Induction of labor more successful with standardization

1. Women whose induction of labor was managed according to a protocol requiring amniotomy within 24 hours of starting oxytocin, intrauterine pressure catheter (IUPC) placement for titration of oxytocin to achieve adequacy (200-300 Montevideo units per 10 minutes), and at least 12 hours of oxytocin after amniotomy were less likely to fail labor induction. 

2. Women whose providers practice varied outside the protocol were more likely to undergo Cesarean delivery with the indication of failed induction of labor (FIOL). 

Evidence Rating Level: 2 (Good)

Study Rundown: Labor induction is becoming an increasingly common obstetrical procedure. At the same time, the Cesarean section rate in the United States continues to exceed the goal set by the U.S. Public Health Service and experts agree that failed induction of labor (i.e. inability to achieve active phase of labor) should be a rare indication for Cesarean. While numerous studies have evaluated the upper limit of a normal duration of the latent phase (18 hours) in nulliparous and multiparous women who will go on to achieve a spontaneous vaginal delivery, no consensus guidelines exist regarding optimal management of all women for induction of labor.

A prior study exploring the safety and efficacy of an induction of labor protocol requiring amniotomy within 24 hours of starting oxytocin and IUPC placement for titration of oxytocin to achieve >200 MVUs found that after 12 hours, only 4% of nulliparous women and no (0%) multiparous women remained in latent phase. Said differently, this study demonstrated that in this study population, adherence to this latent labor protocol nearly eliminated Cesarean sections for failed induction of labor. Building on this finding, the present work evaluates effectiveness of a modified version of said protocol compared to common practice. The authors found that the standardized protocol, which included amniotomy within 24 hours, IUPC placement with oxytocin titration to achieve 200-300 MVUs, and 12-18 hours of oxytocin after amniotomy, was associated with lower rates of FIOL, suggesting that such protocols may improve outcomes, avoid risks of surgery, and decrease healthcare costs.

Limitations of this study include a retrospective design and potential variations in practice over the course of protocol implementation. Inductions beginning in October 2011 were included in the study cohort, but the protocol was not implemented until December of that year. Furthermore, it is conceivable that as providers became more familiar with the protocol, outcomes improved. Future prospective cohort studies with a control group or randomized controlled trials are needed to verify benefits observed herein.

Click to read the study in AJOG

Relevant Reading: Criteria for failed labor induction: prospective evaluation of a standardized protocol

In-Depth [retrospective cohort study]: This study evaluated the effectiveness of a standardized, evidence-based protocol (n=369) compared to standard practice (n=230) for induction of labor in women with an unfavorable cervix. Outcomes of interest were FIOL, Cesarean delivery, time from induction to delivery and various maternal and neonatal complications.

Women whose induction of labor was managed according to an IOL protocol were less likely to be diagnosed with a failed induction (1.4% vs. 7.8%, p<0.0001). This finding was consistent even in women undergoing a vaginal trial of labor (VTOL) after Cesarean. Further, time between induction and delivery was 3 hours less in the protocol-adherent group (p<0.001). Failed induction was a more common indication for Cesarean among women in the protocol-non-adherent group, while nonreassuring fetal heart tracing was the most frequent indication for Cesaren in the protocol-adherent group.

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