The PROVIDE Advisory Group has developed a set of materials specific to Florida and adopted the California Maternal Quality Care Collaborative’s (CMQCC) Toolkit to Support Vaginal Birth and Reduce Primary Cesareans for use in the PROVIDE QI Initiative.   

The FPQC tools and recommendations are dynamic and will be revised as evidence-based information becomes available.  

1. California Maternal Quality Care Collaborative Toolkit to Support Vaginal Birth and Reduce Primary Cesareans
2. The Implementation Guide for the Toolkit to Support Vaginal Birth and Reduce Primary Cesareans (CMQCC)

Additional Implementation Tools:

• 30-60-90 Day Plan worksheet
• PROVIDE 2.0 Quick Start Checklist
• Induction Focus Area:
  • Key Driver Diagram
  • Implementation Planning Guide
• Labor Dystocia Focus Area:
  • Key Driver Diagram
  • Implementation Planning Guide
• Fetal Heart Rate Focus Area
  • Key Driver Diagram
  • Implementation Planning Guide

Note: Because of concerns with interpretation of the terminology related to fetal heart rate monitoring and actions that could result, the PROVIDE advisory group has developed the following statement to facilitate standardized communication:

One difference between the California and the Florida toolkit surrounds the use of the term “fetal distress”. ACOG and other maternal health professional groups have discouraged the use of this term (ACOG Committee Opinion Number 326, December 2005) because the term is imprecise, non-specific, and has low predictive value related to the infant’s birth condition.  The recommendation for PROVIDE is to use the term “fetal heart rate concerns or indications” with additional descriptors such as repeated variable decelerations, fetal tachycardia or bradycardia, late decelerations, or low biophysical profile. 

The FPQC tools developed for this project will incorporate this change throughout in order to provide clarity and consistency.

Supporting Documentation Resources:

• Patient Safety Bundle: Safe Reduction of Primary Cesarean Births: Supporting Intended Vaginal Births - Council on Patient Safety in Women's Health Care and Alliance for Innovation in Maternal Health (AIM)
• Safe Prevention of the Primary Cesarean Delivery - ACOG, SMFM
• Approaches to Limit Intervention During Labor and Birth - ACOG (Updated 2019)
• ACOG Key Definitions
• ACNM Bundle on Promoting Comfort in Labor
• ACNM Bundle on Promoting Spontaneous Labor Progress

Pre-Cesarean Checklists, also known as Labor Dystocia Checklists, have been shown to have an enormous impact on successfully reducing cesarean rates in hospitals working on the issue across the country. 

Sample Checklists:

• Pre-Cesarean Checklist for Failed Induction or Labor Dystocia from CMQCC Toolkit [note: this is the longer form]
• Pre-Cesarean Interdisciplinary Huddle Form (Tampa General)
• Pre-Cesarean Checklist for Labor Dystocia, Failed Induction, and FHR Concerns shared from New Jersey
• ACOG/SMFM Criteria Labor Dystocia Checklist (CMQCC) [note: this is the "shorter" pre-cesarean huddle form]
• Pre-Cesarean Checklist example (Lakeland Regional)

Resources:

• FPQC Labor Induction Algorithm (front/back 11x14 inch print)
• Induction of Labor Checklist (FPQC)
• FPQC PROVIDE Early AROM: Helpful or Harmful? Induction Statement
• Example Induction Forms (Baptist Health)
• Example Induction Booking Form (Tampa General)
• Induction Consent (Tallahassee Memorial)
• Induction Scheduling Form (AdventHealth Waterman)
• Model Policy (CMQCC Toolkit)
• Example Non-Medically Indicated Delivery Guideline (NNEPQIN)
• CMQCC Webinar on Induction
• Induction of Labor and Techniques for Preparing the Cervix for Labor (with Foley insertion technique) Slide Set (David Lagrew, MD/Hoag Health) 
• Foley Bulb Placement for Cervical Ripening Equipment and Procedure (St Joseph Hoag Health)
• Foley Catheter Cervical Ripening Patient Information Sheet (St Joseph Hoag Health)
• Outpatient Cervical Ripening instructions for providers, patient information (USF Health)
• Elective Cesarean Birth Consent Form (CMQCC)
• Pre-Cesarean Checklist for Labor Dystocia (CMQCC)
• Pre-Cesarean Interdisciplinary Huddle Form (Tampa General)
• Pre-Cesarean Checklist (Hackensack)
• Promoting Labor Progress - Optimal Labor Positions Guide
• Model Policy on Freedom of Movement (CMQCC Toolkit)
• Statement on Induction and Augmentation (AWHONN)

Note: Patient Education Resources on Induction are in the Patient Education Resources dropdown below. See the Labor Dystocia Resources dropdown for more information on promoting labor progress.

Resources:

• FPQC Spontaneous Labor Algorithm (front/back 11x14 inch print)
• Did you know... 6 is the New 4 (CMQCC)
• Labor Dystocia Checklist (CMQCC)
• Labor Duration Guidelines (CMQCC)
• Pre-Cesarean Checklist for Labor Dystocia or Induction (CMQCC)
• Safe Use of Oxytocin (CMQCC toolkit)
• Example Latent Phase of Labor Policy (Calgary)
• Best Practices for Epidural (CMQCC)
• Early Labor Admission (CMQCC)
• Active Labor Partogram (CMQCC)
• ACOG Opinion: Approaches to Limit Intervention During Labor and Birth (Updated 2019)
• Pre-Cesarean Interdisciplinary Huddle Form (Tampa General)
• Pre-Cesarean Checklist (Hackensack)

Second Stage Arrest:

• Second Stage Algorithm (CMQCC)
• Second Stage Management for Malposition (CMQCC)
• Evidence for Pushing Non-Supine (Lamaze)
• Operative Delivery, Malposition Interventions (CMQCC)

Labor Support:

• Labor Coping Algorithm (Utah, from CMQCC Toolkit)
• Model Policy on Freedom of Movement (CMQCC Toolkit)
• Promoting Labor Progress: Optimal Labor Positions Guide 
• Labor Positions for Progress (Lamaze)
• Rebozo Technique for Malposition (Journal of Midwifery & Women's Health)
• Intermittent Monitoring for Low Risk (CMQCC)
• Position Statement on Continuous Labor Support for Every Woman (AWHONN)
• Nursing Support of Laboring Women (AWHONN)
• Encourage use of Doulas (CMQCC)
• Improve Support Infrastructure and Supportive Care (CMQCC Toolkit)

Resources:

• FPQC Management of Fetal Heart Rate Tracings Algorithm (prints 11x14)
• FPQC Interpreting the Fetal Cardiotocograph using NICHD Terminology (prints 11x14) 
• Pre-CS Form - Interdisciplinary Intrapartum Huddle (TGH)
• Pre-Cesarean Checklist (Hackensack)
• Algorithm for FHR Tracings (CMQCC)
• Monitoring for Perinatal Safety: Electronic Fetal Monitoring Slide Set (AHRQ)
• Model Policies on FHR Concern (CMQCC)
• Example Guidelines for Fetal Monitoring (NNEPQIN)
• Fetal Monitoring Practice Bulletin (ACOG)
• Bulletin on Management of FHR Tracings in Oxytocin for Inductions (ACOG)
• Statement on FHR Monitoring (AWHONN)
• Intrapartum Management of Category II Fetal Heart Rate Tracings (Clark et al 2013)
• ACOG Approaches to Limit Intervention During Labor and Birth

Intermittent Auscultation:

• Bundle on IA (ACNM)
• Intermittent Auscultation Slides (Denver Health)
• Example Policy on Intermittent Fetal HR (ACNM)
• Institute for Perinatal Quality Improvement IA Simulation-Based Education

Featured:

• Vaginal and Cesarean Birth Pro/Con Rack Cards (FPQC)
  • English
  • Spanish
• Toolkit on Improving Quality and Improving Access to Childbirth Education (CMQCC)
• My Birth Matters: C-Section Consumer Education Campaign from CMQCC, California Health Care Foundation, and Consumer Reports. This page contains videos, social media messages, and printables for professional use (English and Spanish).

On Induction and Cesarean:

• How Will Labor Be Different if I Choose Labor Induction at 39 Weeks? (The Family Way)
• Cesarean Infographic Handout (Lamaze)
• Preventing a Cesarean (ACNM)
  • English
  • Spanish
• Induction (ACNM)
  • English
  • Spanish
• Sample Patient Education on Induction (Tampa General)
• Induction Infographic Handout (Lamaze)

Early/Latent Labor:

• Early Labor Infographic "Keep Calm and Labor On" (Lamaze) 
• Am I in Labor? (ACNM)
• Should I Stay or Should I Go? Poster (PQCNC)
• Not in Labor Yet? Stay Home Poster (PQCNC)

Supporting Labor and Progress:

• Movement in Labor Infographic "We Like to Move It Move It!" (Lamaze)
• "The Rollover" Safe Positions with an Epidural (Penny Simkin)
• Support Person Tips (Mother's Advocate)
• Comfort in Labor (Penny Simkin)
• Coping with Labor Pain (ACNM)
• Is an Epidural My Only Option? Infographic Handout (Lamaze)
• Positions for Labor (Mother's Advocate)
• Rock and Roll Menu (Labor Options Winnie Palmer)
• 8 Positions for Labor Progress (Lamaze)
• Second Stage: Pushing your Baby out (ACNM)
• Bring the Support You'll Need Infographic (Lamaze)

Other Topics and General Handouts:

• 6 Steps to a Safe and Healthy Birth
  • Infographic Handout (Lamaze)
  • Booklet Handout (Mother's Advocate)
• What Every Pregnant Woman Needs to Know (Childbirth Connection)
• Normal Birth and You (ACNM)
• No Food, No Drink During Labor? Infographic (Lamaze)
• The Rights of Childbearing Women (Childbirth Connection)
• EFM Infographic Handout (Lamaze)

Great Websites to Explore and Share:

• MyBirthMatters.org - Videos and great information with embedded links (English, Espanol). Videos include "New Mom Explains C-sections", "L&D Nurse Explains C-sections", "Doctor/Patient C-section Discussion" and "Your Birth Team"
• MothersAdvocate.org - Videos and print material for a Better Birth (English, Espanol) 
• Childbirth Connection: There are a lot of great resources on this website. Here are two: Cesarean Section - Labor Induction
• Lamaze for Parents - There are a lot of easy to understand pages on this site - What to Know About Cesarean Surgery
• ShareWithWomen.com: Patient handouts for download, also available in Spanish
• Health4Mom.org

Videos:

• Healthy Birth Your Way: 6 Steps to a Safer Birth
• "40 Ways to Help a Laboring Woman" for L&D Nurses
• Positions for Labor
• See our Educational Video Snippets dropdown for more videos on positioning tips to prevent cesareans

Note: An additional list of tools are included in the CMQCC Toolkit to Support Vaginal Birth (See Appendix C and Appendix D)

Resources:

• Shared Decision Making Safety Action Series Slides (Council on Patient Safety in Women's Health)
• Opinion: Partnering with Patients to Improve Safety (ACOG)
• Shared Decision Making (CMQCC)
• AHRQ's SHARE Approach (Curriculum, Tools, Webinars) 
  • Shared Decision Making poster for providers
  • Shared Decision Making poster for patients
• Shared Decision Making in Maternity Care from Childbirth Connection
• Birth Preferences Worksheet (CMQCC Toolkit Appendix E)
• Birth Preferences Worksheet (Sacred Heart Hospital Pensacola)

PROVIDE 2.0 Celebration Webinar - May 2022

• Slides
• Sustainability Snippet

PROVIDE 2.0 Mid-Project Meeting - September 2021

• PROVIDE Update
  • Where Are We? (Slides)
  • What Can FL Do to Have CA's Results? (Handout)
• Safely Reducing NTSV Cesareans - California Style (Slides)
• Promising Practices for Educating Busy OB Providers and Staff (Slides)
• Changing Hospital Culture with NTSV Cesareans - We Did It, You Can Too (Slides)

PROVIDE 2.0 Mid-Project Meeting - 2020

• Welcome and Intro (Slides)
• Where We Are Initiative-Wide (Slides)
• Patient Perspective - Repeat Cesarean (Video)
• Continuing to Promote Vaginal Delivery During the Pandemic (Video)
• Nurse Impact: Outcomes and Effective Practices (Video)

PROVIDE 2.0 Webinars are archived here.

PROVIDE 2.0 Orientations - 2019

• Intro to the FPQC
• Background on the Cesarean Issue and Why PROVIDE
• Promoting Primary Vaginal Deliveries Toolkit and National Recommendations
• FPQC PROVIDE Initiative Foci - Induction and Labor Dystocia
• Participation and Applying to PROVIDE 2.0

PROVIDE 2.0 Kick Off Meeting - October 17, 2019

• Welcome: Why Reduce Unnecessary Cesareans (Bill Sappenfield)
• Lessons from the West Coast (David Lagrew)
• Success Stories Panel - Download the Teams' Success Story Info Sheets
• Participant Expectations and Helpful Info for PROVIDE 2.0 Teams
• Change Management for PROVIDE 2.0 (Karen Bruder)
• PROVIDE 2.0 Implementation Planning Tools

PROVIDE 1.0 Webinars are archived here.

PROVIDE 1.0 (2018) Mid-Project Meeting:

• Emphasis on Safe Prevention of the Primary Cesarean: How Can It Influence Your Practice? (Kathleen Berkowitz)
• PROVIDE Shared Decision Making
• PROVIDE PDSA Cycles
• Notes from the Round Robin discussions

PROVIDE 1.0 Kick Off - 2017

• Background on the Issue
• Clinical Recommendations
• Induction
• Labor Dystocia
• Fetal Heart Rate Concern
• Choosing your Focus Area
• Implementation
• Mother/Provider Perspectives
• Quality Improvement Data Reporting

Labor Support Skills to Promote Vaginal Birth Workshop Train-the-Trainer Curriculum

Topics include:

• An overview of the cesarean issue in Florida
• Latent Labor - New parameters for latent labor, national recommendations and evidence for the management of latent phase, shared decision-making, patient education, labor support, hospital admission
• Active Labor - National recommendations and evidence related to the first stage and labor dystocia and interventions in labor, physiology and hormones that promote labor progress, techniques that promote labor progress and help babies rotate
• Comfort Measures -  Evidence for and options for comfort and support techniques, communication with provider, patient and family education resources, shared decision making
• Second Stage - National recommendations and evidence for management of second stage, relationship between fetal position and maternal pelvis in pushing positions, rotating the baby in the second stage, supporting the patient in different positions with and without epidural, patient/nurse/provider communication, patient and family education resources
• Fetal Wellbeing Assessment and Heart Rate Monitoring - Evidence and recommendations for fetal heart rate monitoring, identification and management of category II tracings, appropriate parameters for intermittent auscultation, review Leopold's maneuvers, proper auscultation procedure and documentation, patient education

Resources:

• PROVIDE 2.0 Measurement Grid (Updated Oct 2019) - Lists all process, outcome, structural, and balancing measures for our initiative.
• PROVIDE 2.0 Data Collection Chart Audit Sheet for BASELINE Data 
• PROVIDE 2.0 Data Collection Chart Audit Sheet for Prospective Data (Updated Jan 2020) - Use this form to review charts to determine your focus area or track your progress in implementing quality improvement changes.
• PROVIDE Baseline Data Entry Instructions (12-7-2017)
• Data FAQ and Answers (12-7-2017)
• PROVIDE Accurate Birth Certificate Data Reporting Guide - The variables included in this manual are required to calculate several outcome and balancing measures for the initiative. Please review and share to improve completeness and accuracy of these birth certificate variables.