Safe Reduction of Primary Cesarean Birth
The Safe Reduction of Cesarean Birth patient safety bundle was revised in 2023 to incorporate respectful care concepts, revise existing elements, include new elements related to evidence-informed practices, and update data collection plans. The bundle provides actionable steps to support labor and care processes that can be adapted to a variety of facilities and resource levels to improve quality of care and safely reduce cesarean births.
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Patient Safety Bundle Documents
Patient Safety Bundle
Element Implementation Details
Implementation Resources
Patient Safety Bundle
Element Implementation Details
Implementation Resources
Data Collection Plan
Change Package
Learning Modules
Data Collection Plan
Change Package
Learning Modules
QUICK LINKS
READINESS
Every Unit
- Develop provider, patient community and unit culture that values, promotes, and supports spontaneous onset and progress of labor and vaginal birth and understands the risks for current and future pregnancies of cesarean birth without medical indication.
- Provide education to pregnant patients and families related to their options for labor and birth throughout the perinatal care cycle, with an emphasis on informed consent, and shared decision-making.
- Facilitate multidisciplinary education to healthcare team members on approaches which maximize the likelihood of vaginal birth, including assessment of labor, methods to promote labor progress, labor support, coping mechanisms, and pain management (both pharmacologic and non-pharmacologic), and shared decision-making to all providers and staff that provide care to pregnant and postpartum patients.
- Train staff on trauma-informed care to enhance high-quality outcomes for all patients.
RECOGNITION & PREVENTION
Every Patient
- Implement standardized admission criteria, triage management, education, and support for patients presenting in spontaneous labor.
- Ensure availability and offer a range of standard techniques of pain management and comfort measures that promote labor progress and prevent dysfunctional labor.
- Utilize standardized methods in the assessment of the fetal heart rate status, including interpretation and documentation and encourage evidence-based positioning and patient movement in labor.
- Implement protocols for timely identification of specific conditions, such as active herpes and breech presentation, for patients who can benefit from proactive intervention before labor to reduce the risk for cesarean birth.
- Implement standardized approaches to promote evidence-based interventions for conditions such as macrosomia, low-lying placenta, and oligohydramnios.
RESPONSE
Every Event
- Ensure availability of clinicians, staff, and resources to maintain appropriate ongoing labor assessment and support and respond to labor process disruptions and emergencies.
- Uphold comprehensive standardized induction scheduling with shared decision-making, planning, and preparation of patients undergoing induction.
- Utilize standardized evidence-based labor algorithms, policies, and techniques, which allow for prompt recognition and treatment of dystocia and are consistent with the diagnosis of labor dystocia criteria.
- Adopt policies that outline standard responses to abnormal fetal heart rate patterns and uterine activity to avoid unnecessary intervention and maintain high-quality neonatal outcomes.
- Provide via clinician training, skill development, or referral expertise and techniques to lessen the need for abdominal delivery, such as breech version, instrumented delivery, and twin delivery protocols
REPORTING & SYSTEMS LEARNING
Every Unit
- Perform regular multidisciplinary reviews of indications for cesarean births to determine alignment with established standards to identify systems issues and variations in provider performance.
- Monitor appropriate metrics and balancing measures, including maternal and newborn outcomes resulting from changes in labor management strategies, with disaggregation by patient characteristics.
- Establish a culture of multidisciplinary planning, huddles, and post-event debriefs for unplanned cesarean births, which identify success, opportunities for improvement, and action planning for future events.
RESPECTFUL, SUPPORTIVE & PATIENT-CENTERED CARE
Every Unit/Provider/Team Member
- Include each pregnant or postpartum patient and their identified support network as respected members of and contributors to the multidisciplinary care team.*
- Engage in open, transparent, and empathetic communication with pregnant and postpartum patients and their identified support network to respond to their concerns.*
Additional Resources
Bundle Element Context and Reference List (xlsx)
Journal of Obstetrics & Gynecology
Safe Reduction of Primary Cesarean Birth REDCap Template
Bundle Element Context and Reference List (xlsx)
Journal of Obstetrics & Gynecology
Safe Reduction of Primary Cesarean Birth REDCap Template
Additional Languages
Patient Safety Bundle – Spanish (PDF)
Element Implementation Details – Spanish (PDF)
Data Collection Plan – Spanish (PDF)
Implementation Resources – French (PDF)
Patient Safety Bundle – French (PDF)
Element Implementation Resources – French (PDF)
Data Collection Plan – French (PDF)
Patient Safety Bundle – Spanish (PDF)
Element Implementation Details – Spanish (PDF)
Data Collection Plan – Spanish (PDF)
Implementation Resources – French (PDF)
Patient Safety Bundle – French (PDF)
Element Implementation Resources – French (PDF)
Data Collection Plan – French (PDF)
Patient Safety Bundle Acknowledgements
- This Patient Safety Bundle was originally developed by the Alliance for Innovation on Maternal Health in collaboration with Rita Brennan, DNP, RNC-NIC, APN-CNS; James DeVente, MD, PhD; Joyce Edmonds, PhD, MPH, RN; Jennifer Frost, MD, MPH; Brian Gilpin, MPH; Lisa Kane Low, PhD, CNM; David LaGrew, MD*; Whitney Pinger, CNM, MSN; Dale Reisner, MD.
- This patient safety bundle was revised by Rita Brennan, DNP, RNC-NIC, APN-CNS; Joyce Edmonds, PhD, MPH, RN; Brian Gilpin, MPH; Lisa Kane Low, PhD, CNM; David LaGrew, MD; Elliot Main, MD; Stephanie Radke, MD.
- The American College of Nurse-Midwives and the Association of Women’s Health, Obstetric and Neonatal Nurses reviewed and provided feedback on this document.
© 2025 American College of Obstetricians and Gynecologists. Permission is hereby granted for duplication and distribution of this document, in its entirety and without modification, for solely non-commercial activities that are for educational, quality improvement, and patient safety purposes. All other users require written permission from ACOG.
Standardization of health care processes and reduced variation has been shown to improve outcomes and quality of care. This bundle reflects emerging clinical, scientific, and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular bundle may be adapted to local resources, standardization within an institution is strongly encouraged.