Novel Evidence-Based Labor Induction Algorithm Associated with Increased Vaginal Delivery within 24 Hours

Abstract

Objective: To assess whether concordance with our proposed labor induction algorithm is associated with an increased rate of vaginal delivery within 24 hours. Study Design: We conducted a retrospective review of 287 IOLs at a single urban, tertiary, academic medical center which took place before we created an evidence-based induction of labor (IOL) algorithm. We then compared the IOL course to the algorithm to assess for concordance and outcomes. Patients age 18 or over with a singleton, cephalic pregnancy of 36 6/7 to 42 0/7 weeks’ gestation were included. Patients were excluded with a Bishop score >6, contraindication to misoprostol or cervical Foley catheter, major fetal anomalies or intrauterine fetal death. Patients with 100% concordance were compared to <100% concordant patients, and patients with 80% concordance were compared to <80% concordant patients. Adjusted hazard ratios (AHRs) were calculated for rate of vaginal delivery within 24 hours, our primary outcome. Competing risks analysis was conducted for concordant vs. non-concordant groups, using vaginal delivery as the outcome of interest, with cesarean delivery as a competing event. Results: Patients with 100% concordance were more likely to have a vaginal delivery within 24 hours, n = 66/77 or 85.7% vs. n = 120/210 or 57.1% (p<0.0001), with an AHR of 2.72 (1.98, 3.75, p<0.0001) after adjusting for delivery indication and scheduled status. Patients with 100% concordance also had shorter time from first intervention to delivery (11.9 vs. 19.4 hours). Patients with 80% concordance had a lower rate of cesarean delivery (11/96, 11.5%) compared to those with <80% concordance (43/191 = 22.5%) (p=0.0238). There were no differences in neonatal outcomes assessed. Conclusion: Our IOL algorithm may offer an opportunity to standardize care, improve the rate of vaginal delivery within 24 hours, shorten time to delivery, and reduce the cesarean delivery rate for patients undergoing IOL.

Implementation and Clinical Impact of a Guideline for Standardized, Evidence-Based Induction of Labor

“…In a retrospective study of evidence-based IOL strategies, using 100% of the recommended IOL elements increased the chance of vaginal birth within 24 hours and reduced length of IOL. 25 Unlike a prior study that suggested standardized IOL could reduce racial disparities in clinical outcomes after IOL, 20 we did not observe a reduction in disparities in the use of evidence-based practices, although our power to detect differences was limited by a small proportion of patients identifying as non-Hispanic Black. Whether implementation of standardized IOL practices can reduce clinical disparities is uncertain, as there was no difference in cesarean birth between non-Hispanic Black and non-Hispanic White birthing people in our study prior to or after guideline implementation.…”

“…In a retrospective study of evidence-based IOL strategies, using 100% of the recommended IOL elements increased the chance of vaginal birth within 24 hours and reduced length of IOL. 25…”

Reassessing the Bishop score in clinical practice for induction of labor leading to vaginal delivery and for evaluation of cervix ripening

“…In this regard, efforts to synthesize existing data with more recent findings may improve existing algorithms for IOL and validate an expanded use of the Bishop score. [ 17 , 18 ] The ultimate goal would be to individualize the timing of IOL procedures to optimize outcomes for each pregnancy.…”