Obstetric Quality and Safety
Poster Session 1
Jourdan E. Triebwasser, MD, MA (she/her/hers)
Assistant Professor of Obstetrics and Gynecology
University of Michigan
Ann Arbor, MI, United States
Leah Mitchell Solomon, MD
Clinical Assistant Professor
University of MIchigan
Ann Arbor, MI, United States
Joanne M. Bailey, CNM, PhD
Certified Nurse Midwife
University of Michigan
Ann Arbor, MI, United States
Rebecca F. Hamm, MD, MSCE (she/her/hers)
Assistant Professor of Obstetrics and Gynecology
Perelman School of Medicine, University of Pennsylvania
Philadelphia, PA, United States
Michelle Moniz, MD, MSc
University of Michigan
Ann Arbor, MI, United States
Molly J. Stout, MD, MSCI (she/her/hers)
University of Michigan
Ann Arbor, MI, United States
To assess effectiveness and implementation outcomes after standardizing induction of labor (IOL) practices.
Study Design:
We conducted a quality improvement project in a high volume, academic medical center to increase utilization of 3 evidence-based IOL practices: 1) dual agent ripening; 2) vaginal misoprostol instead of buccal; 3) early amniotomy (≤ 4 cm). Singletons with intact membranes and initial cervical dilation ≤2 cm were included. Prior cesarean and stillbirth were excluded. We assessed effectiveness (IOL length, cesarean birth) and implementation outcomes (utilization, adoption by admitting services) pre-implementation (PRE; 11/1/21-1/31/22) vs. post-implementation (POST; 3/1/22-4/30/22). Cox proportional hazards models, stratified by parity, and adjusted for age, BMI, dilation, and epidural, were used to test the association between time period and IOL length.
Results:
Among 495 patients (PRE, n=293, POST, n=202) there were no differences in baseline characteristics other than epidural use (66.9% vs. 78.2%, p=0.006). IOL length was shorter POST (22.0 vs. 18.3 h, p=0.003) with no difference in cesarean (27.7 vs. 26.7%, p=0.82). Time to delivery was faster POST for nulliparas (HR 1.5, 95% CI 1.2-1.9; Figure) and multiparas (HR 1.5, 95% CI 1.1-2.0). Use of each practice increased POST: dual ripening (31.1 vs. 42.6%, p=0.009), vaginal misoprostol (34.5 vs. 68.3%, p< 0.001), and early amniotomy (19.1 vs. 31.7%, p=0.001). Adoption differed across services: Obstetrics increased use in all practices (32.1 vs. 43.5%, p=0.02; 37.1 vs. 70.8%, p< 0.001; 20.4 vs. 33.9%, p=0.003, respectively); Family Medicine increased use of dual ripening (0.0 vs. 40.0%, p=0.001) and vaginal misoprostol (11.1 vs. 60.0%, p=0.001), but not early amniotomy (11.1 vs. 20.0%, p=0.43); and Midwifery did not increase use of any practice (44.4 vs. 36.8%, p=0.57; 35.6 vs. 52.6%, p=0.20; 17.8 vs. 21.1%, p=0.76, respectively).
Conclusion:
Standardizing IOL practices leads to shorter IOL without increasing cesarean birth providing the opportunity to improve obstetric outcomes, decrease morbidity, and maximize system efficiency.