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Safely Averting NTSV Cesarean Births

Mother and newborn baby


OBI is working with 70+ hospital teams in Michigan to support physiologic birth, offer more equitable, respectful care, and prevent unnecessary cesarean births.

The Problem

The national Nulliparous Term Singleton Vertex (NTSV) cesarean rate is high and varies substantially across hospitals. The NTSV cesarean rate in Michigan is significantly higher than the national average.


Healthy People 2030 NTSV Cesarean rate goal



Michigan’s average NTSV cesarean rate


Variation in NTSV cesarean rate in Michigan hospitals


By December 2025, 50% of participating hospitals will achieve their NTSV cesarean goal.


  • Increase the percent of NTSV cesarean births for dystocia that meet ACOG/SMFM criteria
  • Increase the percent of NTSV cesarean births for abnormal/indeterminate fetal heart rate tracing that have documentation of management with an algorithm
  • 70% of participating hospitals have a process for NTSV cesarean case review
  • Reduce the percent of participating hospitals with an NTSV cesarean rate over 30%
  • Increase the number of participating hospitals with an NTSV cesarean rate below the HP2030 target of 23.6%

Implementation Resources

Initiative Background

Clinical Guidance for Labor Dystocia

Clinical Guidance for Management of Category II Fetal Heart Tracings (FHTs)

QI Planning & Implementation Tools

OBI 2023 Site Visit Summary Report: Barriers, Facilitators, & Strategies for Safely Lowering the NTSV Cesarean Rate

Pre-Cesarean Checklist for Labor Dystocia or Failed Induction

Pre-Cesarean Checklist for Labor Dystocia or Failed Induction. California Maternal Quality Care Collaborative (CMQCC). 2016.

OBI Category II Fetal Heart Rate Tracing Management Algorithm

Clinician Engagement

OBI Criteria Badge Buddy

A two-sided, 4”x 3” inch badge buddy that can be used as a fast reference reminder for Labor Dystocia compliance criteria and Category II FHR monitoring interventions.

Consider printing these for all members of your clinical team!

Training Slide Deck Template

Coming soon!

Moving our Mamas (MOMs) Labor Support Training

To host a hands-on labor support training class for your maternity care staff, please contact Patricia Klassa MSN, RN, CNS-C, IBCLC (pklassa@comcast.net) and Cheryl (Larry-Osman) Bellamy DNP, BS, APRN, CNM, CNS-C, C-EFM (cheryl9800@gmail.com).

Patient Engagement

Labor Support Guide

Use this guide to identify, discuss, and select options for labor support with your team.

QI Evaluation

NTSV Performance Report Manual

A manual to help OBI Champions understand their Push Reports with tips for interpretation & action items.

Sample NTSV Performance Report

Risk-Adjustment & O:E Ratios: A Primer

A brief explanation of how OBI uses risk adjustment and O:E ratios in assessing hospital NTSV Cesarean performance.

Case Reviews


  • NTSV Case Review Primer: Helps Obstetrics Initiative (OBI) champions introduce frontline clinicians to the NTSV Case Review process.
  • NTSV Case Reviews. Presented by Stephanie Ludlow, BSN, RN, and Denise Parrish, MSN, RN, RNC-OB. 2024 OBI Webinar Series, January, 2024. (OBI Members Only) View Recording & Slides.
  • (Coming Soon!) NTSV Case Review FAQ

Tools for Conducting Case Reviews

  • NTSV Case Review Worksheets: Champions can use these worksheets to evaluate practices, determine opportunities, and recognize excellent care. Edit as needed for your site.
  • NTSV Case Review Tracking Template: A template spreadsheet that NTSV Case Review Committees can use internally to track cases reviewed and decisions made. Please do not submit this form to the Coordinating Center to obtain P4P points (you may submit the OBI NTSV Cesarean Case Review Unit Dissemination Form below).

Tools for Dissemination of Case Review Findings