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Quality Initiatives

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Goal

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

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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

Numerator

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

Denominator

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

Project Support Tools & Resources

Clinical Guidance