In 2019, a series of adverse maternal and neonatal outcomes across Victoria, Australia, prompted a critical review through the Consultative Council on Obstetric and Paediatric Mortality and Morbidity. This review identified consistent system-level drivers of poor outcomes in operative vaginal birth (OVB), including failure to recognise fetal malposition, breakdowns in communication, delays in escalation, and deviation from established safety guidelines.¹ These findings highlighted a systemic gap in team-based safety practices and decision-making under pressure.

In response, Monash Health convened a multidisciplinary taskforce in 2020 involving obstetricians, midwives, researchers, and consumers to address these drivers. This led to the development of the OVB Safety Bundle, a structured, evidence-informed intervention underpinned by a continuous learning cycle drawing on both clinical data and women’s experiences. The bundle is designed to standardise care, improve decision-making, and strengthen safety culture while supporting a woman-centred care experience.

Components of the Safety Bundle

The OVB Safety Bundle comprises three integrated elements addressing key vulnerabilities in OVB: structured decision-making and procedural coordination, diagnostic accuracy and case selection, and patient experience.²

Structured team time-out and procedural safety checklist

OVB is time-critical and relies on coordinated teamwork and individualised clinical judgement. The bundle therefore introduces a pre-procedural time-out followed by a real-time safety checklist.

The time-out provides a structured pause before commencing, ensuring the appropriate team is present, roles are clearly defined, and a shared plan is established. In high-pressure settings, there is a risk of narrow task focus; this step broadens situational awareness, aligning technical task allocation with oversight of the overall clinical picture and supporting a coordinated, controlled environment.

The patient is an active participant. The time-out is conducted with her, not around her. The clinical situation, proposed plan, alternatives, and risks are clearly communicated to support informed consent within a time-pressured context. Agreed thresholds for reassessment and escalation, including conversion to caesarean section, are explicitly discussed to ensure shared understanding of how decisions may evolve.³

The procedural checklist is then used dynamically during the procedure, in partnership with the woman, prompting ongoing reassessment of progress, maintenance of situational awareness, and early recognition of deviation from expected trajectory, including reconsideration of instrument choice or escalation.

Rather than a passive tool, it reinforces communication, supports cognitive offloading under pressure, and integrates technical execution, team coordination, and the woman’s experience into a single safety framework.³

Bedside ultrasound prior to OVB

Accurate determination of fetal head position is fundamental to safe OVB. Clinical assessment alone is known to be unreliable, with error rates reported as high as 20-40%.^4-6 The routine use of intrapartum ultrasound as an adjunct to abdominal palpation and vaginal examination improves diagnostic accuracy.^4-6

The bundle incorporates bedside transabdominal ultrasound immediately prior to OVB, using portable equipment in the birth suite. Simple landmarks, including fetal spine and orbits, are used to confirm position, supporting instrument selection and procedural approach, and allowing earlier reconsideration of the delivery plan when needed.³

Birth experience survey and postnatal debrief pathway

The bundle explicitly recognises that safety in obstetrics extends beyond physical outcomes to include psychological wellbeing. OVB is associated with higher risk of negative birth experience, with potential long-term impacts for the mother and child.^7,8

All women undergoing OVB are invited to complete a validated birth experience survey to identify those needing support. Women reporting a negative experience or requesting review are offered a structured debrief with senior midwives and obstetric input as needed, supporting review, clarification, and psychological recovery, with referral to community supports where appropriate.³

Data-driven learning system

Together, these components form more than a set of discrete interventions; they operate as a data-driven safety culture transformation system. Each component generates complementary data, including procedural metrics from the time-out and checklist, diagnostic accuracy from ultrasound, and patient-reported outcomes from the birth experience pathway. These are analysed collectively to identify patterns, variation in practice, and opportunities for improvement.

This supports an iterative learning cycle, where insights from clinical outcomes and women’s experiences are translated into education, simulation, and refinement of the bundle. The system functions as a dynamic, continuously evolving framework rather than a static protocol, enabling ongoing improvement in decision-making, team performance, and patient-centred care. By embedding feedback loops into routine care, it enables sustained change in both safety processes and culture over time.

Clinical Outcomes Following Implementation

Implementation of the OVB Safety Bundle has been associated with consistent improvements in procedural and neonatal outcomes, suggesting better case selection and execution.

Birth outcomes

Following implementation, there was a 32% reduction in births requiring excessive traction, defined as more than three pulls or two or more cup detachments (8.5% to 5.8%), and a 27% reduction in sequential instrument use (6.0% to 4.4%).³ Indicators of failed or suboptimal OVB also improved, with a 26% reduction in caesarean following failed OVB (2.7% to 2.0%) and a 63% reduction in unsuccessful OVB on birth suite (0.8% to 0.3%).³ Importantly, overall fully dilated caesarean section (FDCS) rates did not increase.

Neonatal outcomes

Neonatal outcomes improved in parallel. Unexpected fetal position at birth decreased by 76% (2.8% to 0.7%), reflecting improved diagnostic accuracy.³ This was accompanied by a 25% reduction in neonatal morbidity (5.9% to 4.4%), a 48% reduction in neonatal birth trauma (2.5% to 1.3%), and a 33% reduction in NICU admission (2.7% to 1.8%).³

Overall, clinical outcomes support improved safety of OVB, with strengthened procedural planning, better case selection, and earlier transition to alternative delivery modes when indicated.

Staff Experience and Safety Culture

Beyond clinical outcomes, the OVB Safety Bundle has improved staff experience. Following implementation, staff consistently reported improvements in interprofessional communication, communication with patients, and overall patient experience and safety (unpublished data). These findings suggest a shift in how teams function under pressure, with greater clarity, shared understanding, and confidence in decision-making.

Qualitative feedback supports this, with clinicians describing a more structured and less stressful environment. The bundle provides a framework that supports clinicians at all levels and reframes escalation, with timely conversion to FDCS when indicated considered appropriate care rather than procedural failure.

The Importance of Birth Experience

The birth experience pathway is a defining feature of the OVB Safety Bundle. In early implementation, around 20% of women who engaged with the pathway proceeded to formal debrief, with most subsequently linked to community supports where needed (unpublished data). Among those debriefed, 93% reported improved wellbeing.

Patients describe feeling heard, supported, and better able to process their experience, with debrief providing clarity, closure, and reduced psychological burden after complex or traumatic births. This focus on experience is central to overall outcomes, recognising that safe care includes both physical and psychological wellbeing.

Scaling the Bundle

The OVB Safety Bundle is being implemented across all Level 4-6 public maternity services in Victoria through a structured training and implementation program, with funding support from the Victorian Managed Insurance Authority. Training is staged from engagement and adaptation through to implementation and consolidation, with services supported to tailor the bundle to local context and embed it within existing systems.

A multidisciplinary team provides workshops, simulation training, and ongoing support, including obstetric and midwifery educators alongside research and evaluation expertise. Training is underpinned by data collection, feedback, and continuous quality improvement.

Early adopting sites report improved practice, strong engagement, and highly positive feedback, with most rating training as very good or excellent and recommending it to other services. Sites also report improved readiness for implementation and development of tailored local strategies, supporting sustained cultural change.

A Vehicle for Transformation

The OVB Safety Bundle transforms operative obstetrics by introducing structure, clarity, and support for clinical decision-making at both individual and system levels. It reflects a learning health system approach, incorporating continuous quality improvement, feedback loops, and structured reflection and adaptation to clinical need. Consumer involvement is embedded through patient engagement pathways and co-design, ensuring lived experience informs care delivery and evaluation.

The bundle represents a new approach to operative obstetrics, demonstrating that scalable improvements in safety can be achieved when system-level drivers are addressed. By integrating evidence-based interventions with ongoing learning, cultural change, and patient partnership, it provides a scalable framework to support clinicians and families. As implementation expands across Victoria and interest grows nationally and internationally, the broader potential lies in collective adoption and shared learning across health systems.

The Safer Birthing Centre of Excellence at Monash Health offers a comprehensive OVB Safety Bundle training package designed to transform safety culture and patient experience in maternity care. Built for clinicians and health services ready to drive meaningful change, this program equips teams with the tools and knowledge to drive change and deliver safer outcomes for mothers, babies, and the maternity workforce. For more information on the training package, contact [email protected].