You are the Quality Coordinator for the medical staff. Analyze the chart above and determine steps to be taken next.

Plot control limits, check indicator threshold, and take December charts to OB/GYN Committee if threshold exceeded. 

Plot control limits and take December charts to OB/GYN Committee if December data poi exceeds UCL. 

Plot control limits, pull charts for December, and do a focused review screening. 

Plot control limits and refer to Medical Executive Committee for variation review.