Do practice guidelines guide practice? A prospective audit of induction of labor three years experience

To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures.

Guidelines for induction of labor were implemented in January 1996 following an audit report identifying inconsistency in clinical practice. A prospective audit was carried out following the implementation of a new strategy directed towards pre-induction cervical ripening in nulliparae with unfavorable cervices and the use of low dosages of vaginal prostaglandin E2 for induction of labor. Level of compliance and outcome measures were compared before and after implementation of guidelines.

In the period of January 1995 to November 1997, 1,230 women were induced with a singleton viable pregnancy in a cephalic presentation with a gestational age > or = 37 weeks with no history of rupture of membranes or cesarean section. Completed forms were available for 1,147 women (370, 421 and 356 in 1995, 1996 and 1997, respectively). Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit.

Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.