Table 3.
Fidelity to 8 individual components of the labor induction protocol compared between the pre- and post-implementation.
| Pre (n = 4214) n (%) | Post (n = 4295) n (%) | p-value | Adjusted relative risk (aRR) [95% Confidence Interval]a | |
|---|---|---|---|---|
| Protocol recommendation | Adherence (Fidelity) | |||
| 1. Recommendation: If cervical ripening balloon is utilized, if remains in place at 12 h after placement, remove it and initiate/continue oxytocin. Measure of adherence: If a ripening balloon is utilized, time from placement to expulsion or removal is <12.5 h. |
3414/3590 (95.1) | 3409/3542 (96.3) | 0.017 | 1.01 [0.97–1.06] |
| 2. If misoprostol is utilized, it should only be repeated for up to a total of 6 doses and for no >24 h. If remains in latent labor, initiate oxytocin. Measure of adherence: If misoprostol was utilized, no more than 6 doses were given and time from placement of first misoprostol to time of placement of final misoprostol is <24 h. |
3710/3732 (99.4) | 3930/3950 (99.5) | 0.62 | 1.00 [0.96–1.05] |
| 3. If it has been more than 6 h since misoprostol placement (whether or not cervical ripening balloon is in place), and AROM not yet feasible with no window for another misoprostol, start oxytocin. Measure of adherence: During cervical ripening with misoprostol, there was no window >6.5 h where no active management of latent labor was undertaken. Eligible actions included placement of a cervical ripening balloon or another misoprostol, start of oxytocin, or AROM.b,c |
2513/3732 (67.3) | 2727/3950 (69.0) | 0.11 | 1.04 [0.99–1.10] |
| 4. Latent labor exams should be performed: At least every 3 h if misoprostol and/or Foley being used; At least every 4 h if oxytocin is being used. Measure of adherence: There were no gaps between latent labor cervical exams >4.5 h. |
1479 (35.1) | 1758 (40.9) | <0.0001 | 1.21 [1.12–1.29] |
| 5. If patient is ≥4 cm dilated and has intact membranes, recommend performing amniotomy if feasible. Measure of adherence: If 4 cm dilation was reached with intact membranes, amniotomy was performed at that exam. |
1333/2894 (46.1) | 1576/2890 (54.5) | <0.0001 | 1.19 [1.11–1.28] |
| 6. Exams should be performed every 1–2 h in active labor. Measure of adherence: There were no gaps between active labor cervical exams >2.5 h.d |
3156/3690 (85.5) | 3229/3760 (85.9) | 0.67 | 1.00 [0.96–1.06] |
| 7. If there are 2 exams in active labor 2 h apart with the same cervical dilation and membranes are already ruptured, but oxytocin has not yet been started, start oxytocin. Measure of adherence: If there are 2 exams in active labor 2 h apart with the same cervical dilation and membranes are already ruptured, but oxytocin had not yet been started, it was begun within 30 min of the 2nd exam. |
9/32 (28.1) | 12/37 (32.4) | 0.70 | 1.31 [0.49–3.52] |
| 8. If there are 2 exams in active labor 2 h apart with the same cervical dilation and membranes are already ruptured with oxytocin already begun, place an IUPC. Measure of adherence: If there are 2 exams in active labor 2 h apart with the same cervical dilation and membranes are already ruptured with oxytocin already begun, an IUPC was placed within 30 min of the 2nd exam.e |
61/190 (32.1) | 98/188 (52.1) | <0.0001 | 1.59 [1.14–2.23] |
a
Adjusted for body mass index, history of pregestational diabetes, hypertensive history, indication for induction, modified Bishop score, starting induction agent, and maternal age.
b
AROM, Artificial Rupture of Membranes.
c
The measure was no longer assessed once either oxytocin was initiated or AROM occurred, as this was determined to be the completion of cervical ripening.
d
Among those who reached active labor ≥6 cm dilation.
e
IUPC, intrauterine pressure catheter.