Pregnancy outcomes after implementation of an induction of labor care pathway

Induction of labor is common, however the optimum clinical strategy for induction is less clear. Variation in clinical practices related to labor induction may lead to increased complications and longer induction times. The objective of this study was to analyze whether implementation of an evidence-based standardized care pathway improved clinical outcomes associated with induction of labor. This was an approved quality improvement project implementing a clinical care pathway for induction of labor. We conducted a retrospective cohort study of inductions for 5 months before (January through May 2018) and 14 months after pathway implementation (August 2018 through September 2019). The primary outcome was time from admission to delivery. Time from admission to delivery was stratified by mode of delivery. Secondary outcomes included chorioamnionitis, endometritis, NICU admissions, cesarean delivery, postpartum hemorrhage, and a composite of unanticipated outcomes (chorioamnionitis, endometritis, NICU admissions, cesarean delivery, and postpartum hemorrhage). Pathway adherence was also analyzed. Outcomes were analyzed with two tailed t-tests for continuous data, and Fisher's Exact Test and Chi-square tests for categorical data. Propensity score matching was used to assess for confounding by potential covariates. We reviewed a total of 1,471 inductions, 392 before and 1,079 after pathway implementation. The pathway was associated with a non-significant reduction in time from admission to delivery by 1.2 hours (23.4 hours to 22.2 hours, p=0.08). There was a non-significant increase in time to cesarean delivery before (28.2 hours) and after protocol implementation (28.8 hours), p = 0.71. There was a significant decrease in time to delivery by 1.7 hours for vaginal deliveries, from 22.2 hours to 20.5 hours after protocol implementation, p = 0.02. There was a significant decrease in chorioamnionitis (12.5% to 6%, OR 0.44, 0.29-0.67), a significant decrease in endometritis (6.9% to 2.6%, OR 0.36, 0.2-0.65), and a significant decrease in composite unanticipated outcomes (56.9% to 36.6%, OR 0.46, 0.34-0.56) following pathway implementation. There were no significant differences in postpartum hemorrhage (7.9% to 6.1%, OR 0.76, 0.48-1.22), NICU admissions (18.1% to 14%, OR 0.74, 0.54-1.02) or cesarean deliveries (19.6% to 20.1%, OR 1.03, 0.76-1.4) following pathway implementation. Pathway adherence varied, ranging from 50% to 89%. Introduction of a standardized induction of labor pathway is associated with a non-significant reduction in time from admission to delivery by 1.2 hours, and improved pregnancy outcomes including decreased infections and unanticipated outcomes. Further opportunities for improvements in clinical outcomes may be realized with increased compliance with the care pathway.