title: Avoiding the first cesarean section--results of structured organizational and cultural changes.
abstract: BACKGROUND
  In 2006 the overall rates of instrumental deliveries (10%) and cesarean sections (CS) (20%) were high in our unit. We decided to improve quality of care by offering more women a safe and attractive normal vaginal delivery. The target group was primarily nulliparous women at term with spontaneous onset of labor and cephalic presentation.
  
  
  METHODS
  Implementation of a "nine-item list" of structured organizational and cultural change in Linköping 2006-15. The nine items include monitoring of obstetric results, recruitment of a midwife coordinator, risk classification of women, introduction of three different midwife competence levels, improved teamwork, obstetrical morning round, fetal monitoring skills, obstetrical skills training, and public promotion of the strategy.
  
  
  RESULTS
  The CS rate in nulliparous women at term with spontaneous onset of labor decreased from 10% in 2006 to 3% in 2015. During the same period the overall CS rate dropped from 20% to 11%. The prevalence of children born at the unit with umbilical cord pH <7 and Apgar score <4 at 5 min were the same over the years studied. At present, 95.2% of women delivering at our unit are satisfied with their delivery experience.
  
  
  CONCLUSIONS
  The CS rates have declined after implementing the nine items of organizational and cultural changes. It seems that a specific and persistent multidisciplinary activity with a focus on the Robson group 1 can reduce CS rates without increased risk of neonatal complications.
authors: Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.
authors: Marie
authors: http://orcid.org/0000-0003-4679-550X
authors: M
authors: Blomberg
mesh_terms: D000328:Adult; D001034:Apgar Score; D002585:Cesarean Section / Q000009:adverse effects*; D065246:Culturally Competent Care / Q000379:methods / Q000458:organization & administration; D005260:Female; D005323:Fetal Monitoring / Q000379:methods*; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D008880:Midwifery / Q000379:methods / Q000592:standards; D009321:Natural Childbirth / Q000379:methods / Q000523:psychology; D009936:Organizational Innovation; D010298:Parity; D010348:Patient Care Team / Q000592:standards; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D058996:Quality Improvement; D013548:Sweden / Q000453:epidemiology; D047929:Term Birth
keywords: Cesarean section; Robson group 1; improvement; intervention; nulliparous