Evaluating the impact of a standardized induction protocol to reduce adverse perinatal outcomes: a prospective cohort study

OBJECTIVE: Understanding the importance of standardized care and utilizing the concepts of active management of labor, we developed a standardized induction of labor protocol at our institution. The objective of this study was to evaluate the impact of this induction of labor protocol on reducing maternal and neonatal morbidity in women undergoing an induction of labor with an unfavorable cervix. STUDY DESIGN: We performed a prospective cohort study of women undergoing an induction at our institution from May 2013 to June 2015. Women who were ≥18 years, ≥37 weeks, carrying a singleton gestation in cephalic presentation with intact membranes and an unfavorable cervix (Bishop score of ≤6 and cervical dilation ≤2 cm) were included. Women with a prior cesarean were excluded. We compared outcomes between women managed with the labor protocol versus women in an observation group, managed at the discretion of the provider. Outcomes evaluated were: Labor length, cesarean delivery, maternal and neonatal morbidity, and neonatal intensive care unit admission for >48 hours. Multivariable models incorporated confounders that were specific to each outcome. RESULTS: 855 women were included in this study (491 in labor protocol group; 364 in observational group). Women in the labor protocol group had a shorter time to delivery (15.7 hours vs. 18.0 hours, p48 hours (3.5% vs 8%, p=0.005), and a lower neonatal morbidity (3.0% vs. 7.7%, p=0.003) compared to women in the observational group. There was no difference in the rate of cesarean delivery between the labor protocol group and the observational group (27.7% vs. 32.7%, p=0.13). When adjusting for confounders specific to each outcome, women in the labor protocol group had a 60% reduction in NICU admission >48 hours (RR: 0.41, 95% CI: 0.22–0.76) and a 70% reduction in neonatal morbidity (RR: 0.31, 95% CI: 0.13–0.70). Time to delivery and maternal morbidity were not significantly different between the groups in adjusted models. CONCLUSION: Utilization of a standardized induction protocol was associated with a significant reduction in neonatal morbidity without increasing the risk of cesarean delivery or maternal morbidity.