Policies to reduce 3& 4th degree laceration and Cesarean sections in women giving birth for the first time

by faithgibson on October 30, 2013

Elliott Main, MD

PhotoSutter Health’s First Pregnancy and Deliverny (FPAD) OB Quality program has focused on the L&D management of nulliparous women.

Started in 1999, it has centered on

  • reduction of: episiotomies (and hence 3rd/4th degree lacerations),
  • elective induction of term labor and early admission (<3cm dilation) (and hence labor cesareans) (see Main, E et al, AJOG 1998; 196:225-32).

Sutter Health has >40,000 total births per year.

We have had great success in reduction of episiotomies (from 45% of first time births to the current 14%). Recently we identified that >65% of the inter-hospital variation in Cesarean Birth rate for low-risk nulliparous women was due to differences in the rates of induction and early pregnancy admissions. The keys to the successful quality improvement efforts were continual audit and feedback combined with professional education.

View Elliott’s CMQCC profile.

Elliott Main, MD

Chairman and Chief of Obstetrics; California Pacific Medical Center


Elliott Main, MD, is the Medical Director of the California Maternal Quality Care Collaborative (CMQCC).   Since 1998, he has also been the Chairman of the Department of Obstetrics and Gynecology of California Pacific Medical Center in San Francisco. That department, with over 90 Ob/GYN’s and over 6,000 annual births is one of the largest in the US.  In addition, Dr Main chairs the first-ever California Pregnancy-associated Mortality Review Committee. Through his career, Dr. Main’s clinical work and publications have focused on medical complications of pregnancy and outcomes-based quality improvement. Since 1997, he has also led OB Quality Improvement for all of Sutter Health’s 20 hospitals and 40,000 births and developed and led several large-scale data-driven quality improvement efforts.  These include Sutter Health’s “First Pregnancy and Delivery” quality initiative that focused on the care of nulliparous women.

Dr. Main has been actively involved in multiple state and national committees on Maternal Quality measurement including NQF, ACOG/AMA, The Joint Commission and the RAND Corporation.  Dr. Main trained in obstetrics and gynecology at Washington University School of Medicine (St. Louis, Mo.) and in maternal-fetal medicine at the University of Pennsylvania.  Dr Main is currently Clinical Professor of Obstetrics and Gynecology and Reproductive Science at the University of California, San Francisco, and Visiting Professor of Obstetrics and Gynecology at the Department of Obstetrics and Gynecology at Stanford University.

In his spare time…he helps to edit this web-site (www.cmqcc.org).

Our goal is that the collaborative work we do in California to measure and improve maternal and neonatal outcomes will become a model for the entire United States.

CMQCC Committee Memberships

  • Regional Perinatal Programs of California (RPPC)
  • Maternal Quality Improvement Panel (MQIP)
  • Maternal Information Technology (MIT)
  • Newsletters
  • LAMH (Local Assistance for Maternal Health) Project
  • LAMH (Local Assistance for Maternal Health) Project Advisory Committee
  • Hemorrhage Task Force
  • CMQCC Staff
  • Less Than 39 Week Toolkit Development Task Force
  • Maternal Data Committee
  • MDC Steering Committee
  • Preeclampsia Task Force
  • Preeclampsia Collaborative Expert Panel
  • OB Hemorrhage Toolkit Update Team
  • PAMR (Pregnancy-Related and Pregnancy-Associated Mortality Review) Advisory Committee
  • CMQCC Executive Committee
  • Hemorrhage Collaborative Expert Panel
  • Cardiovascular Disease Task Force

Profile in Improvement

Learn how Elliott Main of Sutter’s California Pacific Medical Center is improving the care for first labors and births.