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Quality Initiatives




The goal of this measure is to provide evidence-based fetal assessment using intermittent auscultation to safely reduce the number of primary cesareans performed for abnormal fetal heart tones.

Scoring Metric

IA will be ordered at admission for at least 80% of eligible NTSV spontaneous labor patients.

Scoring for this metric will include January 1, 2023 – September 30, 2023 delivery dates.  P4P points will be granted as follows:

  • ≥  80% compliance = 15 points
  • 70-79.9% compliance = 10 points
  • <70% compliance =  0 pts

Target Population

Inclusion Criteria

Labor Status at admission = spontaneous onset of labor, membranes intact or spontaneous onset of labor, membranes ruptured

Exclusion Criteria

Labor status at admission = Induction, membranes intact or induction membranes ruptured

Conditions for Exclusion

Provider documentation that CEFM ordered at admission due to one or more of the following:

  • Pre-pregnancy diabetes
  • Gestational diabetes
  • Pre-pregnancy HTN
  • Hypertensive disorder of pregnancy
  • Non reassuring fetal status
  • Abnormal vaginal bleeding
  • Meconium stained fluid
  • Chorioamnionitis
  • Patient labor support preferences require CEFM


IA ordered by provider at admission (may include conditional orders to move to continuous EFM if needed).


NTSV spontaneous labor admissions meeting the above inclusion and exclusion criteria.