analyze and change their practice. Multi-faceted strategies which incorporate peer review, chart audit and performance feedback and identify the barriers to change had the most effect. To be successful, strategies must have the support of hospital administration and commitment of all team members. As the LEAN process has demonstrated at BC Women’s Hospital (BCWH) , sustainable change requires the commitment of team members and provider “buy-in”, clear leadership, infrastructure support, and continuous monitoring of outcomes. Synthesis, reporting and dissemination of data and outcomes are crucial to the success of any improvement strategy. In 1995, BCWH undertook an improvement strategy, a project called “First Births”, modeled on the Institute for Healthcare Improvement (IHI) principles to reduce cesarean rates for primiparous women. Evidence-based, key factors for change were implemented, including eliminating non-medical inductions of labour, reducing the use of electronic fetal monitoring (EFM), in particular the test “admission strip” EFM, decreasing the admission of women in the latent phase of labour and the appropriate management of pain. A collaborative team determined guidelines and policy and conducted ongoing peer review. An initial decrease of cesarean sections from 22% to 18% was achieved and inappropriate inductions were also reduced. Improvement in the cesarean rate did not last for a variety of reasons, including lack of hospital buy-in, both at administrative and care provider levels. Today, the quality improvement program to reduce the number of non-medical inductions of labour continues to be successful.

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Over the past few decades, the rate of cesarean births in the developed world has risen steadily. In Canada in 1997, the national cesarean rate was 18.7%. In 2010, cesarean delivery accounted for 26.9% of all births; in the same year, the rate in BC reached 31.8%, the highest of all provinces and territories in Canada.15 In an attempt to understand and address this issue, in 2006 the Ministry of Health requested assistance from the BC Perinatal Health Program (BCPHP, now Perinatal Services BC), which led to the formation of the Cesarean Birth Task Force (CBTF). The mandate of the CBTF was to determine whether the cesarean birth rate was appropriate for the province and if not, to suggest steps that could be taken to address it. In February 2008, the BCPHP released the Cesarean Birth Task Force Report (available here). This in-depth report reviewed the evidence and identified key projects and strategies for best practices in labour management and cesarean optimization for the province. In January 2008, just prior to the release of the CBTF recommendations, the UBC Collaboration for Maternal and Newborn Health, with support from BCPHP, BCWH, PHSA, and the BC Ministry of Health hosted a consensus conference, Cesarean Birth in BC: Trends, Perspectives and Future Strategies. The conference was adjudicated by a panel of experts who listened, over two days, to expert presentations based on evidence-based research and questioned and dialogued with the presenters. At the close of the consensus conference, the panel produced the Cesarean Birth in BC Consensus Panel Statement, which identified key projects and made recommendations on best practices in labour management and optimizing the cesarean rate. These recommendations were directed at primary care providers, nurses, government bodies, hospital administration, as well as childbirth education strategies directed at the public. In July 2008, BCWH initiated the Cesarean Task Force (CTF), an interprofessional committee of obstetricians, anesthetists, pediatricians, midwives, family physicians, nurses, researchers, as well as representatives from Perinatal Services BC (PSBC). The CTF was directed to implement the recommendations from the Cesarean Birth Task Force Report and the Cesarean Birth in BC Consensus Panel Statement (link here). The committee was also directed to prioritize key projects, implement best practices projects for early and active labour management, and develop strategies for optimizing the cesarean rate. In June 2009, the CTF successfully applied to PHSA for innovative project initiative funding, in order to implement the key projects identified for optimizing the cesarean rate in BC. The CTF Terms of Reference are:

Review and assess the feasibility of implementing the recommendations of the BCPHP Cesarean Birth

Task Force Report

Review and assess the feasibility of implementing the recommendations made by the Cesarean Birth in BC Consensus Panel

Identify and prioritize key projects to achieve the stated recommendations

Cesarean Birth in BC

15. CIHI. Health Indicators Interactive Tool.

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Communicate with appropriate committee structures such as the BCWH Patient Volume Management, Acute Perinatal Leadership, Quality and Safety, and Best Practice Committees

Interface with the PHSA ImProve and Best Practice sub-committee

Support the BCWH Acute Perinatal Planning committee, to set direction for identified priorities by linking with departments, i.e; medical, midwifery, nursing, PSBC.

Facilitate and monitor the evaluation and sustainability of the strategies developed.

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The CTF identified initial key projects that were most likely to promote best practices in childbirth while lowering the cesarean birth rate. The Cesarean Birth Task Force Report and the Cesarean Birth in BC Consensus Panel Statement were carefully reviewed and classified according to five factors: evidence, potential impact, resources required, simplicity vs. complexity to address the issues/changes, and timelines for results. This process resulted in the prioritization of several projects:

Strategies designed to safely increasing the rate of vaginal birth after cesarean (VBAC)

Services to support women with breech presentations at term; specifically external cephalic version (ECV) and vaginal breech birth options

The appropriate management of early and active labour

The appropriate management of pain relief in labour

The appropriate management of labour dystocia

These strategies were rolled out as part of two linked key initiatives: the Power to Push Campaign directed at the public, and the obstetrician-led Best Birth Clinic at BCWH. In addition, the CTF appointed two sub-committees: The Early Labour Management and Active Labour Management committees. These two committees developed algorithms for early labour (included as Appendix K), active labour (Appendix L), as well as an early labour patient information handout, When Labour Starts (Appendix J), which is handed out to women in the assessment room at BCWH. This handout has been translated into Simplified Chinese, Traditional Chinese, Punjabi and Vietnamese. This handout and all other resources developed by the CTF are available for download at the Power to Push website (click here).

Project Direction and Branding In order to maximize the efficacy of the planned initiatives, the CTF engaged the services of a professional creative agency, Signals, (www.signals.ca) to help the committee focus our direction and launch a website and campaign. A series of visioning meetings were held with the Signals team; all members of the CTF committee attended, ensuring input from obstetricians, anesthetists, pediatricians, midwives, family physicians, nurses, and researchers. The team reached consensus on the objectives, target audiences, and information direction. A vision evolved of an accessible consultant obstetrician clinic for women wanting to discuss vaginal birth after cesarean, ECV, vaginal breech birth, and cesarean section for non-medical indications. After our visioning sessions, Signals presented the team with options for the naming of the clinic and campaign, or the “branding” of our campaign. With debate and by consensus, the CTF members chose the Power to Push Campaign and Best Birth Clinic as our brands. Both names have had a high level of impact and visibility, particularly with the public. The visioning exercises also produced a guiding document that outlined the key messages of the campaign, focusing on the needs of childbearing women. This document proved very useful and was helpful in guiding the website and information handouts. The Brand DNA on the next page summarized the campaign focus.

Cesarean Task Force Project Implementation

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The next steps were to select logos, graphic design themes and elements, and map out the website structure for both the public and health care professionals. The final steps were to develop information brochures for women and health care professionals, as well as posters to use for in-hospital promotion.

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The Power to Push (PTP) Campaign was created as the vehicle for the public education initiative identified by the CTF as a key strategy. The goal of the campaign is to provide up-to-date resources for childbearing women and their families throughout BC, encouraging them to know their options, advocate for their choices, and push for the safest and best birth possible. The goal was to develop and present women with evidence-based information to counter myths and misperceptions about childbirth choices, and to create an on-line community of support for women seeking information and support for their birth options. The tagline for the campaign is “Know your options, take control”. The PTP website also offers evidence-based information, resources, and standardized consent documents for maternity care providers in the province (available here). Several elements were then developed as part of the campaign. These include a website, videos hosted both on the website and on a dedicated YouTube page, social media communities on Facebook and Twitter, and a series of brochures translated into multiple languages.

Power to Push Website The campaign website – www.powertopush.ca – has an attractive and dynamic design, and contains information for women and their families as well as for medical professionals. Different sections on the website include information on:

the Best Birth Clinic, its services and eligibility requirements for appointments;

information on different birth options available to women, including different types of care provider;

common misconceptions about birth;

quizzes on birth knowledge;

a resource section with downloadable documents, including referral forms, informed consent forms, handouts and patient information booklets.

The website contains a blog-based news and updates page, and space for users to share their own stories about birth. For audience members and their family members who don’t speak English, a selection of information on the website has been translated into the four other languages most frequently used by women attending BCWH (Mandarin, Cantonese, Vietnamese, and Punjabi). The PTP campaign filmed interviews with 20 women who talked about their own birth experiences. In the videos, women talk about their different perspectives and experiences with cesarean birth, VBAC, ‘normal’ birth, and how they made decisions and informed choices. The videos are intended to help women ‘meet’ and hear from other women who have navigated the choices they may be facing. Many women report that decision-making is made more difficult if they do not know any other women who have made the choices they are considering.

The Power to Push Campaign

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Brochures With the involvement of Signals, attractive and informative patient brochures were developed about the services offered at the Best Birth Clinic (BBC) and by the Power to Push Campaign, and include brochures on:

The Best Birth Clinic The Power to Push Campaign Vaginal Birth After Cesarean External Cephalic Version: Turning the Breech Baby Vaginal Breech Birth

A one-page pamphlet was also developed specifically for distribution to women upon discharge from hospital following their cesarean delivery. This pamphlet presents simple and clear information on the options that may be available to women in their next pregnancies, including the possibility of vaginal birth after cesarean. Posters and handouts have also been developed and distributed to increase awareness of the BBC Choices in Childbirth Clinic. The BBC brochure is translated into Mandarin, Cantonese, Vietnamese and Punjabi. When the PTP campaign and BBC were launched, bundles of each brochure were distributed to the clinical offices of all maternity care providers at BCWH in order to expand awareness of birth options for women in Vancouver. (Brochures are included in Appendix B; PDFs of all brochures are available here).

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Facebook and Twitter In order to expand the PTP campaign’s reach and to engage women in dialogue about birth options, the campaign makes frequent use of popular social networking sites. There are ‘Power to Push Campaign’ accounts on both Facebook and Twitter, which are managed and updated daily by a social media specialist. Through these networks, the campaign has been successful in creating and engaging a locally-based community of women in conversation on birth-related topics and issues in the Lower Mainland. In addition, this community provides vocal support and encouragement for individuals who post about their own pregnancy, birth and new motherhood experiences. These social media communities are effective platforms for the distribution of information, current news and resources.

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Effectiveness of the Power to Push Campaign The PTP Facebook community (www.facebook.com/powertopush) now has more than 1000 fans, with conversations, sharing of experiences and links to other sites occurring among followers daily. The PTP community has become one of the most-followed birth-related Facebook accounts in BC. Resources such as the Patient Information Booklet on VBAC and Repeat Cesarean, and the Early Labour Patient Handout, have been effectively distributed directly to women and their families via the Facebook page, with posted resources often being re-shared by other birth-related accounts and businesses across Canada and in the United States. The PTP Twitter (www.twitter.com/powertopush) account has gained an average of 1 follower a day, and is currently followed by more than 1300 Twitter users, making it one of BC’s most followed birth-related Twitter accounts. PTP tweets are re-tweeted an average of 5 times a week, and the Campaign has approximately 10,000 impressions a week (or number of Twitter accounts who may see our content). The PTP campaign also created the #birthbc hashtag that is now widely used to discuss and promote birth related news, events, research and information, which

has been used over 260 times this year. The PTP campaign has also connected to the #birthgenius

community in the United States and participates in their monthly Twitter chat which discusses birth and the web. According to Topsy, an online tool that searches content on Twitter and the internet, "powertopush" (indicating the website or Twitter handle) has been mentioned more than 650 times online since the campaign’s launch, averaging once a day since September 2010. The PTP campaign has also been mentioned on several high-ranking pregnancy and birth blogs, Facebook Pages, and e-newsletters, including: The Unnecesarean (+16,000 fans), One World Birth (~5,500 fans), Childbirth Connection (~5,000 fans), Ontario Midwives (~2,500 fans), and Prenatal Coach (~1,100 fans). During Social Media Week in Toronto in February 2012, members of the Signals communications firm spoke about the campaign’s outreach and community- building in a talk entitled “The Power to Push Campaign: From conception to birth of an online community”.

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The Best Birth Clinic (BBC) is located in the Diagnostic Ambulatory Program area of BCWH. The BBC is staffed by experienced obstetricians who support women’s choices in maternity care and childbirth. The clinic offers information, medical consultations and procedures for pregnant women deciding whether vaginal birth or cesarean birth would be best for them. The BBC makes appointments for women who have had a previous cesarean birth and are currently pregnant again; women who are over 36 weeks pregnant with a baby presenting breech; and pregnant women who are considering cesarean birth for non-medical reasons. The BBC was launched in September 2010. By September 2012, the clinic has had more than 600 appointments; 47% of the appointments were for VBAC and repeat cesarean consultations, 41% of appointments were for ECV procedures, and 12% were for consultations regarding vaginal breech birth. Referrals For an appointment at the BBC, women are normally referred to the BBC by their maternity care provider and may occasionally self-refer. Women have attended the clinic from Vancouver Island, the Sunshine Coast and the Fraser Valley in cases where options available through the Best Birth Clinic were unavailable in their home area. Maternity care providers are able to refer patients by downloading a referral form from the PTP website. Consultation reports and copies of signed consent forms (when applicable) are faxed back to the referring care

provider’s office. In cases where ongoing care or appointments are required (such as for planned vaginal breech birth), continuing communication is established between obstetricians at the BBC and the patients’ primary care provider. (The Best Birth Clinic referral form is included in Appendix C; PDF available here). When patients attending the BBC elect to book a cesarean birth as their preferred mode of delivery, care providers are given the option of having the BBC book the cesarean for them (with the obstetrician on-call during the next available slot), or they can refer their patient to an obstetrician of their own choosing. Since the BBC’s launch, referrals have largely come from midwives, family physicians and obstetricians practicing at BCWH. The majority of care provider referrals came from the Vancouver area, while approximately one-third of referrals originated from other areas in the Lower Mainland and the province. Midwives made the majority of referrals to the clinic (57%), with family physicians making just under a third (32%) and obstetricians making 11% of referrals. A few women also self-referred to the BBC, almost exclusively to discuss the option of vaginal birth after cesarean (VBAC).

The Best Birth Clinic

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BBC Staffing The BBC is staffed by a team of experienced obstetricians with privileges at BCWH, who are paid a sessional fee to see patients in the clinic. The obstetricians share a supportive philosophy toward women’s choice in maternity care and birth options, and tend to be opinion leaders within the Department of Obstetrics. The BBC employs a part-time Medical Office Assistant to coordinate referrals, appointments, bookings and documentation. The MOA is also responsible for keeping a database with information about the consultations, procedures, choices and outcomes. Physical space for consultation appointments as well as external cephalic version (ECV) procedures was required in BCWH’s already over-crowded ambulatory clinic. The opening of the BBC increased the workload of several departments, including ultrasound (scans are needed prior to and during ECV procedures) and nursing (a nurse is present during the ECV procedure). The operation of the BBC relies heavily on the cooperative support of the Diagnostic Ambulatory Program, both in assisting with staffing and physical space.

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The Choices in Childbirth Clinic The BBC offers appointments with a counselor through the Choices in Childbirth clinic. The clinic takes place two days a week at BCWH, and employs a Registered Clinical Counselor experienced in issues related to reproductive health. Women considering a cesarean birth for non-medical reasons can be referred to the clinic to discuss their concerns, as well as the risks and benefits of cesarean.i Balanced, up-to-date information is provided on both cesarean birth and vaginal birth. Beginning in January 2012, the Choices in Childbirth Clinic began offering counseling appointments for women who have had a difficult birth experience. Women can self-refer to the counselor for help processing their feelings about their difficult birth experience. Women requiring more than counseling and debriefing are referred to BCWH Reproductive Mental Health Program. Between January and November 2012, the Choices in Childbirth Clinic saw 95 women; 80 women for counseling regarding cesarean for non-medical reasons and 15 women to discuss their difficult birth experiences. Of the women counseled regarding cesarean for non-medical reasons, 80% had not given birth before. The most common factors women reported as influencing their decisions about mode of delivery were ‘fear or anxiety about complications’ (61%), and ‘fear or anxiety about pain’ (55%). Only 13% of women listed ‘convenience’ as an influence on their decision. When women were asked for the primary factor behind their decision about mode of delivery, the most common primary factor cited (36%) was ’safety for myself’ or ‘best health for myself’. Half of the women (50%) reported that prior to their appointment they felt they still required more information in order to make their decision on mode of delivery. Almost all women (95%) found the appointment informative and helpful in making their decision, regardless of the mode of delivery they chose. Following their appointments to discuss cesarean for non-medical reasons, 82% of women chose to proceed

with a planned cesarean birth, and 18% chose to plan a vaginal birth. Among those women whose birth outcomes are available (78 of 80 women), 77% had a booked cesarean delivery as planned, while 23% chose to proceed with a vaginal birth (including 5% of those who had planned a cesarean but chose to continue with labour when it occurred). Of those who had a trial of labour, 72% had a successful vaginal birth.

i Currently, BC Women’s discourages women from booking an elective cesarean birth for a non-medical reason without first attending a counseling visit to ensure they have accurate information about the procedure.

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Vaginal Birth After Cesarean (VBAC) Currently at BCWH, a large proportion of cesarean births occur in the elective repeat category; women who have had a previous cesarean and opt to have a repeat cesarean for their subsequent births. Some women still believe the old adage “once a cesarean, always a cesarean,” but for many women, Vaginal Birth After Cesarean (VBAC) can be a safe option for both the mother and her baby.16 In the 1980’s and ‘90’s, the option of VBAC was widely regarded as a safe and reasonable choice across Canada and the U.S.17,18,19 However, beginning in the late 1990’s, VBAC rates began to steadily decline, the result of emerging evidence that suggested the risk of uterine rupture was higher than previously believed. A study published in 2001 by Lydon-Rochelle et al. showed a higher rate of uterine rupture when labour was induced with prostaglandins; the rupture rate for women who were not induced with prostaglandin was found to be a similar low rate to that previously known.20 Despite the discontinuation of prostaglandin for VBAC induction of labour, as well as subsequent studies which supported the safety of VBAC,21 liability concerns escalated along with increasingly restrictive professional practice guidelines.22 As the VBAC rate continued to decline, concerns began to arise about the concurrently escalating cesarean rate and its attendant risks, as well as the increasing restrictions on informed choice for women with a prior cesarean. As a result of this growing concern, in 2010 the US National Institute of Health (NIH) undertook a comprehensive review of all existing evidence on VBAC and repeat cesarean. The NIH report found that in well-selected women, VBAC is a safe choice for both the woman and her baby.23 While it is not risk-free, the level of risk associated with VBAC is possibly lower than the level of risk associated with multiple cesareans. The literature also consistently demonstrates that between 70-80% of women who try will be successful at achieving VBAC.24 The planned VBAC rate at BCWH was as high as 40% in the 1990’s, with a 75% success rate of vaginal birth. However, by 2006, the attempted VBAC rate at BC Women’s had fallen to 21%. The CTF identified safely increasing the planned VBAC rate at BCWH to be an effective means of optimizing the cesarean rate, as well as an important aspect of increasing options of giving birth for women. In order to promote VBAC for women and to decrease the proportion of repeat cesareans, the BBC offers women 45 minute consultation appointments with an obstetrician to discuss the benefits and risks of both VBAC and repeat cesarean, including individualized risk-assessments and discussions.

16. Guise, J-M. et al. Vaginal Birth After Cesarean: New Insights. Evidence Report/Technology Assessment No.191. AHRQ Publication No. 10-E001. Rockville, MD: Agency for Healthcare Research and Quality, March 2010. http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf 17. National Institutes of Health. Cesarean childbirth. Washington, DC: National Institutes of Health, 1981. NIH publication no. 82–2067. 18. Flamm BL, Goings JR, Liu Y, Wolde-Tsadik G. Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study. Obstet Gynecol 1994; 83(6): p.927–932. 19. ACOG Committee Opinion No. 64: guidelines for vaginal delivery after a cesarean birth American College of Obstetricians and Gynecologists. Washington, DC; 1988. 20. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001; 345(1): p. 3–8 21. Landon, M., et al., Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. New Engl J Med 2004; 351: p. 2581-9. 22. Guise, J-M. et al., p. 11. 23. Ibid., p. 2-7. 24. Ibid.

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Up-to-date, consistent and evidence-based information are key elements of the BBC. The CTF has developed a number of VBAC educational tools and handouts to assist women in their decision-making, as well as a standardized informed consent form for women and their care providers. In the BCWH discharge from hospital package, all women receive an information card on VBAC, in order to raise their awareness of the possibility of vaginal births for their future deliveries. (VBAC Rack Card included as Appendix B; Informed Consent included as Appendix D, PDF available here). The CTF also prioritized the development of an up-to-date, comprehensive, evidence-based booklet to assist women with the decision-making process. Current literature comparing VBAC and repeat cesarean risks were reviewed, as was the literature on the communication of risk. The 2010 National Institutes of Health Consensus Development Conference on VBAC had recently taken place and its Conference Statement (‘Vaginal Birth After Cesarean: New Insights’) had just been published. These documents offered the most complete and up-to-date data on the risks and benefits of VBAC and repeat cesarean. (NIH Consensus Statement on VBAC available here).

After an intensive multidisciplinary process involving many drafts, the CTF published its patient information booklet entitled “Vaginal Birth After Cesarean and Repeat Cesarean Birth.” The booklet is a decision-making tool that presents evidence, risk data and other information in a clear and easy-to-understand format. Risks and benefits are presented in visually appealing formats that make them easier to comprehend. The booklet also includes a comparison of the risks associated with each choice based on PSBC outcome data from the past decade in BC, which is more relevant to women than statistics often taken from populations in the U.S. where access to healthcare varies widely. This resource is freely available to women and care providers on the PTP website, and copies of the patient information booklet have been distributed to maternity care provider offices throughout Vancouver. (Included as Appendix E; PDF available here). The booklet has been very well received, requiring several re-printings since its initial publication, and has been requested for use by maternity care clinics across Canada, as well organizations such as the Midwives’ Association of Washington State. Several researchers have also requested permission to adapt the booklet for use in their own materials, including the Association of Ontario Midwives and the Oregon Health & Science University. The booklet has also been cited in an article published in the December 2012 issue of Clinical Obstetrics and Gynecology.25

25. Fineberg AE, Tilton ZA. “VBAC in the Trenches: a Community Perspective.” Clinical Obstetrics & Gynecology Dec 2012; 55(4): p. 997-1004.

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VBAC Outcomes ‐ Best Birth Clinic From the BBC’s launch in September 2010 through September 2012, a total of 281 women have attended the clinic to discuss their options regarding VBAC and repeat cesarean. Following their appointment 61% chose to plan a trial of labour, 9% chose to plan a repeat cesarean, and 30% were undecided. Of the 276 women seen for VBAC and repeat cesarean counseling who had delivered before the end of Sept. 2012, 66% went on to have a trial of labour, 26% had a planned repeat cesarean prior to labour, and 8% had a planned cesarean during labour. Of those women who had a trial of labour, 112 were successful (61% of those attempting, and 40.6% overall). The success rate for attempted VBACs in the population of women who attended the BBC is slightly lower than the overall success rate for BCWH as a whole. This is likely due to the fact that many of the more complex clinical cases are referred to the BBC for the in-depth consult appointments available there, whereas many of the more straightforward cases may not be referred to the BBC at all.

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VBAC Outcomes ‐ BC Women’s Hospital Overall The proportion of women with a previous cesarean delivery who attempted a vaginal birth after cesarean

(VBAC) at BCWH was higher than 40% in the fiscal year 1999-00. However, in keeping with a trend seen across North America that rate declined in the following years, reaching a low of 21.1% in 2006-07. The rate did increase slightly but has remained in the range of 25% since 2008. However, the 2012-13 fiscal year (to date) has seen the first noticeable improvement, with the proportion of women attempting a VBAC reaching 29% with a success rate of 77%. This has meant the number of successful VBACs among all women with at least one previous cesarean delivery has reached 22.4%, the highest rate seen over the past five years. Although this most recent year demonstrates an improvement, further efforts are being made to continue to safely increase the VBAC rate.

Doula Support for Planned VBAC A doula is a trained childbirth attendant (not a friend or family member) who provides continuous emotional and physical support to women and their families during childbirth. Doulas do not perform medical tasks that a nurse, midwife or doctor normally provide. Instead, their role includes providing information and encouragement, being present during the period of early labour, offering methods of non-medical pain relief, and providing a supportive presence to the woman throughout the entire labour and birth. The use of continuous doula support during labour and birth has been consistently shown to have beneficial effects on outcomes. A Cochrane Review published in 2011 reviewed all existing evidence, and found that

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doula support during labour and birth lowered the likelihood of primary cesarean birth and increased the likelihood of shorter labour and spontaneous vaginal birth, as well as greatly increasing satisfaction with the birth experience. The authors of the review concluded that “continuous support during labour has clinically meaningful benefi ts for women and infants and no known harm. All women should have support throughout labour and birth.”26 More recent research in the U.S. has found that amongst Medicaid recipients, doula support during childbirth was associated with a 40% reduction in cesarean deliveries (after controlling for clinical complications and for maternal age, race, or ethnicity).27 Currently, doula support for labour and birth is not covered under provincial health care insurance, and families who choose to have doula support must pay fees privately. Fees charged by doulas in BC can range from several hundred dollars to upwards of $1000.28 These costs are often prohibitive, making doula support inaccessible for many families. Several programs do exist in BC which provide doula support free of charge to their clients. A notable example is the PHSA-supported South Community Birth Program (SCBP), where all clients are offered support by an experienced doula. Research into SCBP’s outcomes found that program participants had a much shorter length of hospital stay, were less likely to have a cesarean delivery than those in the matched control group, and those with a previous cesarean delivery were more likely to plan a vaginal birth.29 The SCBP doulas often also translate for their clients during the labour and birth, as the 42 doulas speak 24 different languages as well as English. In light of the strong evidence of the benefits of doula support, the CTF explored ways to increase the number of women benefiting from doula support during their birth at BCWH. Randomized Controlled Trial on VBAC and Doula Support In order to help women planning a VBAC at BCWH to have the greatest chance for success, as well as to contribute to research and knowledge on effective ways to improve outcomes, the BBC is participating in a clinical study on doula support for women planning a VBAC. This randomized controlled trial (RCT), conducted in partnership with the University of British Columbia (UBC), offers 50% of the women enrolled in the study doula support during their labour and birth. All women planning to give birth at BCWH who have had a previous cesarean and would like to plan for a vaginal birth are eligible to participate in the study. Those randomized to the doula support group are assigned a doula who meets them once prior to labour, provides skilled support throughout their labour and birth and meets with them again once after the baby is born. The VBAC trial doulas speak several languages in addition to English. Those participants randomized to the standard care group receive the same care they would normally and do not receive doula support. Following their deliveries, all participants are asked to answer a short questionnaire about their experiences, and data on their birth outcomes is being collected. The RCT was launched in early 2011. To date 49 women have participated in the study. Upon completion, findings will be submitted for publication in peer-reviewed journals.

26. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database Syst Rev 2011, Issue 2. Art. No.: CD003766. Available online at: http://childbirthconnection.org/pdf.asp?PDFDownload=continuous_support 27. Katy Backes Kozhimannil, Rachel R. Hardeman, Laura B. Attanasio, Cori Blauer-Peterson, and Michelle O’Brien. Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries. American Journal of Public Health. 2013. e-View Ahead of Print. Available online at: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301201 Accessed Feb. 25, 2013. 28. Doula Services Association of BC. http://www.bcdoulas.org/about-doulas/birth-doula-faqs (Accessed Feb. 2013). 29. Harris S, Janssen P, Saxell L, Carty E, MacRae G, and Petersen K. Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. CMAJ Nov. 2012; 184: p. 1885-1892.

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NEW INITIATIVES ‐ 2013 VBAC Survey The CTF launched a survey in February 2013 surveying all maternity care providers at BCWH in order to gather in-depth information on their current beliefs and practice surrounding VBAC. Survey questions ask providers about their attitudes toward the safety of VBAC and repeat cesarean, how they offer options to their patients, and their use of information and resources. The data gathered from this survey will be used to refine the elements of the VBAC bundle, as described below. The VBAC Project at BCWH A further initiative currently underway is the implementation of a ‘VBAC bundle’ for use by care providers at BCWH. A bundle is “a small set of evidence-based interventions for a defined patient population and care setting.”30 The VBAC Project will develop and implement a bundle consisting of a collection of tools that are used to promote informed choice about VBAC. When all elements of a bundle are used in conjunction by care providers, evidence has shown that the group of interventions executed together results in better outcomes than if they were implemented individually.31 The elements included as part of the bundle are:

Informing women about VBAC eligibility for future births at the time of their first cesarean birth. Discussing VBAC with women at the first prenatal visit and at subsequent visits as needed. Actively supporting VBAC for the appropriate women (recommending rather than just offering VBAC

for appropriate candidates): a) providing women with the BCWH/BBC VBAC and Planned Repeat Cesarean Birth patient information booklet. b) discussing and reviewing the decision for elective repeat cesarean birth for appropriate women

presenting in labour prior to ECS date. Using the BCWH/BBC standardized Birth After Cesarean: Consent Form and ensuring it is in the

patients chart.

Pending the VBAC Survey results, the CTF is planning to roll out the VBAC bundle to all maternity care providers at BCWH as part of a research study. Current attitudes towards VBAC and frequency of use of each element of the bundle will be measured via self-reporting through an online survey distributed to all maternity care providers at the hospital. The bundle will then be launched via all Departments at the hospital, as well as through presentation at Grand Rounds and through an education plan. Final evaluation will take place 3 years after the VBAC Project launch, and will audit the frequency of use of each element of the bundle by both individual care providers and by professional group of practitioner, based on careful chart audit. The survey will also be re-administered to measure changes in frequency of use of bundle elements, and of care provider attitudes towards VBAC. In addition, evaluation will be carried out to determine whether changes have occurred in rates of planned and successful VBAC, as well as changes in clinic outcomes and the overall cesarean rate.

30. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.IHI.org) 31. IHI. Bundle up for safety. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ImprovementStories/BundleUpforSafety.htm.

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Breech Currently, approximately 3-4% of all deliveries at BCWH are breech presentation at term (head-up, rather than head-down in the uterus), and the vast majority are delivered by cesarean birth. For women who are discovered to be carrying a breech baby after the 36th week of pregnancy or later, the BBC offers several options to help them make choices about their delivery.

External Cephalic Version (ECV) External Cephalic Version, or ECV, is a procedure in which an obstetrician applies pressure with his/her hands on the mother’s abdomen to lift the baby out of the pelvis and turn it to the cephalic (head-down) position in the uterus. ECV can be an effective method of reducing breech presentation at term, and evidence shows that ECV can be successful in converting the baby to cephalic approximately 30-50% of the time.32 It has been estimated that one cesarean delivery can be avoided for every four ECVs attempted.33 If an ECV is successful, and the baby does not revert to the breech position following the procedure, a woman’s chances of having a normal vaginal birth are about the same as a woman whose baby remains cephalic throughout pregnancy. The BBC offers a dedicated ECV clinic staffed by obstetricians experienced in the procedure. The ECV clinic is located in a procedure room near the operating (OR) area of BCWH, with nursing and ultrasound support provided by the hospital. The clinic has been designed to streamline ECV procedures and to increase the availability of appointments. ECV appointments also include ultrasound scans to provide up-to-date detailed information on the size and exact position of the baby, to assist the obstetrician performing the procedure, as well as helping to identify women who would not be good candidates for the procedure before it is initiated. In addition, hospital protocols for the procedure were examined and updated to ensure they were in line with the most recent evidence, and several aspects (such as use of IV and pre- and post-procedure monitoring time) were revised. Women confirmed as having a breech baby during or after their 36th week of pregnancy are able to make consultation appointments to ask questions and receive information on the procedure and its risks and benefits; women can also make appointments to have a consultation and the ECV procedure performed in a single visit. Informational materials about ECV have been developed, including a standardized informed consent form (Appendix G; PDF available here). There is also a handout that is distributed to women following the procedure to ensure they are aware of possible warning signs to be aware of, with easy-to-read information about what to do and who to call if they have concerns following the ECV (Appendix H; PDF available here). The handout contains a tracking sheet to help women count their baby’s kicks in the hours following the procedure. The clinic has also developed a detailed data tracking sheet that records all information from each ECV to enable future analysis of factors that may contribute to or impede the success of the procedure. (Appendix F; PDF available here).

32. Hofmeyr, GJ, Kulier, R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2012, Issue 10. Art. No.: CD000083. DOI: 10.1002/14651858.CD000083.pub2. 33. Varma, R., D. Horwell, and S. Burrell. The impact of external cephalic version at term in a district general hospital. 29th British Congress of Obstetrics and Gynaecology. 2001. Birmingham, UK.

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In addition, a brochure explaining the procedure to women who have a breech baby is available for care providers to distribute to their patients. The consent form, brochure, handout and data tracking sheet are all available to women and care providers on the PTP website. Between Sept. 2010 and the end of Sept. 2012, the BBC scheduled 251 appointments for ECV procedures. 219 procedures were performed; ECVs were not carried out at appointments for a total of 32 women, due either to babies having spontaneously turned cephalic prior to the appointment, patients being unsuitable candidates for clinical reasons, or patients changing their minds prior to the start of the procedure. ECV Outcomes ‐ Best Birth Clinic Of the 219 procedures performed, the majority (71%) were on women who had not given birth before (primips), and 29% were on women who had had at least one previous delivery (multips). Overall, the success rate of all ECV procedures was 30%. However, the success rate for multips was much higher than for primips (41% vs. 25%). For those women whose baby was successfully turned to the cephalic position during the ECV, a total of 73% proceeded to have a vaginal delivery.

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34. British Columbia Perinatal Health Program. Caesarean Birth Task Force Report 2008. Vancouver BC; Feb. 2008: p. 48. 35. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicentre trial. Lancet 2000;356: p. 1375–83. 36. Su, M., et al., Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003. 189(3): p. 740-5. 37. Glezerman, M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol, 2006. 194(1): p. 20-5. 38. Whyte H, Hannah ME, Saigal S, Hannah W, Hewson S, Amankwah K, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The International Randomized Term Breech Trial. Am J Obstet Gynecol 2004;191: p. 864–71. 39. Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, et al.; PREMODA Study Group. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194: p. 1002-11. 40. Society of Obstetricians and Gynaecologists of Canada (SOGC). Vaginal Delivery of Breech Presentation. SOGC Clinical Practice Guidelines. No. 226, June 2009 J Obstet Gynaecol Can. 2009; 31 (6): p. 557-566. Available at: http://www.sogc.org…/gui226CPG0906.pdf

Planned Vaginal Breech Birth At term pregnancy, the incidence of breech (or buttocks first) presentation is between 3% and 4% of all births. Most women will be identified with a breech presentation during prenatal care, prior to the onset of labour; however, a significant number of women will still be diagnosed with a breech presentation during labour. Starting in the 1970’s, cesarean delivery for breech presentation increased from 14% to 87%, due largely to reports that cesarean delivery may be associated with better perinatal outcomes compared to vaginal breech delivery.34 The acceptance of vaginal breech delivery further decreased following the publication in 2000 of the TERM Breech Trial (TBT), a large multi-centered, Canadian-led, randomized controlled trial of vaginal breech versus breech elective cesarean delivery.35 The TBT demonstrated a significant increase in serious short-term neonatal morbidity and mortality associated with vaginal breech delivery compared to breech elective cesarean. Although the TBT was a very well conducted study, subsequent reviews of the trial found a number of weaknesses, including non-participation in the trial of several large centres reporting safe outcomes for vaginal breech births.36,37 Furthermore, a two-year follow up study of the TBT showed that the serious morbidity associated with vaginal breech birth in the TBT did not have any long-term effects.38 In 2006, the breech PREMODA study (a French acronym referring to presentation and mode of delivery) was published, which involved 174 sites and included more than 8000 women who delivered a breech baby. The results of this study contrasted with those of the TBT. However, participating PREMODA centres followed strict criteria for inclusion in planned vaginal breech birth, including a limit on the progress of the first and second stages of labour. These strict criteria were not identified in the TBT. The PREMODA study found no difference in serious perinatal morbidity or mortality between the vaginal breech labour and birth group and the breech elective cesarean group.39 Overall, the evidence demonstrates that in a tertiary care centre, with careful inclusion criteria and strict labour management protocols, vaginal breech birth is an acceptable and safe birth option for selected women.40 As the rate of vaginal breech birth has declined, there have also been concerns regarding the concurrent decline in skills of graduating obstetricians who have little to no experience in attending and supporting vaginal breech birth. In the past decade, few obstetrical residents have had the chance to witness a vaginal breech birth during their training and many do not feel confident to attend a vaginal breech birth. There is concern that should vaginal breech birth continue to be a rare event, the training, experience and maintenance of this skill set may be lost. In addition, some women (particularly those who have had a previous vaginal birth) are not satisfied with cesarean birth as their only delivery option with a breech baby. Given these trends, the CTF recognized the importance of including support for vaginal breech birth, both for women and for training obstetricians. With the assistance of several obstetricians experienced in vaginal breech birth, research was undertaken to inform the careful development of selection criteria for women most suitable to attempt vaginal breech birth. A protocol for labour management was developed and a patient information consent form was created. This consent form

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details the criteria and guidelines for vaginal breech birth, which also helps to reduce liability concerns for obstetricians involved in attending vaginal breech births. In addition, an informal mentorship agreement was developed within the Department of Obstetrics at BCWH, where obstetricians with experience and confidence in vaginal breech skills made it known that they were willing and available to provide education and support to residents or obstetricians with little or no experience in vaginal breech delivery. Women with a breech baby who are interested in the choice of vaginal breech birth, and for whom ECV has been unsuccessful, are referred to the BBC for an hour-long consultation with an experienced obstetrician to discuss their options. Detailed ultrasounds are scheduled to ensure position of the breech and estimated fetal weight are available to be taken into consideration during the consultation. Women have an individualized assessment for vaginal breech birth suitability. Those who meet the selection criteria and agree with the guidelines for management during breech labour are consented to plan a vaginal breech birth if they wish.(Informed Consent Form is included as Appendix I; PDF available here). Vaginal Breech Birth Outcomes ‐ Best Birth Clinic From the BBC’s launch in Sept. 2010 through Sept. 2012, a total of 72 women have attended a consultation appointment to discuss the possibility of vaginal breech birth. Following their appointment, 45 of the women who were suitable candidates decided to plan a vaginal breech birth (62.5%), 18 (25%) were not suitable candidates and/or decided to book an elective cesarean, and 9 (12.5%) were undecided after their appointment. At delivery, 4 women’s babies had spontaneously turned to the cephalic position, and one returned to her local hospital to deliver. Of the remaining 67 women, 37 had a planned cesarean birth either prior to or during labour (55%); 30 went ahead with an planned vaginal breech birth (45%). Of these 30, 12 had successful vaginal breech births, representing a 40% success rate.

*Vaginal breech data includes women who were >=36wks at delivery with a singleton pregnancy , and who had at least one consultation appointment at the Best Birth Clinic prior to delivery; charts were reviewed to confirm informed consent process occurred for all trial of breech labours.

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Vaginal Breech Birth Outcomes ‐ BC Women’s Hospital Overall In light of the changing evidence and perceptions of safety regarding breech birth mentioned above, the decline of vaginal breech birth at BCWH was similar to that which occurred at most other maternity hospitals. However, as evidence for the safety of well-managed breech birth grew, the willingness to support breech births at BCWH has also increased. At BCWH, the proportion of women attempting a vaginal breech birth rose to a high of 11.5% in 2010-11, more than double the rate two years prior. This rate has remained at a similar level during the past two fiscal years, with approximately 10% of all women with a breech presentation at term choosing to plan a vaginal breech birth.

A number of women were diagnosed with a breech presentation in labour and proceeded to a vaginal breech birth. In addition, several women arrived in labour from other hospitals so they could proceed with a vaginal breech birth. The success rates of these vaginal breech birth attempts have remained fairly consistent since 2008/09, varying between 50-67%. The overall success rate for all patients attempting a vaginal breech birth in 20012/13 (YTD) was 66.7%. This resulted in the highest proportion of successful vaginal breech births (out of all breech presentations at delivery at 36 weeks or greater) seen in the past five years, at 7%.

Data from BC Women’s Hospital Perinatal Database Registry, January 2013. Vaginal breech data includes women who were >=36wks at delivery with a singleton pregnancy; charts were reviewed to confirm informed consent process occurred for all trials of breech labour.

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This initiative addresses recommendations made by the Cesarean Birth in BC Consensus Panel and the BCPHP Cesarean Birth Task Force Report on labour management. These include the appropriate diagnosis and ongoing assessment of early and active labour, the timely diagnosis and management of labour dystocia, and the appropriate management of labour pain. Prior to the implementation of the CTF, there were few standardized protocols for the management of labour at BCWH, not only between disciplines but also within disciplines. In order to address the need for improved labour management standards, the interdisciplinary CTF Early and Active Labour Management sub-committees were mandated to develop protocols and algorithms for labour management, as well as educational materials for the public. Current studies indicate that subjective labour management practices (eg; induction of labour, diagnosis of arrest of dilation, etc) have had a larger impact on primary cesarean rates than more objective medical indications (malpresentation, placenta previa, etc).41,42 Induction of labour, continuous electronic fetal monitoring (EFM), and the diagnosis of labour dystocia in both early and active labour have all been shown to increase cesarean delivery, with no increased benefit to women and their babies.43 Women who undergo EFM on admission are also more likely to have epidural anesthesia and continuous EFM in labour,44 and are 20% more likely to have a cesarean delivery.45 Early Labour Sub-Committee This committee focused their attention on two areas: the definition and management of early labour, and doula support at BCWH. The interdisciplinary committee developed an Early Labour algorithm for the diagnosis and management of early labour, as well as a patient handout, When Labour Starts. This handout is available in care providers’ offices and in the Labour Assessment Room at BCWH, and has suggestions for coping with early labour and when to come to the hospital. It is also available in five languages on the Power to Push website. The Early Labour algorithm is available to all BCWH care providers on the hospital intranet. (When Labour Starts included as Appendix J, and PDF available here; Early Labour Algorithm included as Appendix K). This sub-committee was also integral in the design of an evaluation tool to assess the efficacy of doula care, and the implementation of the currently ongoing randomized controlled trial (RCT) on doula care for women planning a VBAC (see page 19). A second qualitative research study is currently underway examining how the physicians, midwives and doulas work at the South Community Birth Program (SCBP). A Process Evaluation of the SCBP doula program is almost completed as well.

Active Labour Sub-Committee This committee focused their attention on two areas: the diagnosis and management of active labour, and an audit on the use of EFM and intermittent auscultation (IA) at BCWH. An Active Labour algorithm was developed for the diagnosis and management of active labour, and is available to all BCWH care providers on the hospital intranet. (Active Labour Algorithm included as Appendix L).

Labour Management Committee

41. Barber EL, Lundsberg, LS, Belanger, K, et al. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 2011; 118(1): p.29-38. 42. Menacker F, Hamilton BE. Recent trends in cesarean delivery in the United States. NCHS Data Brief No. 35. Hyattsville (MD): National Center for Health Statistics; 2010. 43. Alfirevic, Z., D. Devane, et al. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2006 Issue 3. Art. No.: CD006066. 44. Society of Obstetricians and Gynaecologists of Canada. Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline. SOGC Clinical Practice Guideline No 197, 2007. 45. Devane D, Lalor JG, Daly S, McGuire W, Smith V. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev 2012 Issue 2. Art. No.: CD005122.

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This sub-committee carried out a chart audit which looked at the use of intermittent auscultation (IA) of the fetal heart during labour at BCWH. Although IA is the preferred method of fetal surveillance, this random audit of 68 cases of low-risk spontaneous vaginal births at BCWH demonstrated very low utilization of IA. The CTF is planning to roll out further training and a protocol on the use of IA during active labour.

The Department of Obstetrics Cesarean Audit Project Since 2011, the CTF has been collaborating on a quality assurance initiative with the Department of Obstetrics at BCWH, which involves a large-scale chart audit of cesarean surgeries done between 2009 and 2011. This is a retrospective review of 800 cesareans performed before 2011, and a prospective review of a further 800 cesareans beginning in March 2012. The audit aims to analyze the causes and contributing factors leading to each cesarean, and to identify any emerging trends which may have potentially been avoidable. Charts are reviewed by a high-level multidisciplinary committee involving representation from Departments of Obstetrics, Midwifery, Family Practice, and Nursing. The audit is currently ongoing, and it is hopeful that the findings can be used to improve labour management protocols for all care providers.

Scalp Lactate Sampling Fetal scalp lactate sampling is a test performed during labour to determine levels of fetal stress. The test involves taking a very small sample of blood from the fetal scalp; the level of lactate in the blood indicates whether or not there is acidosis (a sign of oxygen deprivation). Scalp lactate sampling is a fast and reliable method that helps provide reassurance about fetal well-being, or may indicate the need for urgent interventions. In July of 2011, BCWH implemented the availability of scalp lactate sampling throughout its labour and delivery wards. Prior to 2011, scalp lactate sampling had been unavailable for approximately two years. The return of the availability of this tool has helped care providers to improve assessments made during labour.

Other BC Women’s Hospital Initiatives

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Primary Cesarean & Attempted VBAC Rates The primary cesarean rate (the number of women undergoing a first cesarean surgery) at BCWH rose continuously for two years prior to the launch of the CTF initiatives, reaching a high of 21.6% in 2010. However, since 2010, the rate has been declining, dropping two percentage points to 19.6% in 2011-12, and has continued to decline slightly through the current fiscal year to 19.3% (2012-13 to date). The fall in the primary cesarean rate coupled with a recent increase in the number of women choosing to attempt a VBAC (which reduces the rate of repeat cesareans) has resulted in a small but steady decline in the overall cesarean rate. Should both the attempted VBAC rate continue to increase and the primary cesarean rate continue to fall, a further drop in the overall cesarean rate in the coming years could be expected.

Overall Cesarean Rate at BC Women’s Hospital

Data from BC Women’s Hospital Perinatal Database Registry, January 2013.

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Overall Cesarean Rate Like many large tertiary maternity hospitals in North America, the overall cesarean rate at BCWH rose steadily for most of the past decade. The overall cesarean rate reached an all-time high of 34.1% in the 2010/11 fiscal year, the year the PTP campaign was launched. The cesarean rate fell to 32.1% in 2011/12, and has continued to drop with a current rate of 31.1% in 2012/13 (to date). While many tertiary care hospitals have continued to see an increase in cesarean rates, BCWH has begun to see an encouraging decline of 3% since the PTP campaign and BBC were launched. While we have not yet reached our target for lowering the cesarean rate, the trend of increasing annual rates appears to have ceased at BCWH. It is hoped that the continuation of current initiatives and the launch of the VBAC Project will result in further reductions in the overall annual cesarean rate.

Data from BC Women’s Hospital Perinatal Database Registry, January 2013.

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Turning the Tide The Turning the Tide: Balancing Birth Experience & Interventions for Best Outcomes conference was held at the Morris J. Wosk Centre for Dialogue in Vancouver BC on May 11-13, 2011. The conference examined interventions in childbirth and their impact on women’s experience of birth. The conference provided an opportunity for maternity care providers, managers, researchers, students and other parties to engage in discussions on labour and birth and on current initiatives to normalize birth. The conference also allowed participants the opportunity to make recommendations on how to balance interventions and women’s experience for best outcomes in B.C. The conference presentation highlights included:

100 years of giving birth - learning from the past Navigating choices in childbirth What do women believe normal birth is? What is the optimal use of: continuous EFM/induction of labour/epidural during labour Informed consent: When autonomy and beneficence collide Panel: How can an interprofessional team support normal birth? Recommending and supporting VBAC Supporting term breech delivery

A consensus panel made up of interprofessional care providers participated in the conference and completed a final report of recommendations based on the presentations and dialogue. The conference was hosted by the CTF and Power to Push campaign along with Perinatal Services BC and the Collaboration for Maternal and Newborn Health. (Presentations available here; Consensus Panel Statement available here).

Champions for Change The Champions for Change: Nurses Driving Change for Normal Birth workshop, held on October 19th 2012, invited maternity care nurses to share their insight and expertise on supporting normal birth at the patient level. 106 participants traveled from across British Columbia to attend the workshop. The workshop was hosted by the CTF and Perinatal Services BC. In order to showcase the expertise of nurses while encouraging interprofessional discourse, each session was presented by a registered nurse paired with a midwife, family doctor, obstetrician, anesthesiologist or another nurse. The topics of presentations included :

The power maternity care nurses have to overcome the challenges facing normal birth The benefits of group medical care and education (Connecting Pregnancy) as demonstrated by SCBP How a woman’s level of mobility can help or hinder her labour and practical ways that nurses can support

and encourage mobility in labour The pharmacological and non-pharmacological pain management options available to labouring women The appropriate applications of intermittent auscultation vs. electronic fetal monitoring and the benefits and

risks of using each technique The essential elements of good nursing research questions

A moving video was also created and shown at the workshop in which women who had delivered at BCWH presented messages thanking the nurses who had helped them during their labour and birth. (Video viewable here; Presentations and Summary Report available here).

Conferences and Workshops

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Presentations: “Vaginal Birth After Cesarean.” Multidisciplinary Rounds, BCWH (Dr Leanne Dahlgren, Dr Dale Steele, Dr Karen Buhler, and Lee Saxell RM) Nov. 2012. “The Power to Push: Conception to Birth of a Public Health Campaign.” Evening Rounds, Vancouver BC (Robyn Sussel and Susan Pinkney) Sept. 2012. “The Power to Push Campaign & Best Birth Clinic.” Multidisciplinary Rounds, BCWH (Dr Dale Steele and Lee Saxell RM) May 2012. “VBAC Counseling: the Endless Conversation.” Family Practice Maternity Service Meeting, Vancouver BC (Dr Karen Buhler and Lee Saxell) Oct. 2011. “Recommending and Supporting VBAC.” Turning the Tide Conference, Vancouver BC (Dr Dale Steele) May 2011. “Reducing the Cesarean Birth Rate at BC Women’s: Promotion and Education to Increase VBAC.” Webinar presentation to the New Jersey Dept of Health VBAC Task Force (Susan Pinkney) Feb. 2011. “Recommending VBAC: Using the Best Safety and Success Evidence.” Family Medicine Forum, Vancouver BC (Lee Saxell) Oct. 2010. “The Power to Push Campaign & Best Birth Clinic.” Multidisciplinary Rounds, BCWH (Dr Dale Steele and Lee Saxell RM) Sept. 2010. “BCWH Cesarean Task Force Initiative.” Mini Med School-University of British Columbia (Pam O’Sullivan and Lee Saxell RM) April 2010.

Articles & Blog Posts: ACOG.org http://www.acog.org/About_ACOG/ACOG_Departments/District_Newsletters/District_VIII/December_2012/ Power_to_Push_Campaign_in_British_Columbia UBC Obstetrics & Gynecology News http://www.obgyn.ubc.ca/News/2011/01/power_to_push_campaign.html Blog post – VBAC.com http://www.vbac.com/2010/10/the-power-to-push-campaign-has-it-right-about-vbac/ Blog post – Mothers of Change http://www.mothersofchange.com/2010/11/we-have-power-to-push.html Blog post – Mothering Touch http://www.motheringtouch.ca/node/98 Blog post – Ilithyia Birth Support http://www.ilithyiabirth.com/2010/09/power-to-push-campaign.html

Presentation, Articles and Media Coverage

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Blog post - Deme Pre and Postnatal Services http://demepreandpostnatal.wordpress.com/2011/11/09/power-to-push-campaign-and-the-best-birth-clinic-at-bc- womens-hospital/

Resource Page Links Many organizations and maternity care clinics have included a link to the Power to Push Campaign on their website, including: Baby’s Best Chance Perinatal Services BC Optimal Birth BC Born PEI Sheway Vancouvermom.ca Access Midwifery

Westside Midwives West Coast Health Collective Diane Lee Physiotherapy VBAC.com Midwives in Victoria Midwives’ Association of BC The PTP Campaign is also listed as a resource in The Mother of All Pregnancy Books: An All-Canadian Guide to Conception, Birth and Everything In Between by Ann Douglas (Appendix D: Online Resources).

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Successes High-level administrative support and dedicated funding In 2009, the Provincial Health Services Authority (PHSA) provided funding to support strategies to optimize the number of cesareans performed at BC Women’s and throughout the province. Dedicated funding for initiatives has enabled the team to plan and implement projects capable of achieving and sustaining long-term goals. The CTF has also been fortunate to have the full participation and support of the Departments of Family Practice, Midwifery, Obstetrics, Nursing and administrative management at BCWH. CTF teamwork and multidisciplinary participation The CTF found that it was crucial to ensure engaged and positive participation from all departments and areas of professional expertise, both within the hospital and from partner organizations and community members. The CTF committee benefited greatly from the input and opinions of its diverse membership, and was fortunate to have active representatives from obstetrics, midwifery, family practice, nursing, pediatrics, epidemiology, administrative and research departments who approached the project with philosophical support and constructive feedback. All disciplines involved recognized the importance of the respectful teamwork required to develop appropriate programming that would meet the needs of a wide diversity of women. Input from women (consumers of care) during the development of both the website and brochures proved to be invaluable to the substance and content of the CTF’s work.

Developing an effective communications strategy In the absence of appropriate education, women may receive misinformation about birth on television and through the Internet. The CTF designed a successful communications strategy based on quality content, skillful marketing and innovative graphic design. This was achieved through partnering with a professional communications firm, Signals, (www.signals.ca) with specific expertise in health communications strategy and marketing. In addition to providing necessary skills in graphic design and website development, Signals assisted the CTF to elucidate and articulate the purpose of the project in an effective manner, and to come up with an approach that bridged the many perspectives of the multidisciplinary team involved. In addition, their expertise in building and launching online and social media tools was crucial and has allowed the CTF to reach and engage with women directly through channels they are familiar with and use frequently. A vital part of this effective communications strategy was the public information campaign developed using both web-based resources and print media to promote healthy childbirth, reduce fears and dispel misconceptions. The CTF successfully developed multiple information brochures on normal birth, cesarean birth, vaginal birth after cesarean, as well as breech birth. These evidence-based information brochures are available in multiple languages and have been very well received by both the public and professionals, and are available on the Power to Push website for reprinting without cost. Successful launch of the Best Birth Clinic and Choices in Childbirth Counseling Clinic The Best Birth Clinic has tangibly improved the options available to women who are seeking information on VBAC and vaginal breech birth, as well as an ECV procedure for breech presentation. Women receive focused and in-depth consultation and assessment appointments with an obstetrician, which allow them to explore

Successes and Challenges: Lessons Learned

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options, ask questions, and receive standardized evidence-based information. The Choices in Childbirth Clinic offers appointments with a Registered Clinical Counselor for women to discuss cesarean birth for non-medical reasons, as well as counseling for women who have experienced a difficult birth. Survey feedback from women on the counseling has been excellent. Development of early and active labour management plans The CTF established two sub-committees, the Early Labour and Active Labour Management committees. These committees developed algorithms to address the management of early and active labour, the timely diagnosis and management of labour dysotica, the appropriate management of labour pain. These new algorithms addressed the need for standardized labour management protocols at BCWH, both between disciplines and within disciplines. These algorithms have been accepted by the Departments of Midwifery, Family Practice and Obstetrics. Successful CTF conferences and workshops A consensus conference, Turning the Tide: Balancing Birth Experience & Interventions for Best Outcomes was held in Vancouver on May 11-13, 2011 with sold-out attendance. A consensus panel made up of interprofessional care providers participated in the conference and completed a final report of recommendations based on the presentations and dialogue. The conference was very useful for informing the further work of the CTF. A one-day workshop held specifically to support nursing practices. Champions for Change: Nurses Driving Change for Normal Birth was held on October 19, 2012. More than one hundred maternity care nurses traveled from across British Columbia to share their insight and expertise on supporting normal birth at the patient level. The CTF is planning to partner with Perinatal Services BC on a second Champions for Change event in the Spring of 2014.

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Challenges Positively influencing care providers attitudes The optimal management of labour has been identified in several reports and studies as a key factor in reducing the cesarean rate. Multifaceted strategies which incorporate peer review, audit and feedback, and identify the barriers to change, have been shown to be the most effective. To be successful, strategies should have the support and commitment of all team members and care providers, while acknowledging that 100% “buy-in” will never be attainable. Through the continued reporting of CTF activities at site-wide hospital rounds and department meetings, as well as access to timely hospital data to track progress, the acceptance of CTF projects has grown over the past two years.

The implementation of a new clinic in a high-acuity hospital There were several challenges implementing the BBC as a new outpatient clinic within BCWH’s Diagnostic Ambulatory Program (DAP). All levels of hospital administration provided much-needed support throughout the implementation; however, starting a new service requiring dedicated clinical space and resources in a facility stretched to capacity for space proved challenging. In addition, the new BBC clinic required dedicated nursing and ultrasound involvement in ECV procedures. The clinic’s implementation would not have been possible without the flexibility of the staff in the DAP, who put in both time and effort to find ways to adjust their staffing structures and scheduling systems in order to accommodate the clinic’s needs. It is unlikely this problem of space will be fully resolved until the new BCWH hospital is built. High-acuity of appointments at the Best Birth Clinic The BBC is open for obstetrician consultations for women in BC. Women have travelled from Vancouver Island and Northern BC, as well as the Lower Mainland, to access the BBC. As demand for clinic appointments has grown, staffing and space constraints have made it impossible to meet the demand. During very high acuity periods, the BBC has had to restrict access to women registered to come to BCWH for their birth, particularly for ECV. This continues to be a challenge that requires an ongoing search for solutions. Collaboration with external partners The CTF explored the possibility of partnering with other Lower Mainland hospitals in order to roll out initiatives simultaneously across multiple sites. However, many external groups, while positive and supportive of CTF initiatives, did not embrace the possibility of partnering on any initiatives at this time. In the future, this could be explored further in order to extend the reach of CTF initiatives for women throughout the province.

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A. Summary of Recommendations from BCPHP Cesarean Birth Task Force Report .............................................. 39 B. Brochures: ................................................................................... 41 Best Birth Clinic .................................................................. 41 Power to Push Campaign................................................... 42 VBAC.................................................................................. 43 VBAC Rack Card................................................................ 44 ECV .................................................................................... 45 Vaginal Breech Birth........................................................... 46 C. Best Birth Clinic Referral Form .................................................... 47 D. VBAC and Repeat Cesarean Informed Consent Form................ 48 E. VBAC and Repeat Cesarean Information Booklet....................... 50 F. ECV Tracking Sheet..................................................................... 55 G. ECV Informed Consent Form ...................................................... 56 H. After Your ECV Handout .............................................................. 58 I. Vaginal Breech Informed Consent Form ..................................... 60 J. When Labour Starts (Early Labour Patient Handout) .................. 64 K. Early Labour Management Hospital Algorithm............................ 66 L. Active Labour Management Hospital Algorithm .......................... 68

Appendix

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Appendix A

PDF of full text report available online here

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Appendix A

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Appendix B

PDF available online here

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Appendix B

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Appendix B

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Appendix B

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Appendix B

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Appendix B

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Appendix C

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Appendix D

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Appendix D

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Appendix E

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Appendix E

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Appendix E

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Appendix E

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Appendix E

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Appendix F

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Appendix G

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Appendix G

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Appendix H

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Appendix H

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Appendix I

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Appendix I

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Appendix I

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Appendix I

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Appendix J

PDF available online here Translated versions available here

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Appendix J

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Appendix K

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Appendix K

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Appendix L

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Appendix L

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Appendix L

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www.powertopush.ca