Evidence-based protocol decreases time to vaginal delivery in elective inductions

Abstract

Background: Labor induction accounts for over 1 in 5 births in the United States. There is large variability in practices of induction of labor. Standardizing aspects of induction of labor has been shown to have beneficial maternal and fetal effects.

Objective: This study aimed to investigate the impact of the implementation of an evidence-based labor induction protocol on maternal and neonatal outcomes.

Study design: In February 2018, a contemporary labor induction protocol composed of standardized cervical ripening and early amniotomy was implemented in the labor and delivery unit at a large academic center along with comprehensive training of staff. Maternal and fetal outcomes were compared between patients undergoing induction over a 9 month period following the implementation of the protocol and those undergoing induction 9 months earlier, excluding a 2 week washout period while training occurred.

Results: We studied 887 patients who underwent induction of labor of a live singleton at >24 weeks' gestation during our study period (387 patients before the implementation of the protocol and 500 patients after the implementation of the protocol). Baseline characteristics of maternal age, previous vaginal deliveries, and birthweight were similar in patients before and after the implementation of the protocol. There was a significant increase in the number of elective inductions occurring after the implementation of the protocol. There was a significant decrease in time from start of induction to rupture of membranes in all women under the protocol (13.3 hours before the implementation of the protocol vs 10.4 hours after the implementation of the protocol; P≤.001) and decrease in time from start of induction to delivery (21.2 hours before the implementation of the protocol vs 19.7 hours after the implementation of the protocol; P=.04). When the analysis was stratified by elective and nonelective inductions of labor, we found that time from induction of labor initiation to vaginal delivery was shortened after the implementation of the protocol for those undergoing elective induction (18.5 hours vs 14.6 hours; P=.03). There was no difference in cesarean delivery rate (P=.7), chorioamnionitis (P=.3), postpartum hemorrhage (P=.7), or newborn intensive care unit admission (P=.3).

Conclusion: The implementation of an evidence-based labor induction protocol was associated with decreased time to delivery, primarily driven by decreased time to vaginal delivery among those undergoing elective inductions of labor, without compromise of maternal or neonatal outcomes.

Keywords: induction of labor; obstetrics; quality improvement.