(1020) The four critical components of an induction of labor protocol to reduce cesarean delivery

Standardized protocols for management of labor induction (IOL) may reduce cesarean delivery (CD). However, it is unclear if there is a specific threshold of adherence to protocol components or if specific components themselves are associated with reduced CD.

Study Design:

This is a secondary analysis of a prospective cohort study evaluating standardized IOL management at 2 sites from 2018-2022. Singletons ≥37 weeks with intact membranes receiving cervical ripening were included. Adherence was measured to 8 IOL protocol components (Table). CD rate was evaluated by percent of the 8 protocol components each IOL was adherent to (< 50%, 50-74.9%, 75-99.9%, 100%) and tests for trends by group were calculated using Mantel-Haenszel. Next, we aimed to see if there were individual protocol components critical to reducing CD. Poisson regression with relative risk evaluated independent association of adherence to each component with CD while controlling for confounders. Finally, CD rate was evaluated for IOLs adherent to the four protocol components found to be independent predictors in modeling.

Results:

8509 IOLs were included with an overall CD rate of 21.7%. Median protocol adherence was 80%. Increasing adherence to the protocol was associated with decreasing CD rate (< 50% adherence: CD 45.4%; 50-74.9% adherence: CD 23.7%; 75-99.9% adherence: CD 18.6%; 100% adherence: CD 14.2%; p< 0.001). In multivariable modeling, 4 protocol components were independently associated with reduced CD even when controlling for covariates:  “if misoprostol is utilized, it should not be continued >6 doses or >24h; transition to oxytocin”, “if a Foley is utilized, remove at 12h or when falls out”, “cervical exams q2-4h in latent labor”, and “q1-2h in active labor”. Notably, for IOLs adherent to all 4 of these components, CD rate was similar to IOLs adherent to all 8 components (15.0% vs. 14.2%, p=.46).

Conclusion:

There are 4 critical components of this IOL protocol which, when adhered to, were associated with decreased risk of CD. These components include not continuing “futile” cervical ripening and frequent cervical exams.