Date of Award

January 2022

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

Michelle Telfer


Background: The cesarean section (CS) is the most common surgical procedure in the United States and while often necessary and life-saving, brings higher risk of morbidity and mortality for both patient and neonate than vaginal birth (Boyle et al., 2013; Lagrew et al., 2018). CS rates in nulliparous, term, singleton, vertex (NTSV) patients vary dramatically, from 7.1% to 69.9%, throughout US birthing facilities but can be safely reduced via the implementation of evidence-based safety bundles that aim to reduce variation in care (Council on Patient Safety in Women’s Health Care, 2020; Kozhimannil et al., 2013). Local Problem: A large birthing hospital in Maryland has NTSV CS rate of 23% with a reduction goal to 20% or less. Methods: Plan-Do-Study-Act Cycles were utilized as the project model over 3-month period. Intervention: CS rate reporting was scaled out to include Registered Nurse (RN)-specific rate measures in the established clinician audit and feedback process while also tailoring and launching a CS communication tool. Results: While unit CS rates did not decrease during the project period, the RN-specific CS rate measures did identify positive outlier RNs with NTSV CS rates consistently lower than goal, ranging for 0.00% to 16.67%. Conclusion: This project demonstrates the need for continued analysis of RN-specific NTSV CS rates to identify and study the practices of these positive outliers to identify best practices, direct from the frontline, that contribute to successful, safe physiologic birth. Keywords: NTSV, cesarean section, quality improvement, RN NTSV rate, interprofessional team, pre-cesarean checklist


This is an Open Access Thesis.

Open Access

This Article is Open Access